1. Challenges Ahead for the ACA Mary Agnes Carey Senior Correspondent Kaiser Health News “From the White House to Community Clinics: What’s Next for Healthcare Reform? Nov. 8, 2012

2. ACA Timeline March 23, 2010: President Obama signs the health care law, known as the Affordable Care Act, into law. June 28, 2012: Supreme Court upholds health law’s “individual mandate” provision requiring that most Americans have health insurance by Jan. 1, 2014, or pay a fine. The court also rules that the government could not compel states to expand Medicaid, the federal and state program for the poor, by threatening to withhold federal money to existing Medicaid programs. Nov. 6, 2012: President Obama re-elected, Democrats retain control of the Senate, Republicans keep control of the House. With Democrats in charge of White House and Senate, implementation of ACA moves forward.

3. Implementation Challenges Just 13 states and D.C. have passed authorizing legislation for health insurance exchanges. If a state does not set up an exchange, federal government will do it for them. Now that election is decided, some governors may decide to move ahead with ACA implementation. Republican and Democratic governors concerned about how they will pick up their share of Medicaid expansion.

4. Political Hurdles House Republicans – In current Congress, voted 33 times to repeal law or sections, or to defund ACA. In next Congress, House GOP will likely have many committee hearings examining every element of implementation: exchanges, Medicaid expansion, impact of ACA on jobs and economy. – House GOP also will try to cut funding for implementation of ACA. Public split on law - “individual mandate” still unpopular. Fiscal Cliff: Changes to ACA could be part of a larger deal to reduce the federal deficit. Some analysts have predicted scaling back of current subsidy levels and possible changes in taxes on medical device and insurance industry, for example.

5. Possible Implementation Delays? Will Obama administration delay ACA implementation of health law? Exchanges and Medicaid expansion scheduled to begin in 2014. Delay could - – Help save billions in a larger budget deal – Help provide financing for delay in “sequestration,” the automatic budget cuts set to begin in January. Giving states, providers more time could mean smoother rollout but delay benefits to millions of Americans. Administration says law will be implemented on time.

6. Other Pressures Is penalty for not purchasing coverage too low to induce people to enroll? – Will they simply say it’s cheaper to pay the penalty than to buy health insurance? Will Medicare payment provider cuts and other taxes and fees proceed as planned? Will employers decide it’s cheaper to pay fine for employees who get subsidies or if coverage is deemed “unaffordable” than to offer coverage?

7. Health Workforce Demands Millions more covered under ACA puts new demands on health care workforce. Expected shortfall of primary care providers by 2015: nearly 30,000. 40% of practicing physicians are older than 55, about one-third of nursing workforce is over 50. Economists say one-third of physicians could retire in the next 10 years. By 2025, physician shortage could grow by as much as 25%. ACA provides $11 Bln in funding to Community Health Centers.

8. ACA Health Workforce Provisions Increase the number of Graduate Medical Education, or GME, training positions by redistributing currently unused slots. – Priorities given to primary care and general surgery and to states with lowest resident physician-to-population ratios. Ensure residency programs available in rural and underserved areas. Increase workforce supply and support training of health professionals through scholarships and loans. Train medical residents in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals.