Democrats may have overstimated public enthusiasm for health care reform following passage of the Affordable Care Act in March (and underestimated the willingness of the opposition to move public opinion against the law). But they still believe that Americans will support reform once they begin receiving benefits in 2014. The first survey of consumers who receive subsidized health insurance in Massachusetts, which served as a model for national reform, suggest there is reason to be hopeful:

Eighty-six percent of those surveyed said they were pleased with the range of services covered and the quality of care available, while 82 percent had similar feelings about the choice of doctors.

The majority of patients — 81 percent — reported they had seen a doctor for regular care at least once since receiving coverage through the Commonwealth Care program, which is the state-subsidized health insurance program created for low- and moderate income residents under Massachusetts’ 2006 health care law.

The survey also found that some members did report experiencing challenges in scheduling doctor’s visits.

The state exchanges — or the new marketplaces for insurance — that will allow individuals and families to purchase comprehensive basic coverage will differ structurally from state to state, but these results may push more governors to consider the Massachusetts design. Federal regulators can also use the state’s high degree of satisfaction with the “range of services” to make some decisions about how best to structure a essential benefits package, which is widely seen as one of the biggest challenges in reform implementation.

During an Institutes of Medicine meeting in January, John Kingsdale — the former director of the Massachusetts Connector Authority — (Massachusetts’ version of the exchange) warned regulators against “overreaching” in detailing which benefits insurers will have to provide. “My experience suggests revisiting and learning from cases and some flexibility and even phasing in would all be very helpful as you go down the path of defining a minimum benefit that will be extremely controversial,” he said.

This morning, the Institute of Medicine began its second day of deliberations into defining what would constitute “essential health benefits” under the Affordable Care Act. Even though the law identifies general categories that insurers will have to cover beginning in 2014 — emergency services, mental health care, outpatient and inpatient care — these meetings are designed to help HHS reach more specificity on the issue. The agency is also required to ensure that the scope of essential health benefits “is equal to the scope of benefits provided under a typical employer plan.”

During this morning’s second session, John Kingsdale — the former director of the Massachusetts Connector Authority — predicted that defining “essential health benefits” will be “one of the more challenging parts in implementing the ACA” and warned the agency against “overreaching” in detailing which benefits insurers will have to provide:

KINGSDALE: The nation is highly divided by this and so whatever is put into the essential health benefits package that can be portrayed by those who tend to oppose ACA as unfairly burdening those employers or individuals, who want a different benefit package will be used as political fodder to tear down the ACA and I strongly believe that overreaching…could doom implementation. [...]

There is a tendency to think about benefits in the context of negotiation for something more someone else would pay for and I think it continually surprises people to understand, ‘oh there are real people who cannot afford what we consider to be an ideal benefit package and they actually have to pay for it in premiums. ….This was very much about giving people decent coverage as opposed to primarily a policy of it just being about raising the standards of coverage and it seems to me when you have to make close calls about benefits, it’s important to return to that principle. Secondly, obviously, most benefits cost dollars no matter what you will hear about how they will save money and that the ACA will live or die on affordability. And thirdly, that there is a fair degree of consensus about minimum benefit steps and so that you will find most states don’t even mention most of the things that are covered typically by commercial insurance and there are additionally very few benefits that significantly improve [inaudible] or save dollars. So, I think it’s not difficult to find that essential minimum benefits package and then, as you can tell from my other principles, I would advise you to be very conservative about adding on to it. [...]

My experience suggests revisiting and learning from cases and some flexibility and even phasing in would all be very helpful as you go down the path of defining a minimum benefit that will be extremely controversial.

Indeed, as CQ Healthbeat reported, it’s still unclear “if officials will seek a specific list of treatments or ask insurers to mirror benefits in particular plans, such as the Federal Employee Health Benefits Program.” Either way, they will have to balance Kingsdale’s suggestions with the concern that too loose of a definition would allow insurers to design plans differently — possibly even in such a way that would lead to adverse selection.

IOM will publish recommendations for HHS “by September, and HHS will issue its proposed rules by the end of the year, giving insurance companies time to adjust plans before the provisions take effect.”

Jonathan Cohn lays out the benefits of California’s new exchange legislation — currently sitting on the Governor’s desk — and suggests that insurers’ opposition to the measure probably means that the state is doing something right:

Under two bills that the California legislature passed and Schwarzenegger is apparently expected to sign, the state’s exchange authority would have explicit permission to “contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.” That mandate, combined with the bills’ other provisions, means the exchange authority would be able to negotiate pretty aggressively over price and quality, excluding plans that don’t serve consumers well. That’s more or less what corporate benefit departments and the managers of public employee programs, like the Federal Employee Health Benefits Program, do for their members.

