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The Affordable Care Act

Jesse Berwanger

Senior Seminar, PLS 399

Dr. Olejarski

9 May, 2014

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Table of Contents

Introduction……………………………………………………………………………...3

Background……………………………………………………………………………....5

Drawbacks……………………………………………………………………………….8

Positives………………………………………………………………………................11

Implementation………………………………………………………….........................16

Analysis…………………………………………………………………………………17

Conclusion…………………………………………………………………………..…..26

Bibliography…………………………………………………………………………...28

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Introduction

All throughout our lives we get sick, we injure ourselves, and we seek medical attention.

Thanks to health insurance we only have to pay for partial costs if our claims are approved.

Many people are fortunate to be able to have health insurance that can help them avoid serious

hardships brought on by health care costs. Unfortunately, for the 45 million Americans

(Baragona, 2014, 1) without health insurance, these costs have lifelong effects that are very hard

to recover from. Many of these people cannot obtain health insurance due to past health

complications that keep Health insurance companies from providing coverage. In a report done

by the Center for Policy and Research that’s affiliated with America’s Health Insurance Plans,

the main problem is cost, More than one-sixth of the U.S. economy is devoted to health care

spending and that percentage has continued to rise every year. Unfortunately, the system is not

producing the desired results even with the estimated $2.7 trillion spent annually, both by

consumers and by the Government, on health care. Experts agree that an estimated 20 to 30

percent of that spending, which is around up to $800 billion dollars a year, goes to healthcare

that is wasteful, redundant, or inefficient (America’s Health Insurance Plans, 2012, 1). These

people continue to struggle to pay these outstanding medical costs that cripple them financially

and burden them for years on end. It has become a national issue and citizens have called for a

change. That change has come in the form of the Affordable Care Act. The Affordable Care Act

was passed into law by President Obama in March 2010. This piece of legislation makes

preventative care such as family planning and related services more easily accessible and

affordable to many Americans that need it. The Affordable Care Act is a piece of legislation that

seeks to adopt similar features that are currently present in the programs of Medicare and

Medicaid, but also improve them and expand them all to the American people. The Affordable

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Care Act recognizes the health insurance market in an attempt to achieve two goals. The first

goal being to create a sustainable insurance market due to the sharp decline in private coverage

over the last decade, the second goal is to increase competition among health insurers and to

move that competition away from risk competition and toward competition based on cost and

quantity of the health services in their plans (Custer, 2013, 25-26). In order to measure the

success of this policy, goals must be set. Earlier in the year of 2013, the nonpartisan

Congressional Budget Office concluded that about 7 million people would sign up for the

Affordable Care Act during the six-month open enrollment period lasting into 2014 (Banthin,

Masi, 2013, 1).

Some of the biggest concerns facing this piece of legislation is the implementation of it.

There has been much debate as to how this law will be implemented among the people who are

in dire need of affordable health care. Policy implementation of this law affects businesses that

provide healthcare for their employees and how the policy focuses on creating exchanges in each

state for individual and small group markets. In order for the Affordable Care Act to be

successfully implemented, goals must be set by the presidential administration in order to

successfully measure how effective the Affordable Care Act really is, which leads to the big

question. The question of this research paper asks “is the Affordable Care Act meeting its goals

better in states with state-run vs. joint-run vs. federal-run exchanges?” The answer to that

question is yes, the Affordable Care Act is currently meeting its goals better in states with state-

run vs. joint-run vs. federal run exchanges. In order to prove that question, I will use data

collected by the Department of Health and Human Services and measure the states that have

state-run exchanges versus Joint/Federally-run exchanges. Throughout this paper I will provide a

brief description of what the Affordable Care Act is along with a history of attempts at healthcare

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reform, the drawbacks as well as the positives, and how it is being implemented. All of these

points will be discussed and explained how they relate to the question as well as the data being

used.

Background

Since the 1930’s, presidents of both political parties have pushed reforms that promote

universal healthcare. Early attempts at nationalized health care didn’t succeed due to the fact that

medical costs were already low since doctors couldn’t do much for their patients (Rockman,

2012, 1065-1080). Another reason was that medical breakthroughs were beginning to

revolutionize the medical industry which drove up the costs and put too much stress on the

Government at the time. In 1932 an independent committee consisting of doctors, economists,

and hospital administrators published a report on their findings about the increasing costs of

health care and the number of people going untreated as a result. This lead to the independent

committee making a claim saying that health care should be available to all (Associated Press,

2012). The biggest breakthrough came in 1965 when Medicare and Medicaid were passed into

law. Medicare being the focus for providing healthcare for citizens aged 65 and older while

Medicaid was being the focus for providing healthcare to the poor and those experiencing

poverty at the time.

In 2003 President George W. Bush persuaded Congress to add prescription drug coverage

to Medicare in a major expansion of Johnson’s “Great Society” program for seniors. In 2008

Hillary Rodham Clinton makes a sweeping health care plan that is gathering much support. The

plan includes a requirement that everyone have coverage, which was the central to her bid for the

Democratic presidential nomination for the election in 2008. Hillary Rodham Clinton would lose

the nomination to Barack Obama, who had his own plan and was promoting it; unfortunately it

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was less comprehensive and didn’t have as much support. In 2009 President Barack Obama and

the Democratic controlled Congress spend a very intense year ironing out a compromise that

requires companies other than the very small businesses to cover their workers, mandates that

everyone have insurance or pay a fine, requires insurance companies to accept all applicants

regardless of any pre-existing conditions, and assists the people who cannot afford health

insurance (Associated Press, 2012). The history is important to the question due to the fact that

the Affordable Care Act is a milestone in healthcare reform. Many presidents have dreamed

about passing a law that helps people with health insurance but were never able too.

