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A roundtable of reporters weighs in on what’s changed since the ACA became law three years ago for consumers, businesses, state governments, and what’s next for expanding Medicaid and launching exchanges.

A transcript follows.

JACKIE JUDD: Good day, I’m Jackie Judd and this is the “ACA at 3.”

PRESIDENT OBAMA (Voiceover): We have now just enshrined, as soon as I signed this bill, the core principle that everybody should have some basic security when it comes to their health.

JACKIE JUDD: What’s changed since that day for consumers, businesses, state governments, with the coming expansion of Medicaid and the creation of exchanges? What challenges lie ahead?

We answer those questions with journalists who’ve covered every angle of the Affordable Care Act. Joining me: Mary Agnes Carey, of Kaiser Health News, Jay Hancock, also of KHN, Sam Baker, of , and Christine Vestal, of . Welcome to you all.

Sam, exchanges – or marketplaces, as the administration now likes to call them – it’s a mixed bag at the moment: Some states are doing it on their own, some looking to the federal government for support, and then there’s a partnership. Give us a broader picture.

SAM BAKER: Exchanges are arguably the cornerstone of the health care law. It’s the biggest structural new thing that was created. And it was envisioned initially as something the states would very much take the lead on. The assumption was each state would want to control its own marketplace or its own exchange. That hasn’t really proven true. I think the federal government is going to be totally running exchanges in 26 states. Of the minority who are working in some capacity with the federal government, a few are running their exchanges entirely on their own, but there’s also some interest in this partnership model – as what HHS calls it – where the work is divided between the state and the federal government.

JACKIE JUDD: In the states where the federal government alone will be running the exchanges, is it going to be a one-size-fits-all or will the states have input?

SAM BAKER: The states won’t have much input. It’s sort of an interesting question to put to HHS about whether it’s a one-size-fits-all, because on the one hand they say, “Once you build one exchange, it’s easy to upscale that to 26 exchanges.” But they’re also in this pitch to get states to do more and more. They’re also trying to emphasize that each one would be customized to each state, and you’d have different carriers in different states, so a little bit of a balance between the two.

JACKIE JUDD: Enrollment begins in October. They actually start running in January. Are most states at the point – and the federal government as well – at the point at which they will be ready to go in October?

SAM BAKER: The federal government insists that they are. Anytime you ask, it’s “We will be ready. We will be ready.” On the other hand, they did just request and didn’t get some extra money from Congress to help stand up and run exchanges, which would seem to be a sign that there’s not enough money to do that in what they have now, but they say they’ll make it work.

JACKIE JUDD: The other significant expansion of that access, of course, is going to happen through Medicaid when income requirements change. Chris, you’ve spent a lot of time covering that story. How many states are in? How many are out? How many are on the fence?

CHRISTINE VESTAL: Twenty-five governors have said yes, either through their budgets or declarations they’ve made. Eight of those are Republicans. Fourteen have said no, and the rest are undeclared. But that’s not the end of it. Now, state legislatures have to approve the governor’s [declarations], and that’s not necessarily going to happen in all of the states. There are – in the eight Republican-led states – five of them [where] it’s going to be quite a battle.  And if not all states say yes, there will be big disparities in 2014. They can decide later, the following year, and a lot of people predict that’s what may happen.

JACKIE JUDD:  Are some governors trying to cut special deals? You and I just saw a story out of Maine where the governor of Maine is saying: We will expand Medicaid if you, the federal government, pick up the entire bill for the next decade.

CHRISTINE VESTAL:  That’s a one-of-a-kind, as far as I know, but there other deals. Governors early on asked for a lot of things and got some nos and got some yeses.

One of the more interesting deals right now was forged by Arkansas and Ohio, with the administration. It hasn’t come out on paper yet, but apparently the administration is saying they can use Medicaid money from the federal government to purchase private insurance on the exchanges for this new population, which will be adults with incomes up to 138 percent of poverty.

So that‘s privatizing, using more of a market approach, which may appeal to the Republican legislators that aren’t in favor of the expansion.

