It's day two of the A.H.C.R. -- or After Health Care Reform -- era. 

Yesterday, the first series of major consumer reforms required by the federal Patient Protection and Affordable Care Act went into effect. The Kaiser Family Foundation has an excellent run-down of the top eight new measures (along with seven caveats) that started September 23. Among them: Young adults are now allowed to stay on their parents' health plan though age 26; Insurance companies are prohibited from charging fees for many preventative medical procedures, like cancer screenings or routine vaccination; "Rescission," where insurers unceremoniously dump people from their insurance plans if simple errors are made on the application, are outlawed going forward.

Taken together, these new rules mark an important jumping-off point for changing how people get insured. "We have begun to create a more competitive, consumer-friendly insurance marketplace," U.S. Sen. Dick Durbin said on a conference call with Illinois reporters Wednesday. 

Of course, the bill that emerged from Congress for President Obama's pen didn't include a national public option -- the chance for health care consumers to access care through the federal government. Excluding the public option was a big disappointment for progressives, but that doesn't mean there isn't a lot at stake as state governments, including Illinois', start to implement the the Affordable Care Act. In Illinois, more that 1 million residents are expected to qualify for new federal benefits under the reform law.

The official government outlet that will figure out how the state should comply with the federal health care overhaul is the Illinois Health Care Reform Implementation Council. The council, which includes the heads of the state's big human services and health-related departments, must prepare a report, due to Gov. Pat Quinn by December 31, that outlines how Illinois should establish a health insurance exchange, reform Medicaid, and find federal resources and other non-governmental funding grants to deploy the state's new health care system, among many other issues. Over the course of several hours Wednesday afternoon and evening, the council met for the first time in Chicago. Future meetings are scheduled for Peoria and Springfield, and members of the public may also submit written comments about health care reform through the council's website.

Tucked away in the auditorium near the Thompson Center food court, the meeting was mostly a cordial affair, with everyone's feedback and comments duly appreciated by the council. Consumers, employers, advocates, and representatives from insurance companies all gave testimony. 

The presence of the latter two groups signaled some of the fault lines that may lie ahead, which progressives will want to track carefully. A primary issue is how the state's health insurance exchange should be structured. (We previously wrote about this issue in early August.)

The exchanges, to recap, are meant as a government-regulated clearinghouse where those who aren't offered a health care plan through work, nor are eligible for Medicaid or Medicare, can purchase insurance with the help of government subsidies and tax credits. Small businesses with fewer than 100 employees will be able to buy health care through Small Business Health Options Program Exchanges, or SHOP exchanges. The individual and SHOP exchange could be combined as one or offered separately by the state; that's one of the debates the health care implementation council is considering. States are required to have their exchanges ready to roll out by January 1, 2014.

At Wednesday night's hearing, Jim Duffett, the executive director of the Campaign for Better Health Care, offered several ideas about how Illinois' health insurance exchange should look in four years. Among them: ensure that consumers have a voice in the exchange's creation, guarantee the exchange is structured to attract and enroll a broad cross-section of people, and include within it a state-based public option. (Yes, the public option may have died on Capitol Hill, but access to government-offered insurance in Illinois is a possibility, at least, and one we've heard Duffett argue for in the past). Here's Duffett laying out his priorities for the exchange last night:

Michael Brady, on behalf of Blue Cross/Blue Shield of Illinois, argued in favor of making the exchange a competitive marketplace, with "broad participation" in it by health plans. This is a little rich coming from someone whose company dominates the private insurance market in greater Chicagoland, enrolling 66 percent of everyone in the region who has private health care. Brady told the panel there shouldn't be any plan on the exchange that an individual or small group couldn't also get in the private sector:

So in the final analysis, consumers can choose voluntary participation in the exchange or the private marketplace. There's an either/or. To try to set it up in such a way that you can buy one product on the exchange and it's not available in the private sector is to, I think, confuse the consumer rather than help them out.