Until the passing of the Affordable Care Act, the United States had healthcare programs

that helped those in need that can’t afford it, like Medicare as well as Medicaid, that provided

coverage for the retired and those who cannot physically or mentally take care of themselves. As

well as CHIP (Children’s Health Insurance Program) also known as Children’s Medicaid. CHIP

is a medical program that was signed into law in 1997 that provides health coverage to nearly

eight million children in families with incomes too high to qualify for Medicaid, but can't afford

private coverage (Center for Medicare & Medicaid Services, 2004, 1). There were many

programs already in place, but none that covered everyone regardless of age, socio-economic

status, or current physical health. Two programs that are the most popular are known as

Medicare and Medicaid. Medicaid is the most popular among those who are experiencing

poverty and cannot afford proper healthcare, unfortunately it varies by state and is harder some

places. Almost any surgery as well as regular doctor’s appointments can be very costly and

expensive, as well as prescriptions for medicine that people need to survive and Medicaid can

provide that for people desperately in need (U.S. Centers for Medicare and Medicaid Services,

2013). Under the Affordable Care Act, Medicaid expansion will be an unprecedented

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opportunity to improve access to health services for poor and homeless individuals around the

country. Even people suffering from extreme poverty will have greater access to healthcare

through the massive expansion of Medicaid, as for those who can afford to pay for even the

lowest priced plan; which is the “bronze” plan, the ability obtain coverage has become more

possible. (Bharel, 2013, S311-S317). This expansion of Medicaid, which became effective in

January 2014, fills in historical gaps in Medicaid eligibility for low-income adults and has the

potential to extend health coverage to millions of currently uninsured individuals. This expansion

essentially sets a national Medicaid income eligibility level of 138 percent of poverty which is

about $27,000 for a family of three for adults, this being based off the 2013 federal poverty

guideline for a family of three which was originally 19,530 (U.S. Department of Health and

Human Services, 2013, 1). This new standard allows for more people to be covered that are

suffering from nearly extreme poverty, meaning they lie close to being in poverty and suffer the

same results as it but do not qualify for Medicaid, but now they do (Kaiser Family Foundation,

2014, 1). The Federal government will provide a portion of the funding for Medicaid and sets

guidelines for the program. States also have choices as to how they design their program, so the

expansion will vary state by state and may have a different name in your state.

Another provision of the Affordable Care Act is that all states as well as health insurance

providers have to be ready and willing to sign up 32 million new enrollees either for Medicaid or

private insurance plans by 2014 through online insurance marketplaces known as exchanges. The

Affordable Care Act will establish a National Health Insurance Exchange with a range of private

insurance options as well as a new public plan based on benefits available to members of

Congress that will allow individuals and small businesses to buy affordable health coverage

(Office of the President Elect, 2010, 1). One drawback to this however is that due to many

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families prior private healthcare plans being ruled invalid due to not being able to meet the

burdens of coverage, these families have seen their policies canceled or is currently paying more

for their premiums in order to meet the requirements (American Health Insurance Plans, 2012,

1). The expected premium increase is a result of insurance companies to compensate for the

higher costs of new mandates combined with the fact that not enough young and healthy citizens

have registered to offset the losses of the expected medical claim increase (U.S. Small Business

Administration, 2010, 1). A positive however is that the Affordable Care Act can reduce health

care costs and save a typical American family up to 2500 dollars. One example would be on

CNN when Lori Greenstein Bremner had to endure tremendous debt to beat her cancer when this

law could’ve provided that for much cheaper (Bremner, 2013, 1). Another example can be found

in an interview conducted by PBS news. The interview discussed how Martha Monsson was

diagnosed with cancer while at the same time her husband lost his job along with their healthcare

plan. This new law guarantees care for those with pre-existing conditions which let the

Monssons keep their health care (PBS, 2013, 1). This new law achieves these savings through

the lowering of drug costs by allowing the importation of safe medicines from other developed

countries, which increases the use of generic drugs in public programs, and also creates

competition among the private companies which lower prices (Stubbings, 2011, 1-8). These

exchanges are designed to help individuals and small businesses shop around for ideal policies

that are well within their budget which helps achieve the registration goal set by the Presidents

administration. All states are required to provide a standardized, customer friendly application

process to help consumers, as well as low income individuals applying for the expanded

Medicaid program (Rampton, Begley, 2013, 1). This application process has to be consumer

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friendly in order to create convenience in registering for Medicaid as to achieve the registration

goal of 7 million people by March of 2014 (according to an article in time magazine).

Drawbacks

One of the toughest challenges the Affordable Care Act will experience is state

implementation. Some states, like New York, are afraid they’ll fall behind with the policies

(Hastings Center Report, 2013, 2-48). When the Affordable Care Act was written, the writers

assumed that Medicaid, which is the federal state healthcare plan for those who are poor and are

experiencing poverty, would be automatically expanded to low income adults in every state. The

United States Supreme Court however made their decision in July of 2012 that largely upheld the

law but made the expansion by state optional, since then, governors in nearly half the states have

refused to accept it (Hastings Center Report, 2013, 2-48). Another outcome of this decision by

the Supreme Court that results in significant consequences for the health care industry are

personal industry lawsuits; this being because of the significant driver of these verdicts and

settlements is the amount of medical expenses that are legally recoverable and admissible as

evidence. The data for this came from a study done by the U.S. Department of Justice. The data

shows that personal injury plaintiff’s filed approximately 15,624 personal injury lawsuits in the

state courts of the 75 most populated counties in the country in 2005, with the median recovery

of about $33,000 per case. The Affordable Care Act is anticipated to have an impact on personal

injury lawsuits, more specifically, the collateral source rule. The collateral source rule disallows

a tortfeaser, or a person who commits a wrongful act or an infringement of a right leading to civil

legal liability (Geslison, Jacobs, 2013, 239-251), from reducing his damages liability when the

injured party’s medical expenses are covered by insurance or another collateral source (Geslison,

Jacobs, 2013, 239-251). The reason there will be an impact is because of the Affordable Care

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Act ensuring that virtually everyone will be covered when it comes to health insurance. Even

when the collateral source rule is not directly implicated, the presentation of evidence and award

of damages in personal injury suits are likely to be impacted (Geslison, Jacobs, 2013, 239-251).