JACKIE JUDD:  There have been some very tangible results of the ACA. Children — young adults up to the age of 26 — can stay on their parent’s policy. Some preventive services are now free. When it comes to Medicare beneficiaries, over the past three years, Mary Agnes, what kind of changes have these individuals seen?

MARY AGNES CAREY:  There have been some new services added to Medicare. For example, an annual wellness visit that wasn’t there before, some more cancer screenings – and all these preventive services now don’t have copays or deductibles.

For example, in 2012 you had 34 million Medicare beneficiaries avail themselves of these new benefits. There’s also have been some changes in the Medicare prescription drug arena: A closing of this “doughnut hole,” that gap in coverage where seniors are on their own. And about six million beneficiaries have saved almost $6 billion on their prescription drugs as a part of the health law.

JACKIE JUDD:  The secretary of health and human services, Kathleen Sebelius, was touting all of the results of the preventive services piece, in recognition of the third anniversary.

The other big piece of Medicare is the payment structure, linking pay to performance. You attended a Senate Finance Committee hearing just yesterday. What kind of results do we have this early on?

MARY AGNES CAREY:  We don’t have results this early on, and that was a problem for some of the Senate Finance Committee members. Richard Gilfillan, who runs the Center for Medicare and Medicaid Innovation — they’re overseeing the accountable care organizations, bundled payments, the readmissions policies – was really urging the senators and, frankly, every member of Congress: “Please be patient. These take time. Some are going to work. Some are not going to work. And as soon as we have results, good or bad, we’re going to share them with you.”

JACKIE JUDD:  Jay, you have a very big swath of this story. You cover the marketplace, meaning insurance companies, employers, etc.

Going back to the discussion we had with Sam and exchanges, what kind of indications are you seeing from the insurance companies about whether they’re going to jump into the exchanges? And what kind of challenges are there with that?

JAY HANCOCK:  It’s still a little bit early.

JACKIE JUDD:  Really? It’s March. They started in October.

JAY HANCOCK:  Oh, absolutely. It’s March. They started in October, yes.

Part of it is due to the fact that the exchanges are still rolling out. Some of the insurers are saying: We can’t make decisions until we see what the exchanges look like. Some of the rules are still being written by HHS and the Treasury Department. 

What we do know is that the insurers that have spoken out publicly about this – the private insurers – have said, the CEO of United Health, for example, has said: Don’t assume we’re going to offer a plan in every market where there’s an exchange. Even United Health, that has a nationwide footprint, their CEO has said: We will not do it unless it makes sense for us economically, for our shareholders, and unless we think this market’s going to stick around and be there for a while. Which points out the uncertainty of the whole thing — these are critical. The insurance companies are the vehicles. This whole plan was written to be a filtered through the private insurers for the most part, for people under 65. And if they’re not there in force, that’s a big question mark.

JACKIE JUDD:  And so do you think that they would be on the sidelines for a year or two to see how these exchanges work? And are there any carrots that the administration could provide the insurers — or the states even — to encourage the insurance companies to get in?

JAY HANCOCK:  In some cases, if you’re not there in the first year, there’s a penalty. And I don’t think anybody’s going to sit this out entirely. I suspect we’ll see everybody with a foot in the water somewhere, and they’ll forget we’re going to have two national insurance plans which don’t get talked about very often.

But in addition to all the state based plans, there are going to be a non-profit and for-profit national plan in every state that will have benefits and compete with whoever the local offerings are there. The thinking is that the blues organizations will also be quite active in this, and be pretty interested in being in the markets in the first place.

JACKIE JUDD:  Part of the issue of growing the exchanges, as well as expanding Medicaid, is how do you reach people who are eligible and let them know what’s available? The Kaiser Family Foundation just that showed the very people who could most be impacted by the ACA understand it the least. Two-thirds of the people who are uninsured, and about two-thirds of people families who are under $40,000, don’t really understand how it will impact them. So Chris and Sam, you could each take this one: What kind of enrollment efforts are going to be made, or going to have to be made to pull people in?

