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Post-election, question is how PPACA will be implemented

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The immediate clarity the election brings to health care is this: The Patient Protection and Affordable Care Act is here to stay.

Now the question is what, exactly, PPACA implemented will look like. The issues are familiar ones — regulations, Medicaid expansion, public insurance exchanges and how to pay for it all — and the answers emerging in the next months will affect every business in America.

Medicaid expansion

Antoinette Kraus, project director of the Pennsylvania Health Access Network, said the big issue from her perspective is whether Pennsylvania decides to expand Medicaid.

"Right now is the time for Pennsylvania to move forward," said Kraus, who wants Pennsylvania to opt in to the expansion.

The Hospital & Healthsystem Association of Pennsylvania is urging the same action. Carolyn Scanlan, HAP's president and CEO, said that, although Medicaid expansion wouldn't start before 2014 and there is no federal deadline for the decision, many hospital fiscal years run July 1 to June 30.

That means this spring, hospitals will be working on their budgets for the beginning of 2014.

"Knowing what the state intends to do would be helpful," Scanlan said.

PPACA phases out Medicaid Disproportionate Share Hospital payments. Medicaid expansion was supposed to balance that loss with an increase in insured patients that would cut hospitals' uncompensated care costs — but since the Supreme Court's ruling made the expansion optional, HAP has been warning that hospitals serving low-income and uninsured patients in particular could be hit hard if Pennsylvania opts out.

Paying for it all

Negotiations on how to pay for PPACA are coming up — and hospitals are keeping a particularly close eye on them, according to Scanlan, because Medicare and Medicaid feature so largely in both federal and hospital budgets.

Also of note is the "fiscal cliff" situation, which is not directly tied to PPACA but will likely be a concurrent budget battle.

For hospitals, Scanlan said, there are actually several fiscal cliffs. One is the overall Medicare payment reduction of about 27 percent that's set to hit in January unless it's averted as it has been in the past. Another is that, unless Congress reaches an agreement, part of the federal budget cuts that hit Jan. 3 will be a 2 percent Medicare payment reduction.

"As we all go through, there's a lot that we all need to be watching and hoping and pressing for," Scanlan said.

David Vassilaros, director of health care reform and regulatory affairs for Dauphin County-based insurer Capital BlueCross, said the biggest issue before the election is still the biggest issue after the election: the rising cost of health care.

"Nothing that happens in Washington is going to change that," he said, and insurers and hospitals should not and are not waiting for government to fix that. They've been working on sharing data, coordinating care and incentivizing the right things, just as employers are emphasizing wellness.

"Another one is teaching our employees and members to be better informed consumers of care," Vassilaros said. "That's a massive hurdle, and as we tackle that, you're going to see improvements."


"I expect a flurry of regulatory guidance," said Matthew W. Kirk, president of The Benecon Group, a Manheim Township-based benefits administrator and consultant.

Robert Glus, a partner and actuary with Conrad Siegel Actuaries in Susquehanna Township, agreed: "Before the election, the general consensus was there was a huge slowdown in guidance that was coming out."

Some of that guidance will directly affect businesses, while some of it will apply primarily to state and health care infrastructure. In both cases, acting on it will likely be a big job.

"The sheer volume of work to be done in order to fully implement the PPACA will require herculean efforts by the federal and state governments," Kirk said. On the business side, "Administrators, carriers and consultants will need to be diligent on behalf of their clients to be fully compliant with all PPACA requirements."

Glus said general concepts have been known for a long time, but not the nuts and bolts of the processes. Now, he said, employers are waiting to see how the public health insurance exchanges are set up, what happens to premiums and how they'll have to report certain things to the government.

"We've been getting a ton of calls and interest in health care now from our employer customers," said Vassilaros. He wouldn't call it a panic, but "certainly a heightened level of interest."

While the insurer itself will be busy implementing regulations, Vassilaros said, its message to businesses is that Capital BlueCross has "been doing this for the past three years" and has tools to help them, such as its newly released employer mandate calculator. Free to Capital BlueCross customers, it's designed to help them assess the financial impact the "play or pay" requirement might have on them.

Vassilaros also noted that the calculator addresses the trickiest part of the employer mandate: Figuring out how many full-time-equivalent employees a company has. Below 50, employers aren't subject to the 2014 requirement to provide health insurance or pay a penalty, but the regulations are complicated.

Sam Denisco, vice president of government affairs for the Pennsylvania Chamber of Business and Industry, said employers are weighing their options on whether to offer health insurance and how to most advantageously structure their workforce in 2014.

"Employers are looking at each and every employee and their workload from an hourly standpoint," Denisco said. "We've been saying that from the law's inception that we hope that the law wouldn't be a deterrent for employers to hire, saying, 'I'm near 50 (full-time equivalents).'"


Pennsylvania has in the past reported a preference for a state-run health insurance exchange, but its most recent report informed the U.S. Department of Health & Human services that it needed answers to 26 questions before it would be able to officially decide and proceed with planning.

The deadline for announcing a choice to run a state exchange and submit a blueprint for doing so was today. Observers have long said that the state no longer appears to have enough time to pull off its own exchange in time for 2014 open enrollment beginning in October 2013, but instead will likely default, at least initially, to a federal or federal partnership exchange.

Three days after the election, HHS Secretary Kathleen Sibelius announced that the state blueprint deadline was extended to Dec. 14, although states planning to run their own exchanges still had to submit their letters by Nov. 16. She also indicated that more guidance would be forthcoming shortly.

As of Monday, Pennsylvania Insurance Department spokeswoman Rosanne Placey said there had been no response to any of those 26 questions.

"We're currently evaluating the HHS extension letter to see how it may impact the current timelines," Placey said, noting that the extended deadlines "appear to indicate flexibility in the overall timeline, which we see as a positive development."

"There's a lot of infrastructure that's going to have to be built to make the exchanges work," said Glus. He said he suspects Pennsylvania will eventually try to run its own exchange after learning from an initial federal effort.

Glus said the real value of the exchanges lies not in functionality but in the federal subsidies for people earning up to 400 percent of the federal poverty level. And, he said, the new rating rules will also have an impact.

"Pennsylvania's not really had a lot of small-group and rate reform in the past," he said. "It's going to be very curious to see how the carriers react to this stuff with the exchanges and gender and age rating issues."

Where there's uncertainty, insurers tend to play it safe, he said — and "you have to believe at least in the short term, you're going to have a disproportionate amount of high risk" on the exchanges.

There are going to be bumps in the road, he said, but "to truly assess whether this is going to work is going to take a number of years."

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