The second act

The Nov. 6 election reaffirmed the 2010 healthcare overhaul and set the stage for a host of major healthcare decisions lawmakers must consider in the weeks and months ahead.

Even House Speaker John Boehner (R-Ohio) joined healthcare executives, analysts and consultants in saying the election's results cement the Patient Protection and Affordable Care Act as the law of the land. For healthcare providers and the states, the re-election of President Barack Obama and the preservation of a Democratic majority in the Senate remove any lingering doubts about the fate of Obama's signature domestic legislation.

The practical effect is that the Obama administration will resume issuing a slew of regulations implementing the ACA after slowing the pace in the run-up to the election.

“I think we're going to see a parade of policies, rules and regulations coming out very quickly,” said Ilisa Halpern Paul, managing government relations director at Drinker Biddle & Reath in Washington. “With Nov. 16 as the deadline for states to know of their intention on moving forward with exchanges, I think it's critically important that the administration get out as much information as possible.”

The regulations related to the health insurance exchanges, a core element of the law, are among the most eagerly anticipated. Scheduled to start in 2014, the exchanges are expected to expand insurance coverage to about

15 million people. Two days after the election, HHS sent proposed regulations to the Office of Management and Budget—the last stop before they go to the Federal Register—that outline the “essential benefits” that will be required of health plans participating in federally run exchanges.

The election also highlights—ironically to some—the large role that states will have in the future of the healthcare law. States must decide whether to undertake either the law's expansion of Medicaid eligibility to 133% of the federal poverty level, or as high as 138% of the federal poverty level. And states will consider whether to launch their own insurance exchanges, undertake a “partnership” exchange or let the federal government run their exchange.

Many of the 29 Republican governors—and some Democrats—have voiced varying degrees of resistance to one or both of the two primary means by which the healthcare law aims to extend insurance coverage to about 30 million more people. A new major test for the Obama administration is whether and to what extent it can move those states to participate, according to health policy experts.

With the ACA's newfound air of certainty seemingly putting that fight to rest, all eyes in Washington now turn to the so-called fiscal cliff, shorthand for the array of tax increases and massive spending cuts scheduled to take effect in the new year, compelling a new round of deficit-reduction negotiations between Congress and the White House. Healthcare industry leaders can count on another certainty: Changes to Medicare and Medicaid are on the way.

“I don't think there's any question but that entitlement reform will be a part of whatever new agreement is reached,” former Senate Majority Leader Tom Daschle (D-S.D.) told a group of healthcare providers in Washington last week.