Meeting demand also means training more doctors, and Mitchell worries about a pipeline that is already underfunded. Federal support for physician training has been frozen since 1997, and further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell said.
Explore This IssueJanuary 2014
Costs All Over the Map
Another one of the plan’s biggest goals and part of its name—affordability—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.
With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku said, is that all plans must now include 10 “essential health benefits” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he said, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.
Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or asking enrollees to switch to other ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year.
The Long View
Despite the intense focus on the first few months of health insurance enrollment, however, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate.
If they succeed, however, the ACA exchanges could have several long-term consequences. “If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” Dr. Berenson said. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.