CHRISTINE VESTAL:  One thing that’s going to happen is that [with] Medicaid, states don’t have a choice. They have to make it easier to enroll in Medicaid. So the application process will be easier, which should mean that more people are successful once they find out about it. And this lack of outreach has been a problem in Medicaid already. There are thousands, maybe millions, of people who already qualify for Medicaid and haven’t either heard about it, don’t want to apply, or tried to apply and couldn’t pull together all the paperwork. But I think most of the marketing is going to be through the exchanges.

SAM BAKER:  The exchanges could be sort of a heavier lift, you know. The administration has said it’s going to have a pretty significant outreach education campaign over the summer. There’s an independent group that’s formed called Enroll America, which is an offspring of some advocacy groups, that’s also going to try to help raise [awareness].

JACKIE JUDD:  That helped elect the president.

SAM BAKER:  Right, [it] now will take ostensibly a more objective role in just making sure that the law works. But that poll that you mentioned really did indicate the challenge of explaining something that is pretty complicated. You know there was a big political fuss, last week or two weeks ago, about a draft of the application to enroll.

JACKIE JUDD:  15 pages or something like that.

SAM BAKER:  Right. It had all sorts of information that most people wouldn’t know about their employer plan and almost asking them to figure out for themselves whether they were eligible for subsidies – which is a really complicated determination even for the IRS. So, there are some real hurdles there.

JAY HANCOCK: One of the underrated enrollment forces here is going to be the providers. Nobody has a bigger incentive to make sure that you have coverage than the hospital or the doctor who’s taking care of you.  I suspect they may also be part of the mix.

JACKIE JUDD:  Have you seen evidence or heard evidence of that, Jay?

JAY HANCOCK:  Yeah. The hospital –one of the for-profit hospital companies, Tenet Healthcare, told investors a couple weeks ago that they’re gearing up in a very disciplined fashion to make it easy for their patients to explore their options on the exchanges if they don’t have coverage when they’re at the hospital.

MARY AGNES CAREY:  And they’re also going to have a series of navigators, right? These are individuals that are kind of boots on the ground to explain to people: You do qualify for Medicaid; this is how you navigate that exchange form. But to your point, it’s also in the best interest of the providers to get these folks enrolled, because otherwise they’re uncompensated care. 

JACKIE JUDD:  And some states are being pretty aggressive in terms of simplifying the process. I know in one state – I believe it’s Utah or possibly Michigan – you can sit down in front of a computer with a navigator and find out instantly if you going to be eligible for Medicaid. If so, you would then get the benefits.

Jay, you also cover employers, small business. You talked, before we started taping, about something called avoidance and coping strategies. What do you mean by that?

JAY HANCOCK:  Well, we should call it avoidance, coping, and compliance strategies, because many employers will end up signing employees up for insurance.

To back track a little bit, the Affordable Care Act requires employers with at least fifty workers to offer affordable coverage to their full-time workers. After that headline, there’s a lot of moving parts underneath. What’s a full-time worker? One of the things employers are looking at now is: Okay. If I had sixty employees, and I’m not offering coverage, is there some way that I can go under that fifty line? Employers are talking about hiring part-timers. So that reduces their total employee count. It’s part of their formula – it’s part-timers plus full-timers and then you take an average of their hours.

They’re talking about outsourcing. There’s a lot of talk about partnering with temp staffing agencies like Manpower and Kelly Services, because if all my frontline employers are working for Manpower, they aren’t technically my employees. That might put me under the fifty mark. That might be a way to increase my part-time workers.

There’s a lot of discussion going on about this in the employer community. There are also small employers saying: Look. We have a health plan for our employees. They like it. It helps us retain good workers, and we think it will be good for you as well.

JACKIE JUDD:  Are you talking about the self-insurance there?

JAY HANCOCK:  Self-insurance is another wrinkle in this. That wasn’t what I was referring to, but self-insurance is a whole other thing that I think is going to get more attention this year because of federal court cases that go back way beyond what we want to talk about. If you’re self-insured as an employer, which is to say if you fund most of your employees’ health cost through your own finances, you are exempt from several measures under the Affordable Care Act including the insurance premium taxes that come with this, including the pricing rules that says you basically can’t charge a lot less for young healthy employees and you can’t charge a lot more for older folks with pre-existing conditions.