The California model would follow the Massachusetts example, where the exchanges have the authority to include only the most efficient and quality-centric issuers into their connectors. Massachusetts has controlled costs for the expanded population (although costs have gone up in the entire system) and increased consumer satisfaction. Jon Kingsdale, the former director of the Massachusetts Connector Authority told Cohn that allowing any plan that hits minimum standards to sell in the exchanges “would be like telling your grocery store they have to offer every single kind of bread baked by every single bakery. … The exchanges would be nothing more than an automated Yellow Pages.”

And Massachusetts residents agree. For instance, focus groups conducted by the Massachusetts Connector revealed that consumers felt that too much choice was “confusing” and “overwhelming.” “Participants expressed a desire for a manageable numbers of plans (e.g. three to four) offered by four to six carriers. In addition, consumers expressed difficulty making plan comparisons under the existing model.” “Instead, consumers preferred for information to be presented in a simple and standardized format that clearly distinguished between different benefit design options,” the Connector’s Fiscal Year 2009 report concluded.

The for-profit insurers are weary that they may be excluded from the market and are asking the Governor to veto the bills. But the exchanges are one of the only ways states can protect consumers from plans that do not offer good value and cost-effectiveness. As Kingsdale explained to me during our interview in October, “We estimate that we’ve done about 6 percent reduction in premiums and saved about $140 million a year on subsidized care for about 180,000 people. Because we’ve been able to a) be aggressive in selecting and setting rules for health plans and b) set up an Exchange that translates the various costliness of their networks into a price that the consumer understands,” Kingsdale said. “The consumer doesn’t understand the price of a visit or the price of a procedure, or the price of an x-ray and can’t shop on that basis, but can shop annually for a premium, or monthly. And the trick with the Exchange is to translate the generators of cost and value and quality into a package called a health plan from which consumers have a choice and they have both funding but they are the price differences. And so with that program, we’ve been able to do it and have substantial impact.”

With 21 states suing the federal government over the constitutionality of health care reform and another 15 refusing to participate in the high-risk insurance pools, there is little to suggest that implementation will be any easier than the 15 month battle to pass health care reform. Nobody understands the importance and perils of implementation better than Jon Kingsdale, director of the Commonwealth Connector Authority. In today’s Boston Globe, Kingsdale outlines the lessons learned from implementing near-universal coverage:

1. It’s a campaign: In any successful campaign, continuous progress must be demonstrated and broadly communicated. In Massachusetts, we built partnerships with private and public groups, so that people heard and read about the law everywhere — at Fenway Park, in church, while shopping, or riding the subway. We launched this effort with the Red Sox, and held more than 300 educational forums across the state, the equivalent on a national scale of 15,000 outreach meetings. As a result, voter support for reform has remained high, ranging from 59 percent to 75 percent.

2. Adequate resources: The Massachusetts Legislature appropriately funded implementation with $35 million in the first year; the equivalent on a national scale would be $1.65 billion. Never were shortages of time, expertise, or resources allowed to stand in the way of meeting legislated deadlines.

3. Coordination: Somebody has to be on point to drive implementation across federal agencies and the other organizations needed to execute this undertaking. The Health Connector used multiple consultants and outsourcing strategies, while staffing up, to meet deadlines. With 50 states and far broader legislation, the federal effort will require a Herculean coordination effort.

4. Experiment and evaluate: This effort is new and not everything will go as planned. For example, running an exchange means offering customers what they want to buy, but that’s neither obvious nor unchanging. Massachusetts’ exchange is a learning organization. Key initiatives were launched as pilots, and we have not been afraid to revise them and try again.

5. Transparency: The biggest challenge Washington faces in “helping’’ Americans gain access to care is their distrust of government. Transparency is the antidote: making tough decisions in public; meeting endlessly with employers, unions, insurers, clinicians, and citizens; and both talking and listening out there, in at least 15,000 communities. These are essential to building trust.

6. Harness the market: State exchanges are essentially stores that sell insurance, combining government’s responsibility to protect consumers with a retailer’s need to serve customers. Brow-beating various industries may be good partisan politics, but the Health Connector has worked diligently at creating solid, long-term working relationships.

In other words, the get out the insurance enrollment campaign will probably be more important than the mandate penalties, Congress may have to appropriate more dollars for implementation, and lawmakers have to prepare for the reality that Congress can’t possibly “know enough to specify for every community, the exact design for care that is safe, effective, timely, patient-centered, equitable and sustainable.” They’ll have to allow regulators to experiment!

“The executive branch has 3 1/2 years to work with 50 very different states in bolstering popular support and executing effectively. That will require massive amounts of technical expertise and project management, combined with public outreach and creative communications,” Kingsdale writes, in what I suspect is a great understatement. But Kingsdale himself is not ducking the challenge. He has announced that he will step down from his position in June and while it’s unclear if he’ll come to Washington to lend his Massachusetts experiences to the national effort, he will likely remain an important source of “expertise.” You can read my earlier interview with him here.