At Bon Secours Medical Group in Richmond, Va., Robert Fortini has put in motion substantive changes during the last three years.

Many health systems have as well, in fact, since the Patient Protection and Affordable Care Act was signed into law March 23, 2010.

“We have redesigned care delivery to a team model and embedded case managers in the practices,” explained Fortini, Bon Secours vice president and chief clinical officer. “In addition we are aggressively using registries for population management.” To name just a few examples.

Indeed, there’s little question that the Patient Protection and Affordable Care Act (ACA) has demonstrable benefits already — even if as a Kaiser Poll found this week Americans still don’t understand them.

What’s less clear is how the ACA will fare long-term given this tumultuous political environment. One thing to be gleaned from the budget Wisconsin Rep. Paul Ryan proposed last week is that the GOP-controlled House is showing signs it will continue trying to repeal the law or certain provisions of it.

Uncharted territory
“Pushing ACA over the finish line on time would be hard enough even if there was a play book ready for the taking,” which of course there is not, according to Claudia Page, co-director of Social Interest Solutions, a non-profit focused on health IT and policy.

That is perhaps more apparent in the health insurance exchange and Medicaid expansion provisions, the two most contentious pieces of the law right now, and the areas requiring the most technological heavy-lifting.

Rattling off a list of associated IT projects, Page pointed to security, identity resolution, program rules, systems integration between existing state and county systems, federal systems, other agencies, new call centers, and more. “IT systems transformation of this scale in this amount of time is like nothing the public benefit world has ever seen.”

  “I don’t think [the ACA] is a settled issue by any means. The big questions are going to be whether this is a sustainable model.”

— Karl Rove, GOP strategist

Here’s why that matters: If the government fails to stand up the federal exchanges, does not reach those uninsured Americans that both Medicaid expansion and the health insurance exchanges aim to bring into the coverage pool before the end of president Obama’s second term, then the law faces the possibility of anti-ACA Republican administration taking over — the less already accomplished the easier it might be to halt or slow progress.

To borrow an IT cliché, Medicaid expansion and health insurance exchanges are mission-critical to the ACA’s success.

And as early as December 2012, if not before, at least one healthcare IT analyst predicted that the October 1, 2013 and, subsequently, the January 1, 2014 HIX deadlines would have to be pushed back in accordance with the project’s enormity that Page described.

“My sense is we’re going to see enrollment in October and there are going to be lots of bumps. It’s not going to be perfect. But it’s going to go live and then January 1, benefits will be eligible and people are going to be seeing their doctors, people are going to be using the system, with insurance,” said John Criswell, CEO of Pulse8, an emerging big data and analytics company already working with state HIXs. “As time moves along it will get better and smoother.”

By no means settled yet
When Healthcare IT News Managing Editor Mike Miliard interviewed Karl Rove at HIMSS13, the long-time GOP strategist said that the ACA’s survival of a Supreme Court case challenging its constitutionality and the subsequent presidential election settled little more than the matter of the individual mandate.

“I don’t think [the ACA] is a settled issue by any means,” Rove said. “The big questions are going to be whether this is a sustainable model.”

Pointing to potential economic pitfalls, Rove suggested that America has “roughly ten years of Medicare cuts, 8 years of tax increases in order to fund a program that is ramped up for two years and is in full operation for only four out of the first ten years. We spend over 85 percent of the money on the Affordable Care Act in the last four years of the first decade it’s on the budget,” and now is the time to look at the other years from a budget perspective.

All of which does not actually mean that the ACA won’t move forward — but there are certainly a number of knots to untangle for the law to succeed.

“The defiance to the law might further substantiate the law ... The net-net could be exactly what the opposition didn’t want: a federal program.”

— David Whitlinger, executive director of the New York eHealth Collaborative

“We are likely to see a very divisive debate about whether or not this is sustainable for the long haul,” Rove added.

Indeed, look no further than states opting against expanding Medicaid or standing up a health insurance exchange for instances of such polarity.

Potential for irony
The Supreme Court, in late June, surprised the nation by upholding the individual mandate but limiting the federal government’s ability to fine states not participating in Medicaid expansion, a ruling that did not appear to bode well for that particular provision.

Justice Antonin Scalia’s Godfather quip about an offer states can’t refuse during oral arguments might prove more prescient than snarky as GOP governors follow Fla. Gov. Rick Scott’s about-face and accept those federal dollars to ratchet up the number of Medicaid enrollees on the federal dime.

“The defiance to the law might further substantiate the law,” said David Whitlinger, executive director of the New York eHealth Collaborative. Since approximately half of U.S. states opted out of building a health insurance exchange and the federal government has to do that for them, “that could ultimately lead to a pseudo single-payer system.”

Whitlinger continued that at some point with, say, around 50 or 60 percent of the population in the exchanges or Medicaid, it might start to closely resemble a single system.

“The net-net could be exactly what the opposition didn’t want,” Whitlinger said, “a federal program.”

Forecast: Progress slow but steady
Bon Secours’ Fortini, in the meantime, will keep trekking toward implementation of the law.

“We are continuing to redesign primary care and are preparing for rapid growth of primary care services with an emphasis on increasing the number of skilled nursing and Nurse Practitioners,” Fortini explained. “We have signed contracts with three payers for a new payment model — care coordination fee, FFS schedule and gain sharing in later years. We have just entered into the MSSP ACO pilot and are expecting significant gain sharing with a risk model in later years.”

On the national scale, Pulse8’s Criswell and SIS’ Page anticipate small but consistent progress over the long haul.

“Whether its Medicare, Medicaid or the health insurance marketplace, yes, there are a lot of things that are very different,” Criswell said, but after listening to a senior HHS leader this week, he walked away feeling more confident than he previously was that the administration can deliver. “I’m optimistic.”

Page echoed that outlook.

“While there is still considerable political jockeying around ACA implementation, and concern about ACA's long-term financing, each day delivers new progress,” Page said. “The nation has changed because of ACA, and it will continue to do so even with all the challenges.”

Healthcare IT News Editor Bernie Monegain contributed to this article.

Related ACA at 3 coverage:

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Healthcare Finance News: Urban Institute study finds hospitals could reap $293 billion under Medicaid expansion