2. Affordable Care Act: A strategy for effective implementation 2012 Budget: $26 million U.S. PIRG October 12, 2012

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.  Subsidies  Exchanges  Medicaid expansion  Insurance reforms  Individual mandate ACA Coverage Framework

6. Targeted State Strategy Technical Assistance Monitoring Consumer Engagement Successful Implementation in Target States National Programs State-Based Programs Strategy – 2011-2014

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

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 8 InsurersLaborProvidersBusiness Political parties

10. Consumer Engagement 9 InsurersLaborProvidersConsumersBusiness Political parties

11. Consumer Engagement Health Affairs September 2011

12. Challenges Complexity of the law Problems with the law

13. Remaining uninsured 23 million Source: Urban Institute’s Health Insurance Policy Simulation Model (HIPSM).

14. Challenges Complexity of the law Problems with the law Partisanship

15. 2190600 34178039 yeas nays Ds Rs D/Is Rs House Senate 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. Direction on Health Care Awaits Verdict of Presidential Race By ABBY GOODNOUGH and ROBERT PEAR Thursday, October 11, 2012 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. Partisan rhetoric heightened State implementation stalled Repeal possible Election

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

21. Progress Establishing Exchanges 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. Heather Howard Testimony, House Ways and Means Subcommittee on Health September 12, 2012

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 ahyman@rwjf.org 609-627-5764