Fwd: qotd: Timothy Jost reviews what four years have brought us

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Subject: qotd: Timothy Jost reviews what four years have brought us
Date: Tue, 14 Jan 2014 11:00:04 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs
January 2014
Implementing Health Reform: Four Years Later
By Timothy S. Jost

Despite enormous potential, the Affordable Care Act has been plagued by
controversy and confusion from day one.

Looking Ahead

It is likely that more complaints will be heard once people actually use
their ACA coverage. Many exchange carriers are offering limited provider
networks. Narrow networks allow insurers to reduce premiums as they
exclude the most expensive providers and negotiate steep discounts with
those who remain. Consumers will like the low premiums but will be
unhappy to learn that their doctors are not available and shocked to
discover charges from out-of-network specialists when they go to
in-network hospitals.

Consumers may also be surprised by the magnitude of cost sharing under
ACA plans. Bronze plans may have $6,000 deductibles, and silver plans
can have deductibles of $2,000 or more. Even at these levels, of course,
cost-sharing obligations will be lower than many policies found now in
today's nongroup market. But this is not free care, or anything close to it.

Millions of low-income Americans in states that refuse to expand
Medicaid will find themselves too poor to receive any help. This is, of
course, not the fault of the ACA but rather of its opponents. But the
public may not grasp this distinction.

Other problems will also attend the implementation of the 2014 reforms,
and all will be widely reported. Employers may continue to reduce
employees to thirty hours or otherwise try to avoid offering health
insurance to their employees. Insured and self-insured plans will bear
part of the cost of expanding coverage and reinsuring high-cost
enrollees in the individual market, increasing their costs. Finally,
public outrage is sure to hit the headlines again when tax filing time
arrives in 2015 as some individuals will be assessed the penalty for
remaining uninsured, while others will face a repayment demand for
overpaid premium tax credits.

Going forward, one of the most important challenges facing the ACA will
be whether its benefits become apparent quickly and dramatically enough
to offset the problems that are currently dominating the news coverage
of the health reform law. Even more important may be the question of how
much it will matter that the greatest beneficiaries of the ACA are
likely to be low-income Americans, who are less likely to be politically
active than many of the higher-income Americans who will be adversely
affected by higher insurance premiums and taxes.

In the end, the most important fact is that the ACA addresses a real and
dramatic problem: nearly fifty million uninsured Americans. Its
opponents in Congress have failed to put forth any credible proposal to
address this problem since the law was enacted. As disruptive as it may
in fact be, the ACA does address this problem. If it succeeds, America
will be a better place. If it fails, it is unlikely that another
solution will be forthcoming any time soon, perhaps not for another
generation.

http://content.healthaffairs.org/content/33/1/7.full


Comment: Timothy Jost is one of the most astute, objective analysts and
observers of the unfolding of the Affordable Care Act. We should listen
to him when he describes the negative impact that ACA will have on
moderate- and higher-income Americans. They will be especially unhappy
with their loss of choice of physicians and hospitals because of the
narrow or ultra-narrow networks, and they will be greatly displeased
with out-of-pocket costs that are much greater than they previously
experienced.

Although Jost suggests that the determination of the success or failure
will be based on how successful the enrollment of the 50 million mostly
lower-income uninsured Americans will be, it is more likely that those
with incomes above 400 percent of the federal poverty level who will be
bearing the full costs of their insurance, directly or through wage
concessions, will consider the shift in employer-sponsored plans toward
narrow networks and high cost sharing to be a failure of policy.

Although Jost also discusses the positive features of ACA, they do not
offset the negative since we did not have to accept such a compromised
system.

Although he suggests that another solution is unlikely for a generation,
once the politically active people with good jobs and decent incomes
realize what happened and what they could have had, the demand for
single payer Medicare for all will move the process much earlier. At
least for their benefit, and for the benefit of all U.S. residents, we
hope so.