Some Patient Protection and Affordable Care Act (PPACA) exchange system supporters are celebrating how much use of the public exchange enrollment system is growing. PPACA critics are celebrating any signs that sign-up activity is weak.

I think that’s a little like focusing on how well your favorite professional football team, which did not get into the Super Bowl, did in a pickup game against some college team in April. 

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On the one hand, obsessing over the enrollment numbers is fun. 

But, on the other hand, the current ups and downs in sign-up numbers have little to do with the issues that are still open for debate.

At this point, PPACA exchange system supporters have shown that tens of millions of consumers are willing to use a well-publicized website to shop for health insurance, and that those consumers are especially likely to buy the coverage, even if the website is terrible, if their share of the premiums is low.

Some consumers who would qualify for free or cheap coverage are not sure how to use the website, but it appears that a high percentage of those consumers are vague about what day of the week it is. Their lethargy is the result of general social problems, not with flaws in the idea of using an exchange to help ordinary consumers get health coverage.

Republicans who hate Democratic programs, and democratic socialists who hate the idea of private-sector involvement in health care, can find all sorts of ways to strangle the exchange system, but those efforts would just show that it’s possible for opponents of a program to cripple the program. Surprise.

Still, on the third hand, there are plenty of major open questions.

One is whether budgeters can realistically assume that many public exchange users will ever sign up for coverage on their own, even if the websites work, or whether, in the real world, typical consumers will usually talk to a live human. (Example: you). If most consumers will be talking to live human advisors, and the advisors will be the ones making the most use of the exchange websites, what does that mean for how the exchange system should be designed and funded?

A second question is whether, after taking all costs, benefits and important non-financial issues into account, the public exchange system is efficient and effective enough to be at least as appealing as the major alternatives. 

A third, closely related question is whether the managers of the public exchange system, and the players involved with the potential alternatives, can be open enough for us to compare the systems.

A year ago, the Hawaii exchange, which now uses the HealthCare.gov enrollment and administration systems, estimated exchange programs were costing an average of $15 to $210 per resident, and an average of $108 to $3,158 per uninsured resident. But the Hawaii exchange managers seemed to have a hard time getting those basic cost figures.

Seeing how well PPACA-compliant coverage competes against the alternatives could be a good way to grade the PPACA exchange system, and the PPACA World rules for all individual major medical coverage.

Minnesota might be one great experiment.

That state offers low-income residents Medicaid. Residents with somewhat higher incomes qualify for a kind of souped-up managed Medicaid program, or Basic Health Plan (BHP) program, called MinnesotaCare, and residents higher up the income ladder qualify for ordinary exchange plan tax credits.

Instead of obsessing about exchange enrollment numbers, one way to compare the appeal of the two systems would be to give some Minnesota residents in a certain income bracket a chance to choose between exchange plan coverage and MinnesotaCare coverage with similar enrollee premium costs. See who chooses which coverage, and why, and what the cost, quality and satisfaction outcomes are for all players, including healthy enrollees, sick enrollees, health care providers, and payers. Maybe the results of that competition are what should determine the PPACA exchange system grades for 2016.

See also:

Weird PPACA plans

PPACA program appeals to Medicaid expansion fans

 

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