January 14, 2014
During the fourth quarter (4Q) of 2013, operational issues dominated implementation of the Affordable Care Act (ACA). Of particular importance were ongoing problems with inadequate outreach and education (continuing from the weak foundation developed in previous years); delays in the development of regulations and directives (also continuing prior trends); and the demonstration of inadequate preparation for the online computer-based marketplaces.
Throughout the 4Q, the Department of Health and Human Services (HHS) and associated groups attempted to play “catch-up” with outreach and education programs for the public. This essential aspect of ACA implementation was largely neglected from 2010 through mid-2013, when it then became clear that neither strategies nor budgets were in place for a rapid expansion of these communications activities.
Similarly, delays in the development of regulations and directives left HHS unprepared to enforce its own schedules and requirements. Without notice, at the start of the 3Q, the large-employer mandate was postponed until 2015. And as the 4Q proceeded, it became progressively more obvious that HHS did not have allof the program framework in place, leading to other postponements and rescheduling.
However, these failures were rapidly overtaken in the 4Q of 2013 by significant flaws in the federal Exchange located at www.HealthCare.gov, and by similar flaws in some of the state Exchanges. In response, HHS somewhat-frantically sought first to downplay the problems, then to shift to “crisis mode” to address the problems.
As it turned out, the federal Exchange achieved minimally-acceptable operations at the last minute (in December, 2013), enabling a last-minute surge in enrollments to take place. Some of the state Exchanges also were able to achieve significant operations, contributing to the 4Q outcomes. It was announced that about 2 million people had successfully achieved coverage through the ACA.
However, many software problems still remained at the end of December, including errors in data transfers to insurance companies.
Final judgment on the ACA by the public still remains a work in progress for 2014.
Advocates for the ACA no longer have to deal with a fixed performance date (like the October 1 date for the Exchanges), but can shift to a more-distributed sequence of objectives without a single “go live” date, and seek to “lower the temperature” of criticism through a series of more-limited successes.
Some publicity for “winners” who have gained through implementation of the ACA can also be spread out over the year, in an attempt to develop an aura of steady success for the program.
At the same time, critics of the ACA can seek to “string together” a set of 2014 problems to create a steady “drumbeat” of failures and complaints. Case studies can be presented of individuals with poor outcomes due to the ACA.
Critics can also play on the “social pain” being experienced by many individuals as they attempt to adjust from the old ways of handling health insurance to the “new way”.
Throughout 2014, these competing narratives will build and compete, before and after the November elections.
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.