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States Have Much Discretion to Speed, Slow Health Reform’s Effects

December 27, 2010 at 5:58 PM EST
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While many aspects of the federal health reform law don't take full effect until 2014, states can choose whether to speed up or slow down some of the sweeping changes to the U.S. health care system. Margaret Warner gets some national perspective on health reform implementation and what's to come from NPR's Julie Rovner.
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MARGARET WARNER: Tomorrow night, we will look at how California is trying to accelerate implementing the new law there.

To help put all this in a national perspective, I’m joined now by Julie Rovner, who covers health care for NPR.

And, Julie, welcome back. So, broadly, where are we now in implementing health care reform? How much got done, kicked in, in 2010?

JULIE ROVNER, health policy correspondent, National Public Radio: Well, I think what Congress wanted to do that first year was really do some small benefits that affected a lot of people.

So, what you saw were this patients bill of rights. These were insurance changes, letting people keep their adult children on their health plans until they turn 26, not having insurance companies rescind people’s plans for minor mistakes, and for Medicare patients, having them — getting them…

MARGARET WARNER: Or preexisting conditions.

JULIE ROVNER: Right — well, no, not preexisting conditions, not yet — preexisting conditions for children.

Then, for Medicare patients, they get a $250 check if they fall into that notorious doughnut hole if they spend too much on their drugs. This coming year, 2011, some more, again, incremental changes: Health insurance companies will have to pay a certain amount of each dollar, spend each dollar on medical services, 80 cents or 85 cents of each dollar. If they don’t do that, they will have to give rebates.

The real changes don’t start until 2014, as we saw in the piece. That’s when people, individuals, uninsured adults without children will be eligible for Medicaid. That’s when most people will have to have insurance. That’s when these insurance exchanges will begin. So, that’s another three years away.

MARGARET WARNER: So that’s where — if they are going to insure 26 to 32 million more people, that is where the bulk will come in.

JULIE ROVNER: That is where the bulk of them will come in. Along the way, we have gotten some people covered.

MARGARET WARNER: So, if, today, you are the — one of the classic kind of Americans for whom this was designed. You are a working person, you may make, I don’t know, $50,000 or $60,000, but your employer doesn’t offer health insurance — you might even be married and your husband makes the same amount, and that’s still not a lot of money — are you still in the same fix? You are still out in the private market trying to figure it out yourself?

JULIE ROVNER: You probably are. There is this high-risk pool for people who have a — do have a preexisting condition and couldn’t get insurance. So that’s one small piece. Those people were allowed to get insurance this year.

But the kind of people you were talking about, they’re going to have to wait until 2014.

MARGARET WARNER: So, how much autonomy do the states have in this time period, in other words, to either slow it down or speed it up?

JULIE ROVNER: Well, the states have quite a bit of autonomy under this law. Again, they’re going to be allowed to build their own insurance exchanges. They’re going to decide when they want to expand Medicaid.

They have to do it by 2014, but they can do it any time now until 2014. They can run these high-risk pools, or they can let the federal government do it. So, they can do a lot of things. If they don’t, then the federal government comes in behind them to do it. So, they have a choice of how they want to do it, but, if they don’t, the federal government will.

MARGARET WARNER: Meanwhile, we also — there are also challenges now broadly in the courts and in Congress. What does the landscape look like on those two fronts for 2011?

JULIE ROVNER: Well, in the courts, we have had about 20 lawsuits filed.

A number of them have been dismissed outright, but of the ones that have actually gone to the merits, as we say, two have found for the administration that the law — or at least the part of the law that requires most people to either get health insurance or pay a penalty is constitutional. One, as I think many people have heard, has found that individual mandate to be unconstitutional.

There are more coming down. Everyone assumes this will ultimately be decided by the Supreme Court. That will take another year or two. Meanwhile, the new Republican House of Representatives will take a vote certainly on repealing the law. That will probably be approved in the House, but it probably won’t be in the still Democratic Senate, wouldn’t be signed, in any case, by President Obama.

But there will be efforts otherwise to try to defund it or slow it down or do other kinds of ways to — to thwart the law, the implementation.

MARGARET WARNER: Meaning that the Republican Congress might make it difficult for the administration to get the dollars it needs to hire the people to work on this?

JULIE ROVNER: That would be one way to do it. That would be probably one of the more effective ways to do it, because a lot of — their hands are tied in a lot of ways about how they can actually slow this down.

MARGARET WARNER: Julie Rovner of NPR, thanks so much.

JULIE ROVNER: You’re welcome.