Body Blow or Flesh Wound? Mandate Delay Hurts Access

The big news of the week was the delay of the employer mandate in the Affordable Care Act, which required businesses of 50 or more employees to offer affordable health insurance for someone who works at least 30 hours a week or face an annual penalty.  The Obama administration acted abruptly in its announcement to push the mandate back one year to 2015 and beyond next year’s midterm election.  It was explained that businesses needed more time and clarification on the rules in order to properly comply with the new requirements (i.e., many business owners/leaders were incredibly unhappy with these provisions).

The action by the Administration does not technically postpone other central provisions of the law.  Yet, it does question if other central tenets–like the health insurance marketplaces in the states–will be ready by January 1, 2014.  Whether the employer mandate continues to morph from its current form or simply be delayed, it is certain that this action by the Administration will reduce the number of uninsured people who will gain coverage, if for the short-term.

And, if you were to take stock today of the healthcare reform in terms of access, you would see varying success on a state-by-state basis, particularly as it related to the expected participation in the new health insurance exchanges (From October 1, 2013 onward, Americans who do not have affordable health benefits through a job will be able to get insurance through new health insurance exchanges or marketplaces.)

According to the Commonwealth Fund
, 16 states will operate their own state-based marketplace, with the remaining 34 states having a federally facilitated marketplace.  In states like California, 13 carriers have been approved to sell insurance.  Some states are going a step further and putting resources towards publicizing the new marketplaces–Minnesota has started a call center and Colorado awarded $17 million to have 58 partnering organizations help enroll people. Contrarily, in other states, you see little support to promote the exchanges and encourage insurer participation.  In Mississippi, for example, only one insurer has applied to sell through the marketplace (worse yet, 36 of the state’s 82 counties have no insurer).

For us in Georgia, the Governor and Republican leadership did not elect to expand Medicaid nor run a state-led marketplace.  Seven health insurers in Georgia–Aetna, Alliant, Blue Cross of Georgia, Coventry, Humana, Kaiser, and Peach State–have signed up to offer insurance on the exchange.

What has been interesting has been the steps the White House has taken in the background to win support.  It is estimated by the Urban Institute that 5.7 million uninsured adults with incomes below the poverty line, who otherwise would have gained coverage under the Act, live in a state that is not expanding Medicaid.  In places like Florida and Texas that blocked Medicaid expansion, the Administration has begun to reach out to citizens directly. As noted by the New York Times, the White House is focusing on Hispanics, who are much more likely to be uninsured, to educate them about the insurance exchanges and encourage enrollment.  And in many cases, local counties who have legal obligations to help pay for care are listening.  They see the marketplaces as a means and a promising opportunity to reduce costs and improve the health of the uninsured, who frequently use the emergency departments as their primary source of medical care.  (And it isn’t just Democrats who are exploring such options in these states).
The biggest opportunity of the Affordable Care Act to improve the well-being of all Americans is to expand coverage to as many of those who currently lack health insurance.  The delay of the employer mandate slowed the universal access train; it was not a fatal blow.  I am confident other measures of the Affordable Care Act like the exchanges will have a large impact in improving access.  Yet, more needs to be done today by the Administration than roundabouts to unobliging state governors and business leaders, particularly as it comes to Medicaid coverage.  Hopefully, this week’s news will be a wakeup call to double down and prove the case to businessman, Congressmen, and Americans why access is so critically important to a healthy population and more cost efficient health system.

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