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There was a recent discussion in the Penn Gazette between David Grande, an assistant professor of medicine at University of Pennsylvania, who specializes in health policy, and Tom Baker, the William Maul Measly Professor of Law and Health Sciences in the Penn Law School. It's a fascinating conversation as they discuss how the Affordable Care Act (Obamacare) will evolve over the years, now that it's the law of the land. In particular, they focused on some of the finer points of the new state health-insurance exchanges: how they'll vary from state to state, the promise and peril of privately run exchanges, and how the exchange model might create opportunities for new startups in the insurance marketplace.

Here are only a few excerpts:

How does the Supreme Court's ruling impact the major stakeholders in the health care system? The assumption that this law was going to be implemented in block meant that all the players in the health care system, when they were negotiating compromises in the bill, all assumed that all of these coverage provisions would happen. So, hospitals, for example, agreed that some payments they currently receive to cover uncompensated care will be ended -- there are current federal funding streams to hospitals to help cover the cost of uncompensated care that will go away once health reform is fully implemented. So it's ironic that if a state decides not to expand their Medicaid program, the residents of that state will still be contributing their federal tax dollars, but the state won't be reaping any of the benefits of the Medicaid program. The hospitals will be potentially worse off than they were before health reform, because they agreed to have their uncompensated-care funding cut. So the healthcare industry, I suspect, will be some of the most vocal advocates within the states to move forward with expanding Medicaid.

Do you have any ideas about changes that might make the law more palatable to the people who seem to be driven so crazy by it?
At the end of the day, this is so politically contentious and charged right now I don't even think you could have a policy discussion about health reform. I think that you need to let the law start to be implemented, and tweak it as it gets implemented. I think the fundamentals are all there. The basic premise and ideas and approach makes sense. There will clearly be hiccups along the way that need to be addressed. I think at this point the focus should be on implementing it well rather than revisiting the approach. Because implementing it well is a lot of hard work, and it could easily be implemented poorly if people don't devote the time and resources to making sure it’s done well.

What will be the signposts to tell us if things are being implemented well or poorly?
Right out of the gate, it'll be the process of people navigating new choices in health insurance and how overwhelmed people are or how user-friendly it is -- so that for people who qualify for help, it's easy for them to get help. The mere process of getting people signed up for coverage in a way that is painless is really the most immediate signpost in terms of the first stages of implementation. There will be more complex questions about making sure that participation is high. Within individual health insurance exchanges, to make sure that both low-risk and high-risk people are participating in health insurance exchanges, because at the end of the day that will help keep health insurance premiums from spiking. If these programs are set up in a way that low-risk people are not buying in, then premiums will go up. So I think some monitoring of premiums and participation, and risk of those that are buying in, is important. And then there's a longer-term issue, which is how does the ACA relate to fundamental changes in the delivery of care and reining in costs? And there are certainly major changes that are set in motion by the Affordable Care Act in terms of trying to pay doctors and hospitals in different ways, and trying to have doctors and hospitals organize care differently. But, you know, that is a project that's really indefinite in nature.

Make sure to read the entire article. It's a fascinating take on the future of health care in this country post-Obamacare implementation.

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