Three days of hearings before the U.S. Supreme Court have raised questions about whether the Affordable Care Act is constitutional. But the state of California has already started implementing some provisions of the Act. It has set up a health benefit exchange. It's expanding Medicaid and has passed laws to enhance and extend health coverage.
Capital Public Radio's Health Reporter Pauline Bartolone talked with Diana Dooley, who's California Secretary of Health and Human Services, and Chair of the California Health Benefit Exchange board.
Bartolone: If the Supreme Court were to strike down the entirety of the Affordable Care Act, how would that affect how California is rolling out with health reform?
DOOLEY: California is building a health benefit exchange with funds provided under the Affordable Care Act. And those funds are available through 2014. My agenda is to use as much of that as possible, as quickly as possible, to be sure that California has a marketplace even if we don't have the full promise of the ACA - the Affordable Care Act. I believe that the constitutional questions will be answered in favor of the law. I believe that the law will be upheld. But I'm also working very hard to assure that we have as much benefit for California as possible, even if we don't have the full promise of the Act.
Bartolone: Tell me a little bit more about using the federal funds to implement the exchange. Would the exchange also need money from the federal government to operate the exchange once it's already set up?
DOOLEY: Under the terms of the Affordable Care Act and the California legislation that implemented that, both require that the exchange be self-supporting in 2015 so that as a marketplace for people to buy insurance, the insurance providers that are offering their product will pay a fee for this marketplace. So the federal funds are to start up the exchange, but it must be self-supporting, whether or not the Affordable Care Act is upheld.
Bartolone: Would the exchange work without the individual mandate?
DOOLEY: With the mandate, the operation of the exchange will move more quickly at the outset. But there is a strong appetite in the marketplace for people to buy insurance. And if the exchange can offer insurance at an affordable price, in transparent… people know what they're getting and they know which doctors and hospitals they can go to, there will be a marketplace for that even without the mandate and the subsidies. It will be very hard to do because many well-intentioned people would like to buy insurance now but they can't afford it. So it's much more about the affordability.
Bartolone: Is there any aspect of health reform in California that you feel that California couldn't move forward on without the federal government's support?
DOOLEY: I think the most significant challenge that California faces in the short run is our budget deficit. We have had to make very serious reductions because of the recession. There are more people without jobs and therefore without health insurance now than even five years ago when California was looking at healthcare reform. So in the short run, it will be very hard for us to move forward to expand health coverage without the additional federal funds that we would have under the Affordable Care Act. We simply have to balance our budget and get California on a strong footing to do any of this work.
Bartolone: So it sounds like the Supreme Court decision will help determine how California moves forward with health reform, not if?
DOOLEY: I think that's a very fair characterization. The Supreme Court will define how California will move forward and how quickly California will move forward, but I believe our history and our current understanding of the real mess that the healthcare system - loosely called a system - is in need of reform. And if we have to do it without our federal partners we will find a way to do it. But it will be a much better transition to better health if we can do it with the benefits of the Affordable Care Act.