Affordable Care Act At 4 Years: March Madness?

The NCAA college basketball tournament invariably features surprise winners and losers. Shockers in this year’s Big Dance include Dayton’s upset of Syracuse, Mercer’s knockout of the Duke Blue Devils and the Kentucky Wildcats toppling #1 seed Wichita State.

The Affordable Care Act has its own version of March Madness, with the ACA’s four-year anniversary on March 23 and the deadline for exchange plan open enrollment on March 31. All this suggests an ACA “bracket” of winners and losers.

ACA’s winners would include:

1. A prohibition on pre-existing condition exclusions for children up to age 16, beginning in 2011, and for everyone else starting this year;
2. A ban on lifetime dollar coverage limits that took effect in 2011 and on annual dollar caps beginning this year;
3. The requirement that preventive health coverage be provided without patient cost-sharing;
4. The opportunity for employees to add dependent children up to age 26 to their group health plans, for plan years starting in 2011;
5. A maximum 90-day waiting period for health coverage to become effective for otherwise eligible employees;
6. Statutory limits on cost-sharing, effective this year, to cap patient out-of-pocket costs at $6350 for single coverage and $12700 for family plans.

Perhaps the biggest surprise in the 2014 bracket is that there are a number of ACA “winners” in this controversial issue. Few senators or representatives would wish to repeal all of the above.

Still, ACA March Madness has its share of tournament “losers”—provisions that so far have disappointed in their implementation.

1. Health Insurance Exchanges. Starting with the fumbled rollout of the federal exchange in October, this key part of the healthcare reform law has failed to meet expectations. Sign-ups are now expected to be in the 5 million range when the enrollment window closes on March 31, 2 million short of the goal.
2. Risk Pool Mix. Potentially a serious problem, the exchanges are not yet attracting enough younger and healthier people to balance insurance risks. Aiming for 40% of the enrollees to be between ages 19 and 34, it looks like the final figure will be closer to 25%, portending higher premiums for 2015.
3. Coverage Expansion. The ACA’s #1 goal was to extend coverage to 35 million uninsured. If present trends continue only 25% of the exchange enrollees will have been uninsured in 2013, a huge setback.
4. Cost. Clearly a big upset, ACA was forecast to reduce health insurance premiums by an average of $2500. All indications are that insurance premiums have continued to rise.
5. Existing Plans. Healthcare reform’s biggest boosters concede that this #1 seed going into the tournament was knocked out in the first round. Many individual health plans have been canceled and new networks sometimes don’t include preferred physicians and hospitals.

Predicting the teams that will reach the NCAA Sweet Sixteen or Final Four is almost impossible with so many regional powerhouses and inevitable upsets. Likewise, it’s impossible to predict how the Affordable Care Act will fare going forward. There will continue to be winners and losers, encouraging the President and members of Congress on both sides of the aisle to work together, maybe in 2015, to improve on what’s working and fix what’s not.