The reason for this is that under the Affordable Care Act health insurance will become the

exclusive method of transacting for health care services; the price of health care services could

shrink significantly. The relevance of health care prices in personal injury lawsuits dwindles to

next to nothing (Geslison, Jacobs, 2013, 239-251).

The most notable impacts however will be through costs, whether it be to the patient,

insurer’s whether private or public, and the Government as well. The Affordable Care Act’s

biggest impact of these costs is placed on personal physicians due to the 32 million newly

insured patients expected in the coming years, increasing stress on physicians to practice better

efficiency. This impact is also leading to a rise of mid-level physician’s assistants, eliminating

the traditional rivalry between doctors and creating a partnering relationship (Ghosh, C., 2013,

68-70). There are many causes of higher health care costs and spending. These causes include

higher prices for medical services, paying for volume over value, defensive medicine, use of new

technologies and treatments without considering effectiveness, and a lack of transparency of

information on prices and quality. There is also evidence that provider consolidation is having a

significant upward pressure on health care costs. The causes of higher health care costs and

spending are not simply or easy to solve, but they must be addressed or the impact will be severe

(America’s Health Insurance Plans, 2012, 1). The level of transparency being implemented with

the Affordable Care Act makes physicians nervous of having their reputations tarnished from

information being put online (Fontenot, S., 2013, 86-91). Industry representatives argue that the

disclosures may result in the unfair revelation of trade secrets and oppose the idea of a federally

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run exchange in order to keep their information private (Fontenot, S., 2013, 86-91). Another

impact is the continued exclusion of pharmacists from provider status recognition could

negatively impact patient outcomes and result in unnecessary health-related costs due to a direct

relation to a lapse in communication with other parties involved in the health care system and

patients alike surrounding medication prescriptions (MacKinnon III, G.E., 2013, 300-302). There

is also fear that financial performance of insurance companies may have an indirect effect on

quality through impacts on physician behavior which would lead to a dependency of the quality

of healthcare being reliant on the financial performance of an insurance company (Quast, T.,

2013, 1-10).

In an article regarding Medical Loss Ratios, an insurer’s Medical Loss Ratio being

approximately measured as the health expenses paid by the insurer divided by the premiums paid

by enrollees (Quast, T., 2013, 1-10). The Affordable Care Act includes a provision that penalizes

insurance companies if their Medical Loss Ratio drops below a specific threshold. To measure if

this provision is meeting its goal of providing incentives to insurance companies so that they will

lower their premiums (Quast, T., 2013, 1-10). The author, Quast, employs a ten-year sample of

market-level financial data and quality variables for Insurers in the state of Texas, as well as

relevant control variables, in regression analyses that utilize insurer and market fixed effects

(Quast, T., 2013, 1-10). From this the results show out of the fifteen quality measures, there was

only one that has a statistically significant relationship with its Medical Loss Ratio, which was

also a negative relationship. Which leads to the conclusion that although the Medical Loss Ratio

provision in the Affordable Care Act may provide incentives for insurance companies to lower

premiums, this sample does not suggest that there is likely to be a beneficial effect on quality

(Quast, T., 2013, 1-10). Even though the data from the controlled study is concluding that the

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provision in the Affordable Care Act that provides incentives for insurance companies to lower

premiums will be most likely ineffective, there is still opportunity for modifications of this bill to

occur that can yield a better result involving incentives for insurance companies that lower their

premiums. The incentives could change to better suit the insurance company’s interests which

would give them more incentive to lower their premiums, thus benefitting the citizens paying for

these premiums by being able to maintain possession of their policies but pay a lower rate for it.

Another Drawback would be how the health insurance companies of 76 million

Americans now have to meet the 80/20 rule, where they must spend at least 80 cents of your

premium dollar on your health care or improvements to care. If they fail to meet this standard,

they must provide a rebate to their customers; this varies state by state due to tax codes, making

the state-run exchanges more feasible as opposed to federally run where there would be a set

standard for all states (U.S. Government, 2014, 1-6). This provision has a positive impact as

well; small businesses will receive a rebate from the government in an effort to offset the

expected premium increase over the next few years. As stated before the expected premium

increase is a result of insurance companies to compensate for the higher costs of new mandates

combined with the fact that not enough young and healthy citizens have registered to offset the

losses of the expect medical claim increase (U.S. Small Business Administration, 2010, 1). One

serious drawback is the lack of young and healthy citizens registering for a health insurance plan.

According to James Lee, President of the Susquehanna Polling and research, young and healthy

citizens are signing up at a much slower rate when compared to older, sicker adults. This is

suggesting a possibility that the registration goal of the Affordable Care Act is not being met. In

response to this, the goal for the Affordable Care Act was set by the Presidential Administration

based on the nonpartisan Congressional Budget Office report that concluded that about 7 million

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people would need sign up for the Affordable Care Act during the six-month open enrollment

period lasting into 2014 (Banthin, Masi, 2013, 1). This goal is still being met in terms of overall

registration, even though the young and healthy citizens are still yielding a high registration rate,

which has an effect on the future costs of coverage. According to an article in New Republic, 28

percent of the enrollees are aged 18-34, which is significant in the sense that at least a noticeable

percentage of young people are enrolling in exchanges (Cohn, 2014, 1). One of the reasons why

young and healthy people haven’t contributed a high registration percentage is due to one of the

provisions of the Affordable Care Act; the provision allows young adults to stay on their parent’s

health insurance plan until they reach the age of 26. What this means is that the lack of young

people that aren’t registering that are needed to offset the cost of the expected increase in the cost

for health insurance premiums are staying on their parents health insurance plans thanks to the

Affordable Care Act. Even though ¼ of the enrollees are young adults in the age range of 18-34

(Cohn, 2014, 1), there may be need for drastic changes. Unfortunately that change may need to

come in a removal of the provision allowing young adults to stay on their parents plans till the

age 26 in an effort to increase young and healthy people registering for health insurance plans so

that they can actually offset the expected increase in the cost for health insurance premiums.

