With the fundamental direction of health policy in our country on the line, health policy wonks in all 50 states and D.C. – not to mention health care providers, businesses, and families with health care needs — have been waiting with baited breath for Election Day. But those who were hoping for an end to all the crystal ball-gazing might not yet get their wish.
A second term for President Obama means that the Administration and states can continue with the complex task of implementing the Affordable Care Act – but the ultimate success of health care reform depends on critical implementation decisions yet to be made.
It’s always worth remembering how we got here in the first place: health care costs were skyrocketing, small businesses were forced to drop coverage, and policyholders were paying higher out-of-pocket costs – all to pay for a health care system that, despite the best efforts of individually dedicated health professionals, has not been able to reliably deliver high quality, safety, or good health outcomes.
What do health insurance markets have to do with these health system malfunctions? For decades, we have been contending with a fragmented patchwork of coverage, an individual health insurance market that could turn people away or charge them prohibitively high premiums if they had a pre-existing health problem, and almost no affordable options for those who lost their job-based coverage. The result: nearly 50 million uninsured Americans and a health insurance market that’s based on insurers competing to turn sick people away, instead of on how well they lower costs and improve health outcomes.
The Affordable Care Act seeks to change that, weaving the existing patchwork of public and private insurance into a strong, seamless system of coverage that will allow Americans to access coverage – and more importantly, actual health care — regardless of income or health status. To achieve that goal, the law includes strong rules of the road for the private health insurance market: no denying coverage based on pre-existing conditions, no discrimination based on gender or health status, requiring justification for premium increases over 10 percent, and eliminating the annual and lifetime limits on health care that can be so devastating to those with serious illnesses or injuries.
Health reform also set up new health insurance exchanges to help organize the individual and small group markets and make it easier to comparison shop for coverage. As we at CHIR are actively monitoring, states have been working hard to set up exchanges in time for the open enrollment season in October 2013. Those that don’t will have a federally facilitated exchange in their state, and the law provides lots of flexibility as to how states can implement their exchange.
But the devil is always in the details, and the efficiency and fairness with which the health insurance market functions across the country will depend on some critical decisions the states and the administration make in the coming months and year. These include the structure of state and federal exchanges (not that anyone is counting down to the November 16th deadline for states to declare the type of exchange they wish to implement); how states implement the 2014 market reforms and create a level playing field for insurers both inside and outside the exchanges; and looming questions about whether current levels of premium tax credits, cost-sharing subsidies, and the Medicaid expansion survive intact after what’s sure to be another bruising year for budgets at the federal and state levels (for more on this, check out Tim Jost's analysis on the Health Affairs Blog). Our team at CHIR will be watching closely as new developments arise in the states – many of which will be making important decisions now that we’re past the election milestone — and will be keeping readers posted as regulations are released on important topics such as essential health benefits, the federally facilitated exchange, the 2014 market reforms, and actuarial value calculations.
Here is what we do know: next year, about 1.6 million Americans will be diagnosed with cancer, 785,000 will have a heart attack, and another 1.9 million adults over 20 will be newly diagnosed with diabetes. About 4 million babies will be born – at a cost of anywhere from $9000 to $17000 or more for parents without insurance. And still other Americans will be forced to grapple with catastrophic costs related to an injury or disabling condition like MS. For these people, decisions about the health insurance market, Medicaid program, and health care delivery system in their states will have a material and lasting impact on their health and financial well-being – affecting not only whether the care they receive is adequate or affordable, but in some cases whether or not they can access health care at all. For these individuals, that strong, seamless system of coverage – and the other promises of the Affordable Care Act – cannot come soon enough. All eyes will now be on federal policymakers as they issue important rules and state policymakers as they make critical decisions during the 2013 legislative session.