Brendan Benner, a spokesman for the Medical Device Manufacturers Association, said companies are making marketing and sales decisions based on what they expect to happen, but that presents problems. "When you don't know what the answer to the question is, it's hard to make a decision," he said.
Between 2014 and 2019, the government will cut $36 billion from the money that goes to hospitals that treat large numbers of poor patients. The cuts were included under the rationale that many currently uninsured patients would be covered either through the Medicaid expansion or through subsidized insurance.
The administration has to figure out how it will allocate those cuts among hospitals — a task made more complicated by the Supreme Court ruling that allows states to opt out of expanding Medicaid. On the one hand, hospitals in states that don't expand Medicaid will continue to serve a crush of uninsured patients, so they will want more federal support. On the other hand, experts note, the government doesn't want its policy to reward those states by ponying up more money to soften the blow.
"It's a paradoxical situation," said Chip Kahn, president and chief executive of the Federation of American Hospitals. "In states that choose not to do the Medicaid expansion, they're going to still have the uncompensated care, and those people are still going to go to hospitals."
For the administration, some of the trickiest decisions concern how insurance policies must be designed, priced and sold starting next October, when open enrollment begins for the new online exchanges that will offer plans to individuals and small businesses. For instance, the law allowed insurers to alter their prices for people based on age, family size, where they live and tobacco use. The Department of Health and Human Services has to determine how insurers can go about setting those prices.