Joan Henneberry is a principal of Health Management Associates, a national health policy research and consulting firm.
If people were busy with health reform implementation before the election, hold onto your hats. Now that it appears we'll be "staying the course" with the Affordable Care Act, expect a great deal of activity and planning in 2013.
President Obama will continue on the path of implementing the ACA. Since there are things within the ACA that need fixing or adjusting, we'll see if the administration can get Congress to come to the table and make changes without gutting the intent of the legislation.
Because fiscal and budgetary challenges will be the first priority for the president and Congress, it's possible they'll scale back parts of the ACA to avoid other reductions. Most likely, members of Congress will try to pick at pieces of the ACA they don't like, using declarations and budget processes to keep the entire package of policies from moving forward.
The Center for Medicare & Medicaid Services (CMS) will issue a flurry of rules and regulations regarding the ACA's implementation. States have been waiting for guidance that wasn't forthcoming prior to the election. That means representatives of health insurance exchanges, health plans and other stakeholders will need to review the impact of these final rules and determine whether to proceed with building a state exchange or default to a federal exchange.
States now have the privilege and burden of deciding whether they should take advantage of an option under the ACA to expand Medicaid. Estimates of how many individuals in Colorado would be eligible under an expansion in 2014 vary but could be as high as 200,000. To expand in 2014, most states would need legislation passed in the 2013 session. Until further guidance is provided, it is assumed that states have the following options:
Expand Medicaid as outlined in the ACA, to 138 percent (133 percent plus disregards) of the federal poverty level (FPL) for all non-elderly legal residents.
Expand Medicaid but propose doing so in phases (up to 100 percent of the FPL by 2014, 125 percent in 2015 and 138 percent in 2016; or postpone the expansion to a later date).
Examine the use of a Basic Health Plan for individuals up to 200 percent of the FPL, with individuals above that income going to the health insurance exchange for coverage.
Fully implement the early expansion funded (currently paid in Colorado by a hospital provider fee) from 10 to 100 percent of the FPL. Individuals earning more than 100 percent of the FPL can receive subsidies for obtaining coverage through the exchange.
Expand eligibility while the ACA provides a 100 percent match of federal funding, then roll back eligibility when the state has to provide match.
Many of these options would require federal approval through a state plan amendment or waiver, and it is not clear if the Secretary of HHS would have the authority (or willingness) to grant waivers for all of these options.
There's also been interest on the part of the Obama administration to secure congressional authority to move up the date of the "innovation" waivers described in the ACA from 2017 to 2014. If that happens, we'll see more states asking for comprehensive waivers (as is planned in Vermont to redesign their Medicaid programs or entire health systems to be more cost-effective and include new service delivery and payment models.
Although 2013 will be consumed by budget negotiations, policy decisions and readiness for ACA implementation, there are still big problems in health care that need attention – mainly costs and affordability.
Even with generous federal matching for the early years of the Medicaid expansion, states know that bringing down costs of care and coverage have to be a priority. Massachusetts learned that lesson, having first tackled expansion and coverage, then access, and now cost containment – what they consider their next phase of health reform. Once again watch the commonwealth learn from their successes and mistakes. Without a doubt, other states will try and quickly replicate new, promising practices based in part on those experiences.
HHS should expect to see some creative proposals from states where elected officials understand the need to cover everyone, but where the state wants more control over how services are delivered and how public monies can be spent to secure better value for the dollar.