A growing US deficit may be a bigger threat to President Barack Obama's healthcare reforms than the Supreme Court or the 2012 elections, according to health experts. Even if the 2010 Patient Protection and Affordable Care Act is repealed, innovations in healthcare delivery and state health insurance exchanges are likely to continue. However, former healthcare policymakers from both Democratic and Republican administrations warn that cost control measures could be at risk if arbitrary spending cuts are made in response to fiscal pressures. Dr. Don Berwick, former head of Medicare and Medicaid under Obama, believes that cutting benefits and shifting the burden to the poor and taxpayers will only make things worse. The Affordable Care Act aims to extend coverage to over 30 million uninsured Americans by expanding Medicaid and creating state exchanges for subsidized private insurance. It also requires new ideas to 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. In the coming spring, the Supreme Court is expected to rule on the constitutionality of the individual mandate, a key provision of the law that mandates all Americans to purchase insurance. Months later, voters will determine whether Republicans or Democrats will have control of the White House and Congress. Current and former healthcare officials are optimistic about changes that would reward healthcare providers based on patient progress rather than the number of tests and procedures they perform. Dr. Mark McClellan, who previously oversaw Medicare, Medicaid, and the Food and Drug Administration under President George W. Bush, stated that healthcare reforms have the potential to significantly impact healthcare costs in the long term. Innovations such as "bundled payments" and rewarding healthcare providers for successful outcomes while saving money were gaining momentum in the private market before the passage of the healthcare bill in March 2010. The law's efforts to implement these innovations in Medicare and Medicaid, which together spend about $900 billion annually to care for 100 million beneficiaries, have accelerated their adoption across the United States. The Center for Medicare and Medicaid Innovation, which is a year old, plans to develop approximately two dozen innovation models with private partners in the coming years. Experts believe that advancements in care delivery are important as they help healthcare providers deal with increasing cost pressures from employers and government agencies. Don Moran, a healthcare consultant in Washington who previously worked in President Ronald Reagan's Office of Management and Budget, stated that these innovations are driven by market demands rather than just reform efforts. The future of innovation in healthcare could be impacted by potential across-the-board cuts to Medicare and Medicaid after the November election, which may reinforce traditional fee-for-service healthcare. These innovations are at risk because they have not yet proven their ability to reduce costs, which makes it difficult for the Congressional Budget Office to assign concrete dollar values for deficit reduction. Gail Wilensky, who previously oversaw Medicare and Medicaid during the administration of President George H.W. Bush, is concerned that Congress may resort to the usual tactic of reducing payments to healthcare providers in order to address budget concerns. This could potentially lead to providers refusing to accept Medicare patients. She expressed these worries during a forum at the Harvard School of Public Health. Some experts believe that financial pressures may prompt the Obama administration to postpone certain aspects of the healthcare law, such as the establishment of state health insurance exchanges and the individual mandate for health coverage. Delaying the implementation of the law could lead to significant cost savings for the government and allow officials more time to establish exchanges, which have been developing slowly due to uncertainties caused by the Supreme Court case and the upcoming election. An administration official has stated that there are currently no plans to postpone the implementation of the law. Analysts believe that the election outcome is unlikely to determine the fate of the law, unless President Obama loses re-election. Even if Republicans gain a slim majority in the Senate, Congress is not expected to overcome partisan gridlock. It is possible for certain sections of the law, such as state insurance exchanges, to move forward even if the individual mandate is overturned in court, repealed after the election, 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. He cited Medicare Part D as a successful example, where early enrollment is rewarded and late enrollment is penalized. While acknowledging that state exchanges may be less effective without the individual mandate, McClellan noted that this could lead to deficit savings. However, there are currently no discussions or plans to use Part D enrollment restrictions as a substitute for the individual mandate.