Health policy update 2014: another exciting and turbulent year ahead.

Implementing the ACA The fumbled roll out of the healthcare.gov website and the mixed experiences with the various state exchanges has had the biggest impact. Although many had expected bumps in the road, no one anticipated the completely dysfunctional operation of a website as critical to the enrollment of the uninsured as that experienced by healthcare.gov. The federal website has been reasonably functional since December 2013. The website, however, was a major contributor to the far lower-thanexpected enrollment in private insurance by year’s end— 2.1 million (including an unknown number of people who had previously been insured but whose insurance was not renewed because it did not meet ACA requirements) as opposed to the expected more than 3 million. Maryland, Minnesota, Oregon, and other states have had difficulty with their own insurance exchanges, which has contributed to the low overall numbers. Insurers have also reported substantial problems about the accuracy of enrollee information received from the exchanges; it has been hard for insurers to send premium notices to some enrollees. Health insurance enrollment markedly increased in January and February, and as of early March, enrollment has reached approximately 4 million. Although a clear improvement over 2013, the enrollment numbers do not reflect the number of enrollees who have paid at least their first month’s premium, which is what is required before an individual is actually covered. Estimates vary as to how many people have paid their first month’s premium, but no estimates are higher than 80% of those enrolled and some estimates are substantially lower than that. Because the federal government has not made payment information available, the true number is not known yet. However, no more than 3.2 million people are likely in a position to use their private insurance, with the assumption that those who paid their firstmonth premiums will continue to pay their premiums. The lower-than-expected enrollment raises concerns that those enrolling will be older and/or higher users of services. This could raise premiums for 2015 or discourage some insurers from continuing or expanding their ACA enrollment offerings. Initial reports confirm this concern. As of early February 2014, approximately 25% of the enrollees were aged between 18 and 35 years, compared with the 38% to 40% share for this age group that had been anticipated. The Obama administration hoped for another surge in enrollment late in March, as the end of the open enrollment period nears. Medicaid enrollments have also faced challenges— mainly in the accuracy of the information that has been transferred from the federal government to the states. Thus far, only 25 states have chosen to expand their Medicaid programs, which means that 5 million people who would otherwise have been eligible for Medicaid will not be covered. Estimates vary about how many of the 7 million people who have been reported as being eligible for Medicaid at the end of December 2013 represent those who are newly eligible as a result of the ACA. Most credible estimates put the number between 1.2 and 2.6 million. The others are part of the Medicaid “churn”— people who need to reenroll to extend eligibility and those who had previously been eligible but had not enrolled. The upside of the smaller-than-expected enrollments is that the newly insured are less likely to stress the health care delivery system than if there were more new enrollments. Nonetheless, concentrations of new enrollees with either private insurance or Medicaid may present problems to certain areas—California, for example, has a large number of new Medicaid recipients. Enrollment was not supposed to be the big challenge for the ACA, although that has turned out to be the case. Getting services to the insured and the effect of increased insurance on population health are the clear justifications for the ACA. Establishing ways to measure changes in these services will be important. The recent findings from Oregon about the expansion of their Medicaid lottery indicate that it may take more time than anticipated for persons to change their health-seeking behavior. For example, increased emergency department use may be seen initially, as newly insured patients seek services in settings that are familiar and easy to access, but with limited direct effects on their health outcomes. Early effects of the ACA on employer-sponsored insurance are also likely to be important in 2014. It would not be surprising if many “smaller” employers (those with 100-250 employees, since employers with fewer than 100 employees have been exempted from ACA requirements until 2015) are told in the fall of 2014 that the policies they have been offering employees do not meet the ACA’s requirements and that they are not eligible under the grandfathering provisions. Should that happen, such employers are likely to press for exceptions, as were granted in 2013 to people with individual insurance policies. VIEWPOINT