In the year since the federal health care reform law was passed, it has drawn a mixed reaction from Americans — including a court challenge from 20 states and efforts to cut funding by their representatives in Congress.
But little of this seems to have spilled over to Maryland, where officials have embraced the act's provisions and moved aggressively to ensure that residents gain access to new benefits. They also have taken a leadership role in preparing for an influx of newly insured.
"Maryland is in a group of states that really wants to implement the law effectively and sees enormous potential here," said Dr. Joshua M. Sharfstein, secretary of Maryland's Department of Health and Mental Hygiene. "There's potential not just to expand coverage but to get a grip on costs."
Supporters such as Sharfstein point to reform's impact: seniors who have begun receiving prescription drug rebate checks, young adults who can remain on their parents' policies until they are 26 and small businesses that can use tax credits for insurance.
They look forward to the exchanges where the uninsured will shop for affordable coverage beginning in 2014. And they point to the nonpartisan Congressional Budget Office estimates that the law's repeal would cost the U.S. Treasury about $230 billion over a decade.
The enthusiasm for expanding coverage in Maryland, where about 700,000 people —13 percent of the population — are uninsured, didn't begin with the federal effort. Officials moved on their own to add about 250,000 children and their parents to the rolls in recent years, largely by expanding the federal-state Medicaid program. The state had also already offered some small-business tax benefits and required insurers to cover young people through their parents' policies.
"At the end of day, it's about a healthier community," said Lt. Gov. Anthony Brown.
But support for the federal law is not universal in Maryland — and certainly not nationally.
Congressional opponents, who deride the law as "Obamacare," say the CBO estimates use accounting gimmicks. They estimate that the law will add $701 billion to the deficit in a decade and cost 1.6 million jobs. Meanwhile, challenges by some states have found some receptive judges, and the Supreme Court is expected to ultimately decide the matter.
Del. Anthony O'Donnell, the Republican leader in the Maryland House of Delegates, has said he believes state officials should hold off on implementation until the fate of the law is decided.
In the meantime, one Rockville contracting business owner believes that the law is already costing him more money. Scott Harding, president and chief executive of F.B. Harding Inc., attributes at least some of this year's premium increase to the law. He pays all of his 47 employees' premiums and will continue until it becomes unaffordable.
"It's no surprise because mandates or regulations never make costs go down," he said. "And the larger point, about our future, it adds a lot of uncertainty for us. Uncertainty is bad for business and job growth."
Many conservatives are looking to Congress to rescind funds already allocated for the law, or to the courts to strike it down. That includes Earnest J. Istook Jr., a former GOP congressman from Oklahoma who is now a fellow at the Heritage Foundation.
Istook says 85 percent of Americans who mostly have coverage through their employers will pay more to help cover 32 million uninsured. Medicaid will be expanded, but federal subsidies will end eventually and leave the states and their taxpayers "on the hook" again, he said.
Supporters acknowledge that costs must be brought down for the system to work. But Sharfstein said that "access to health care and cost savings don't have to be mutually exclusive."
He points to programs that can improve care and cut costs in Maryland, some encouraged or funded by the federal government as part of the reform law. Those efforts include a pilot that pays primary care doctors extra to keep their patients healthy and out of the hospital.
One person who has benefited from the law says the health reform debate shouldn't be solely about costs. Jamal Lee, a Baltimore resident and owner of a four-person Laurel audio production and lighting company, says he was "disgusted" that he couldn't afford insurance.
He recently bought coverage for his Breasia Studios employees for about $170 a month per employee using federal benefits. Past quotes were for $400-$600 per employee and not affordable, he said.
In general, Lee says, health care reform means no one goes bankrupt because of an illness or has to work into retirement to pay for care.
"If I'm able to provide health care to my employees, they will be happier and healthier and maybe working harder," he said. "Maybe this becomes a more attractive place to work, and because this benefits my bottom line, it allows me to create a new position."
And those on both sides of the debate will be watching to see if he does.