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How to tell if PPACA is working

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We had to pass the Patient Protection and Affordable Care Act to know what was in it, and we had to implement it to know what was wrong. 

Now, how will we know it is actually working? 

There are lots of metrics (both real and made-up) on the failures of the ACA, and a few similarly questionable indices on the law’s success. For example, there were several recent stories on how there were more people buying pot than signing up for insurance in Colorado. Amusing, perhaps, but not very useful.

Both CFOs and journalists are very suspicious of metrics and statistics, and both have asked me for advice on how to tell if the ACA is working over time.

There are not many sources of objective information. I look forward to getting statistics from the U.S. American Community Survey. Many people don’t know about this survey, but it’s a good one. Starting in 2000, the Census Bureau took the long-form census and set it up as an ongoing continuous survey of the United States (about 50,000 random citizens per month), asking questions on health insurance coverage along with multiple other data points.  If the ACA is working, this should show an increase in the number of people with insurance, starting with the 2014 report, which will be released in 2015.  I’ll be watching.

On a faster reporting cycle, we’re starting to get more detailed statistics on the marketplace enrollees, with the Department of Health and Human Services releasing some demographic breakdowns on enrollments through December. Nice to learn that after two fairly low enrollment months (364,000 through November), HHS is reporting that there was an increase in plan selection in December with enrollment numbers growing by over 1.7 million in December to a now-cumulative three-month total of more than 2.1 million enrollees.    

So, what other metrics can we track? Health care policy reporter Sarah Kliff wrote a good post on this subject in the Washington Post a few weeks back, and reviewed some conventional wisdom points on how to tell if the ACA is working. The main points were to pay attention to how many more people get coverage, if there is better access to health care, does this create a healthier population, and more overall affordability.  All fine points for a macro view, but I think there are others a little closer to the ground.

We’ll know it’s truly working when …

In business:

  • CFOs of hospitals report an increase in profit margins due to a reduction in bad debt from non-payment for services.
  • There is an increase in consumer transparency of health care charges, and you can get a generally accurate answer to the question “How much will this procedure cost?”
  • Emergency rooms are used for emergencies, and ERs report lower levels of routine care.
  • There is a statistical difference in the economic performance of adjacent states that are taking different paths with the implementation of the ACA – good ones I will be watching will be Arizona vs. Texas, or Indiana vs. Kentucky.
  • There is more organizational mobility, resulting in a spike in new business startups from people who are no longer excluded from the individual marketplaces.

In the media:

  • The content of media stories shifts, and articles appear on specific issues that need adjustment instead of macro-based calls for repeal or retention.
  • Americans talk in general conversation about benefits to them of having health care coverage, and can explain how sharing risk is a positive part of life. I look forward to an informed citizenry debating the core issues – right vs. privilege of health care, and freedom vs. personal accountability for well-being.
  • The Heritage Foundation and Newt Gingrich (correctly) take credit for creating some of the core concepts of the ACA on the Sunday talk shows. Watch the shifting of the talking points of the pundits that are so firmly opposed over the next five years, if the law stands. They will have to go through the classic steps of managing change – denial, resistance (also known as trash-talking), exploration and acceptance.  Only when political reality emerges from the fog of war will our political leaders meet in the middle to make needed changes to the law. 

In our culture:

  • The new focus on wellness and well-being reduces the number of deep-fried food products at our state and county Fairs.
  • There is a drop in the number of “marriages of convenience” that are based on getting health insurance.  (My wedding nine years ago was timed with the expiration date of my fiancée’s individual health plan. How romantic.)

Finally, don’t forget to focus your attention on where the biggest impact would be felt, and pay particular attention to the people truly targeted for coverage.  Ask the “Is it working?” question of early retirees with limited resources, the previously uninsurable with a chronic condition, those with mini-med policies that were at risk from bankruptcy, the “young invincibles” that do not understand the need for risk-sharing, and those under the federal poverty line. 

Simply put, the ACA is part of a complex marketplace and we have a diverse set of citizens.  As benefits professionals we need to keep an eye on the hidden metrics to better guide our adjustments to the ACA’s many moving parts.

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