Which begs a question: If the exchange doesn't provide uninsured consumers and small businesses with options that are not already offered in the private health care marketplace, what's the point of setting one up in the first place?

Michael McRaith, the director of the state's Department of Insurance and a member of the implementation council, offered a similar statement toward the end of the insurers testimony. "I'm not trying to make a point," he said, "but if the rules are the same, I don't understand why we'd need to sell them in different places. That is an open question. I'm trying to understand that."

For another view, the Illinois Public Interest Research Group made three recommendations earlier this summer about structuring the state's future exchange.

Unlike Brady's comments above, PIRG is saying, essentially, don't neuter the exchange! Their ideas:

• It should offer a powerful, easy-to-use set of tools that put consumers in charge of their coverage, including clear comparisons between plans and quality and cost ratings, that ensure there is a range of clear, distinct choices, rather than an endless array of confusing products. 
• The exchange can improve care quality and lower costs by encouraging insurers to adopt reforms that deliver better care for consumers. It should also be able to actively negotiate with plans on behalf of consumers and stop excessive premium hikes.
• States must ensure that the exchange’s governance is transparent, accountable, and responsive to consumers’ interests, not those of the insurance industry.

Getting Ready For More Medicaid

In addition to the exchange, by January 1, 2014, more people across Illinois will be allowed to enroll in Medicaid, the joint federal-state health care program for the poor. 

An expanded Medicaid program will allow anyone who earns around $14,000 for an individual and $29,000 for a family of four to enroll. For the three years after the Medicaid expansion, the feds will take care of 100 percent of the expanded Medicaid bill, and 90 percent of it after that time period, with states picking up the remaining 10 percent.

Some 750,000 people who currently do not have health insurance will be eligible for Medicaid under the expanded enrollment rules starting in 2014, estimated Julie Hamos, director of the state's Department of Healthcare and Family Services. (This will turn out to be an amazing deal for Illinois, as the state can insure almost 70 percent of working poor adults who lack health care coverage for just about $40 per person annually.)

That influx will boost Medicaid's share of the total insurance market in Illinois to 24 percent, she said. In combination with the 3 percent of the insurance market state workers and retirees comprise, that will give state government a lot of power to shift the overall health care system. "We will have a very strong market position," Hamos said. State government will use this leverage to focus on nine key Medicaid reform priorities, from creating an easier system to enroll newly-eligible residents in the program to improve home- and community-based care and expanding the number of physicians serving these Medicaid clients.

Until the health exchanges and Medicaid expansion in 2014, residents with pre-existing conditions can apply to enroll in the Illinois Pre-Existing Condition Insurance Plan (IPXP), the state's plan to cover those who can't other access insurance.  

Stephanie Altman, who works for Health and Disability Advocates, testified at the implementation council hearing that hundreds of thousands of Illinoisans currently can't get Medicaid nor private health care because of pre-existing conditions. A 19-year-old student who came to Health and Disability Advocates looking for help was typical. Though the student has no income, she can't access Medicaid and she can't buy private insurance because of a colon condition. She has applied to enroll in IPXP, however, which might allow her to access the care she needs before 2014.

Duffett, from the Campaign for Better Health Care, said Wednesday that state lawmakers could do more to help those with pre-existing conditions between the ages of 20 and 64. (Remember that one of the rules that kicked in yesterday is that people 19 and younger can't be denied coverage due to pre-existing conditions, and Medicare, which kicks in for those 65 and older, takes everyone.) The governor and General Assembly could pass a law making it illegal to deny coverage based on pre-existing conditions for folks who presently fall between the age gaps. Duffett argued such a bill could come up during the fall veto session or early next year. 

Beyond these nitty-gritty implementation details, the political ground beneath health care reform is still shifting. House Republicans in Washington have pledged again to repeal or defund the bill. Health care reform may have passed last spring, but the debate about its future is really just beginning.