A year ago, I tried to imagine how the start of major Patient Protection and Affordable Care Act (PPACA) coverage expansion programs and health insurance rules would change the health insurance community.

I compared the new PPACA World to a hammer that was about to fall on the old U.S. health insurance world.

“PPACA might come and smash Managed Care World as we know it to bits Jan. 1, or a few weeks or months later, or it might just blow away, or something else,” I wrote.

I now think the best description of what PPACA World did is “something else.”

The hammer still … seems … to … be … falling… ever so slowly, toward our heads.

Someone else has a PPACA public exchange plan. Someone else has doctors struggling with the new narrow provider networks. But many people, including me, are still in some kind of grandfathered plan, grandmothered plan, or other non-PPACA plan that’s operating pretty much the same old way it always has. 

Here’s a self-evaluation of how I did with the other predictions I made for 2014, and a list of seven predictions for 2015.

2014 predictions: what we got right, what we got… maybe right or wrong?

1. For some people, PPACA World will be heaven. 

Correct.

This is not the case for most of the people reading this. PPACA World has not been easy on health insurance brokers, benefits compliance specialists, or the many conscientious people who are now paying more for less coverage.

PPACA has been great for the sick people who were shut out of the commercial health insurance system for years. Their coverage may not work all that well, but at least they have coverage to complain about.

2. Exchange managers will get into brutal court fights with the vendors that designed, built and integrated balky exchange enrollment systems.

Yep. This seems to be happening, or on the verge of happening, in a number of states.

3. In states that have relatively low exchange plan enrollment because of exchange enrollment system problems, doctors, hospital executives, insurers and insurance regulators will send thank-you notes and bouquets to the information technology companies that caused the system problems that held down enrollment.

I can’t yet tell. At this point, few providers seem to be complaining all that much about exchange plan payment problems, but it’s hard to tell whether that’s because there are no problems, or because the problems are so serious the providers don’t yet grasp how big the problems are.

4. The insurers, agents and brokers that sell hospital indemnity insurance, accident insurance, critical illness insurance and other products that are exempt from PPACA underwriting and pricing rules will flourish.

As far as I can tell, yes, at least in terms of sales. We won’t really know how the underwriting went until the statutory annual reports come out in 2015. 

Insurance regulators tend to view rapid growth as a risk factor for an insurer as well as a blessing, and that might be as true for the issuers in the gap-filler market in PPACA World as for issuers in any other hot market.

5. Health policymakers will start thinking about what PPACA World 1.5, Son of PPACA, or Anti-PPACA World might look like.

Maybe. The answer here depends on whether you regard the various House PPACA repeal and change proposals as efforts to create the Anti-PPACA World or simply efforts to rattle the Democrats.

6. The people directly involved with the dental, vision and disability insurance markets will be looking for someone — anyone — to talk to.

Yes. It’s hard to express how guilty I feel about some of the dental, vision and disability stories I have failed to cover this year because of PPACA Mania. 

7. The flexible spending account (FSA) carryover rule will bite employers and their human resources’ staffers and vendors in the hind parts.

See my self-evaluation for the sixth question. I suspect that this is the case, but it’s hard to get myself to move from thinking about PPACA to thinking about… something else.

So, I think I got three of the predictions correct. It’s too early to tell whether I was right or wrong about the other four.

Now, for the 2015 predictions…

Asteroids

1. The story of the PPACA exchange programs and exchange plans will continue to be full of drama.

Maybe the enrollment systems will work worse during the coming open enrollment season. Maybe they’ll work better. Maybe aliens will take over the exchange plan billing computers. With the PPACA exchange system, you never know. At all.

Supreme Court

2. The Supreme Court will cause mischief.

Opponents of PPACA had some trouble getting standing to file lawsuits over coverage expansion programs that didn’t yet exist and health insurance rules will in force. Now plaintiffs may have an easier time showing that have a real reason to bring a case and pushing it up to the Supreme Court.

Risk

3. The three R’s fights will get nasty.

In 2014, just about every health insurer could dream of being in a receivables position with respect to the PPACA risk corridors program, which is supposed to use cash from carriers with fat margins to help carriers with thin margins, and the PPACA risk-adjustment program, which is supposed to use cash from carriers with low-risk enrollees to help carriers with high-risk enrollees.

In 2015, some carriers will have to acknowledge that they’re in a payables position, and they may not like that very much.

Advisor walking toward a storm.

4. One of the CO-OPs will have turned out to have gone spectacularly wrong.

Some of the new nonprofit, member-owned health plans created by PPACA seem to be doing great, but, given all of the commotion surrounding glitch-plagued exchange enrollment and administration systems, they haven’t gotten much attention.

Their performance will start to get more attention in 2015, when they file their annual statement blanks.

Blank stare

5. A strong private exchange will start to suck the life force out of one really bad public exchange.

At some point, if one of those new private exchanges is doing most of what a public exchange is supposed to do — and doing with smoothly, and affordably — a state might start to wonder why it can’t just hire a private exchange program to take over from the clowns at the public exchange office.

A nurse and a patient in Utah

6. Medicaid expansion will grow on (most of) us.

One question critics raise about the PPACA Medicaid expansion program is philosophical. Should the government take such a direct role in providing so much health care? Another question is practical. Can the U.S. government keeping scraping up the money to pay for Medicaid expansion?

But the critics face practical challenges of their own.

Insurers love Medicaid expansion, because they get to bid on Medicaid contracts.

Hospitals love Medicaid expansion, because patients are more likely to be able to pay them.

Whenever the critics want to hold a congressional hearing attacking Medicaid expansion, the hospitals will be able to round patients who have benefited from Medicaid expansion. After a few of those hearings, the critics may give up on attacking Medicaid expansion and go after an easier target.

Image: A nurse and a patient at a hospital in Utah. (AP photo/Rick Bowmer)

Leader

7. Agents and brokers will make a comeback because everyone needs your ability to solve problems.

Insurers and consumers really don’t want to have to pay for your services now. But they didn’t want to pay for your services 50 years ago, or 100 years ago. Eventually, they started paying you, because they needed you.

Agents and brokers emerged because people had problems with buying and using insurance, and insurers had trouble with selling insurance. Producers could help with those problems.  

The system has changed, but the problems are still here, and that means that the agents and brokers will still be here.