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Health Care Reform: What's Next?

The Obama administration has turned from celebrating its victory to moving forward with the rollout of the ACA. The administration and the states have to make decisions on a number of outstanding issues in order for the ACA to be implemented on schedule.
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Watching the election results come in this week, I found myself thinking back to The West Wing and to a certain phrase that floated through the Bartlet White House. As presidential candidate Jed Bartlet explained to Josh Lyman at their first meeting, "When I ask 'What's next?' it means I'm ready to move on to other things. So, what's next?"

Even as I write this, the Obama administration has turned from celebrating its victory to moving forward with the rollout of the Affordable Care Act ("Obamacare"), which also had a good night on Tuesday. A repeal of the act had been a key part of Governor Romney's platform and would have denied access to quality, affordable health care to millions of people.

Already, the ACA has allowed more than 6 million young adults to access health care by allowing them to stay on their parents' insurance until the age of 26, helped 54 million access preventive care services, and provided access to health care to millions of children with pre-existing conditions.

Experts estimate that when implementation is complete, the ACA's Medicaid expansion alone could reach up to 17 million uninsured Americans. Other provisions in the law will help up to 129 million Americans with a pre-existing condition get and keep health insurance.

So, what's next?

Over the coming weeks and months, the administration (particularly the Department of Health and Human Services) and the states have to make decisions and take actions on a number of outstanding issues in order for the ACA to be implemented on schedule. Here are a few things to look out for:

Who controls your local Health Insurance Exchange?

When the ACA was passed, many argued convincingly that the public deserved access to an array of health insurance options similar to those enjoyed by members of Congress. The Exchanges are the ACA's answer to this: state-based insurance pools that allow individuals to take advantage of rates typically enjoyed by large groups.

Some Republican governors dragged their heels on getting their Exchanges going, waiting to see the election results. They don't have long to play catch-up: By November 16, every state (and the District of Columbia) has to let the administration know whether it will run its own Exchange or whether the federal government will need to come in and do it.

Who is going to make recommendations to reduce Medicare spending?

We all heard a lot in the presidential campaign about President Obama's proposal to slow Medicare spending by making the program more efficient. An independent, non-partisan committee of 15 people -- the Independent Payment Advisory Board -- will be tasked with identifying potential areas of cost savings for Congress to consider. Medicare enrollees should not be affected by the results: The panel is not allowed to make recommendations that would (among other things) ration care, increase taxes, change program benefits or eligibility requirements, or increase premiums.

Members of the Board must be approved by Congress, and President Obama is expected to make nominations soon.

What health care benefits are covered?

New health insurance options under the ACA, including the Exchanges, individual and group plans, and the Medicaid expansion, must offer a certain minimum standard of coverage across 10 categories, known as "Essential Health Benefits." While states are moving ahead with identifying their own benchmarks for coverage, everyone is waiting for the administration to issue regulations to help guide this process.

Who is covered?

Decisions by governors and the administration will help determine who can benefit from the ACA. In the wake of the Supreme Court's June decision upholding the law, states now have the option to reject the Medicaid program expansion, which would provide access to affordable health care to adults under 65 making roughly $1,300 or less a month. I have explained previously how rejecting the expansion would be a decision to put politics over one's own population -- the federal government will cover the lion's share of the costs associated with the expansion -- but some governors seem set on doing so anyway.

Other populations to look out for include the "DREAMers" (an initial decision that they are not eligible for the Exchanges or other benefits could be reversed in a final rule), women whose employers are challenging the administration's decision on contraception coverage, and minority populations who should benefit from the law's efforts to tackle health care disparities.

There are even more details associated with the health care law to be worked out, and of course a few other issues -- the "fiscal cliff," immigration, and Afghanistan all come to mind -- to tackle. Fortunately, this administration has a strong cast and runs 24 hours a day, 7 days a week.

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