Close Close

Life Health > Health Insurance > Your Practice

The big open question about the ACA exchange system

Your article was successfully shared with the contacts you provided.

Here’s my instinctive bias: Although writing about the possibility of the U.S. individual major medical market imploding in 2018 is interesting, and necessary, Seema Verma will probably come in and save us all.

Verma, an Indiana health care program consultant who is President Donald Trump’s pick to be the next Centers for Medicare & Medicaid Services, sounds as if she’s probably the sort of person who will talk sense into everyone and make it all OK. Maybe she’ll also be a wonderful data wrangler who will find ways to answer all the health policy questions we’ve ever had — going back to what was up with that apple Adam and Eve tasted.

Related: Trump picks ACA foe as HHS chief, adds Pence associate

But so far, I think one big problem with all of the Obama administration love lavished on the Affordable Care Act exchange system, and the Republican hate smeared on it, is that the emotional debate over health policy has left important questions unanswered.

Overall ACA exchange plan enrollment for 2017 seems to be down a little, as opposed to up a little. But all that really proves is, if the Republicans in Congress really hate you, they can hurt your sales a little, by, for example, starving the health insurance risk management program subsidies that insurers were counting on. No surprise there.

What might be a little more interesting would be a clear, honest count that determines how much the ACA exchange system and coverage really cost when compared with likely alternatives.

One reason Congress looked into setting up a government-run version of to start with is that eHealth Inc., the Mountain View, California-based parent of, was too small to knock state regulator and insurance company heads together and get everything standardized, or create underwriting simplified enough to make instant web sales possible.

In most states, eHealth had a hard time selling health insurance through an instant sales process, the way would sell books, because consumers had to go through a medical underwriting process, and compare plans that were about as similar as chickens and lawnmowers.

So now that the rules have been standardized, and the exchange enrollment and administration systems are set up, after a fashion, how much does the ACA exchange enrollment process cost per enrollee?

How much does the account administration process cost per enrollee?

How much does the coverage cost the government, and how much does it cost the enrollee? (CMS has given us answers to this question for earlier years; now we just need the 2017 data.)

Then, how much do the enrollment and enrollee relationship administration processes cost for managed Medicaid plan enrollees, and how much does managed Medicaid coverage cost?

What if you beefed up the managed Medicaid plan coverage to be more comparable to exchange plan coverage. How much would benefits richness and provider network adjusted managed Medicaid coverage really cost for people now in the ACA exchange plan coverage?

What would the comparable costs be if we put everyone in Medicare Advantage plans?

Just for kicks, how much might the comparable costs be if and other web brokers and brick-and-mortar brokers crowded out the ACA exchange system? What would all the costs be then?

If we had nice charts comparing the costs of the different kinds of systems side by side, then we could choose an alternative based on facts, as opposed to emotion.

What we need, basically, is a national health care system selection website that would let us compare and select national health care systems on an apples-to-apples basis. Maybe we could rate the richness of national health care systems based on the level of actuarial value provided, with some kind of Summary of Benefits and Costs that would be like a milk carton nutrition label for national health care systems.

I think I’ve heard of something like this before. If I step away from the computer for a while, maybe the name of that concept will come to me…

Allison Bell is a senior editor at


Why Kentucky couldn’t kill Obamacare: A lesson for Congress

Obama administration adjusts ACA exchange program for 2018

We’re on Facebook, are you?