Positives

In order for the Affordable Care Act to be successful, health care insurance providers are

expected to be altering their plans everywhere to comply with this new federal law, regardless of

what individual states do or say in regards to this legislation, there must be federal oversight of

how this law is implemented. One thing is obvious is that these states don’t want to provoke and

invite enforcement action from any government bodies, other states or Centers for Medicare and

Medicaid Services (Scott, D., 2013, 1). The conforming legislation just avoids the complications

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of two coexisting regulatory schemes (Scott, D., 2013, 1). The Affordable Care Act sets a date as

to when people will start receiving benefits. Some states are already experiencing a large flow of

applicants, causing the date to be pushed back a few times and the final date to register is March

31st, 2014 (U.S. Government, 2014, 1). These new marketplaces, called health benefit exchanges,

will provide consumers with information to help them choose and purchase health insurance

plans that will save families a lot of money in medical bills (Albright, H.W., 2010, 1564-1574).

These State-based health benefit exchanges will permit individuals and families that have

incomes between 133 percent and 400 percent of the federal poverty level to purchase insurance.

Premium as well as cost-sharing subsidies will be available to help make coverage more

affordable (Albright, H.W., 2010, 1564-1574). These exchanges also mean that small businesses

will be able to purchase coverage for their employees through similar, but separate, exchanges.

One important aspect of these exchanges is that individuals and employers will be subject to

incentives and penalties for obtaining, or not obtaining, coverage, respectively. One example

would be how employers with more than 50 employees will be fined for not providing coverage

for them, and, because the penalties are based on the number of employees, these penalties could

be significant for large employers (Albright, H.W., 2010, 1564-1574). An individual who does

not have health insurance by 2014 will be penalized $95 or 1 percent of income, whichever is

greater, so long as the amount does not exceed the cost of a basic health plan (Albright, H.W.,

2010, 1564-1574). If people still refuse to pay by 2016, the penalty increases to $695 for an

uninsured adult, and up to $2085 for a family, or 2.5 percent of income, whichever is greater

(Albright, H.W., 2010, 1564-1574).

As stated before, the big problems are costs; rising health care costs have a negative

impact on our nation on multiple fronts. For families as well as senior citizens, the soaring cost

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of medical care results in less money in their pockets and forces hard choices about balancing

food, rent, and needed medical care. For small businesses and Fortune 500 companies alike, they

make it more expensive to add new employees, more difficult to maintain retiree coverage, and

harder to compete in the global economy (American Health Insurance Plans, 2012, 1). The

Congressional Budget Office released a report that concluded that the direct spending and

revenue effects of the Affordable care Act will lead to an increase the Federal budget deficit by

210 billion dollars over a period from 2012-2021 (Elmendorf, 2011, 2). Unless changes are made

regarding the cost of the Affordable Care Act for businesses, many people will soon find

themselves out of work due to their companies being unable to cover employee health insurance.

The Congressional Budget Office reported that estimated 2.3 million jobs will be lost due to the

Affordable Care Act, and another 2 million will decide either not to work or work less hours due

to the new law (Farley, 2014, 1). The reason why 2 million people will make this decision is due

to the ACA subsidies requirements, which is creating a “disincentive” for some low-income

people to work, or to work more hours, so that they do not lose the health care subsidies they are

receiving through the Affordable Care Act (Farley, 2014, 1). Unfortunately these people

choosing not to work or working less is damaging to the economy. If the number of people

increase that are choosing not to work or working less so that they can keep their health

insurance subsidies, then the cost to the economy in lost productivity could severely affect it. For

federal, state, and local governments, the rising health care costs lead to higher costs for

Medicare and Medicaid. This leads to reduced funding on other priorities such as infrastructure,

education and public safety (American Health Insurance Plans, 2012, 1). The net results of

rising health care costs are far-reaching and incredibly harmful. This leads to higher costs for

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health insurance, the fraying of the nation’s safety net, erosion in our global competitiveness, and

long-term fiscal insolvency (American Health Insurance Plans, 2012, 1).

In order to solve this cost problem we must have a solution, reducing the rate of growth

in health care costs requires a collaborative, inclusive, and bipartisan approach. While there is no

simple formula for lowering the growth in health care costs, stakeholders have long recognized

that there are many areas where common ground can be found (American Health Insurance

Plans, 2012, 1). Health plans are playing an important role in lowering health care costs. They

are partnering with providers to create innovative, high value payment systems to reward value

and quality over volume (American Health Insurance Plans, 2012, 1). Health plans are also

empowering patients with new coverage options that focus on high-performing providers and

key tools like care coordination and case management for individuals with chronic conditions,

these types of approaches are helping to move the nation away from the broken and

unsustainable fee-for-service system toward a health care system better suited for the 21st

century (American Health Insurance Plans, 2012, 1).

In an article I found written by Sarah Freymann Fontenot, health law professor for Trinity

University (San Antonio). She wrote about cost reduction and the Affordable Care Act, used

information from The Institute of Medicine’s 2001 report entitled Crossing the Quality Chasm,

and concluded that an educated patient is essentially a less expensive patient due to the creation

of a central computer system containing people’s medical records (Freymann Fontenot, S., 2014,

68-72). If patients possess immediate access to an accurate copy of their personal electronic

health record and educational resources available on the internet specific to their disease process,

this will result in a cost-conscious patient, and a cost-conscious patient will be more likely to

focus on prevention of future ailments over intervention (Freymann Fontenot, S., 2014, 68-72).

