Daunting Challenges for Creating, Implementing Health Reform Law’s Insurance Exchange Program

Creating and implementing the insurance exchange program required by the new health reform law is a daunting challenge.(Image: Jon Schulte/iStockphoto.com)

Washington, DC—One of the considerable challenges presented by the Affordable Care Act (ACA) is implementing the insurance exchange program required by the ACA, agreed a panel of state insurance regulators gathered earlier this week at the AcademyHealth Health Policy Conference in Washington, DC.

Affordable insurance exchanges, which are to be in place in 2014, are intended to provide a central point of access for health insurance, where individuals and family members can enroll in private or public health insurance coverage and where people with low-income small businesses can find private health insurance plans to offer to their employees. Insurers participating in the exchange will be required to provide a minimum benefit package to qualify and must agree to limits imposed on premiums, deductibles, and co-payment requirements and caps on out-of-pocket expenses. Families earning less than $88 000 per year for a family of 4 (a sum that is 4 times the federal poverty level) will be eligible for subsidies when insurance is purchased through the exchange. Some small businesses will also eligible for subsidies but only for 2 years.

Considerable challenges remain in getting the exchanges up and running by 2014—even for states that embraced the exchange notion early on, such as California, which established an independent governmental entity, the California Health Benefit Exchange, in 2010. Despite the early start, “creating the insurance exchanges is not for sissies,” said Kimberly Belshé, one of the exchange’s 5 board members. “California has multiple IT systems and 27 000 eligibility workers who support today’s eligibility and enrollment for Medicaid and human services programs, along with a separate system and approach for our CHIP [Children’s Health Insurance Program],” she explained. The ACA presents an imperative to streamline these systems and business processes to accommodate the estimated 4 million people who will be newly eligible for public insurance affordability programs, an endeavor that “represents a big change,” said Belshé.

There also are unresolved problems in working out how to keep an entire family together in a single health plan, said Charles Milligan Jr, JD, deputy secretary for health care financing in the Department of Health and Mental Hygiene for Maryland, another state that has embraced the insurance exchange concept. As one member of the family moves in or out of the insurance exchange program, other family members may not be eligible for the same plans. This may be especially problematic for families whose children are insured by CHIP and thus have an entirely different set of health insurance plans than the rest of their family.

Ensuring continuity of care as people move in or out of various insurance plans is yet another unresolved issue, said Milligan. For example, although it is often best for patients in the midst of treatment for a disease to remain with their current clinicians, this may not be possible if they are moved to a different insurance plan that does not have those clinicians in its network. The ACA’s requirement of real-time enrollment, a level of customer service not yet achieved by many government programs, also remains a challenge.

Of course, political pressures add to the challenges. Susan Voss, the Iowa state insurance commissioner, who has a long history as an insurance regulator, characterized the competing pressures from the Iowa legislature and governor, combined with the tight timeline for getting the health insurance exchanges functioning by the 2014 deadline, as daunting.