Another View of the ACA
By Ferd H. Mitchell and Cheryl C. Mitchell
One of the most difficult administrative tasks is to deal with the implementation of new programs that involve both short-term and long-term objectives. Adjustments in short-term activities can cause large changes in outcomes for long-term objectives.
There are often numerous short-term pressures that make it appear reasonable to revise current requirements. However, revisions may also serve to help defeat or compromise long-term objectives.
Consider implementation of the Affordable Care Act (ACA). A long-term objective is for all individuals to have Qualified Health Plans (QHPs), which are health insurance policies that cover “essential health benefits.” Insurance companies are being restricted to offering QHPs and individuals are being pushed to buy these plans through the individual mandate.
At the same time, employers are also being pressured to provide employees with QHPs in the longer term (after a year of delay).
However, short-term issues are getting in the way. Under political pressure and due to previous “guarantees” about keeping prior insurance plans—and the difficulty of switching to QHPs due to the technical problems with the Health Exchanges—the Department of Health and Human Services has backed down to allow non-QHP plans to continue for 2014.
States have split as to whether they will allow or not allow such continuations. As recognized, such short-term adjustments may have long-term impact on the ACA. The expectation may develop that the move to QHPs is not “serious,” and can be readily compromised.
Similarly, the one-year delay in implementing the large employer mandate has allowed employers to also go “non-QHP” for 2014. Again, expectations for the longer-term future are being compromised.
Phasing can help avoid such conflicts. An initial manual enrollment system for the ACA could have been implemented a year or so ago, to relieve pressure on the high-tech approach. Such an initial start could have helped get ready for 2013, while leading more smoothly to long-term objectives.
Insurance companies could have been allowed several years to transition to long-term QHPs in a clearly-defined series of steps, based on revisions to existing health insurance plans. At any stage in this phasing, adjustments could have been made in short-term activities.
The ACA could also have allowed employers to provide transition periods to QHPs from existing plans, to allow for learning by all involved before the long-term shift was complete.
A basic problem with ACA implementation has been the rigidity of fixed start-up dates for the entire program to “go live.”
This is inherently a fragile strategy, that encourages criticisms both before and after critical dates. The Administration is now trying to “retrofit” in a more gradual and phased approach to implementation, but it still seems to lack a comprehensive strategy for how to combine phased activities with long-term objectives.
This is installment #14 in the “Affordable Care Act and Public Administration” series.
Previous installments of this series have considered impact of the ACA on the field of public administration from a variety of perspectives. Refer to the archived postings for this blog to review all of these installments and obtain an overview of the combined commentary. (Or search for “health care”, “ACA” or “Mitchell” in the search box somewhat below the top of the home page).
More on these and related ACA topics, including coverage of how organizational reactions affect implementation efforts, may be found in a recent book by the authors that describes evolution of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.