And, there’s the worry now that even smaller employers are going to be switching to self-insurance, which they can do by buying reinsurance policies, which is something else we don’t need to get into, but the bottom line is it’s another potential out.

I had a story last week in which one of the people I talked to, who is no fan of the Affordable Care Act, sees this as a loophole that could undermine small business exchanges in the states, because if employers see an opportunity to self-insure their young, healthy workers, that may leave older sicker folks in the exchanges and drive up premiums and make it less affordable.

JACKIE JUDD: Others who were not fans of the Affordable Care Act three or four years ago and to this day, of course, warn that for some small businesses the impact of the law would mean they would be out of business. Is there evidence of that?

JAY HANCOCK: “Out-of-business” would be the extreme case. I haven’t heard too many people saying this is going to make me close up my doors and go home. However, whether or not this is effecting job creation is something that’s being talked about a lot these days. The Federal Reserve, which does a periodic survey of business conditions and is not a partisan organization, reported a few weeks ago that businesses were telling their surveyors that they were holding off a little bit on hiring. They wanted to see how all of these uncertainties about the exchanges that we’re talking about were going to play out. They wanted to understand the law more. And until that happens they may hold off — if they are talking about expanding that would put them over the 50 mark — that may keep them from doing some hiring as well.

At the same time, however, you should point out that the economy is doing pretty well. We had a great jobs report last month, and we’re just going have to see how things turn out between now and next year.

JACKIE JUDD: Sam, in recent days backers of the ACA, friends of the White House, have begun to express some concern that premiums will be higher than had been anticipated and had been promised when the law was being debated. What are you hearing?

SAM BAKER: There are sort of two sides to that question. In one sense and for some plans, premiums will be higher basically by design. The law does away with certain plans that are referred to as mini-meds that are very cheap but also the coverage is usually pretty skimpy — it will carry high out-of-pocket costs or have a cap on how much it will play out. So people who were insured with one of those plans will now have a more comprehensive plan that will be more expensive, but that’s sort of a value determination that the law makes that this is something that should happen.

There is also the question – insurers refer to it as premium shock, the sticker shock once so many new regulations kick in at the same time, which would be the beginning of next year that you have new limits on how much you can charge based on age, based on health status, pre-existing conditions. Younger people are probably the people who would bear the brunt of any increases, because they are generally cheap to insure now, and by bringing sicker people into the system and by providing guarantees of coverage to them you might be shifting some costs onto the younger workers.

JAY HANCOCK: What insurers will also tell you, generally off the record, is that they’re insuring what by definition is sort of terra incognita, an unknown territory. These are people who by definition have lacked coverage in the past, and insurers will say: Look, we don’t know the health histories of these populations. We don’t know the claims histories, and when push comes to shove that may cause us to decrease our risk by raising our premiums rather than taking the chance that there might be higher than expected claims histories with some of these newly insured folks.

JACKIE JUDD: And one part of the unknown territory, Chris, is this question of with so many more people becoming insured, will there be enough doctors, especially primary doctors, to take care of them?

CHRISTINE VESTAL: That’s a big question, especially for Medicaid, because Medicaid pays lower rates. Primary care doctors got a raise this year, paid for by the federal government. It will be paid for one more year. After that it will be up to states to continue the pay raise or not.

But one of the things states are doing as they look at this expansion, they’re saying this program isn’t working anyway. A lot of them feel that it is inefficient and that doctors’ time is not spent well. So one of the ways, rather than adding new doctors, which you can’t do overnight, states are looking at having doctors work in teams so that they’re not the only ones spending time with patients.

JACKIE JUDD:  Nurse practitioners?

CHRISTINE VESTAL: Nurse practitioners, also expanding their scope of practice so that they can work at the top of their skill level. That’s another initiative that’s going forward.

JACKIE JUDD:  We can’t really have a conversation about the ACA without talking about the politics, which continue in force.

Just last week Congressman Paul Ryan introduced a budget on the House side, in which he called for the repeal of the ACA. As time goes on that seems so, kindly put, less and less likely. So what is the goal of Republicans in the coming year as the ACA becomes more ingrained in our system?

