Social factors have a substantial impact on healthcare outcomes and spending, particularly with respect to lower-income populations. As the nation’s largest payer for healthcare services for lower-income populations, Medicaid is front and center when it comes to these issues. This report coauthored by Milliman’s John Meerschaert and Shelly Brandel identifies practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues.
This article was published by The Commonwealth Fund. Manatt’s Deborah Bachrach and Jocelyn Guyer and RTI International’s Sarah Meier also co-authored the article.
Today’s elections will have major implications for healthcare reform. Back in February, Mike Sturm and John Meerschaert provided foresight on how healthcare reform could be affected by the U.S. Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA) and the general election. As we now know the Supreme Court preserved the constitutionality of PPACA, except that states can opt out of Medicaid expansion.
Here is an excerpt from Sturm and Meerschaert’s article “Healthcare reform in 2012: Blind curves ahead” discussing the effects of potential election results:
The November 6 general election may prove to be a bigger factor than the Supreme Court decision, because the potential result could be a complete repeal of the PPACA… here are three scenarios:
President Obama is re-elected. If the president is re-elected, a Republican-controlled Congress may try to repeal the healthcare reform legislation, but President Obama will veto the repeal. Unless Congress overrides the veto—which is doubtful because it requires a two-thirds majority in both houses—the program will move forward; the exchanges will be created, and all other provisions of the PPACA (minus any that are ruled unconstitutional) will eventually become operational. If the Democrats control either house, no repeal bill is likely to pass.
There is also some speculation that President Obama might back off of some PPACA provisions because of their political unpopularity, but this remains, at most, a remote possibility.
A Republican president is elected, but the Democrats control at least one house of Congress. No attempt at repealing the 2010 legislation is likely to pass, and PPACA will remain the law of the land. However, the real power of implementation rests with the executive branch, and it is probable that the new president’s appointees in the Department of Health and Human Services and the Centers for Medicare and Medicaid Services will delay the major provisions of the law. In particular, the exchanges will probably not be implemented by the currently scheduled date of January 1, 2014.
The Republicans capture the presidency and both houses of Congress. In this scenario, it is almost certain that the 2010 legislation will be significantly modified, if not repealed. States that have already taken steps toward setting up exchanges may or may not carry them forward in the absence of federal subsidies should the Republicans repeal the subsidies.
If polls are to be believed, the third option is a real long shot. Perhaps we will know which direction healthcare reform is headed by tomorrow morning.
In addition to the Supreme Court challenge to the Patient Protection and Affordable Care Act (PPACA), the upcoming presidential and state elections are likely to have an effect on the implementation of the law. Milliman consultants John Meerschaert and Michael Sturm projected some of the possible outcomes in a recent feature story. As they point out,
The November 6 general election may prove to be a bigger factor than the Supreme Court decision, because the potential result could be a complete repeal of the PPACA.
Assuming the law is not struck down in its entirety by the Supreme Court, the authors predict that the elections are likely to result in one of the following outcomes for the PPACA:
- President Obama is reelected. Repeal legislation will be vetoed, the PPACA will move forward in whatever form is left by the Supreme Court, and exchanges will go forward.
- A Republican president is elected, but the Democrats control at least one house of Congress. No attempt at repealing the 2010 legislation is likely to pass, and the PPACA will remain the law of the land. Major provisions of the law may be delayed, especially exchanges.
- The Republicans capture the presidency and both houses of Congress. The PPACA will be significantly modified, if not repealed. Without federal subsidies, states would have less incentive to create exchanges, although some states might keep moving forward.
One of the most interesting questions is this: if they win, what would Republicans replace the PPACA with, if anything? The National Journal offered some perspective in a recent discussion, and Uwe Reinhardt today offered his take on the Economix New York Times blog.
The uncertain fate of the Patient Protection and Affordable Care Act (PPACA), which is due to a Supreme Court challenge and the upcoming elections, is making 2012 an interesting year for states. While some healthcare stakeholders may be taking a wait-and-see approach, the clock continues to tick toward PPACA deadlines—as demonstrated with today’s release of exchange regulations.
A report recently released by the White House says that 28 states are making significant progress toward establishing exchanges. The National Conference of State Legislators shows on its updated web page that 12 states have passed legislation to establish exchanges. In all, according to The Commonwealth Fund, 28 states have received federal grants for the establishment of exchanges. On the other hand, many are waiting for more information, an action HHS Secretary Sebelius called “pretty appropriate” according to City & State, a newspaper that covers New York State politics.
So what will happen if the law is struck down in whole or in part by the Supreme Court? Two Milliman consultants, Michael Sturm and John Meerschaert, examined the issues in detail in a recent feature story. They see several possible outcomes:
- The law is ruled wholly constitutional by the Supreme Court. While the authors see this as unlikely, it is possible. Even so, however, deadlines for implementation of exchanges would likely be delayed. States would not be out the dark yet, as the November elections could still have a significant impact on which provisions are implemented.
- Part or all of Title I is ruled unconstitutional by the Supreme Court. The most vulnerable part of the law is the trifecta of individual mandate, guaranteed issue, and prohibition of the ability to consider preexisting conditions. If these are eliminated, exchanges will most likely be used by healthier, less wealthy segments of the population as they will receive a subsidy. For more on the strength of the individual mandate, see this Milliman Research Report by Paul Houchens.
- Part or all of Title II is ruled unconstitutional. Due to precedent, this is unlikely, but if it happens, states will probably continue operating their current programs and the rise of managed care in Medicaid will continue.
- The entire law is struck down. This is also seen as unlikely. Even if this occurs, some states may go ahead with the establishment of exchanges.
Assuming the Supreme Court decides before November, and assuming that it leaves some portion of the law intact, the PPACA won’t be a settled issue until after the general election. In a subsequent post, we’ll look at implications of the November 2012 general election for the PPACA at the state level.
This feature story by Milliman consultants Michael Sturm and John Meerschaert discusses the potential impacts of the pending Supreme Court case on the constitutionality of the 2010 Patient Protection and Affordable Care Act (PPACA), as well as the possible outcomes of the November 6 general election. We talked about their predictions regarding implications for the states, but what about health plans? A major portion of PPACA is not so much healthcare reform as health insurance reform, so insurers have a big stake in the outcome.
As far as the Supreme Court is concerned, Sturm and Meerschaert say:
Many observers believe that the court will uphold the law, but strike down parts of it. The individual mandate, guaranteed issue, and prohibition of the use of pre-existing conditions appear particularly shaky, and it will not be surprising if they are struck down. It is unlikely that the court will overturn one of these three components but not the others, as both the administration and plaintiff states agree that these parts of the law are inseparable. It also seems unlikely that the rest of Title I, some of whose provisions have already been implemented, will be invalidated.
Major deadlines imposed by the 2010 Patient Protection and Affordable Care Act (PPACA) are less than two years away, but health plans and states face an unsettled future as they wait out two uncertain outcomes: the pending Supreme Court case on the constitutionality of the PPACA, and the November 6 general election.
This feature story by Michael Sturm and John Meerschaert discusses the potential outcomes and implications of this uncertain year.