Despite being signed into law last year, the Affordable Care Act (ACA) has continued to be a point of debate for government officials, political pundits and medical professionals.

As Gail Wilensky, PhD, of Project Hope and Rita Redberg, MD, MSc, FACC, Department of Medicine, University of California, explain in an editorial published June 2 in JAMA Internal Medicine, a number of challenges still lay ahead for the U.S. and its reformed health care policy.

One of the biggest challenges is the actual implementation of the ACA. "Enrollment was not supposed to be the big challenge for the ACA, although that has turned out to be the case," write Wilensky and Redberg. "Getting services to the insured and the effect of increased insurance on population health are the clear justifications for the ACA." Unfortunately – as many Americans are already aware – one of the leading setbacks of the ACA was in the roll out of the healthcare.gov website and the mixed experiences with various state exchanges. Because of the site’s unreliable functionality by December 2013, only 2.1 million people managed to secure enrollment in the program. While this number has risen to 4 million as of early March, Wilensky and Redberg insist that "the lower-than expected enrollment raises concerns that those enrolling will be older and/or higher users of services. This could raise premiums for 2015 or discourage some insurers from continuing or expanding their ACA enrollment offering. Initial reports confirm this concern. As of early February 2014, approximately 25 percent of the enrollees were aged between 18 and 35 years, compared with the 38 percent to 40 percent share for this age group that had been anticipated." Facing their own kind of difficulties are Medicaid enrollments, specifically the accuracy of information that has been transferred from the federal government to the states. Currently 25 states have chosen to expand their Medicaid programs, essentially making 5 million people who would otherwise have been eligible uncovered. According to Wilensky and Redberg, the early effects of the ACA on employer-sponsored insurance are also likely to be important throughout the year, as smaller employers (those with 100-250 employees) are likely to be told that the policies they have been offering no longer meet the ACA’s requirements and are not eligible under any grandfathering provisions.

Other challenges that may prove to be a thorn in the side of the ACA’s future is the spending limit for Medicare physician services, better known as the sustainable growth rate (SGR). For years Congress has delayed a decision to address the issue, particularly since $140 billion in other spending cuts would have to be found if the sustainable growth rate were removed. Bipartisan legislation introduced in the House and the Senate would repeal the SGR and would provide larger increases in rates to physicians who participate in alternative delivery systems that improve "value," reducing payments to physicians who cannot demonstrate improved value or efficiency.

The new classification of hospitalized Medicare beneficiaries to inpatient or observation status also has complications, resulting in major implications for billing and revenue. According to the Centers for Medicare and Medicaid Services (CMS), only Medicare beneficiaries classified as inpatients are covered by Part A hospital insurance and covered for subsequent care in a skilled nursing facility after three days of hospitalization. The established two-midnight rule states that inpatients are defined by being in the hospital for at least that time. While CMS eventually postponed enforcing financial penalties if patients are misclassified, there is still the statutory Recovery Audit Contractor program, created by the Tax Relief and Health Care Act. Though designed to help CMS find and reduce fraud and abuse, contractors of the program are paid a percentage of the fraudulent monies they uncover. This consequently puts hospitals at risk of overzealous contractors evaluating assignments of a beneficiary to inpatient or observation status. As hospitals are forced to appeal these determinations, it creates an increased workload that is entirely unrelated to patient care.

Yet another challenge foreseen by Wilensky and Redberg is the unique device identifier (UDI), a specified number assigned by the manufacturers to a version or model of a device. As the UDI looks to provide production-specific information, including the product’s lot number and manufacturing and expiration date, the U.S. Food and Drug Administration hopes to implement a publicly searchable database of the UDIs, which could be searched for a given device to understand its background and history.

Finally, Wilensky and Redberg discuss the Choosing Wisely program. Developed by the American Board of Internal Medicine Foundation, the program advocates for professional societies to post their top five procedures or treatments that patients and physicians should question or discuss before using. With many physicians thinking of new ways of incorporating these principles into their practices, the initiative is encouraging a better dialogue on improving quality of care.