The Affordable Care Act and Health Insurance Exchanges

The Affordable Care Act (“ACA”) provides for the establishment of State or regional health insurance exchanges where individuals can shop, compare and purchase medical care coverage beginning the last quarter of this year for coverage effective January 1, 2014. 

In connection with establishing a state-based health insurance exchange by October 1, 2013, there are so many issues to address that some states are electing to use the federally-facilitated exchange, which may also not be ready in time.  Given that an exchange must permit an individual to enroll on-line, in-person, by phone, fax or mail and also provide culturally and linguistically appropriate assistance, the task to accomplish this seems overwhelming.  

Only 17 states plus the District of Columbia have decided to establish their own state-based exchange and have each received conditional approval to do so from the U.S. Department of Health and Human Services (“HHS”).  One state, Utah, has proposed running the exchange for small employers while allowing the federal government to handle the individual exchange.  The individual exchanges are the more difficult due to the breadth of information required by the individual.  HSS continues to evaluate that proposal.  

New York and two other states have established exchanges through an executive order, and New York is feverishly working to comply with the October 1, 2013 deadline.  Given the diversity of its citizens, New York has a formidable challenge and even if New York is ready by October 1^st, things are bound to be bumpy.  

Consider that the individuals staffing the exchange need to be well-versed in the products being offered through the exchange, eligibility requirements for public programs such as Medicaid or Child Health Plus and determining premium tax credits and cost-sharing subsidies, the staffing of the exchanges will be a challenge in and of itself.  Add to that challenge the multi-language needs for exchanges to be effective for those populations that do not speak English.  Also consider that those without coverage are more often than not minorities where English may not be the primary language.  Enrolling and explaining the benefits and eligibility of these individuals will be a challenging endeavor. 

Before the exchanges, health insurance general agents and brokers and employers gathered information from their employees and accounts to determine eligibility.  This process will continue to take place through employer groups.  However, the individuals that will seek coverage through the exchanges will be individuals with either sporadic employment or no employment who are considering coverage for themselves and their families.  The cost of coverage is currently unknown but expected to be roughly $20,000 per year. 

There is one thing that will be certain concerning the implementation of the health insurance exchanges – it will be a bumpy ride for a while. 

One suggestion that will benefit those groups of individuals where English is not their primary language is to provide group seminars or information lectures where individuals are educated on the appropriate personal information necessary to establish eligibility and obtain coverage.  These workshops should commence immediately in the geographic areas where the highest prevalence of uninsured reside.  This would facilitate the enrollment of and increase healthcare coverage for those for whom the Affordable Care Act was targeted. 

Another key component to increasing healthcare delivery will be a universal system for accessing an individual’s complete medical history including all past and present diagnostic testing.  Patient information technology is key to accomplishing all of the principles imbedded within the Affordable Care Act.  However, effective and efficient enrollment in the exchanges is essential to achieving this goal. 

The Affordable Care Act, in principle, will facilitate better healthcare delivery to many who were forced to seek treatment through emergency rooms as their last resort rather than receiving periodic wellness checks. 

If the Affordable Care Act accomplishes this goal, individuals and families who had not been insured will have access to the complete continuum of healthcare including nutrition and wellness initiatives by averting very expensive hospitalizations through preventative efforts.