Some 20 months after the historic passage of the federal Affordable Care Act, where are we?

A panel of experts gathered at The Inquirer on Wednesday to review the impact of the law so far, and speculate about its future.

The media, of course, tend to focus on political squabbling and efforts to undo the law. But even as criticism keeps bubbling, most states are making progress toward implementing a key part of it: insurance exchanges.

Of the 50 states, only Alaska has not applied for a grant to plan an exchange, said Joel Ario, a former Pennsylvania insurance commissioner who directed until this fall the federal office overseeing the creation of state-based health insurance exchanges.

These online marketplaces - often described as the health insurance version of an - must be in place by 2014 so that people without group coverage can purchase affordable policies.

Twenty-nine states are beyond just planning, and have gotten grants to implement their plans, Ario said. (Two states - Massachusetts and Utah - already have online exchanges.) Pennsylvania and New Jersey officials have announced they are moving forward with exchange though their exact composition is up for grabs.

"At the ground level, most states are moving forward" despite uncertainties about the fate of the law, he said.

Casting a shadow over the whole process are lawsuits challenging the constitutionality of the affordable-health-care law. Earlier this month, the Supreme Court agreed to hear a challenge to the law brought by the attorneys general from 26 states, including Pennsylvania.

Robert Field, a professor of health management and policy at Drexel University (and a blogger for The Inquirer at, pointed out that political pressure also comes from the vast healthcare business community - including insurers, pharmceuticals and hospitals - that backed the new law because they saw commercial opportunities.

"They're not going to be very happy if this gets repealed," he said.

Although many pieces of the law will not kick in until 2014, it has already expanded access to care. For example, about 2.5 million uninsured young adults have taken advantage of a provision that allows them to be added to their parents' insurance policies until age 26.

"But what happens to them at age 26?" Field said, speculating that insurers might offer lower-priced plans to keep young, healthy people in the "risk pool."

The new law poses some huge challenges, the experts agreed. It mandates expansion of Medicaid coverage - another 16 million Americans would become eligible. Yet low reimbursements have forced some primary care doctors to reject Medicaid patients. And the system is facing an expected shortage of primary care physicians.
"Small primary care offices are dying because Medicaid reimbursement is so low," said Jeffrey Brenner, a Camden, N.J. family physician who ran such a practice.

Brenner is now the founding director of the Camden Coalition, a nonprofit he created to improve the quality and accessibility of care in that city.

For years, Brenner said, that care has been characterized by "fragmentation and dysfunction." By analyzing seven years of hospital billing data, he found that half of Camden's residents visit an emergency room each year - including 12,000 visits for mundane head colds. The most expensive patients account for just one percent of the ER patient census - but 30 percent of costs.

As healthcare reform moves forward, "my goal is to make Camden the first city to improve quality while cutting costs," Brenner said.

Models of lower-cost, quality care exist, Brenner said, citing the Ryan White HIV clinics and the PACE Programs of All-inclusive Care for the Elderly.
Field predicted a growth of "urgent care centers" to ease the burden now shouldered by hospital emergency rooms.

Inquirer health and business editor Karl Stark, the panel's only journalist, cited a trend of big retailers, such as Walmart and Walgreens, moving into patient care.