Haggling over health care reform is like a children's game

Two years since the Affordable Care Act (ACA) was signed into law, implementation has steadily advanced. But the law still faces big obstacles. It's reminiscent of the children's game “Red Light, Green Light.” For every step forward (green light!), there is a chance of reform being sent back to the beginning (red light!).

Let's first talk about the green lights.

So far, most of the initial reforms appear to be working well, without any unintended disruptions to the health care system. Insurers are complying with the requirements that they extend coverage to young adults and children with preexisting conditions. Millions of seniors are getting discounts on brand-name drugs when they end up in Medicare's “donut hole” coverage gap.

Hundreds of thousands of primary care physicians are benefiting from a 10% Medicare bonus on their office visits and other evaluation and management services. More than $9 million in National Health Service Corps awards was granted to fourth-year medical students in 30 states and the District of Columbia to serve as primary care physicians in underserved areas after graduation.

These improvements have been accomplished without driving up health care costs or premiums. According to the most recent data on total national health care expenditures, health care costs have increased at the lowest rate in more than half a century, and the specific provisions from the ACA added only a statistically insignificant amount to the total.

There has been only one notable failure: the administration's decision to abandon a voluntary program (CLASS Act) created by the ACA to provide access to long-term care because the numbers didn't add up.

Much of the infrastructure to expand coverage to nearly all legal residents in 2014 is also being created. States have been given money to set up health insurance marketplaces called exchanges, which will be the “go to” source of coverage for at least half of the currently uninsured population; the rest will be covered by Medicaid. Proposed regulations have been issued to define the “essential benefits” that will have to be offered by insurers through the exchanges.

And Medicare's Center for Medicare & Medicaid Innovation is in the process of launching multiple initiatives to test new models of delivering care and paying physicians, such as patient-centered medical homes and accountable care organizations.

Even with such advances, the ACA may soon run into a series of red lights. The first, which has the greatest potential to reverse it entirely, is the forthcoming Supreme Court decision on the law's constitutionality. If the Supreme Court upholds the law, implementation will continue without major setbacks, at least through the November election. If the Supreme Court instead finds that the individual insurance requirement is unconstitutional but allows the rest of the law to stand, the result will be massive confusion.

Some experts say that even without the mandate, most of the law can still be successfully implemented, even though it would cover fewer people. Others argue that elimination of the individual mandate would make the law fundamentally unworkable.

Congress could enact alternative policies to encourage people to buy insurance without fining them if they don't, but that would require bipartisan agreement. This is unlikely when the GOP-controlled House has pledged to repeal the whole law.

If the Supreme Court throws out the expansion of Medicare to lower-income uninsured persons, then it will open up a huge coverage gap for the 16 million low-income persons who are scheduled to be covered by Medicaid beginning in 2014. If the Supreme Court tosses out the ACA in its entirety, it's game over. No realistic scenario would result in Congress and the president agreeing to an alternative program to provide health insurance coverage to nearly all Americans.

The other looming red light is the election. If the November elections result in a new president who is committed to repealing the law, and if Republicans maintain control of the House and gain control of the Senate, it is likely that many parts of the ACA will be repealed or substantially altered, although the GOP may still not have the votes to repeal it outright. That's because Senate Democrats could filibuster full repeal unless the GOP gets to 60 seats. But if President Obama wins re-election, Congress almost assuredly would not have the votes to repeal the law, since a two-thirds majority in both the House and Senate would be required to override an expected veto of any repeal bill.

Even if the Supreme Court and the elections don't yield a decisive decision, the ACA could still face other red lights that may send it back several steps, if not all the way home. These include resistance by some states to setting up the health exchanges, challenges to the essential benefits package (as evidenced by the controversy over coverage of contraceptive services), and budget cuts that may deny the administration and states the money needed to successfully expand coverage.

Today, the ACA remains in play. It has helped millions of people already and will soon cover nearly all Americans, even as it faces challenges that could limit it or even upend it entirely. But this is no children's game. The lives and health of just about every American will be affected by it.