<p>The <em>New England Journal of Medicine </em>(NEJM) published an <a href="http://www.nejm.org/doi/full/10.1056/NEJMhpr1405667 ">article</a> on July 17 that was positioned as a "progress report" on healthcare coverage under the Affordable Care Act (ACA). NACDS Director of Federal Public Policy Chris Smith analyzed the article and identified 15 key points that characterize the current operating environment related to the ACA.<br />
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The NEJM article was authored by David Blumenthal, M.D., M.P.P. and Sara R. Collins, Ph.D. <br />
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The key points identified by Smith include the following:</p>
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<li><span style="text-indent: -0.25in;">State and federal officials estimate that 80 to 90% of the 8 million exchange enrollees paid their first month’s premiums. However, it remains to be seen whether these individuals continue to pay their premiums month after month.<br />
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<li><span style="text-indent: -0.25in;">It is estimated that an additional 4 million people may gain insurance through the exchanges through special enrollment periods during 2014.<br />
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<li><span style="text-indent: -0.25in;">Hawaii, Minnesota, Maryland, Massachusetts and Oregon had malfunctioning exchange websites last year, so it is believed that if they have working websites next year, then they will boost enrollment.<br />
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<li><span style="text-indent: -0.25in;">This year, the Congressional Budget Office (CBO) projects that 5 million individuals will gain coverage through direct purchases from insurers, separate and apart from the exchanges and Medicaid.<br />
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<li><span style="text-indent: -0.25in;">One-in-five individually insured adults received cancellation notices for the 2014 year, but some of the cancellations would have occurred even in the absence of the ACA. Between 2008 and 2011, only 42% of those with individual policies still had those policies after 1 year. Thirty-eight states allowed renewals of non-ACA compliant plans in 2014 and estimates are that 500,000 people renewed such plans.<br />
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<li><span style="text-indent: -0.25in;">In 2014, premiums were 16% lower than predicted by CBO. Note that reinsurance payments, alone, reduced premiums by 10% in 2014.<br />
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<li><span style="text-indent: -0.25in;">Thirty-one percent of exchange enrollees were age 18 to 34, but it is unclear whether that percentage was consistent with insurance company projections for purposes of predicting 2015 premium rates. Even if the population skewed older than projected, the 2015 premiums are predicted to increase by only 1-to-2%.<br />
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<li><span style="text-indent: -0.25in;">Narrow networks were used to keep premiums down and are likely to continue in the future. However, the federal government and several states are beginning to scrutinize network adequacy.<br />
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<li><span style="text-indent: -0.25in;">In states that did not expand Medicaid, nearly 5 million uninsured are expected to be left without new coverage options because they do not qualify for Medicaid or exchange subsidies.<br />
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<li><span style="text-indent: -0.25in;">Medicaid enrollment increased by 6 million this year and CBO is predicting 7 million by the end of the year and eventually 13 million. By 2018, 17% of the nonelderly US population could be enrolled in Medicaid.<br />
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<li><span style="text-indent: -0.25in;">Because the federal government delayed some aspects of the Small Business Health Options (SHOP) Program, there are no estimates yet on SHOP enrollment or how many people are gaining coverage through employers because of the ACA.<br />
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<li><span style="text-indent: -0.25in;">The NEJM study estimates that 20 million gained coverage under the ACA as of May 1, including: 1 million young adults gaining coverage through their parents, 8 million exchange enrollees, 6 million Medicaid enrollees, and 5 million who purchased insurance directly from insurers.<br />
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<li><span style="text-indent: -0.25in;">CBO projects that the uninsured rate will decrease by 12 million this year and 26 million by 2017. Polling shows the number of uninsured may have already declined by 5 to 9 million, but these surveys were done early on and may be underestimates. The uninsured rate fell from 18% in the 3</span><sup style="text-indent: -0.25in;">rd</sup><span style="text-indent: -0.25in;"> quarter of 2013 to 13.4% in May, 2014.<br />
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<li><span style="text-indent: -0.25in;">Non-Medicaid expansion states will benefit less from the ACA than expansion states leading to increasing disparities in health care across states/regions.<br />
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<li><span style="text-indent: -0.25in;">Cost control is key to ACA success. Otherwise, premiums will become unaffordable. Insurers who try to control costs through narrow networks will ultimately leave Americans less satisfied with their healthcare. Accordingly, there needs to be new approaches to health care delivery that provides high quality at lower costs.</span></li>
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