5 questions to ask about the ACA right about now

I sat at a hotel bar last week in a Washington suburb, trying to eat a late dinner when the guy sitting next to me slurred out to the man on the other side of me that the country had gotten far worse over the past 50 years, with "Obamacare" among its leading ills. A few minutes later, with more under his belt--and slightly more more under his breath--he wondered if the Nuremberg Laws weren't worth revisiting.

I was about to inquire as to how the Affordable Care Act could fare poorly in comparison to the Nuremberg Laws, knowing full well that such a question to a drunk in cowboy boots in a bar in Northern Virginia meant I could be on the receiving end of a right hook. Fortunately, he got up and left before I could open my mouth, his eyeglasses still sitting on the counter.

Of course, that wasn't really a relevant question to the ongoing debate about the ACA, which has been thick with emotion and disinformation. But here are five others I think we should ask right about now:

1. Why weren't the health plans brought in to direct the design of the federally-operated exchanges? They're the ones that are ultimately going to benefit from those who apply for coverage, and commercial payers have spent the better part of three decades perfecting complicated electronic claims submissions systems. They could have ensured that many of the present bugs–at least on the back end–were avoided.

2. What do hospitals plan to do about price transparency? Millions of Americans will buy insurance on the state health insurance exchanges (assuming they ever work correctly). They will receive all sorts of information on prices, subsidies and what's covered. And if they wind up in the hospital for an overnight stay, they could be on the hook for thousands of dollars in out-of-pocket costs and have little idea as to why. The industry needs to address this issue.

3. Are ACOs actually working? There has been a veritable beehive of activity regarding the formation of accountable care organizations, but little actionable data to date. Occasionally, I receive a press statement announcing the savings of a particular initiative, but little else. Some ACOs pulled out of the Pioneer model, but the Centers for Medicare & Medicaid Services didn't even explain why. Am I being inpatient about this or is there a timetable?

4. What will the state-by-state imbalance regarding Medicaid expansion reap? Will it prompt an exodus of residents from holdout states? Texas could be the very last state in the union to expand Medicaid, if it ever does at all, even though nearly 30 percent of its residents lack coverage. By comparison, California was the very first to expand Medicaid through a special pilot program launched last year. Yet Texas Gov. Rick Perry has been visiting California, trying to entice companies to move to the Lone Star State. Will California Gov. Jerry Brown make the opposite trip in a year or two, enticing companies with guarantees even their poorest workers will get coverage? I'd like to see that--if only to watch Perry's reaction.

5. Could someone please explain why the ACA, if implemented, would destroy America? That was the primary talking point of Sen. Ted Cruz and the rest of the hard-liners during the government shutdown. I never once heard a journalist ask how and why. Economic collapse? Nuclear apocalypse? Asteroid strike? Giant termites? Or is just that old Cold War fear of a Socialist takeover rearing its ugly head? Cruz went to Princeton and Harvard--he must have formulated some sort of a cogent answer. I'd like to know.

Do you have other questions? Let me know in the comments section below. - Ron (@FierceHealth)

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