PPACA exchanges float toward 5 more rapids

The U.S. Supreme Court today freed health insurance industry players who want to get a few days off in July from having to cancel their vacations to try to restructure the U.S. commercial health insurance market, for the second time in five years.

The court’s 6-3 ruling in King v. Burwell (Case Number 14-114) means that public exchange managers, private exchange managers, health insurers, regulators, agents, brokers, providers, patients and other parties can continue paddling their kayaks down the health policy river created by the Patient Protection and Affordable Care Act of 2010 (PPACA).

See also: PPACA: A History

The court held that the PPACA public exchanges established by the U.S. Department of Health and Human Services (HHS), rather than by the states, can continue to offer the PPACA premium subsidy tax credit, even though the court acknowledged that the text of PPACA does not clearly say whether the HHS exchanges can offer the subsidy.

The decision will keep a sudden withdrawal of premium subsidy support from throwing off the actuarial assumptions health insurers used to set individual health rates for 2015, and are now using to set rates for 2016.

See also: Health rate filings crack open PPACA window

But the PPACA exchange system still faces many other charted and uncharted obstacles. For a look at some of the obstacles that could still overturn the kayaks, read on. 

1. Small Business Health Options Program (SHOP) exchanges

Even officials at HHS sound somewhat skeptical about the future of the PPACA exchange system’s small-group division.

Lawmakers in Minnesota, a state generally viewed as one that supports its state-based exchange, provided funding for the exchange but is requiring the exchange to seek HHS permission to let small businesses in the state qualify for the PPACA small-group coverage tax credit using off-exchange coverage.

See also: 3 state-based PPACA exchange snapshots

The same PPACA underwriting and product standardization requirements that, in theory, should help the SHOP exchange system sell group coverage through Web-based shopping systems are helping managers of private exchange systems do more and attract more employers and insurers. 

See also: How private exchanges are trying to stand out

2. Operational funding 

PPACA requires a public exchange to find ways to support itself, without help from federal tax money, after one year of operation. The exchange can get that money by imposing fees on users, drawing on tax money from its state, or using just about any other legal mechanism that the state will allow.

Some states with state-based exchanges have decided that, however much they like the idea of offering a state-based exchange, they hate paying for running an exchange, or they are unable to handle the technical and management demands involved with running a successful exchange.

Several states, including Hawaii and Oregon, have given up on running their own exchange enrollment and administration systems and have asked HHS to take over providing exchange services for their residents.

3. Consumer and provider acceptance 

Health policy groups have published survey data showing that many consumers like having exchange coverage and report having a good level of access to care.

Hospital companies have put significant political muscle into backing PPACA.