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These digital medical records can help with physicians saving money by allowing them access to

all of their previous notes that have been digitally saved which is much more efficient than a

loose collection of papers in a file (Freymann Fontenot, S., 2014, 68-72). Digital records will

also decrease costs, duplication and claim processing time by allowing multiple providers to rely

upon one laboratory finding regarding medical ailments that can help other doctors treat patients

with the same medical problems (Freymann Fontenot, S., 2013, 72-76).

The Affordable Care Act also has many changes that affect not just the health industry

but other factors of people’s lives as well. In an article I came across the author Theo Francis

explains how due to the Affordable Care Act there is an increase in scholarship is funding, loan

repayment programs and tax breaks on state repayment programs as to encourage more primary

care physicians. Subsidies are also being set aside for those who cannot afford health insurance,

billing is becoming more standardized and there are incentives being provided for doctors to

create accountable care organizations and adopt electronic medical records (Francis, T., 2013,

64-67). Theo also discusses how the Affordable Care Act states that insurers must offer an

appeal process for coverage denials, coverage of many kinds of preventive care, and incentives

for doctors to create Accountable Care Organizations and adopt electronic medical records

(Francis, T., 2013, 64-67). In a study conducted through the American Journal Of Public Health,

two authors (Tsai and Rocenheck) analyzed data for 8710 veterans from a 2010 National Survey

of Veterans, classifying it by veterans’ age, income, household size, and insurance status, the

took the results and were able to discover that out of 22 million veterans, about 7 percent, 1.5

million, were uninsured and will need to obtain coverage by enrolling in the Medicaid expansion

through a health insurance exchange mandated by the Affordable Care Act. Compared with

veterans with any health coverage, those who were uninsured were younger and more likely to

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be single, of African American ethnicity, and low income and to have been deployed to Iraq and

Afghanistan. 55 percent of these uninsured veterans, 800,000, are eligible for obtaining coverage

through state exchanges as well as Medicaid expansion if states implement it. The authors

conclude that the Affordable Care Act is likely to have a considerable impact on uninsured

veterans, which may have implications for the US Department of Veterans Affairs, the Medicaid

expansion, and the health insurance exchanges. The impact being that not only do veterans who

were uninsured and couldn’t afford proper health care become eligible to receive good quality

care, it also means more people are registering through exchanges which helps accomplish the

goal of the Presidential Administration in regards to the Affordable Care Act (Tsai, J., &

Rosenheck, R., 2014, e57-e62).

Before we move on to the implementation section of this piece, let’s recall the

information and argument that’s been addressed. We’ve identified what the affordable care act is

and how it aims to lighten the financial load of healthcare costs on the American people. We

have examined a brief history of attempts at healthcare reform that weren’t as successful as well

as the two programs that are still going strong today (Medicare and Medicaid). Some of the

provisions of the Affordable Care Act have been addressed, such as how all states as well as

health insurance providers have to be ready and willing to sign up 32 million new enrollees

either for Medicaid or private insurance plans by 2014 through health insurance exchanges

(Office of the President Elect, 2010, 1). The drawbacks have also been examined and have been

made well aware of, especially the cost impact and the causes that have already been labeled

earlier. In response to the drawbacks, the positives have also been examined, such as how the

Affordable Care Act is calling for Health plans partnering with providers to create innovative,

high value payment systems to reward value and quality over volume (American Health

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Insurance Plans, 2012, 1), as well as lowering costs by providing cost-subsidies as well as a

transitional reinsurance program, which provides funds to help offset the impact of high-cost

enrollees (America’s Health Insurance Plans, 2012,1).

As we progress further into the paper, we will now see hard data collected that will show

whether the Affordable Care Act is meeting its goals better in states with state-run vs. joint-run

vs. federal-run exchanges. How it will be implemented is going to be discussed as well.

Implementation is important because as stated before policy implementation of this law affects

businesses that provide healthcare for their employees and how the policy focuses on creating

exchanges in each state for individual and small group markets.

Implementation

There are many skeptics and questions as to how this new law will be implemented. Each

state must pass legislation that changes that states insurance regulations so they match up with

the new federal reforms. These changes, also known as pieces of “conforming legislation”

embed the federal law’s new insurance reforms such as letting kids stay on their parents’

insurance until age 26, forbidding the exclusion of people with pre-existing conditions, and

settling dollar limits for out of pocket expenses into the state code so that they become

mandatory immediately. Generally, insurance companies support states passing this conforming

legislation. This new legislation helps insurance companies establish long term customers which

help it have steady profits (Bernstein, J., 2013, 1). Other new regulations that come with the

ACA are a new set of requirements for hospitals to keep or receive tax-exempt status. Nearly 60

percent of hospitals in the United States are currently tax-exempt. Failure to comply could result

in monetary penalties that have drastic effects on hospitals all around the country (Bailey, W.A.,

Tidd, R.R., & Cahalan, R., 2013, 57-62). In an article focusing on public health goals, a study

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was done that reviewed the patients seen in 2012 at federally funded Health Care for Homeless

clinic. Out of the 836,980 patients, 61.1 percent were uninsured and the vast majority lived

below the poverty line as well. Providers and administrators in both the criminal justice system

and the community not only share the same group of patients, but also the same public health

goals. These goals include increasing community safety, reducing incarceration and health care

costs, improving patients’ health status, and increasing the community’s capacity to deliver

needed medical and behavioral health services to improve overall health (DiPietro, B., &

Klingenmaier, L.,2013, e25-e29). According to an article in time magazine, the Obama

Administration announced on April 17th, 2014 that at least 8 million people have signed up for

insurance plans under the Affordable Care Act (Miller, 2014, 1), meeting its self-imposed target

of 7 million newly insured Americans that are participating in exchanges in all of the states. The

majority of these claims belonging to states that use state-run exchanges (Hirschhon, Dan., 2014,

1). It hasn’t been determined yet how many of these registered participants in the health

exchange system previously had insurance. Meaning that it is possible that there could be a

considerable percentage of these participants that may have canceled the health insurance plan

they received from their job and obtained health insurance through one of the exchanges. It is

also important to note how many of these participants have actually paid their first premiums.

