Purple grades for PPACA

Holding a nonpartisan, evidence-based conversation about how the Patient Protection and Affordable Care Act of 2010 is affecting the U.S. health insurance system is still difficult.

Deep Red enemies of Obamacare gave it a permanent F in 2010.

Deep Blue supporters gave the Affordable Care Act a permanent A, for “Amazing,” or a grade of “We could easily fix the problems, if only the Republicans would cooperate.”

Read: Lawmakers play PPACA CO-OP failure blame game

Insurance advisors may be able to look past partisan rhetoric, but they may be too busy helping clients with specific PPACA-related problems to think much about the big picture.

We’ve tried to help by developing a system report card, and to spark discussion by showing how we fill out the report card, as of early June 2016. We’ve assigned letter grades ranging from F (or zero) to A (or 4). When we computed grade point averages (GPAs), we deducted 0.3 points for a minus and add 0.3 points for a plus. A B+, for example, is worth 3.3 points.

For a look at how we came up with a grade for the health insurance system of, roughly, a C+/B-, read on:

1. Gamemakers

Employee Benefits Security Administration: C-.

It seems to have helped other agencies draft PPACA regulations in a methodical way. Labor law firms say it’s been auditing health plans for several years, but it posts no health plan compliance administration data.

Internal Revenue Service (IRS):A.

It implements PPACA requirements in a methodical ways, and it and its watchdog agencies post clear IRS PPACA program administration data in a consistent way.

U.S. Department of Health and Human Services (HHS)*: D+.

HHS runs PPACA programs through its Centers for Medicare & Medicaid Services division. CMS runs PPACA programs through its Center for Consumer Information & Insurance Oversight. HHS got complicated PPACA programs running quickly, in the face of fierce Republican opposition. But it rarely publishes the kind of data that a lay observer could use to determine how any particular PPACA program, other than exchange program enrollment, is doing.

State insurance regulators: B.

They developed PPACA regulations and procedures quickly. But, aside from Vermont, where the insurer strangled a Consumer Operated and Oriented Plan (CO-OP) in the cradle, they were slow to react to CO-OP problems.

Read: PPACA employer mandate may start two-step fights

An assister helps a consumer sign up for coverage at a health fair in Sacramento, Calif. (Photo: Rich Pedroncelli/AP Photo)

2. PPACA coverage expansion programs

CO-OP carriers: D.

When Kent Conrad and Max Baucus retired from the U.S. Senate, they orphaned this effort to use federal loans to create a new family of nonprofit, member-owned health insurers. Thirteen of the 23 CO-OPs have already died from a combination of HHS red tape, PPACA risk management problems, and bad pricing moves. But they have inspired entrepreneurs to create other new, non-CO-OP carriers, such as Oscar Health Insurance and Canopy Health Insurance, that could prove to be sturdier than the CO-OPs.

Coverage expansion program cost: ?

Analysts at Conning have suggested that coverage expansion may be costing at least $685 per newly insured American per month, or about $8,200 per year.

Medicaid coverage expansion*: A.

A research team led by Kosali Simon of the University of Indiana found that Medicaid expansion has led to a clear improvement in childless, low-income adults’ access to health care services. In expansion states, the average number of days when health problems kept those people from working fell to 9.3 in 2014 from 10.6 in 2013.

Health insurance exchange system: B-.

Boards of exchanges in some states, such as California, Colorado and the District of Columbia, post clear, detailed budget and performance data. Boards of some other exchanges seem to have studied at the HHS School of Health Program Transparency.

Advance premium tax credit (APTC)*: B-.

APTC money helps millions of moderate-income exchange plan users pay for coverage. But the APTC program requires recipients to predict what their income will be in the coming calendar year. The APTC is so complicated to administer that the IRS has had terrible problems with programming its systems to process APTC returns properly.

Cost-sharing reduction program: B.

This program has been quietly helping lower-income exchange plan users pay health plan deductibles and co-payments. House Republicans have asked whether HHS has the legal authority to fund the program.

Read: How has PPACA affected people’s health?

(Photo: Allison Bell/LifeHealthPro)

3. PPACA commercial insurance architecture

Bipartisan favorites:

• Ban on annual and lifetime benefits limits: A+.

• Ban on use of personal information other than age and location in health coverages sales decisions in open enrollment period coverage sales decisions: A+.

• Guaranteed renewability: A+.

Rep. Jeff Sessions, R-Texas, and Sen. Bill Cassidy, R-La., have proposed killing most PPACA commercial health insurance provisions but keeping this in a PPACA overhaul bill.

Essential health benefits package: C.

The standardized benefits package is supposed to be a pillar of the PPACA health plan comparison shopping system. It was also supposed to help all U.S. children get preventive dental services. Instead, administration of the children’s dental benefit mandate is so poor that HHS doesn’t even publish clear data on the percentage of children who have (or lack) preventive dental services benefits.

Metal levels: A.

Even harsh many critics of PPACA seem to like the platinum-gold-silver-bronze system.

Preventive services package: B.

PPACA now requires non-grandfathered plans to cover basic preventive services, such as checkups and vaccinations, without imposing out-of-pocket costs on the patients. Surveys have shown that Americans’ overall use of preventive services has been increasing since the requirement took effect. But the Kaiser Family Foundation found in the spring that only 47 percent of the consumers it surveyed knew about the preventive services benefits requirements.

Summary of benefits and coverage, and the uniform glossary: B.

Everyone seems to like the concept of having all plans create a short, standardized “milk carton label” for health plans. Everyone seems to think the struggle to keep the notices short is conflicting with the need for completeness and readability.

Read: Sessions-Cassidy PPACA overhaul bill, dissected

4. PPACA ‘three R’s’ insurer risk management programs

PPACA reinsurance program: B.

This program is supposed to use cash from a fee imposed on health insurers to provide a cushion for individual coverage issuers with catastrophic claims in 2014, 2015 and 2016. HHS has collected enough revenue from the fee to pay obligations to insurers for 2014 and 2015. But PPACA also calls for the reinsurance program to make payments to the U.S. Treasury. The program has not yet brought in enough to make the payments to the Treasury.