Now that the Supreme Court has unequivocally upheld the Affordable Care Act (ACA), it’s time to get back to our ongoing work of implementing the law. As we’ve said before, the rubber hits the road for the ACA at the state and local levels, and this is especially true for the 26 states proposing demonstration programs that would integrate care for people dually eligible for Medicaid and Medicare (dual eligibles).

These projects offer unprecedented opportunities to build innovative new programs that would better coordinate the medical and non-medical services dual eligibles desperately need to stay out of the hospital and live safely in their homes and communities.

The projects also offer the opportunity to stabilize the ever-escalating costs associated with dual eligibles’ greater-than-average health care needs. At a time when more than 30 states are still coping with serious budget shortfalls, the promise is very attractive.

But we remain worried that the lure of savings is so great that it will overshadow the need to create new systems of care tailored to the complex needs of the people being served by these projects. And, we are concerned that both the federal and state governments’ expectation of savings is so overly optimistic that it doesn’t take into account the realities: plans will need to make significant upfront investments in developing these systems and in getting people the care they need. Savings may not come for a while.

Together with 70 other national and state organizations, we conveyed these concerns to Secretary Sebelius last week. In our joint letter, we emphasized three key points:

  1. The public doesn’t know how much these projects are expected to save
  2. States have provided little to no comprehensible information about how, realistically, they intend to achieve these savings
  3. States using a fully capitated, managed care approach need to take steps that account for the needs of people with complex conditions to make sure managed care plans are appropriately paid

While these concerns may seem wonky for advocates – and are certainly not the only big issues CMS and states must address (just read the recent MedPAC report on this topic) – they are so fundamental to the success or failure of these projects. Without sufficient information or safeguards, we could end up overpaying or underpaying plans. On the one hand, over-payment could undermine the goal of cost savings. On the other, underpayment could compromise quality or encourage “cherry picking.” Either way, the experiment these projects represent will have failed.

As one advocate has often said, this is a “once-in-a-generation opportunity” to improve the health and welfare of vulnerable older adults and people with disabilities. The Supreme Court has given the go-ahead on the law that created these opportunities. So, let’s get back to work and get it right.

— Renée Markus Hodin, Director, Integrated care Advocacy Project