The ACA was the political hot topic throughout 2013.
Multiple story lines emerged that were – and continue to be – focal points for and against the success of this landmark legislation. Now that the enrollment period is finally completed as of mid-April 2014, it is possible to look back and survey the main topics. How did things turn out? You may listen to Fox News or CNN, the Tea Party spokespersons or Nancy Pelosi and House Democrat leaders. We have summarized what we see as the main stories. We rank them in order of how HOT or COLD these stories are today at the start of the second quarter of 2014.
We have compiled a table of outcomes that were predicted for the Affordable Care Act. The debated outcome is in the center column. Positions pro and con are listed with a sample source for each side. The predictions are presented in order of their controversial temperature; that is, how HOT or COLD the topic is today at the start of the second quarter of 2014 after the initial data have been reported.
HOT TOPIC #1: Did a sufficient number of Millenials enroll? The economic viability of the ACA is predicated on having enough healthy young people in the premium-paying pool between ages 18 and 40. How many were needed? The target was 40% of total enrolled. The reported outcome has increased from 24% to 27% within months. We are gradually reaching our goal. This remains, in our view, the hottest topic and one that will remain vital in the coming year.
HOT TOPIC #2: President Obama announced in November 2013 that “you can keep your plan if you want it.” The White House had to scramble on this one because 6 million people lost their so-called “catastrophic” plans when the new minimum standards for ACA eligible health plans were clarified. What became clear was that 6 million insured persons lost their crummy plans while 8 million people were newly enrolled; a net overall gain. A related story was that premiums would generally increase. A recent OMB report estimates premiums will in fact decrease. Decreasing premiums also has its exceptional cases because states with low enrollments will likely see increases in premiums. The White House extended the deadline to dump non-conforming plans for a year, which cooled this story off a little… for a while. We expect the story will heat up again.
WARM TOPIC #3: Not enough people will enroll to make the ACA work. The target was 8 million and it was exceeded; California accounted for half! The next test will be whether enrollees pay their premiums. The number of estimated uninsured is between 30 and 40 million. Over the next decade these individuals must also be enrolled. 8 million is a very good start. Look for a new round of predictions for continued enrollment and the pace of enrollment especially around the Fall 2014 voting season.
NEUTRAL TOPIC #4: Will the Health Exchanges enroll enough people? The Health Exchanges are supposed to provide elective opportunities for citizens to change their current health plans (marking the end of catastrophic coverage plans which we refer to as “your money or your health”). This was the candy that incentivized insurance companies to offer conforming plans to would-be paying consumers; in other words the Health Exchanges encouraged greater competition among insurance plans. For many the concept of business competition among insurance plans was as incomprehensible as how reimbursements work (see Stephen Brill’s defining 2012 article). Many states with GOP governors elected to opt out of creating their own Health Exchange. The impact was to force residents in these states to enroll on the federal Health Exchange. Covered California is the largest state operated exchange and our enrollment was highly successful; 1.4 million new members under new plans. We believe this topic never got much traction the result of complicated essential questions: who is participating and who is not in terms of insurance companies, hospitals, and providers? With 13 insurance plans participating in the nation’s largest exchange –Covered California – enrollment was a sure winner.
COOL TOPIC #5: Are there enough providers to meet consumer demand? This is the “access to care” issue. According to an early LA Times article there were not going to be enough doctors to take care of the wave of newly eligible patients wanting services. It remains difficult to find information supporting the sufficiency position. Lawmakers in California have been working on expanding the practice scope of health professionals such as Physician Assistants, Nurse Practitioners, and Pharmacists. There are insurance plans with more physicians contracted than other plans which will surely lead to an imbalance of care for patients enrolled with fewer providers. What patients and analysts need to know is the ratio of contracted primary care providers and specialists for each plan. It will be awhile before we see those data.
COLD Topic #6: There appears to be considerable confusion and misunderstanding concerning participation of non-white persons, especially Latinos, in the health exchange. The overall enrollment goal has been met however, the national enrollment demographics are unclear. Slightly more than half of California’s population is Latino, yet only twenty-eight percent of enrollees in California have identified themselves as Latino. Outreach and education programs, in particular targeting Latinos, were late getting started. When these programs did get underway they may have helped account for the late surge in Latino enrollment over the final 60 days. As a population group Latinos are younger and more healthy. The participation of eligible Latinos in the ACA is critical to its success.
ICY TOPIC #7: The federal ACA website rollout was big news in the fourth quarter of 2013. It was the most talked about failure of the ACA. People were not able to enroll in healthcare plans. How could the government penalize would-be enrollees for not having insurance if it was not possible to login and sign up? Now that the initial enrollment deadline has passed, and the initial target has been reached, this story is colder than San Francisco in August.
Looking into the future we anticipate the following stories will provide plenty of material for the media and policy analysts in 2014.
What will be the follow-through on the 8.2 million who signed up? How many will actually pay their first premium? And how many will renew their enrollment come the October 2014 enrollment period?
How many new enrollees are projected in 2014-2015? With a target between 30 and 40 million over five years what is the White House enrollment forecast through 2018?
How will wait-times-to-be-seen by a physician – one form of access to care – and the availability of providers to see newly insured patients, play out? We expect to see more of these stories reported this Summer and Fall.
California is the mule team pulling this wagon. This bodes very well for California and the ACA. Some folks will be very unhappy about this. However, we believe more will be happy.
This article was prepared by Mary Bezjian and Steve Stumpf. Ms. Bezjian is a senior at California State University Northridge majoring in Health Administration.