The Congressional Research Service (CRS) has compiled the states’ estimates of the costs of complying with the provisions in the health care law and found that the numbers vary drastically depending on the generosity of the existing programs, state decisions about implementation, and the the number of uninsured who sign up for coverage. The federal government has yet to issue regulations surrounding the state exchanges and states can only estimate how many applicants will actually enroll in the expanded Medicaid programs. Below are some of the early projections:

California: low billions of dollars, Florida: $1.2 billion by 2019; Indiana: $3.6 billion; Kansas $621 million; Maryland: Savings of $829 million; Michigan: $200 million; North Dakota: $1.1 billion; Texas: $27 billion;

Ultimately, I’d argue that reform is still a pretty good deal for the states: they will be able to cover a large number of residents at little direct cost. The law provides states with a lot of extra cash, insures more residents and — consequently — allows states to reduce payments they make to support uncompensated care costs. Significantly, the federal government picks up a large part of the tab for these reform. States will receive grants to establish their exchanges and have full federal funding to expand Medicaid for the first two years (with a decreasing contribution thereafter). The federal government also fully finances the payment rate increase for Medicaid providers for two years and provides states with a series of grants from rate review to reinsurance. CBO estimates that states will have to spend some $20 billion (just 4% of the total cost) to implement the coverage provisions for Medicaid and CHIP between 2010 and 2019 and the Kaiser Commission on Medicaid and the Uninsured reached a similar conclusion.

It’s also worth pointing out that states will have a good deal of flexibility in how they implement reform. As the report notes, “a state may opt to have HHS establish its exchange,” can set-up separate exchanges for individuals and small businesses, or establish just one exchange for both. Individual states also may decide to allow large businesses in the exchange.”

In 2010, Sen. Chuck Grassley (R-IA), like the rest of the Republican Party opposes the individual health insurance mandate. He believes that the provision violates the 10th amendment of the Constitution and argues that only states have the authority to require their citizens to purchase coverage.

But this wasn’t always the case. In 1993, Grassley proposed an alternative to President Bill Clinton’s health care initiative that required every American to purchase health insurance coverage. He endorsed the mandate in 2007 when he co-sponsored the Wyden-Bennet health care plan and even backed the idea as recently as 2009.

Today, when Grassley’s Democratic challenger Roxanne Conlin confronted the Senator with his record, Grassley explained that his thinking on the mandate changed in April or May of 2009:

Grassley responded: ”My name was on a bill in 1993, but there’s a lot about the constitution you learn over the period of the next 15 years and I’m not a lawyer, but I do read the constitution. I do read some of the laws and I came to the conclusion that it’s unconstitutional, just like the attorney generals of about 22 states.” [...]

After the program, Grassley told reporters it was in April or May of last year that he changed his mind about requiring Americans to buy health insurance just like drivers are required to buy insurance on their vehicles. ”And then you have people raise the question, ‘Well, where is it in the constitution that you have to buy anything?’” Grassley said.

Grassley is confusing his dates, because he expressed support for the policy as recently as August 2009. Asked “how does this bipartisan group that you`re a member of get to more health insurance coverage if you don`t mandate that employers provide coverage,” Grassley replied “through an individual mandate and that`s individual responsibility and even Republicans believe in individual responsibility.” Here he is expressing that very belief in June of 2009 on Fox News Sunday:

Now, Grassley’s explanation mirrors the thinking of fellow Republican Orrin Hatch, who after years of supporting the policy also confessed that constitutional study (and apparently Obama’s election) changed his mind.

This morning, ABC News’ Jake Tapper asked President Obama about a recent CMS report which found that health care spending will increase slightly faster than projected — at an annual rate of 6.3 percent, rather than 6.1 percent. Obama began by saying that “bending the cost curve on health care is hard to do,” and admitted that the administration expected that annual spending would increase as the newly uninsured enter the health care system:

TAPPER: CMS study from February predicted a 6.1% increase and now post health care, 6.3%, so it seems to have bent it up.

OBAMA: As I said Jake.I haven’t read the entire study, maybe you have. But, you know, if what the reports are true, what they’re saying is that as a consequence of us getting 30 million additional people health care at the margins that will increase our costs, we knew that. We didn’t think that we were going to cover 30 million people for free. But that the long-term trend in terms of how much the average family is going to be paying for health insurance is going to be improved as a consequence of health care. And so our goal on health care is, if we can get instead of health care costs going up 6% a year, it’s going up at the level of inflation and maybe just slightly above inflation, we’ve made huge progress.

Watch it:

Ezra Klein tweeted that Obama should bring charts to his pressers, and I agree. Because if you actually look at the graph in the CMS report, you’ll see that while the cost curve does go up during the period of coverage expansion, once the cost savings and efficiencies kick in, the cost curve actually goes down.

Beginning in 2014, as 30 million+ individuals begin receiving health care coverage and visiting doctors, health care expenditures will naturally increase. Costs will continue to grow higher than current law until around 2015, at which point the Medicare savings, the excise tax on so-called Cadillac health plans, and the Medicare payment board will cause costs to “decelerate.” As you can tell from the graph, between 2017 and 2019 the red line is below the blue line — the annual growth rate is decreased under reform for that period.

Look:

The graph suggests that if Congress maintains the efficiencies in the bill, the so-called cost curve will continue to decrease and more can be done to bring it down lower and faster. For more ideas on that, check out this RAND Corporation study on options for lowering health spending.

When I debated him last year, Rep. Mike Burgess (R-TX) — the chairman of the Congressional Healthcare Caucus — insisted that tort reform presented one of the best solutions to lowering health care costs. But now, in light of a new study which finds that malpractice adds just 2.4% to health spending, Burgess may be softening his rhetoric — and if that’s any indication of where the party is as a whole, it may suggest that the GOP is willing to reconsider its favorite cost prescription.

Healthwatch’s Mike Lillis has the story:

Rep. Michael Burgess (R-Texas) argued that the cost of malpractice to the healthcare system is “a huge sum of money,” but also conceded that limiting malpractice claims won’t translate into instant healthcare savings.

“Defensive medicine is a learned methodology, and one that cannot be unlearned quickly, and I believe this contributes significantly to the reason why costs do not decrease quickly and steeply immediately after medical liability reforms are passed,” he said in an e-mail. “Our nation’s healthcare system is very complex, and I have never suggested that medical liability reform is a silver bullet.”

The authors of the new Health Affairs study point out that “physician and insurer groups like to collapse all conversations about cost growth in health care to malpractice reform, while their opponents trivialize the role of defensive medicine.” Burgess is both a physician and a Republican. He’s from a state that has capped non-economic damages but has seen no corresponding decrease in health spending. When I debated him, he (like the whole of the GOP) insisted that caps should be a big part of the solution. These statements seems to be far more reflective of the literature.

The health care law does try to address malpractice costs. It “includes some pilot programs to test alternative systems for settling malpractice cases” and while those projects have been authorized but not yet funded, HHS has distributed $20 million in development grants and planning grants “to states and health care systems” developing ways to reduce malpractice costs. My sense is that it’s easy for politicians to argue that the government can or should do more on this side of reform and it probably should. But providers also have a responsibility to begin adopting innovative solutions (i.e. Sorry Works programs) without waiting for lawmakers to act. The hospitals that received the HHS grants are leading the way in testing successful alternative models and if the GOP is really moving away from its caps-centric focus, it’s the kind of programs Republicans and Democrats can both champion.