Keeping Score

Is the Affordable Care Act a disaster, another step in the evolution of health care or a godsend? Well, the answer still is unclear, but that hasn’t stopped analysts of all stripes from trying to assign a score, or at least an adjective, to the law. In fact the law, three and half years after its passage, is still at least a year away from full implementation.

Information technology troubles lead to the postponement until 2015 of the requirement that employers offer affordable coverage or pay a fee and a reduction in choice in the SHOP exchange for small employers. Under the law employers with over 50 employees who did not offer coverage were subject to pay a fine for each employee (after the first 30). Employers who offered coverage that was deemed unaffordable paid a fine for any employee who received a subsidy in the exchange. The difficulty of developing the appropriate information technologies to allow that choice have forced SHOP exchanges run by the Federal government to delay employee choice for at least a year. Both of those delays effect the employer’s incentives to offer health insurance .

The June 2012 Supreme Court ruling made the expansion of Medicaid optional for states. Georgia, and 25 other states, do not plan to implement the expansion for 2014. In Georgia that means between 400,000 and 500,000 individuals will remain uninsured in 2014. Given the amount of money and resources Georgia gives up by not expanding Medicaid it seems likely this is viewed as a delay for in implementation for 2014 rather than a permanent rejection.

So given these delays in access to coverage how should we evaluate the performance of the Affordable Care Act in October 2013? One measure is surely the number of people who are directly affected by the law: those who gain coverage or participate in the health insurance exchanges.

The ability of parents to include children under the age of 26 on their health plans has lead to 2 million young adults gaining health insurance . That addition coverage increased the costs of employer-based family health insurance by about 2 percent, although that last two years have seen the smallest increase in premiums for any two years in the 21st century.

Open enrollment for the exchanges tried to start October 1st, but poor IT coordination, bad system design, and uncoordinated decision making contributed to a faltering and failing website that made enrollment difficult if not impossible for those states with a Federally operated health insurance exchange. There were similar but considerably less troublesome glitches in states what were running their own websites.

Prior to the opening of enrollment in the exchange most of the analysis focused on the number of plans available in the exchange and the premiums offered through the exchange. The results suggest that for nationwide and in Georgia, metropolitan areas had sufficient competition to keep premiums comparable to those offered by group plans.

There has been a great deal of confusion on this point that has been created by political analysis and politicians themselves. This confusion was compounded by the choice HHS made in designing the website not to let individuals compare plans until they have fully enrolled in the website Healthcare.gov. That chioice created a bottleneck in the application process that prevented most people from being able to enroll. HHS chose that sequence because they were afraid that people would mistake the premium for their total costs if they couldn’t simultaneously see their eligibility for a tax subsidy.

They created a workaround last week so that individuals can see the range of plans available to them and get some notion of the premiums. They aren’t the exact premiums because this part of the website gives the premiums in age ranges rather than the specific premium by age. Readers can access this part of the website and compare plans here: https://www.healthcare.gov/find-premium-estimates

In states that operate their own exchange there has been a steady enrollment for coverage within the exchange, over 42,000 in those states compared to only about 5,000 in the states with a Federally run exchange. These numbers are far too low to have a significant impact on health insurance coverage or even to create a sustainable exchange, but it is 2 months before enrollment closes for coverage starting January 1st, 2014 and 5 months before enrollment for 2014 ends.

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