March 31st marked the end of open enrollment for Year One of Obamacare with 7.1 million Americans signing up for health plans using federal and state health insurance marketplaces. While these enrollment numbers exceeded the Administration’s target of 7 million, it’s far too soon to mark down this first year as a success. In fact, we’ve rounded up a bevy issues to keep on your radar over the coming months and years whether you are one of those 7.1 million who enrolled, are someone who chose to sit this one out, or just have an intellectual curiosity about the future of this landmark – and controversial – law.
Impact on the Uninsured: Driven by a recession and rising unemployment, the number of uninsured Americans was climbing to historic levels as President Obama took the White House and Congress began seriously considering health reform legislation. These trends provided considerable fuel for the ultimate passage of the law. According to the U.S. Census, 48 million Americans (or 15.4 percent) were uninsured in 2012. While the list of goals of the Affordable Care Act (ACA) arguably goes on and on, one key yardstick of success will be the number of Americans that remain uninsured after this initial year. We explored here and here how definitive numbers may be a long time coming, but over the course of the next several weeks and months, the Administration and others will inevitably try to make their interim estimates. One thing is certain: The uninsured rate will never reach zero. While some may blame a lack of knowledge, one recent poll indicates that half of the uninsured will choose to remain uninsured despite knowledge of the requirements of the law.
Health Care Access: Despite the political rhetoric, insurance doesn’t equate to access. The issues that impact access comprise a veritable laundry list. Chief among them is whether covered individuals actually choose to access their benefits. During the ACA debate, we heard that our system in America had become one, not of health care, but of sick care – only treating patients’ ailments rather than incentivizing and focusing on prevention. It was for this reason that the law requires that all health plans cover 15 preventive benefits at no charge to patients – whether or not the plan was purchased through an exchange. Of course, the onus remains on patients to actually use those benefits, and we all know it’s much easier to drag yourself to the doctor when the need is eminent than to make time for a little check-up. Furthermore, according to a March poll, only about 43 percent of people even know these benefits exist – despite being available since late 2010.
Another important issue affecting access is the availability and accessibility of health care providers. We’ve long heard about provider shortages – particularly in primary care and rural areas. Additional demand from individuals insured for the first time and those with newly available benefits will surely exacerbate these issues. On top of this, we’ve heard account after account that many of the plans being offered on the exchanges are keeping their prices low by offering narrow and restrictive provider networks. In fact, new rules from the Administration for 2015 plans are requiring the inclusion of more safety net providers. Over the next few months and years, we will surely hear of – or perhaps even experience it ourselves – the result that these dynamics may have on access to health care.
Health Care Costs: During the health reform debate, many argued that the first step to reform should be to address rising health care costs and that universal coverage couldn’t survive on an unsustainable foundation. Health care costs have been taking up a growing share of our national GDP – with growth exceeding inflation for over four decades. While there’s little-to-no agreement on the best way to address these costs, there’s no arguing that they impact families’ ability to purchase insurance and access health care more than any other single factor. The fact of the matter is that Democrats had one opportunity to make universal health coverage a reality, and they weren’t going to waste it with a piecemeal approach. Having said that, the law includes a number of elements aimed at reforming how health care is delivered towards the end of shifting incentives and ultimately slowing down costs. We’ve written about how the Administration is taking steps to test new approaches. Of course, such fundamental changes to a system as big, fragmented, and independent as ours will be painful and take significant time. We won’t likely see big impacts in this first year, but over the long haul, the success or failure of Obamacare will hinge on the ability of both federal programs and private health insurers to incentivize and even compel providers to rethink the way they deliver care.
State Medicaid Expansion: Another big issue in the coming months will be the future of Medicaid expansion in the handful of states still on the fence. The health insurance expansions in the ACA were predicated on expansion of Medicaid coverage to all individuals below 138 percent of the federal poverty level. While the Supreme Court upheld the law’s individual mandate, it did say that the federal government could not withhold Medicaid funding from states that did not implement the ACA’s expansion. In doing so, the Supreme Court effectively made the Medicaid expansion an option for the states. While 27 states and DC moved forward with the expansion for 2014, 24 states did not. As a result, nearly 5 million Americans who would have qualified for Medicaid coverage do not have the Medicaid access envisioned in the ACA but are too poor to qualify for the subsidies available in the marketplaces. Five of these 24 states, however, remain on the fence for expansion in 2015 – including Indiana, Missouri, Pennsylvania, Utah, and Virginia. All eyes will be on these states in the coming months to help whittle away at the 5 million coverage gap into 2015.
Legal Questions: As highlighted above, some of the biggest legal questions surrounding the ACA are behind us, but a few important ones remain. We wrote about the challenges to the law’s requirements to cover contraception back in December. Arguments in these cases took place in late March, and the Supreme Court’s decision on these cases will be out in June.
More sweeping, however, are three recent challenges that the ACA doesn’t actually allow subsidies to be available for plans purchased through the federally-facilitated healthcare.gov by individuals in states who chose not to run their own exchanges. After two rulings by district courts in favor of the subsidies, arguments in the furthest along of the three cases reached the Circuit Court of Appeals – the last stop before the Supreme Court – in late March with a decision expected in June. An ultimate ruling blocking subsidies for healthcare.gov plans could essentially cripple the law’s ability to help low-to-middle income individuals purchase insurance in 36 states.
Next Year: With open enrollment for 2015 beginning on November 15th, information about next year’s plan offerings will be available before we know it, and this information will tell us a lot about how well the law is meeting some of its goals. In fact, the Administration’s guideline updates for its 2015 plan reviews are already revealing some weak spots. As we recently highlighted, these updates reveal that perhaps many lost access to need prescriptions, faced overly-restrictive provider networks, or felt that cost-sharing structures were discriminatory.
What’s more important, the number and prices of plans in 2015 will likely tell us a lot about how well the risk pool shook out in 2014. As we discussed back in November, not only the number of people but also the kinds of people that ultimately enrolled in a plan this year will be important drivers of the long-term sustainability and affordability of plans.
With so many moving pieces in a complex law set in the context of a complicated and fragmented health care system, there are dozens of standards by which the success (or failure) of Obamacare may be measured. So if you thought the last couple of years were exciting, buckle up, because we’ve only just begun!