According to an article in the California Healthline, three large U.S. insurers in prepared

congressional testimony say that between 80% and 90% of their new customers who enrolled in

health plans through the Affordable Care Act's health insurance exchanges have paid their first

month's premiums (California Healthline, 2014, 1). One of these insurers being Aetna, which is

on the exchanges in 17 states, reported that over 600,000 members who had enrolled, roughly

500,000 members who had paid (Dupree, 2014, 1). Another one of the large insurers, WellPoint,

Berwanger 21

reported that about 70% of its customers that enrolled in its exchange plans between Oct. 1,

2013, and April 15 have paid their premiums. However, WellPoint executive Dennis Matheis

also mentioned that the proportion is higher among people who have passed their payment

deadline which ranges up to 90% of the customers depending on the state (Pear, 2014, 1). The

third health insurance company, Health Care Services Corporation; who offers health plans on

exchanges in Illinois, Montana, New Mexico, Oklahoma and Texas reported that among its

exchange customers who had a payment date of Jan. 1, about 85% have paid. Meanwhile, about

90% of its ACA customers who had a payment date through April 30 have paid (Dupree, 2014,

1). This shows that not only is the Affordable Care Act meeting its goal. The majority of these

customers are actually following through and paying their first premiums. Unfortunately the data

for the 8 million enrollee report has not been made public yet on the Department of Health and

Human Services website or healthcare.gov. So I must work with data that dates up to March 1st.

When focusing on the implementation of the Affordable Care Act, we recognize that

some of the major provisions of the Affordable Care Act have been delayed and have yet to be

implemented. Some of these provisions include the individual mandate, which has been

suspended by the Presidential administration until 2016. There has been speculation why but it is

rumored that the Presidential administration is trying to avoid administering the fine that would

be placed on uninsured citizens just for the fact of being uninsured, meaning that the Presidential

administration is trying to avoid the political blowback from placing a hefty tax on people who

are uninsured just because they are uninsured, whether they had a choice in it or not (Adams,

2014, 1). The Affordable Care Act has been reportedly tweaked, delayed, and modified in an

effort to increase enrollment in the health insurance exchanges (Adams, 2014, 1).

Analysis

Berwanger 22

As stated earlier in the paper, in order to measure the success of this policy, goals must be

set. In 2013, the nonpartisan Congressional Budget Office concluded that about 7 million people

would sign up for the Affordable Care Act during the six-month open enrollment period lasting

into 2014 (Banthin, Masi, 2013, 1). This is what makes the Affordable Care Act effective at

meetings its goals. As stated earlier in order for the Affordable Care Act to be successfully

implemented, goals must be set by the Presidential Administration in order to successfully

measure how effective the Affordable Care Act really is. This is it! The goal was set at 7 million

people registered through exchanges by March 31 and it was reached and then some! Meaning

the Affordable Care Act has been successfully implemented so far! 8 million people have signed

up and exceeded the Affordable Care Act’s insurance exchange registration goals set by the

Presidential Administration! 8 million people are now registered and have affordable health care.

After the hard times American citizens have had to endure when it came to medical costs, this is

a way out! A way to cheaper, more affordable, better quality healthcare! Healthcare that takes

care of you when you’re sick not kicks you to the side saying it’s a “pre-existing condition”. We

finally have a healthcare system that’s aim is to serve the people who need healthcare, not try to

maximize profits like some businesses in the health industry do. Thanks to the unprecedented

opportunity presented to us, we have been able to improve access to health care services for poor

and homeless individuals around the country through Medicaid expansion. Even people currently

suffering from extreme poverty in our great nation will have greater access to healthcare!

(Bharel, 2013, S311-S317) Not only did the Affordable Care Act exceed the Presidential

Administrations goal, it succeeded more in State-run exchanges! Now I will present my data on

how State-run exchanges performed much better than Joint/Federally-Run Exchanges.

Berwanger 23

Kathleen Sebelius, Secretary for Health and Human Services, noted that "Success looks

like at least 7 million people having signed up by the end of March 2014” (Condon, Stephanie.,

2013, 1), which reinforces what the goal of the Presidential Administration is for the Affordable

Care Act. After collecting data from the Department of Health and Human Services, I measured

the data by taking the amount of people who actually registered and compared it to the amount of

people who are eligible in each state for both State-run and joint/federally-run exchanges. I

divided the actual amount of people who registered through a health exchange and divided it by

the amount of people who are eligible in each state. The data is from the Department of Health

and Human Services March enrollment report that covers October 1st 2013- March 1st 2014.

When looking at state-run exchanges compared to joint/federally-run exchanges. The

chart below identifies what states have state-run exchanges vs. joint/federally-run exchanges, the

number of individuals who have selected a marketplace plan, the amount of eligible individuals

for enrollment, and the difference identified as percentages. Each percentage in the “%

Difference” column identifies the percentage of eligible people who actually participated in the

health insurance exchange market, whether it be State-Run or Joint/Federally-Run. To better

understand the chart, states are listed under the column “State”, the actual amount of people who

registered in that marketplace exchange is under the column “Actual”, the amount of people

eligible for signing up in an insurance exchange is under “eligible”, and the percent difference

when looking at how many people actually participated in the insurance exchanges versus how

many are eligible too is under the column “% Difference”. In the “total/Average %” section for

both charts, for “% Difference”, the “total/Average %” represents the percentage difference

between the total amount of all the people added up who participated in a healthcare exchange

and the total amount of all the people added up who were eligible to participate in the healthcare

Berwanger 24

exchange. There are two totals, one for State-Run Exchanges, and one for Joint/Federally-Run

Exchanges. In the State-Run Exchanges, you’ll notice Massachusetts has a percentage difference

of 218. According to the Department of Health and Human Services, due to Massachusetts’

system constraints, data for Individuals Determined or Assessed Eligible for Medicaid/CHIP are

not available at this time. Massachusetts’ cumulative data for individuals who have selected a

marketplace plan does not include the 48,000 new applicants above 133 percent Federal Poverty

