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After ruling, Obamacare still a work in progress in Md.

Thursday’s Supreme Court decision was a win for supporters of the Affordable Care Act, but advocates and officials in Maryland — where consumers weren’t in danger of losing insurance subsidies —are still working to implement the law’s goals.

The cost of care remains high, improvements are needed to the state’s health insurance marketplace, and further outreach is needed to enroll the state’s uninsured, officials say.

“It’s great news that we’re not being diverted into a huge political fight over subsidies,” said Dr. Joshua Sharfstein, former secretary of the state’s Department of Health of Mental Hygiene and now an associate dean at the Johns Hopkins Bloomberg School of Public Health.

“[But] the fundamental challenge with health care is that it is too expensive and we don’t get great results as a whole. That’s not a Maryland issue, that’s a national issue,” Sharfstein said.

But Maryland is in a better position that many states to reduce costs, in part because of how the state regulates hospital revenues, he said.

At the beginning of 2014, Maryland adopted a new, global-budget system where hospital revenues are capped each year, giving hospitals and health systems a financial incentive to reduce costly and preventable hospital admissions by improving care outside of the hospital, Sharfstein said.

The state’s health insurance exchange, though plagued by technical problems when it launched in 2013, had a very successful second year, Sharfstein said.

But the exchange may not be pairing consumers with the best plans, said Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society. Many patients end up purchasing high-deductible, bronze-level plans, which mean they are still essentially paying out-of-pocket for many of their medical expenses, Ransom said.

Those costs means that despite having insurance, patients may still put off seeking treatment they need, Ransom said.

Of the 125,651 people who have enrolled in private health plans through the exchange since the last enrollment period began in November, more than 28,000 have signed up for bronze-level plans, according to data provided by the exchange.

About 70 percent of those who obtain coverage through the exchange do so online without assistance, and would benefit from more tools to help them determine if they are choosing a plan that’s the best fit for them, Ransom said.

“A lot of people don’t know what questions to ask,” Ransom said.

Officials hope to make more tools available for exchange customers within the next few years, said Carolyn Quattrocki, executive director of the Maryland Health Benefit Exchange.

Exchange users already have access to a quality rankings for health plans and a provider director, allowing them to see if their doctors are the network of a plan they’re considering, Quattrocki said.

But consumers would also benefit from tools being developed that will allow them to identify plans that cover a specific medication they’ve been prescribed and help calculate their out-of-pocket costs, she said.

Right now, some people may not realize they can get cost-sharing subsidies for some silver-level plans — which generally have higher premiums but lower deductibles — meaning they end up with a bronze plan when a silver is a better fit, Quattracki said.

“What we’re trying to do is improve and support consumer decision-making,” Quattrocki said.

Another troublesome issue, which Ransom says needs to be fixed in Washington, is the 90-day grace period during which patients must pay their premiums before coverage is dropped. Insurers are only required to pay for claims for services made in the first 30 days of that period, which puts physicians at financial risk for services provided during the remaining 60 days, Ransom said.

Quattrocki said her her agency will continue reaching out to the state’s uninsured residents, a population whose size can be tricky to estimate. But extrapolations from national data suggest outreach needs to be targeted at the state’s Hispanic and African-American communities, she said.

That outreach will also be a priority for advocates like the Maryland Citizens’ Health Initiative, said Vincent DeMarco, the organization’s president. DeMarco said the initiative planned to work hard to make sure those eligible for coverage get coverage; he also praised the high court’s decision to support the law.

“This is a great day for health care in America,” DeMarco said. “We’re thrilled about that.”