Health Reform……One Year Later

Health Reform, now commonly known as the Affordable Care Act, is one year old this month. About a year ago, I wrote a blog post discussing my initial thoughts on the legislation from an unbiased perspective, and while there were many disagreements and differing opinions when it was passed (and since), the one thing everyone agreed on was that the law was going to continue to change as it was implemented.

Almost immediately its constitutionality became suspect, with 26 states appealing the law. A Virginia judge ruled the individual mandate is unconstitutional, and a Florida judge has ruled the entire legislation is unconstitutional. As a result, many of the 26 states are refusing to implement health reform in its current form. Despite this opposition, the Federal administration continues to hold its position that health reform will result in a large cost savings in Medicare that would be lost if provider reimbursement reform were sacrificed. The Federal administration has also appealed the Florida judge’s ruling, and this case is expected to reach the U.S. Supreme Court.

In addition to the argument over the constitutionality, two of the largest challenges posed are the feasibility of certain types of plans operating under the new guidelines and the Individual Mandate clause. By way of compromise, the administration has approved two types of waivers. One waiver exempts certain plans, including Mini-Med plans (plans that offer limited or reduced set of benefits at a low cost) from the 80% Medical Loss Ratio mandate portion of the law. This is important, as one of Merrill’s largest healthcare clients is a Mini-Med plan. The second waiver type allows states to “opt out” of the Individual Mandate if they can prove their state-run alternative meets or exceeds expectations as outlined in the law. Again, this is important, as another one of Merrill's large healthcare clients operates in the individual market.

As we continue to move through the implementation of health reform, we must be knowledgeable and agile, understanding our health plan partners’ day-to-day challenges in adjusting and adapting to frequent and ongoing alterations to the law. The more we understand the changing climate of healthcare, the better positioned we will be to strengthen our partner relationships and manage internal change to accommodate market conditions.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.