In terms of regulation requirements, 2011 will be a quiet year on the federal health care reform timeline. The next major components of reform won’t go into effect until 2014, but the extensive amount of controversy, compounded with the lawsuits from at least 20 different states regarding the constitutionality of the Affordable Care Act’s individual responsibility provision, have left employers and providers alike somewhat unclear on what to do next.
“What is being challenged is whether or not the federal government has the authority to dictate whether or not people have to purchase anything,” said Bob Barry, senior vice president of product and market strategy for Connecture Inc., a Waukesha-based online health insurance process automation firm. “Historically, those types of regulations have been very much off limits for the federal government. That kind of authority is traditionally left up to the states.”
In two instances, the Affordable Care Act provision has been ruled constitutional and in one instance it has been deemed unconstitutional. Barry and many others suspect the matter will eventually reach the U.S. Supreme Court for a final decision.
“If it is found that requiring able individuals to purchase coverage is unconstitutional it could potentially create significant problems for reform,” Barry said.
Jane Cooper, president and chief executive officer of Milwaukee-based Patient Care, a health advocacy company, finds it very unlikely the entire Affordable Care Act will be rescinded, despite the lawsuit.
“I definitely agree that the uncertainty will continue, but too many things have already begun to happen for the bill to be rescinded entirely,” Cooper said. “I think the cost pressures are going to continue and maybe even increase and the taxpayer burden for those programs will no longer be able to continue without some structural changes on those issues.”
Barry agreed and said that if the personal responsibility mandate on its own is ruled unconstitutional the insurance industry would be harmed.
“Underwriting is very much incumbent on having all able people to participate,” Barry said. “It’s a risk to the insurance industry bottom line. It would be like allowing individuals to purchase auto coverage after they hit the tree. It would be financially devastating to the whole system.”
While Barry has indicated the likelihood of the lawsuits being expedited to the Supreme Court, it is unknown when a final decision on the manner will be made.
“So many things in the legislation are really dependent on a decision being made one way or the other,” Barry said. “I don’t know if one branch can pressure the other, but I would think all would like to see this resolved sooner than later.”
In the meantime, state governments are in the process of setting up programming for the health insurance exchanges that would be enacted Jan. 1, 2014, Barry said.
“An unconstitutional ruling doesn’t mean there couldn’t be health insurance exchanges,” Barry said. “Exchanges could still help take significant costs out of the overall equation, and creative ways of implanting enrollment periods every two years or something would have to be implemented to protect the insurance industry bottom line.”
Regardless of what happens legislatively, Cooper feels that the trend will be to shift more responsibility and more cost to the consumer.
“Brokers and employers are going to say, and have said, that they can’t wait to see what the federal government is going to do,” Cooper said. “What I’m seeing more and more of is employers, insurance companies and even providers looking for ways to control their administrative costs. I think we will see a continuing trend to larger deductibles and increased responsibility on consumers.”
Cooper predicts that even more wellness, nutritional and community programs that were traditionally free for consumers will be reduced, changed or modified in order for carriers to comply with the medical loss ratio requirements of the Affordable Care Act.
“There will definitely be fewer free options for consumers and there will be a shift of more personal responsibility on the consumer,” Cooper said. “No one is going to do it for you.”
Cooper also indicated that through 2011 and 2012 more transparency on the provider side is going to be expected from a consumer standpoint. According to her, the Affordable Care Act did not do enough in terms of requirement, but responsible consumers are going to expect it anyways moving forward.
According to Dr. Ian Gilson, internist and primary care physician at the Medical College of Wisconsin, primary care physicians have a fair amount to gain from reform.
“The Affordable Care Act is really primarily care friendly in that it has a goal of establishing more community health centers, increasing our reimbursement and increasing the money for training additional primary care doctors,” Gilson said. “Because of the shortage of primary care doctors within the system, for reform to work it not only has to be enacted, it has to be enacted with funding behind it or it won’t succeed.”
Another component of reform is to move the system towards the development of Patient Centered Medical Homes, which Gilson defines as a new primary care certification that is centered on patient relationships with their providers.
The medical homes provision is designed to provide better access to health care, increase satisfaction and improve the overall health of the patient, Gilson said.
Dr. Lee Biblo, chief medical officer of the Medical College of Wisconsin physicians, and associate dean for clinical affairs has indicated that clinics associated with the Medical College and Froedtert Community Health system have already started moving in that direction in anticipation of reform.
“For us, the next couple of years are going to be about an expansion of access,” Biblo said. “We’re aggressively changing our primary care clinics to function more as medical homes to not only position ourselves for what we see health care reform is going to be, but to do what is right in health care. I don’t think we’re alone in those efforts.”
Aurora Health Care recently announced that 21 of their primary care clinic sites had received “level three” recognition as Patient Centered Medical Homes. Wheaton Franciscan Healthcare has also earned a medical home center designation and is in the process of transitioning other clinics to the medical home model in preparation for health care reform.
