December 19, 2013
Changes in access to health care are helping drive organizational reactions to the ACA.
During the period 2010-2012, implementation of the Affordable Care Act (ACA) by the Department of Health and Human Services (HHS) was focused on internal decision making, the writing of regulations and procedures, and contracting out of key program operations. These were all familiar tasks and approaches to program management.
Other organizations in the Health Care System were primarily in a reactive role, watching and evaluating HHS activity.
Then, during 2013, the results of previous efforts by HHS surfaced. It rapidly became clear that the HHS preparation activities were not leading to results that were consistent with smooth implementation of the ACA.
Outside health care organizations began to resist these surfacing efforts. In a turnabout, outside organizations started to become the active drivers of program activities, while HHS was often forced into a reactive role.
Political resistance by many states was expressed through decisions to not implement state Exchanges. This threw a much broader and unexpected burden back on HHS. Given the situation, these reactions might have been anticipated; however, HHS was forced into a late reactive role to set up a federal Exchange to serve 36 states.
Similarly, about half of all states refused to adopt the new Medicaid expansion, leaving unresolved how to provide insurance to individuals without enough income to qualify for subsidized policies. HHS is still struggling to find a workable reaction to this problem.
As October 1 arrived, it rapidly became clear that the federal Exchange was not ready. Reactions by HHS evolved from early denial, to blaming contractors, to bringing in outside experts and then asserting that problems had been largely solved. Turmoil continued as individuals tried to enroll and often found themselves frustrated.
During the fourth quarter of 2013, other reactions by outside organizations also began to require attention.
Large employers charged that regulations were not yet ready for the large-employer mandate, and HHS reacted by postponing the mandate for another year. This has not kept these employers from being vocal about the transition problems that they face.
Insurance companies complained about errors in the information coming from the federal Exchange, which brought forth efforts to provide abbreviated and alternative files for new enrollees.
Individuals began to complain about having their old insurance policies terminated, so an effort was made by HHS to reinstate these policies for another year. Insurance companies announced that this would be burdensome and in conflict with ACA objectives. State insurance commissioners split on this “fix”, with some allowing it to go forward and others “opting out”.
Many providers found themselves excluded from the new “narrow” networks set up by insurance companies in order to compete under the ACA. Some individuals began to complain over being excluded from the providers that they preferred. HHS listened but had no strategy to “correct” the situation.
Word also began to spread of large deductibles that individuals might experience under the new ACA-driven policies. HHS largely chose not to respond, since these features were built into the ACA plans. However, it was clear that these complaints were likely to worsen in 2014.
All of these problems and reactions to HHS actions are affecting access to care.
The longer-term results of the ACA may be improved access to care for the public at large, but 2014 seems likely to be a difficult transition year, with access reduced in important ways for many individuals.
More on these and related ACA topics, with an in-depth discussion of organizational reactions to implementation issues, may be found in a recent book by the authors that describes evolution of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.