It’s 12/12/12, and you know what that means. Time for the blog to kick back into gear after an self-imposed extended hiatus for professional growth. It’s as good a day as any to get the healthcare policy discussions going once again. Today’s characterizations may have much to do with fertility and fidelity (who knew?), but it is also a day to arbitrarily reflect upon where we are going in 2013 now that the creator of the biggest domestic policy accomplishment of the past 4 years heads into another term. As most who follow the healthcare policy space know, many of the more popular provisions of the ACA are already firmly in place.

The second phase of political and media scrutiny will come next year as eager states (like Minnesota) and not-so-eager ones (like Texas) place the government’s role in providing the infrastructure for health care exchanges up for all to discuss and follow. Should be very interesting to understand the level of commitment on states who are at the forefront of increasing access to healthcare for those for whom it would have been impossible without the law. The compelling characteristic of the marketplace provision of Obamacare is that there are many means to an end, and those means will be as varied as the participating states that implement them.

On the recalcitrant side, states like Mississippi, Texas, Oklahoma, and most recently, Tennessee; don’t have much skin in the game now, but as 2013 unfolds, look for cracks in their unwillingness to accept crucial aspects of federal involvement as the reform law unfolds. Proclamations of defiance against the SCOTUS-approved decision on eliminating mandated state Medicaid expansion provisions under the ACA by these and other states, for example, might cause difficulties in maintaining hospitals — the high-revenue jewels in the crown for many health systems — and the acute care they will have to provide to the suddenly swollen rolls of beneficiaries under the ACA.

All in all, with respect to health policy, Obama is looking to craft his legacy. Seems like he may have the upper hand with historians who choose to link increased access to care, efficient care, and decreased healthcare costs over the next 10 years with those states that choose to take this path with him. Will the (mostly red) states follow suit? Check back in a year.