Guest Blogger Professor John V. Jacobi - Post-Enrollment: Ensuring Successful Follow-Through for Health Reform

Millions – including millions of the “young invincibles” – have been enrolled in the ACA’s private and public insurance programs.  And a recent study by Sommers, Long, and Baicker in the Annals of Internal Medicine, suggests that this enrollment will save lives.  That’s great news for all interested in progressive health reform.  But there is a lot of work to be done to ensure that care follows coverage.  In this and subsequent posts, I’ll point to key implementation issues that share two characteristics:  First, they go beyond the very important enrollment issues.  Second, although federal implementation and advocacy is vital, my issues can be addressed largely through state and local government or private parties.  

But before that, let’s call it: 2014 enrollment in ACA-related care is a success.  The numbers are quite compelling.  Private plan enrollment totals a surprising 13 million.  This includes the 8 million signing up through federal or state exchanges, and the additional 5 million signing up outside the exchanges with plans that must meet Qualified Health Plan standards and share a common risk pool with in-exchange plans.  About 28% on-exchange, and 45% of off-exchange enrollees are in the important 18-34 age group.  More good news?  Insurers report   that at least 4 out of 5 have already paid their first month’s premium.  And an additional 4.8 million are newly enrolled in Medicaid and SCHIP.

Sustaining that success won’t be easy.  As Henry Aaron describes in the current issue of the New England Journal of Medicine, the success of the ACA in the short term will be subject to “brutal political war.”  Aaron also describes the legacy of the political war that led to crafting of the ACA as an incremental plan, rather than a comprehensive, coherent design.  The practical problem, in Aaron’s words, is that:

[R]eform had to be built on the most complex, kludgy, and costly system on planet Earth.  Multiple layers of health coverage – as a fringe benefit of private employment, as compensation for military service, as public charity for the poor, as public coverage for the elderly and disabled, and as a private commodity purchased by individuals in a remarkably dysfunctional market – overlap and intersect to pay for care through a bewildering variety of agents in a system that even experts seldom fully comprehend. 

“Kludgy” is exactly the word for it (not as cool as Henry Aaron?  Here’s a definition).  But it is a big step forward from the pre-ACA system – tens of millions newly covered, an end to the worst features of American health insurance underwriting, meaningful financial support for those previously shut out of coverage, and a variety of new delivery design initiatives. 

The reforms embodied in the ACA can be sustained and improved, but only through the efforts of those in and out of government dedicated to improving access for those historically shut out of care.  The case is not unlike that of Medicare, now a beloved social insurance system with almost 50 million beneficiaries, but in the 1960s a fragile program loved by few and reviled by many.  As Ted Marmor, Jonathan Oberlander and others remind us, Medicare was born in a political maelstrom, and has been sustained, changing over time, through the hard work and creative accommodations by many in and out of government.

As with Medicare, there will be tough political fights about the future of the ACA, and grindingly difficult administrative challenges for federal regulators.  But the states and private actors are critical to the ACA’s success.  The fact is that the ACA’s innovations largely lay over the construct of existing insurance law.  In addition, gaps in coverage and ambiguities in the protection of civil rights means that those outside of the federal political and administrative processes will have lots to do.  Those tasks include:

• Affordability.  Many advocates are concerned that people newly enrolled in QHPs will have trouble affording care notwithstanding the ACA’s subsidy systems.  This concern goes beyond premium costs, and runs to patient cost-sharing through deductibles and copayments.  States should be considering the adoption of a Basic Health Plan option, and innovative “bridge” and “wrap-around” programs.
• Coverage of immigrants.  In perhaps no other area of implementation are the political and the pragmatic so at odds.  The fragmented regulation of access to care for different cohorts of immigrants has caused confusion, limitations on access, and bad results – both intended and unintended.  States can take the lead here.
• Protection of people with disabilities/chronic conditions.  The structure of the ACA’s underwriting reforms are good news for people with disabilities, as are its nondiscrimination mandates, as Sara Rosenbaum has described in detail.  But the reforms mix uncertainly with the financial incentives that remain in the insurance system, and state regulatory oversight and advocacy will be essential to fulfill the statute’s goals.
• Denials and network adequacy.  The ACA embodies a paradox: it both federalizes the regulation of health insurance, and largely devolves that federal regulation back onto the states for supervision and enforcement.  That means that QHPs will continue to employ utilization management tools, including medical necessity review, to limit access to care – properly and improperly.  Perhaps more pressing is the problem of narrowing networks of providers in health plans.  Properly constructed networks can be a benefit to consumers; improperly constricted networks can deny access in covert and dangerous ways.  Vigilance by states and private actors will be crucial here.

The ACA’s goals are noble, and its somewhat clumsy (or kludgy) structure can succeed, but only through a lot of work from a lot of people.  I’ll return to these issues in upcoming posts.

- Professor John V. Jacobi 

[cross-posted at Health Reform Watch]