One Year Later: What's Changed Since the Obamacare Verdict

by Dan Diamond, California Healthline Contributing Editor

TOPIC ALERT:

Ever since its controversial passage in 2010, the Affordable Care Act has been plastered with a range of polemic labels. Critics say Obamacare is job-killing; supporters herald it as life-saving.

Here's another, perhaps unexpected label: personally profitable.

If you were among the true believers in the law a year ago today, there was easy money to be made. Nearly 80% of bettors on InTrade expected the law to be found unconstitutional; strategically spending about $25 in favor of the ACA could've netted you $800, based on how InTrade's short-selling rules worked.

Much has changed, certainly, since Chief Justice John Roberts cast the deciding vote to uphold the law. (Beyond those bettors' account balances, and the existence of InTrade itself, which mysteriously shut down in March.)

Here's a look at how the Supreme Court's decision on June 28, 2012, affected five hot-button issues related to the health law.

States' decisions on Medicaid expansion

As of June 27, 2012: Several states with progressive governors and legislatures, like California, had moved to expand Medicaid ahead of the Supreme Court's ruling. The Golden State's leaders also had pledged to pursue universal coverage if the ACA was ruled unconstitutional.

But most states were waiting on the resolution of the constitutionality battle.

Since June 28, 2012: After the Court's decision that the mandate was constitutional but that the Medicaid expansion was optional for states -- which "took everyone by surprise," said Matt Salo, executive director of the National Association of Medical Directors -- governors were suddenly forced to decide whether the expansion made financial, and political, sense. Within a week, about ten states had signaled they'd expand Medicaid under the ACA.

However, many wary governors chose to wait for the November elections, and the knowledge of who would hold the White House, before announcing their plans; following President Obama's reelection, a flurry of governors clarified their Medicaid stances throughout the winter and spring.

As of press time on Wednesday, the governors of 25 states and the mayor of Washington, D.C., have said they will opt into the Medicaid expansion.

Medicare's payment pilots

As of June 27, 2012: While there were questions over whether Medicare's payment pilots would keep their funding if the ACA was struck down, officials had moved ahead with a slew of ambitious projects to innovate on care delivery and population health. In one of CMS's flagship efforts, 64 accountable care organizations -- 27 Shared Savings ACOs, 32 Pioneer ACOs and six Physician Group Practice Transition Demonstration organizations -- were working with Medicare to reduce the total cost of care for an assigned population of beneficiaries.

Since June 28, 2012: Medicare has added 195 more ACOs. Officials continue to hope that the new reimbursement scheme will eventually be extended to its entire Medicare population.

Private-sector efforts to control costs

As of June 27, 2012: Many employers were watching to see if the ACA's individual mandate would be found unconstitutional -- which would have set up a major push to have Congress strike down the law's mandate on employers, says Steve Wojcik of the National Business Group on Health.

Meanwhile, many large firms had begun their efforts to scale back their employee health benefits in hopes of avoiding the planned 2018 excise tax on "Cadillac" health insurance plans.

Since June 28, 2012: Employers have accelerated their efforts to bring down the costs of their plans and avoid the Cadillac tax. Meanwhile, there has been a wave of innovative efforts to redesign care delivery models and explore new relationships with providers, like Wal-Mart's push to directly contract with six leading hospitals. However, businesses probably would have pursued such cost controls regardless of the ACA's fate, Wojcik tells California Healthline.

GOP efforts to repeal the ACA

As of June 27, 2012: House Republicans had voted 31 times to strike down the law or rescind specific parts of it.

Since June 28, 2012: The House has voted for a full or partial repeal seven more times, including a high-profile effort announced the day the Supreme Court handed down its decision.

Americans' opinions of the ACA

As of June 27, 2012: The law was generally unpopular, with 44% of respondents holding an unfavorable view of the ACA in the May 2012 Kaiser Family Foundation tracking poll, and 37% holding a favorable view.

Since June 28, 2012: In the immediate aftermath of the Court's decision, most Americans wanted the law's critics to halt their efforts to overturn it. But the general anti-ACA sentiment persists today; 43% of respondents to Kaiser's ongoing tracking poll still hold negative views of Obamacare, compared with 35% who hold favorable views.

Around the nation

Here's a look at other reform-related stories making news this week.

The ACA's Obamacare problem: At the American Prospect, Jonathan Bernstein argues that many Americans who will come to love the ACA's actual provisions will still hate the existence of Obamacare itself, given their lack of understanding of the law's specific provisions and how the ACA has become so politicized.

Part D was less popular than Obamacare when it launched: Sarah Kliff at the Washington Post's "Wonkblog" gets back in the time machine to revisit how that earlier health law, which also sparked controversy, became more widely accepted.

Sebelius says the exchanges should enroll 7 million by March: Politico's Jennifer Haberkorn reviews the White House's ambitious goals.

Obamacare transforming hospital cafeterias, too. Writing at Kaiser Health News, Phil Galewitz details how the health law's push to improve patient satisfaction is leading to better, healthier food for hospital patients.


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