Health care in the USA: turning the corner

The Affordable Care Act (ACA)—the federal statute enacted to increase the number of Americans with health insurance—has reached an important milestone in the journey towards universal health coverage as the major components of the law came into effect in January, 2014.

As part of the multiphase implementation of the ACA, the new year brought several key changes, including a ban on insurance companies from denying coverage on the basis of pre-existing medical conditions and terminating coverage if a policy holder becomes ill.

The first phase, the opening of online exchanges where consumers could compare health-care plans, was fraught with problems—technical glitches, widespread confusion about how the marketplace would function, and who was responsible for maintenance (some 14 exchanges being run by individual states and the other 36 federally). By contrast, the second phase of implementation seems to come down to one word: enrolment.

Jan 1, 2014, has been a much awaited date in the roll-out of the ACA. On this day, any consumers who had enrolled in a new health-care coverage package by the Dec 24, 2013, cut-off would now be actively covered by those plans.

This development alone might be seen as a sort of triumph given critics who were sure that, after opening with abysmal enrolment numbers, insurance exchanges were failing.
The Obama Administration enthusiastically announced that 2•1 million users had signed up for health-care plans during the initial enrolment period, which is well short of the proposed 3 million users to be enrolled by the end of 2013. Compounding that missed goal is the Congressional Budget Office’s projection of 7 million Americans expected to sign up by March 31, the end of 2014 open enrolment, which might be impossible to reach.

But enrolment is not just a numbers game. It is also one about who is enrolling.

As Kathleen Sebelius, US Secretary of Health and Human Services, has suggested, success requires more than signing up a set number of uninsured Americans: “It’s both about numbers and hopefully getting a balanced risk pool.” That is, a risk pool balanced by younger, healthier enrollees—around 40% or so—to, in theory, keep premiums down.

It is easy to imagine challenges to achieving this balance, such as willingness by younger individuals to pay the tax penalty (currently 1% of income and up to 2•5% by 2016) incurred by not signing up for a health-care plan, as well as the demographic differences that each state might introduce to the federal pool.
Moreover, enrolment doesn’t mean that a plan has actually been purchased. The next important date on the ACA calendar was Jan 10, 2014—the deadline for when the first month of insurance premiums were due. In some sense this date might truly forecast the ACA legacy—will the Obama Administration have succeeded in nominally meeting enrolment projections and will those enrolled have taken that next step and begun paying premiums?

But enrolment is unlikely to put everyone’s minds at ease: insurance companies must anticipate how rates may change, newly insured Americans are waiting for coverage confirmation, and health-care providers are looking to see how this momentous January will translate into patient load. With all these moving parts, it seems foolhardy not to expect some difficulties, and critics of the ACA will be watching eagerly for any deviation from the script.
The next wave of political opprobrium is likely to centre on the veracity and transparency of numbers and demographics—if enrolment doesn’t continue as projected, detractors will maintain that the ACA is failing. If the March goal is reached, those data may be questioned.

After such an inauspicious start, the cloud of criticism surrounding the ACA is partly warranted, but some bright spots are apparent.
By expanding Medicaid, the federally funded coverage for low-income individuals, an additional 3•9 million Americans are now eligible—a number which is likely to increase as more states opt to expand.
The Jan 1 changes have also ushered in new protection of essential health benefits and the mandate for free preventive services (eg, immunisation and yearly check-ups) as part of health insurance plans—a major shift in aligning coverage with broader public health goals.

With so much yet to play out, it is time for the shift from reactive to proactive politics—instead of continuing the tired refrain of referring to the ACA as a “train wreck”, its opponents should start considering doing whatever they can to keep the train on track and apace.

lancet-11TH JAN 2014.

G Mohan.