Level who are in temporary subsidized coverage; these individuals will be processed for

eligibility determination and potential coverage. The reason for this lack of data is due to

Massachusetts commonwealth care system, sharing many similarities to the Affordable care Act,

it is a health insurance program for uninsured individuals, age 19 and older, with incomes that

fall within certain guidelines and who meet other qualifications and is run by the

Commonwealth Health Insurance Connector Authority (Department of Health and Human

Services, 2014, 1-26)

State-Run Exchanges

State Actual Eligible % Difference

California 868936 1190260 73

Colorado 83469 145877 57

Connecticut 57465 85804 67

D.C. 6249 10515 59

Hawaii 4661 10968 43

Kentucky 54945 165684 33

Maryland 38070 50900 75

Massachusetts 12965 5943 218

Minnesota 32030 95862 33

Nevada 28535 94926 30

New York 244618 533948 46

Berwanger 25

Oregon 38806 76223 51

Rhode Island 18902 30158 63

Vermont 24326 64645 38

Washington 107262 197220 54

Total 1621239 2758933 59

Joint/Federally-Run Exchanges State Actual Eligible % Difference Idaho 43861 74085 59 New Mexico 15012 35416 42 Alabama 55034 134329 41 Alaska 6666 13893 48 Arizona 57611 137069 42 Arkansas 27395 58173 47 Delaware 6538 15085 43 Florida 442087 990455 45 Georgia 139371 341650 41 Illinois 113733 246188 46 Indiana 64972 145189 45 Iowa 15346 40113 38 Kansas 29309 65057 45 Louisiana 45561 107480 42 Maine 25412 47444 54 Michigan 144587 313644 46 Mississippi 25554 68562 37 Missouri 74469 170180 44 Montana 22542 39917 56 Nebraska 25582 54311 47 New Hampshire 21578 43256 50 New Jersey 74370 187231 40 North Carolina 200546 390925 51 North Dakota 5238 10394 50 Ohio 78925 193152 41 Oklahoma 32882 78444 42 Pennsylvania 159821 394151 41 South Carolina 55830 136414 41

Berwanger 26

South Dakota 6765 16047 42 Tennessee 77867 204075 38 Texas 295025 758344 38 Utah 39902 78258 51 Virginia 102815 251566 41 West Virginia 10599 24133 44 Wisconsin 71443 158048 45 Wyoming 6838 14296 48 Total 2621086 5992974 44

As you can see, looking at the percentage of actual individuals that have enrolled in an

exchange. State-run exchanges have had a much higher turnout with an overall 59 percent of

people eligible to enroll that have participated in the exchange and selected a marketplace plan.

Joint/Federally-run exchanges have an overall of 44 percent of people eligible to enroll that have

participated in that exchange. It is clear that State-run exchanges have had a higher turnout than

joint/federally-run exchanges. That being said, other factors also need to be addressed, State-run

may have less states than joint/federally-run exchanges which would result in an easier way to

obtain higher percentage turnout, however, joint/federally-run had much more eligible applicants

that they could’ve obtained but were unable too due to the poor setup of their exchanges. The

success of the state-run exchanges can be found in how they managed their sites. When we

define what a “successful” state is, a state is successful if they managed to create their own

exchange that vastly outperforms other exchanges and allows more people to participate in the

exchanges and help accomplish the goal of the Presidents Administration for the Affordable Care

Act. For example, Connecticut, Washington, Rhode Island and Kentucky all have sites that have

run especially smoothly, becoming models for states such as Arkansas, Idaho, Illinois and New

Mexico that are planning to launch their own sites in 2014 (Vestal, Christine, Michael Ollove.,

2013, 1). Due to ongoing problems with the federal site, other states that are using it might also

Berwanger 27

decide to build their own next year. Instead of creating the ultimate health insurance exchange

with lots of features like having multiple ways to search for an insurance policy, the successful

states created a simpler version that includes a plan to add more functionality in the future.

Successful state-run exchanges also devoted months, not weeks, to exhaustive, round-the-clock

testing. Kentucky for example tested for three months (Vestal, Christine, Michael Ollove., 2013,

1), while the U.S. Department of Health and Human Services reportedly devoted only the last

two weeks of September to testing healthcare.gov before its Oct. 1 launch. Dan Schuyler of

Leavitt Partners, a consulting firm that helped design an early exchange in the joint exchange

state of Utah in 2009, noted that state exchanges would have a better turnout if they screened for

Medicaid eligibility and linked to the states existing Medicaid enrollment site, rather than

attempting to enroll consumers directly from the exchange (Vestal, Christine, Michael Ollove.,

2013, 1). However, even though the 15 exchanges run by states and the District of Columbia

serve less than a third of the U.S. population, they accounted for more than half of all Medicaid

enrollments and 75 percent of private insurance sign-ups in October, according to the federal

government's most recent enrollment report (Vestal, Christine, Michael Ollove., 2013, 1).

In addition to the charts I have provided, I also made bar graphs to illustrate the

difference in the amount eligible to participate and the amount that actually participated. The

first graph below is of the State-Run Exchanges. On the X-axis are the states that have chosen to

make their own healthcare exchanges and go with the state-run exchange option. The Y-axis

contains numbers that represent the amount of people that are either eligible to participate or are

actually participating. The blue bars represent the actual amount of people who are participating

and the red represents the amount that’s eligible to participate. Upon first glance it doesn’t seem

Berwanger 28

like much but when you can distinguish the fact save for a few high eligibility, the amount of

people who actually participated is approaching the eligibility amounts, as said before the

California

Colorado

Connecticu

tD.C.

