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    The Affordable Care Act

    Focus shifts to implementing, not repealing, health care law

    WASHINGTON — The future of health care reform loomed like a specter in a bitter campaign fought over the appropriate size and role of government. With President Obama touting his signature domestic achievement and Mitt Romney vowing to repeal it, the 2010 law symbolized the deep ideological divide in Congress and in the country.

    Now, with Obama emerging victorious, Republicans failing to take the Senate, and the Supreme Court upholding the legality of the law, the debate around expanding health care to the uninsured is shifting from political posturing to the practical. States must meet their next deadline in just nine days.

    “It’s a new ballgame now,” said Drew Altman, chief executive of the Kaiser Family Foundation, a nonpartisan health policy group. “Certainly the window of opportunity for opponents to kill the Affordable Care Act is now largely closed. The story now will be about the details of implementation, and once the law is in place, there will be pressure to improve the benefits it provides.”


    States face a Nov. 16 deadline to submit a blueprint to the federal government for an online portal that will make it easier for people to compare and purchase insurance plans. States could also partner with the government in creating such so-called exchanges, or allow the government to run it.

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    The Web portals are supposed to come online by October 2013 for enrollment to begin in January 2014, when the law is fully implemented.

    Every state except Alaska, which did not request any funding, has received federal planning grants for the exchanges. Some, like Massachusetts, Connecticut, Rhode Island, Vermont, and Maryland, are further along with their own exchanges.Other states such as Arkansas plan to partner with the federal government in setting up an exchange.

    Despite a historic Supreme Court decision midway through the campaign that proclaimed most of the law constitutional, many Republican governors and legislators continued saying they would repeal it. However, most states whose governors have publicly opposed the law have quietly been preparing for it anyway, Altman said.

    He expects most states to not only move ahead with setting up the insurance exchanges but also with the controversial Medicaid expansion, the only portion of the law the Supreme Court struck down.


    As a result, states no longer have to increase their pool of residents eligible for Medicaid in order to continue receiving federal funding for the health care provided to low-income families.

    Under the health law, the federal government will pay 100 percent of Medicaid expansion for newly eligible people from 2014 through 2016, before slowly ratcheting down to 90 percent over a decade.

    Currently, the federal government pays roughly half the cost of Medicaid.

    The deal, Altman said, is too good to pass up for states not to expand, especially as the economy improves over time and states could better afford to foot their share.

    Some states, most notably Texas, have refused to sign on.


    The government is able to pay for the insurance expansion in part by taxing the biopharmaceutical and medical device industries, starting in 2013. Hospitals, at least initially, would be winners because they could expect to see a rise in the number of insured patients — and thus expand their profit margin.

    ‘The Affordable Care Act has now survived both the Supreme Court and the presi­-dential election.’

    “More states are going to expand Medicaid, provide subsidies for people to purchase insurance, and get exchanges up and running than if Romney had won,” said Jason Gurda, a research analyst at the Boston investment bank Leerink Swann, which focuses on health care.

    Commercial insurers, however, may have fared better under a Romney administration because he probably would have eased the law’s regulations limiting companies’ profits and rate increases, Gurda said.

    A victorious GOP would have also dulled the law’s impact through executive orders, new laws, and defunding, according to a report by Leerink Swann.

    Dr. Gene Lindsey, president and chief executive of Atrius Health and Harvard Vanguard Medical Associates, said the election’s outcome has resolved many questions for physicians across the country, who have been in limbo on how best to deliver care.

    “A lot of folks were sort of waiting to see, even within our state, whether to get involved” with some aspects of health care reform, said Lindsey, such as programs that curtail medical spending by paying doctors a lump sum for patient care, rather than reimbursing them for each procedure or test.

    Altman, at Kaiser, said: “The Affordable Care Act has now survived both the Supreme Court and the presidential election. Now it will move forward to a real-world test.”

    But for the immediate future, analysts say, the health care spotlight will be on cuts threatening Medicare and Medicaid, given the upcoming debate over the budget deficit and the fiscal cliff facing Congress.

    Tracy Jan can be reached at