MARY AGNES CAREY: We’ve talked about a lot of these provisions that kick in in 2014, so that’s a year away. So if you’re going to make the case against the ACA, if you have any hope of stopping implementation, which as you noted, they really don’t because the president is a Democrat and the Democrats run the Senate, they still want to make their case.

Paul Ryan was asked a question during the budget rollout at a news conference like: You didn’t win the election. Republicans didn’t get the White House. You didn’t get the Senate. Why do you persist? And this and a variety of other provisions that don’t seem likely to go forward, and Paul Ryan said: Look, these are our principles.

They don’t like the ACA. They want to defund it. The House voted something like 33 times last year to defund either part or all of it. And you see those amendments coming up again on the budget resolution, on the continuing resolution. And while they’re not successful, Republicans tell me: This gives us the chance to make our case on why we think the ACA is terrible.

Even yesterday in the Senate Finance hearing I attended, Orrin Hatch, the ranking member, a Republican from Utah, said he sees a train wreck in 2014; things will be a disaster and then people will finally understand the Republicans’ concern about the ACA.

But one note on the Paul Ryan plan. We’ve got to remember that while he would repeal the ACA, he would keep all those savings, all those cuts to providers as part of his budget. So, there was some questioning on that as well.

JACKIE JUDD: I would like to end our conversation on predicting, as your lawmaker did, a year from now, what things may look like in each of your areas, Medicaid, exchanges, marketplace and Medicare. A year from now, what will you be looking for to report on whether things have been successful or whether they are not working as people had hoped. Chris?

CHRISTINE VESTAL: Well with Medicaid, first of all, it will be interesting to see how many states actually do take the very good offer from the federal government and expand Medicaid. And then, among those that do, how well is it working?  How much are these new people using their Medicaid card?  Are they having to wait too long to get appointments?  And how are the hospitals doing? That’s going to be a big question, especially in states that don’t expand.  Because they [the hospitals] will not get a subsidy that they’ve been getting for uninsured patients.  So there may be a push in those states to go ahead and make the move.

SAM BAKER: On exchanges, I think the top-flying concern is just how many people enroll which will sort of be how you judge the law’s political success. They said it would cover about 30 million people. How close do you get to that number?  And how many young people enroll?  Because that will have a pretty big impact on premiums and on whether the goal of bringing young people into the system to offset other projections is fulfilled.

JAY HANCOCK:  I think we will have functioning exchanges in every state, but I suspect there will be hiccups.  A lot of people are concerned that 2014 will be the acid test of the Affordable Care Act, and I would suggest that that’s probably not the right test.  A lot of people compare this to Medicare Part D, which was passed in the last decade.  I think that’s a good benchmark.  The lesson is, in terms of how long it takes to work things out.   And when Medicare Part D was adding prescription drug benefits to Medicare, Mary Agnes, how many years did that take to get smoothed out and have everyone understand it and insurers participating and so forth?

MARY AGNES CAREY:  It took a while, but the thing to remember about this is that [program] was adding drug coverage to a population that understood the Medicare program. What’s really different here is you’re bringing in millions of people who may not know anything about how to get health insurance, so that’s a further complication in implementation.

JAY HANCOCK:  That’s true. What the Act’s defenders say is don’t judge us on 2014.  And I think that’s probably fair.

JACKIE JUDD: As a final word, I’ll let you judge 2014, Mary Agnes.

MARY AGNES CAREY:  I think we have to see do these measures to link the payment for care to the quality delivered, do they really work?  You’ve already see wrinkles in implementation of the ACOs – the accountable care organizations, bundled payments, the readmissions policy that providers are pushing back on.  We have a series of payment changes to Medicare Advantage and to hospitals and other providers.  And now we have sequestration – this additional 2 percent cut that’s in place [for Medicare providers]. Providers have a way of putting political pressure on to reverse cuts. And what will happen with those in 2014 and the years ahead?

JACKIE JUDD: Thank you to each and every one of you for bringing your expertise to the table. I appreciate it.  Thank you for watching The ACA At Three.  I’m Jackie Judd.

This video was produced by Kaiser Health News with support from .