Hawaii

Kentucky

Marylan

d

Massach

usetts

Minnesota

Nevada

New Yo

rk

Oregon

Rhode Isla

nd

Vermont

Washingto

nTo

tal0

500000

1000000

1500000

2000000

2500000

3000000

State-Run Exchanges

ActualEligible% Difference

The second bar graph below contains Joint/Federally-Run Exchanges. Same as the other

bar graph. . On the X-axis are the states that have chosen to either join their own healthcare

exchanges with the federal exchange or are completely relying upon the federal exchange

entirely. The Y-axis contains numbers that represent the amount of people that are either eligible

to participate or are actually participating. The blue bars represent the actual amount of people

who are participating and the red represents the amount that’s eligible to participate. Upon

examining it, it’s apparent that there is a greater difference between the amount of people who

actually participated in healthcare exchanges and those who were eligible.

When comparing the “Totals” of each bar graph. I notice how even though the numbers

for Joint/Federally-Run exchanges are higher, they also have twice as many states as the State-

Berwanger 29

Run exchanges. Joint/Federally-Run account for a total of 2,621,086 actual participants in the

health insurance exchange out of the 5,992,974 people that are eligible for 36 states. Where

State-Run exchanges account for 1,621,239 actual participants out of the 2,758,933 people that

are eligible for 14 states plus the District of Colombia. Looking at raw percentages again, State-

Run exchanges were able to allow 59% of its eligible participants to sign up where

Joint/Federally-Run only managed to allow 44% to sign up. I have provided evidence as to what

obstacles Joint/Federally-Run exchanges encountered that hindered their health insurance

exchange registration. Those states should become State-Run exchanges and adopt the ways of

the already successful State-Run exchanges. The turnout for actual participants will increase

greatly due to the benefits of having a State-Run exchange, one of them being convenience when

registering. States that have State-Run exchanges may not all be perfect but they’re able to adopt

the ways of the successful states and not have the exchange website crash constantly.

Idaho

Alabam

a

Arizona

Delaware

Georgi

a

IndianaKan

sasMain

e

Mississ

ippi

Montana

New Ham

pshire

North Caro

lina

Ohio

Pennsyl

vania

South Dak

otaTex

as

Virginia

Wisconsin To

tal0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

Joint/Federally-Run Exchanges

ActualEligible% Difference

Berwanger 30

Looking at the data as well as why state-run exchanges were so successful, it makes sense

to have state-run exchanges due to their high enrollment. If the states that used federally or joint-

run exchanges switched to state-run. They would absorb the very successful website style used

by the state-run exchanges that would result in a more smooth registration which leads to higher

enrollment. There have been some State-Run exchanges that have totally crapped out, some

examples would be how Hawaii, Oregon, Vermont and Maryland have had significant problems

with their exchange websites such as poor maintenance as well as lack of equipment necessary to

handle the internet traffic flowing through the website. The state of Oregon has been regarded as

the biggest failure due to the state failing at properly setting up a functioning health insurance

exchange and spending 250 million dollars on it in the process, the only people who have been

able to enroll in a health insurance exchange have been the people who had to resort to paper

applications due to the website not working (Goldstein, 2014, 1). However, even though the 14

exchanges run by states and the District of Columbia serve less than a third of the U.S.

population, they accounted for more than half of all Medicaid enrollments and 75 percent of

private insurance sign-ups in October (Vestal, Christine, Michael Ollove., 2013, 1), according to

the federal government's most recent enrollment report (Department of Health and Human

Services, 2013, 1-28).

Conclusion

In conclusion, after finding that states that chose to implement state-run exchanges not

only fulfilled the goals of the Obama administration for this policy but also yielded the highest

registration rates for the new health care bill, it is apparent that state-run exchanges are much

more effective at implementation than federally-run or joint-run exchanges when measuring

registration goals. The major agreements here are that there is a definite need for health

Berwanger 31

insurance for those who are in dire need of it and cannot afford it. State-run exchanges also yield

very high registration rates even with all the complications encountered whether it be from the

pressure on physicians to practice better efficiency due to the flow of new patients throughout

the states, or the rising costs of prescriptions due to the lapse in communications between

physicians, patients, pharmacists and other third parties involved in the health care system. In

order for the Affordable Care Act to keep meeting its goals, it must take direction towards

promoting state-run exchanges due to its increasing popularity. The government must also

provide federal oversight of these exchanges to maintain a level of transparency of the health

care system as to educate patients that will be more informed as to how to stay healthier and will

choose preventative care measures which will have lower costs over intervention care measures

which focus on removing an ailment. The government must not integrate themselves into joint

exchanges as to avoid decreasing popularity along with registration rates. States that have their

own exchanges are already showing steady increase in patient registration rates and are already

exceeding goals set by the Obama administration that were once thought of as impossible. Many

of the drawbacks it currently faces can be resolved within a relatively short period of time, and

even though some of these drawbacks can last over a period time; like low enrollment turnout for

young and healthy Americans as well as expected premium cost increase. There can be

modifications to the law that can require more young people to enroll in a health insurance

exchange. This does involve the removal of the provision that allows young adults to stay on

their parents plans till the age of 26, but if more young and healthy people enroll in health

insurance exchanges, it can offset the expected premium cost for everyone else. As for the

concern about how many enrollees will actually pay their first month’s premiums, when looking

at reports from three large insurance providers, not only is the Affordable Care Act meeting its

Berwanger 32

registration goals, the majority of these customers are actually following through and paying

their first premiums (California Healthline, 2014, 1). This law exercises its ability to create a

new standard for health for the people of this country. A country that cannot take care of its own

people is destined to perish. The people of this country need a health care program that provides

them easy and affordable access to quality healthcare. When it comes to taking care of people

and their medical problems no one wins unless everyone wins and we can’t win if we keep

shutting people out from receiving the medical care they need that they also cannot afford due to

the extreme costs set by private companies. The lasting positives are vast when compared to the

temporary negatives that come with this law. This reform has been long overdue and will put

America on the right track to being the best country to live in the world.

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