It's worth pointing out once in a while some of what the right got out of health reform--those shifts that take the system in the direction they'd like to see it go. Making top-anything lists always involves a judgment call and there are cases to made for this or that other provision topping the list, but I'd say the top five things conservatives got out of reform are: Movement toward high deductible health plans Pressure to pare or eliminate state benefit mandates Interstate health insurance sales Small business pools, along with the option for employee choice Malpractice liability reform grants to states A closer look at those: Movement toward high deductible health plans Many conservative-minded folks seem eager for a health system in which consumers have more skin in the game due to enrollment in high-deductible plans. Obviously HDHPs that can be paired with a Health Savings Account already exist and will continue to exist. But the ACA gives them a little boost (not least by explicitly tying the ACA's numerical contours to the numbers governing the GOP-passed legislation that created the HDHP-HSA system in the first place). In the individual market (which will be mostly the exchange market) for folks without insurance through their job, high deductibles are likely to be pretty common. KFF commissioned three actuarial firms to estimate what deductibles will look like for plans in the exchanges: In the group markets for employer-sponsored coverage (where most people currently do and will continue to get their insurance), the limitless tax exclusion for health benefits has encouraged more generous, lower premium plans. However, the ACA caps that exclusion, giving employers a strong incentive to keep plan costs below that threshold. And, as Mercer's recent employer survey found, employers have noticed: Aside from wellness programs, one of the best ways to try and keep costs below that threshold (and beneath the threshold set by the law's affordability requirements) is to play up high-deductible plans for employees: Aside from that, exchanges are required to offer catastrophic plans (meaning plans that have less than a 60% actuarial value) to consumers under age 30 or those who can't find affordable coverage. Pressure to pare or eliminate state benefit mandates Exchange plans must meet baseline benefit standards. A draft of those standards is expected to be released soon for public comment; however, the group charged with providing recommendations as to what those standards should look like issued its opinion two months ago. Their suggestion is to keep it limited (HHS "should make it a priority to keep premiums reasonable, even if that means allowing plans to be less comprehensive, counseled the committee of the National Academy of Sciences Institute of Medicine (IOM).") However, state benefit mandates on exchange plans in excess of those baseline standards will have to be paid for by the state government. Since state governments will, for the first time, directly feel the costs of insurance benefit mandates, there will be a pressure not only to cease tacking on new mandates but also to re-examine the ones they already have on the books. States May Yet Regret Their Many Mandates Interstate health insurance sales There are a few avenues to allowing out-of-state plans into state exchanges to allow more options for consumers and potentially stimulate price competition between insurers. Multi-state plans. This is the surefire one, as every state will ultimately have multiple nationally-sold plans introduced into its individual market. Health insurance plans that want to sell in multiple states will go through the same process they go through now if they want to participate in the Federal Employees Health Benefits Plan, the program through which members of Congress currently get coverage. In practice, this means that consumers will have access, if they wish, to exactly the same kind of system of competing private plans that serves federal employees and federally elected officials (an idea popular in the rhetoric on both sides). It also means, of course, new options and more competition in state insurance markets. Interstate health care choice compacts. The ACA paves the way for states to voluntarily enter into compacts that would allow health plans to be offered in all participating states. Multi-state exchanges. If states choose to, they can actually merge their exchanges so that their individual health insurance markets stretch across multiple states. If the goal is to offer consumers more options than currently exist in their states, that will be achieved. Small business pools, along with the option for employee choice A common refrain from both sides of the aisle has been that it should be easier for small businesses to access coverage options for their employees. Enter the SHOP Exchange concept (based in large part on concepts pioneered in ruby red Utah): The design of SHOP exchanges is ultimately a state prerogative. They can place choice primarily in the hands of the small business owner, allowing him to offer a select slate of plans to employees from the newly organized marketplace. An alternative design would look more like Utah's small business exchange, which uses an employee choice model. In that model, employers specify a defined contribution toward employee health expenses, and the employee takes that contribution into the Exchange and puts it toward the plan of his choice (paying the difference between the plan's premium costs and his employer's contribution himself). Malpractice liability reform grants to states This one was a first (federal) step on the prickly issue currently dividing the GOP as to whether tort law itself can or should be federalized. The ACA offers "grants to States for the development, implementation, and evaluation of alternatives to current tort litigation," using language that's been floating around GOP circles for years, from Mike Enzi's health reform legislation, to Paul Ryan's Roadmap, to the Republican Study Committee bill (Herman Cain-endorsed!) to the Burr-Coburn/Ryan-Nunes Patient Choice Act. The idea, of course, is to offer states carrots to get innovative and tackle reform of their state tort laws themselves. So we're looking at a higher prevalence of high-deductible plans, fewer state benefit mandates, access to more plans than currently operate in states' insurance markets, an easier time connecting small businesses and their employees to health insurance (with the option of offering employers greater predictability regarding costs, and employees more control over their plan choices), and a vehicle for spurring state-level innovation around tort reform. Wins for conservative rhetoric and, indeed, their policy agenda, assuming their agenda at least loosely aligns with the rhetoric.