Affordable Care Act: A strategy for effective implementation

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2 Affordable Care Act: A strategy for effective implementation U.S. PIRG October 12, Budget: $26

3 Objective 1972 Universal coverage 2010 Affordable Care Act enacted Coverage for 95% of all Americans by 2020

4 What the law does Improves quality and control costs Promotes public health Expands health care workforce Covers nearly all Americans

5 ACA Coverage Framework Subsidies Exchanges Medicaid expansion Insurance reforms Individual mandate

6 Strategy National Programs Technical Assistance State-Based Programs Targeted State Strategy Consumer Engagement Monitoring Successful Implementation in Target States

7 RWJF 10 States Alabama Colorado Maryland Michigan Minnesota New Mexico New York Oregon Rhode Island Virginia

8 State Health Reform Assistance Network Princeton University, Woodrow Wilson School Focus on coverage expansions. Theory of change: help diverse group of states develop and disseminate successful implementation models Technical Assistance approach: Multi-disciplinary team Operational level technical assistance Meet states where they are Peer-to-peer learning Inform federal policymaking Sustained and nimble

9 Consumer Engagement Insurers Political parties Labor Business Providers

10 Consumer Engagement Insurers Political parties Labor Business Providers Consumers

11 Consumer Engagement Health Affairs September 2011

12 Challenges Complexity of the law Problems with the law

13 Remaining uninsured Not exempt from individual mandate, 5M 22% Medicaideligible, 8.5M 37% 23 million Exempt from individual mandate, 4.1M 18% Undocumented immigrants, 5.2 M 23% Source: Urban Institute s Health Insurance Policy Simulation Model (HIPSM).

14 Challenges Complexity of the law Problems with the law Partisanship

15 Partisanship House Senate Ds Rs D/Is Rs yeas nays This is a problem...

16 Challenges Complexity of the law Problems with the law Partisanship Public opinion Legal challenges

17 Supreme Court Decision Individual mandate constitutional Medicaid expansion constitutional, but now a state option

18 Challenges Complexity of the law Problems with the law Partisanship Public opinion Legal challenges Budget debate Election

19 Election Partisan rhetoric heightened State implementation stalled Repeal possible Thursday, October 11, 2012 Direction on Health Care Awaits Verdict of Presidential Race By ABBY GOODNOUGH and ROBERT PEAR When Americans go to the polls, they will cast a vote for one of two profoundly different visions for the future of the country s health care system.

20 Progress Establishing Exchanges Washington Oregon Montana North Dakota Minnesota Vermont Maine California Nevada Idaho Utah Wyoming Colorado South Dakota Nebraska Kansas Iowa Missouri Wisconsin Illinois Michigan Indiana Kentucky Ohio Pennsylvania West Virginia New York Connecticut New Jersey Delaware Maryland Virginia New Hampshire Massachusetts Rhode Island Alaska Arizona New Mexico Oklahoma Arkansas Tennessee Georgia North Carolina South Carolina States with exchanges by executive order or legislation Hawaii Texas Louisiana Mississippi Alabama Florida State with exchange grants

21 Progress Establishing Exchanges Heather Howard Testimony, House Ways and Means Subcommittee on Health September 12, 2012 We have heard today that the reason for state inactivity is lack of guidance from HHS. But [then]one would expect the leading states to be confronting the most barriers and complaining the most loudly... In reality, the opposite is true. Those states are seizing the flexibility afforded them to pursue innovative approaches. Indeed, the primary factor contributing to this variation is the political climate in the states.

22 Scenarios Obama wins Romney wins Republican Senate Romney wins Democratic Senate Law preserved Law repealed Law preserved

23 Questions ACA preserved Change or modify strategy? Change states? Leading states? Middle tier? Hopeful? Focus on certain issues? Dissemination approach? ACA repealed Stick with coverage? Explore what can be preserved, built on? Address other coverage-related issues? E.g., specific populations? Innovative insurance models? Safety net?

24 Have a nice day Andy Hyman RWJF

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