Think 2013 was a bad year for health politics? Just wait for 2014
It was the gift that kept on giving: The disastrous roll-out of the
health-insurance exchanges provided daily fodder for Republican
opponents of Obamacare. And the dire state of U.S. health care, coupled
with a headlong rush by people to get health insurance, gave Democrats
ample opportunity to say "we told you so."
So once it's
January 2014 and people can start having their new insurance and all the
deadlines have passed, can we relax and talk about something other than
Not a chance, say experts. They predict 2014 will be, if anything, worse than 2013.
will be an election year, and the GOP has pledged to make the
Affordable Care Act one of its top issues. So yes, I think we can expect
even more politics," says Sabrina Corlette, senior research fellow at Georgetown University's Health Policy Institute.
"Scary thought, I know."
health-insurance exchanges were supposed to be the crowning glory of
the 2010 Affordable Care Act, now known widely as Obamacare. The new law
was designed to get health insurance to the 45 million Americans who don't have any.
also meant to lower costs and improve quality of care over time by
helping people get treated earlier, before they develop expensive
conditions, and by encouraging doctors, hospitals and other providers to
work more closely in collaboratives called Accountable Care
The federal government has ended up doing the heavy
lifting on the exchanges, running them for 36 states. Almost as soon as
they opened, it became horribly clear they weren't working.
have not done a very good job. That's an understatement," says Henry
Aaron of the Brookings Institution. "With time, I am sure they will get
For the early part of 2014, however, this will mean
lots of questions about who is covered and who isn't. One fear is that
people will think they signed up for coverage even if they didn't take
the final and vital step of paying the first premium, and will seek
care. Another problem: The system has been passing along erroneous
information to insurers, something the Health and Human Services
Department has been racing to fix.
"When people try to use their
benefits, we'll find out if information transmitted to insurers," says
Matt Eyles of health-care consulting firm Avalere Health. "Were people
getting billed for the correct amount? Are the plans collecting the
In emergency rooms on Jan. 1, "there are going to
be people out there who think they are insured … but who can't connect
with an insurance plan," says Timothy Jost, a professor at Washington
& Lee University who's a supporter of the ACA. "These transitions
are always bumpy. This one is going to be particularly bumpy."
Everything that goes wrong will get picked up and amplified on talk
shows, in editorials and in Congress, the experts predict. Douglas
Holtz-Eakin, a health-policy expert who heads the center-right-leaning
American Action Forum, imagines an easy target if insurance subsidies
"start going to phonies and prisons and dead people." Payment cutbacks
and limited networks could also come under attack.
that limited networks could be a big issue. "It is one way that health
plans can compete because they can't compete by cherry-picking patients
anymore," Jost says.
The law forbids insurance companies from
turning away clients and also limits how much more they can charge
someone because of age. They can vary premiums based on whether a person
is a smoker, and on geography, but that's about it. So instead, many
will limit where customers can get care.
"Narrower networks are
less expensive," Jost says. "It really gives the plans more bargaining
power. They can say 'if you can give us a discount , we'll give you
People will squeal, but studies show that the care is
just as good for most people using a narrow network of doctors and
hospitals as those who have more choice, Jost says. But Corlette, of
Georgetown's Health Policy Institute, says it's a question that remains
to be answered, especially in states with few insurers.
predicts renewed focus on whether insurance coverage is working as
intended or as expected. "Insurance is supposed to provide financial
security and peace of mind. Are these new plans providing that?" she
asks. "And, people who haven't had insurance before may get a surprise
hit from things like deductibles, in-network vs. out-of-network,
pre-authorization, coinsurance and co-payments."
Democrats and the
administration can be expected to emphasize disparities in coverage.
Only about half the states elected to expand Medicaid to people who
won't be able to afford to buy health insurance. Because the ACA assumed
all the states would expand Medicaid, millions of poor in states such
as Texas and Florida will be left with no coverage.
will be filtering through what is pure election politics, what actually
is a temporary start-up problem and what is a real policy flaw," says
Holtz-Eakin. "It's going to be an interesting year. It is not going to
Aaron, of the Brookings Institution, says there are a
lot of what-ifs, including how many people will enroll and how sick they
are. All this will affect whether insurance companies make or lose
money — and whether they hike premiums for 2015. "Everything is fixable,
given time. The question is whether the politics of the situation give
the administration the time they it need to fix this."
system gets into working order, "It could become a positive for
Democrats, an emblem of how limited government involvement in social
areas can improve the lives of the American people."
If things are
rocky, on the other hand, the issue could "cast a very long, dark
shadow over Democratic prospects in 2016," he said.
"I think many
Democrats assume that Social Security and Medicare and Medicaid as we
know them are so entrenched in American life that they are untouchable.
But Republicans have a plan to transform them."
Does Aaron think the administration can fix the flaws in time for the election and turn around public opinion?
"As a betting person," he said, "I think the right has the better prospects right now."
Wednesday, August 23 2017 11:49 PM EDT2017-08-24 03:49:44 GMT
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