What the Affordable Care Act Means for Otolaryngologists and Their Patients

While most adult otolaryngology patients are covered either by private insurance or Medicare, a larger percentage of pediatric patients—especially those in academic settings—are covered by Medicaid. If concerns over uneven reimbursements continue, Dr. Boss said otolaryngologists may flock to larger healthcare systems where they’re more insulated from losses, or remain in solo or smaller practices but reduce risk by limiting access to those with private insurance plans.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a shaky start on Oct. 1, 2013, when computer issues hobbled the main healthcare.gov portal for 36 state exchanges and temporarily plagued many state-run sites as well.

While exchanges in some states have generally earned high marks, others have struggled. One reason why analysts have worried about the balkiness of the main web-based portal is that older and sicker patients are generally more motivated to keep trying to enroll. The same isn’t necessarily true for younger and healthier people, whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot and stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters worry that malfunctioning exchange sites could cause many would-be enrollees to delay or drop out.

Because the health insurance exchanges were already highly controversial even before they launched, said Dr.Ku, who also sits on the board of the Health Benefits Exchange Authority in Washington, D.C., every problem is likely to be magnified by critics. It’s too early to say whether the exchanges can meet the Congressional Budget Office’s prediction of seven million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges also will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network providers higher patient volumes in exchange for discounted reimbursements. Others are now finding themselves excluded from most private plans in favor of cheaper options.