In 2012 most of the big questions surrounding the Affordable Care Act (ACA) were answered in 2012. The biggest questions were settled with the Supreme Court ruling in June and the election results in November. Those two events determined that the ACA will be the law of the land and will shape the future of the health care financing and delivery system. The actual shape of the health care delivery system will be determined in 2013.
In the coming months decisions by HHS, the State of Georgia, insurers, and providers will determine access to care, the cost of health care, and the health of the population.
The largest decision with respect to access to care will be the states choice on Medicaid expansion. If the state participates in Medicaid expansion the percentage of Georgians without health insurance will fall from 22 percent to less than 9 percent. Without Medicaid expansion the ACA reduces the uninsured to about 18%. Medicaid expansion is expected to cover between 600,000 and 1 million Georgians.
Financing care for those uninsured Georgians without Medicaid expansion will continue to be borne largely by state taxpayers and consumers in the form of higher prices for health care services and health insurance premiums.
Medicaid expansion and the increased coverage through the exchange will stretch the capacity of the health care delivery system. A back of the envelope estimate indicates that Georgia will need over 400 primary care physicians to ensure access to care. That estimate assumes that the way health care is delivered does not change.
Providers have been working diligently over the last few years in adapting systems of care to the changing financing environment. A major thrust of this change is developing new ways to provide primary care. The development of patient centered medical homes, integrated systems of care and accountable care organizations alter the physician-patient relationship and encourage the use of alternative providers of primary care. The potential for increased access to care increased insurance coverage combined with greater efficiencies in the delivery of care will be determined by the regulatory decisions made by the state and HHS in 2013.
The costs of insurance coverage will be affected by the operation of the health insurance exchanges. The operational details for the exchanges and division of regulatory authority between the state and the Federally operated exchanges will be determined in the first half of 2013. Those details will determine the participation of insurers within the exchange, the amount of risk sorting that occurs among plan types and offerings, and the actual price of coverage to consumers.
The cost of care will be determined by the efficiencies encouraged by competition in the health insurance exchanges, by increased coverage, and by public program reimbursement. Lack of access to coverage without Medicaid expansion may increase costs and reduce provider’s ability to make systematic changes that increase efficiency.
Finally, the health of the population will be determined not only by access to affordable health care services but importantly by the success or failure of the population health measures contained in the ACA. Those measures affect the plan design of newly available coverage, the organization of health systems, and broad population initiatives aimed at chronic illnesses. The operational details of those programs will be revealed in 2013.
The amount of operational detail necessary to met the goal of fully implementing the ACA on January 1st, 2014 means that 2013 will begin with flood of decision-making on regulations and rule making and end with insurers, providers, regulators and consumers frantically trying to understand and adapt to the changes wrought by the decisions made in the beginning of the year.