Many health experts believe that innovations in medical care delivery and the establishment of state health insurance exchanges will continue even if President Obama's healthcare reforms are struck down or repealed. However, former healthcare policymakers warn that cost control measures could be jeopardized if arbitrary spending cuts are implemented in response to fiscal pressures. Dr. Don Berwick, former head of Medicare and Medicaid under Obama, cautioned against cutting benefits and Medicaid coverage, stating that it would worsen the situation. The Affordable Care Act aims to provide healthcare coverage to over 30 million uninsured Americans through Medicaid expansion and subsidized private insurance options in state exchanges. It also requires new ideas that could steer America's $2.6 trillion healthcare system, the most expensive in the world, towards incentives aimed at controlling costs. The law is facing strong opposition from Republicans and is entering a period of significant uncertainty. The Supreme Court is expected to make a decision on the constitutionality of the individual mandate next spring, which is a critical component of the law that mandates all Americans to purchase insurance. Later on, voters will determine whether Republicans or Democrats will control the White House and Congress. Current and former healthcare officials are optimistic about changes that would reward healthcare providers based on patient outcomes rather than the quantity of tests and procedures they perform. For a panel discussion on the topic moderated by Reuters at Harvard School of Public Health, visit www.ForumHSPH.org. Dr. Mark McClellan, who supervised Medicare, Medicaid, and the Food and Drug Administration under President George W. Bush, stated, "These reforms have the potential to significantly impact healthcare costs in the long term." Various innovations, such as "bundled payments," establish cost goals for specific conditions that teams of doctors must achieve. Some innovations also incentivize healthcare providers to keep patients healthy and achieve successful outcomes while saving money. These innovations were already making an impact in the private market before the healthcare bill was signed into law by Obama in March 2010. The momentum of these innovations has accelerated across the United States due to the law's efforts to implement them in Medicare and Medicaid, which collectively spend about $900 billion annually to provide care for 100 million beneficiaries. The Center for Medicare and Medicaid Innovation, which is a year old, plans to develop around two dozen innovation models with private partners in the coming years. According to experts, innovations in healthcare delivery are important as they help providers deal with increasing cost pressures from both employers sponsoring health insurance and government agencies trying to reduce spending. Don Moran, a healthcare consultant in Washington who worked in President Ronald Reagan's Office of Management and Budget, stated that these innovations are a response to market realities rather than just reformist interests. The future of innovation in healthcare could change significantly after the November elections if Washington decides to address deficits by making cuts to Medicare and Medicaid that support the traditional fee-for-service model. However, these innovations are at risk because they have not yet demonstrated a track record of cost-cutting that could be quantified by the bipartisan Congressional Budget Office for deficit reduction. Gail Wilensky, former head of Medicare and Medicaid, is concerned that Congress will reduce payments to healthcare providers, potentially leading them to stop treating Medicare patients. She believes this short-term solution may not be in the best interest of senior citizens. Some experts suggest that financial constraints could prompt the Obama administration to postpone certain aspects of the healthcare law, such as state health insurance exchanges and the mandate for individuals to have health insurance. Delaying the implementation of the law could result in significant cost savings for the government, allowing officials more time to establish exchanges that 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 no current plans to postpone the implementation of the law. Analysts suggest that the election may not significantly impact the fate of the law unless President Obama is not re-elected, as partisan gridlock in Congress may prevent any major changes even if Republicans gain a slight majority in the Senate. 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 by political and budget constraints. McClellan suggested that rather than mandating insurance purchases, the government could implement voluntary rules similar to Medicare Part D, which offers rewards for early enrollment and penalties for late enrollment. Although state exchanges may not be as strong without the individual mandate, this could lead to savings. There are currently no discussions about using Part D enrollment restrictions instead of the individual mandate.