The world of health care is changing dramatically -- whether the controversial law mandating universal coverage survives or not.
As the U.S. Supreme Court prepares to deliver its verdict this month on the constitutionality of the federal law, many elements are already in place. Seniors are receiving discounts for prescription drugs, and adults under 26 are staying on their parents' plans. Lifetime limits on insurance payouts and co-pays for preventive care have been eliminated.
Advocates say the changes have expanded access to many uninsured Americans and made care more affordable for others. But technological innovations and cost pressures in the market place are doing the same thing as well.
And no matter what the Supreme Court ultimately decides, reforming the health care system -- one way or another -- will remain in the forefront of public policy in Minnesota and the country, health care professionals and regulators say. "We'd be derelict in our duty to say we'll stop and let things ride for a while," Minnesota Health Commissioner Ed Ehlinger said.
The federal law aims to make health care more affordable and to expand care to 32 million uninsured through state-regulated exchanges and an expansion of Medicaid, the state-federal program that covers the poor. The high court is considering the constitutionality of an individual mandate provision that requires everyone to either buy insurance or pay a penalty.
Supporters of the mandate see it as central to achieving the health care law's aims, since it delivers a large pool of paying customers to health insurers. Many opponents think individuals should be free to decide whether to buy coverage.
But regardless, pressure to drive down costs is already forcing fundamental changes. Insurers and providers are sharing information and working together to provide treatment as efficiently as possible, said Karen Ignagni, CEO of America's Health Insurance Plans, a Washington-based industry lobbying group.
"There's much more coming together," she said. "It's so different than anything we saw in the 1990s. The data makes all that possible. That's why I'm optimistic about what I see."
Technology plays a key role. Doctors can check whether someone has filled a prescription. Or find out over the phone whether a heart patient has gained weight -- a red flag for problems.
Unlike in some states, Minnesotans can go online and compare the cost of a mammogram or find out about errors made each year at the state's hospitals. Such attempts to make health decisions more consumer-friendly are components of the health reform law.
Former U.S. Sen. Dave Durenberger, now chair of a health policy institute at the University of St. Thomas, said that with hospital systems slowly changing the way they expect to get paid, insurers competing directly for patients and entrepreneurs entering the market, "reform will be there even if the law were to go down."
Though millions of dollars in federal aid hang in the balance of the high court's ruling, the pace of innovation in Minnesota may be slowed but not derailed.
"Minnesota didn't need the national government to create a Center for Medicare Innovation and some of these other things," Durenberger said. "Systemic reform -- what we pay for, how we are paying for it and how we are delivering it -- is already underway here."
With reform efforts begun in the 1990s and expanded in 2008 under former Gov. Tim Pawlenty, the state is miles ahead in adopting such reform basics as establishing electronic medical records and turning to primary care providers as a home-base for health care.
Fairview, Allina and Park Nicollet are federally designated "pioneers" for their creative approaches to improving care and lowering costs of chronic conditions, such as diabetes and heart disease. The Mayo Clinic is long established as a leader in team-based care and efforts to improve public health.
Even local governments have gotten into the act. Hennepin County started a pilot project this year to lean on its fleet of social service agencies to focus on keeping its poorest and sickest patients from bouncing in and out of the hospital, at taxpayer expense.
Slowly, battle lines between hospitals and insurers are breaking down, as leaders see access to claims data and nurse hot-lines as a way to keep costs and readmissions down.
"Insurance companies have the benefit of information and of having that first connection [with patients]," said Kathryn Correia, new CEO of HealthEast Care System, a champion of collaboration. "Let's not waste that. Let's not just have them hand the patient over to a provider. Let's look at how we can improve that patient experience and create value right from the beginning."
The state has drawn more than $31 million in federal grants to start building the exchange, but legislators have been unable to agree on a bill, despite backing from the Chamber of Commerce and key Republicans.
Members of Gov. Mark Dayton's administration say they'll push forward with the idea if the high court strikes down the law.
"If the [law] goes away, if the individual mandate goes away, we would still be working on getting universal access in Minnesota because it's been a goal in this state for a long, long time," Ehlinger said.
The ruling promises to bring some welcome clarity to Minnesota's businesses, which have been crunching numbers and becoming familiar with the law's requirements and complexities.
"It'll be a relief," said Mary Madison, senior benefits administrator for Bachman's. "Then everybody can get back to the business of doing business rather than health care."
The Minneapolis-based gardening retailer operates six Twin Cities locations and a wholesale nursery in Lakeville. With 500 employees that can mushroom to 1,200 with seasonal workers, Bachman's health care expenses could change drastically depending on what happens.
Coverage currently is offered only to those who work 40 hours a week, and about 155 employees take advantage of it. Under the law, the definition of a full-time equivalent is unclear, but sets the bar at 30 hours a week using a formula that likely will require Bachman's, which is self-insured, to offer benefits to more workers or pay a penalty.
"In an ideal world, we would be able to offer health insurance to everyone," Madison said. "But we can't because of the cost." Jackie Crosby • 612-673-7335