For over two years, health reformers have been holding their breath waiting to see if the ACA would be a home run or just a long fly-out. With the re-election of President Obama and an expanded Democratic majority in the Senate, the news on the scoreboard is clear enough for even John Boehner (but not Rick Perry) to read: the ACA is here to stay.
Not only that, but the most drastic proposed restructurings of Medicare and Medicaid -- vouchers and block grants -- have also been sent to the showers.
But while the election outcome came as an enormous relief to health care advocates, the time for celebration is fleeting. The next chapter in the Obamacare Odyssey is already beginning.
What do we do now?
Now comes the hard part (OK, it's been hard all along, so let's just call it the next hard part)--making the ACA work. This is a task for both state and federal policy makers because there remain a whole fleet of critical regulations and sub-regulatory guidance the feds have to issue that will shape the implementation of the ACA. Also, , at least initially, the task of standing up the Health Insurance Exchanges will fall more to the federal government than to states, notwithstanding the most recent extension granted by CCIIO for states to get their Exchange plans together.
Congress will also be getting in on the act. Just because we can kiss repeal votes good bye (we never really did hear too much about replace), doesn't mean that everyone will come together and sing “Kumbaya.”
Especially in the negotiations over reducing the federal debt, expect all kinds of ACA-related agenda items to be on the table. Some are obvious, such as delaying the implementation date (most probably a non-starter) to paring back the financial assistance available to low- and moderate-income households to make health care more affordable, to reducing other components of the law like the Prevention and Public Health Fund and spending by the Innovation Center. Many ideas, such as repealing the Independent Payment Advisory Board (IPAB) or eliminating various revenue raisers in the ACA, will actually increase rather than reduce the debt. But don't let that little inconsistency trouble you.
Perhaps the area of greatest concern is the interaction between federal Medicaid policy and the ACA. Since states, courtesy of the Supreme Court, have the option not to adopt the Medicaid coverage expansion, any indication from the federal government that it plans to reduce federal health spending by shifting costs onto states cannot help but have a chilling effect on state take up.
In the on deck circle
The first critical step in the debt reduction process begins this week as Congress reconvenes in lame duck session. During the lame duck, or perhaps likely early next year, we can expect Congress to agree on "top line numbers" for debt reduction. Although actual policy proposals will take well into 2013 to develop, a big number for health care savings will drive the committees responsible for drafting (mainly Senate Finance, and House Energy and Commerce and Ways and Means) toward making cuts in Medicare, Medicaid, and the ACA that could undermine the affordability of coverage and impede access to care.
There is an implicit bargain on the table -- Republicans agree to revenue increases if Democrats agree to changes in Medicare, Medicaid and/or Social Security. What’s striking is while Republicans have been clear on their position on revenue (no increases in tax rates, even for the wealthiest Americans), there has been no similar clarity from Democrats with respect to health care. Ideally, the President and Democratic leaders will articulate a clear position rejecting any cuts in benefits or increased cost sharing for Medicare, Medicaid or ACA beneficiaries. Yes we have to reduce health care spending, but let's make sure we do it the right way, by going after the excessive costs and inconsistent quality that plague the US health care system. (More on this in future posts.)
Meanwhile, back in the states...
At the same time the high stakes federal negotiation is going on, states will have to make the crucial decisions leading up to the launch of the ACA coverage expansion in 2013. This includes, perhaps most significantly, whether to expand Medicaid to low-income uninsured adults. (Coverage does not begin until 2014, but open enrollment starts in October 2013, and there is a lot to do to get ready for that deadline.) We can hope that now the ultimate fate of the ACA has been settled, partisanship will recede and there will be a more pragmatic attitude toward implementation in states that have previously been undecided or opposed to moving forward. However, at least three factors suggest that pragmatism will take root only gradually rather than all at once.
First, there is very little time between ACA launch and the 2014 elections. Rather than commit themselves to implementing the ACA, there will be a strong temptation for some leaders to remain aloof and to use the (inevitable) implementation bumps as fodder for campaigns in 2014.
Second, all politics is local, which means governors in states that President Obama did not carry may not feel any pressure from their electorate to move forward. Even in states the President carried, local legislators may still see strong opposition from their districts and be in a position to block or impede progress.
Republican governors may have yet another consideration when weighing whether to reconsider their past opposition to the ACA. How many of them are now mulling a run for president in 2016? All? Half? How many want to run in the Republican primaries in danger of being labeled soft on Obamacare? For these reasons, and perhaps others, we won't see a real pragmatic acceptance of the ACA until it is up and running and the dire predictions about it are proved false. That is why successful launch is so important and why our time dancing in the stands, though real, must be brief. The next time for action is now.
-- Michael Miller, Director of Strategic Policy