Gail Wilensky is a health economist and a fellow at Project HOPE, an international health foundation. From 1990 to 1992, she directed the Medicare and Medicaid programs and also served in the White House as a senior health and welfare adviser to President GHW Bush. She's overseen several changes from a health care perspective and testifies regularly before Congress. Wilensky spoke with DOTmed News about the implementation challenges ahead for the law.

DMN: It seems like each week, there is some news about a little-noticed ruling in the Affordable Care Act or a loophole. For example, the other day, the New York Times reported that the law grants a one-year grace period to some health care insurers allowing them to set higher limits or no limit at all on some costs. Do you think these kinds of revelations will continue and what might be the consequence?

GW: I think that we are going to continue to see things like that. This next year is going to have lots of bumps in the road. It's not at all clear what is going to happen when Oct. 1 comes. And some of the protocols in the federal government exchanges, which may have not been tested as much as they should have, go online live. Or if it turns out that there are higher than predicted call volumes that come in — people don't know if it will be in tens of thousands or hundreds of thousands — whether the systems will be able to handle whatever volumes come or whether these various state exchanges will be able to function. But having said that, I like to remind people: don't take comfort that the Affordable Care Act is likely to go away because it's not. It's just likely to be a rocky bumpy road for the first year. This is way more complicated than anything I can remember getting involved with in my professional lifetime. I mean, it's way more complicated than the Part D prescription drug coverage benefit that was added in 2006.

There are many features of this that are only going to be understood in terms of how serious they are once they've been tried, but that doesn't mean the law is going away. It just means it will take some time to get this right. I like to remind some of my Republican friends of that.

DMN: For the most part, premiums on various state health insurance plans that will be sold in the new health exchange marketplace have been lower than expected. Do you think this can be sustained?

GW: I think it's nice that the premiums are lower than people thought they might be, but of course, you have to be careful. You have to look at what you're buying for some of those premiums, which may have, for an example, a substantial deductible or copay. So it might not be a premium for a very full benefit plan.

I tell people don't get too excited until you see what the next year's premiums are going to be because there is enormous uncertainty. I think the reason some of the big private companies have very selectively participated in the exchanges — and they have only selectively participated in maybe 8, 10, 12 of the exchanges — is because they are very concerned that there will be substantial adverse selection this first year. It will mainly be the people who are unable to go to the high risk pools or who have been actively trying to buy insurance in the past and haven't been able to who will be first in line. It's unclear how many of the unhealthy will show up this first year. It's very expensive to them [insurance companies], actuarially, by virtue of the rules that the administration put in place. So you'll know if after the first year it looks like the premiums were about right, then it's real. But until you actually have real live experience it's a crapshoot for everyone involved.

DMN: Do you think the administration will be able to meet its enrollment goals in order for the law to work?

GW: No. It's already made clear since the enrollment goal for the exchanges is now 7 million, which is about half of what it was when the legislation was passed. The "goal" will be a moving target. It's kind of ridiculous what they were saying early on as though it wouldn't take three to four or even five years to ramp up to some steady state. It clearly will. I guess in some ways it's a good thing because if the exchanges are going to get stressed with 7 million, it's hard to imagine what it would have done at 15 million.

DMN: What are some other funding issues the law is up against?

GW: Obviously, the Republicans in the House who remain primarily against this legislation are not eager to be helpful in providing additional funding where that might have helped it proceed more smoothly.

DMN: What's your overall view of the law? Are there certain things you think should have been included, or not included?

GW: I'm very supportive of the notion of getting more insurance coverage out. I am concerned about a number of the specific features of the exchanges — there are some that get quite technical. For example: requiring insurers in the exchanges to continue providing insurance for 90 days whether or not people are paying their premiums. It seems like an invitation for bad behavior and it's very different from the practice that exists in the commercial sector, for example, where you basically pay for the month as you go into the month, and if you don't pay after 30 days, your insurance is terminated. It also strikes me as something that will be up for revision.

We are fortunate that we are in period of lower spending growth that I think is heavily influenced by the deep, continuing recession. We'll know how much of it is not recession-associated when we get to the point of two to three years of robust recovery, but we are obviously not anywhere near that yet. And I would have liked to have seen more aggressive ways to take some of the innovations that are being sponsored by the innovation center and make sure that scaling and replicability are an automatic part of the process if they show initial promise in terms of improving quality and lowering costs. The secretary can do that but there is nothing that requires the secretary to do that. And given the history of even having promising demonstrations and pilots get lost over time, I'm very worried that the coverage and spending will happen but the improved efficiency will be much more unknown. Because what we've done now is commit to reimbursing less for Medicare. We haven't done anything to lower cost and those are very different activities that people get confused by.