Many health experts believe that improvements in healthcare delivery and the establishment of state health insurance exchanges will continue even if President Obama's healthcare reforms are overturned. However, former healthcare policymakers warn that efforts to control costs and improve quality of care could be hindered by arbitrary spending cuts in the near future. Dr. Don Berwick, who recently left his position as head of Medicare and Medicaid, criticizes the current plan of cutting benefits and shifting the burden to the poor and taxpayers, stating that it will only make things worse. The Affordable Care Act aims to provide healthcare coverage to over 30 million uninsured Americans through Medicaid expansion and subsidized private insurance options on state exchanges. It also calls for innovations that could steer America's $2.6 trillion healthcare system, the most expensive in the world, towards incentives for controlling costs. The law is facing strong opposition from Republicans and is entering a period of significant uncertainty. The Supreme Court is expected to rule on the constitutionality of the individual mandate next spring, which requires all Americans to purchase insurance. Voters will then decide whether Republicans or Democrats will control the White House and Congress. Current and former healthcare officials are optimistic about changes that would reward doctors and other providers based on patient progress rather than the quantity of tests and procedures they conduct. For a panel discussion on healthcare reforms moderated by Reuters at Harvard School of Public Health, visit www.ForumHSPH.org. Dr. Mark McClellan, who previously oversaw Medicare, Medicaid, and the FDA under President George W. Bush, stated that these reforms have the potential to significantly impact healthcare costs in the long term. Various innovations such as "bundled payments" and incentives for healthcare providers to keep patients healthy and deliver successful outcomes while saving money have been gaining momentum. These innovations were already being implemented in the private market before the healthcare bill was signed into law in March 2010. The law's efforts to apply these innovations to Medicare and Medicaid, which collectively spend about $900 billion annually on care for 100 million beneficiaries, have further accelerated their adoption across the United States. The Center for Medicare and Medicaid Innovation, established a year ago, plans to partner with private entities to develop about 24 innovation models in the coming years. According to experts, these innovations in care delivery are important for providers facing increasing cost pressures from employers and government agencies. Don Moran, a healthcare consultant based in Washington, believes that these innovations are a response to market realities rather than just reformist interests. However, the future of healthcare innovation could be uncertain after the November elections, as Washington may choose to address deficits by making cuts to Medicare and Medicaid, reinforcing the traditional fee-for-service model. The lack of a proven cost-saving track record for innovations makes them vulnerable to potential budget cuts. Gail Wilensky, former head of Medicare and Medicaid under President George H.W. Bush, is concerned that Congress may choose to reduce payments to healthcare providers, which could lead to doctors dropping Medicare patients. She expressed this worry during a Harvard School of Public Health forum, stating that Congress may prioritize this action due to the credit they would receive for it. Some experts believe that deficit concerns could prompt the Obama administration to postpone certain aspects of the healthcare law, such as state health insurance exchanges and the individual mandate for health insurance. Delaying the implementation of the law could result in significant cost savings for the government, allowing officials more time to establish exchanges amidst uncertainties caused by the Supreme Court case and the election. An administration official stated that there are currently no plans to postpone the law's implementation. Analysts believe that the outcome of the election may not affect the fate of the law unless Obama is not re-elected, as Congress is unlikely to overcome partisan disagreements even if Republicans gain a slight majority in the Senate. McClellan noted that certain aspects of the law, such as state insurance exchanges, could still move forward even if the individual mandate is overturned, repealed, or weakened due to political and budgetary pressures. McClellan suggested that rather than mandating the purchase of insurance, the government could create voluntary rules to incentivize participation in exchanges, citing Medicare Part D as a potential model. He acknowledged that state exchanges may not be as strong without the individual mandate but suggested that this could lead to deficit savings. There are currently no discussions about using Part D enrollment restrictions as a substitute for the individual mandate.