ACA Administrative Issues for 2014

By Ferd H. and Cheryl C. Mitchell

During 2014, a variety of administrative issues will face those groups and individuals charged with getting the Affordable Care Act (ACA) “up and running.”

health servicesFrom a positive perspective, as more individuals become aware of the improved health insurance coverage to be provided by “Qualified Health Plans (QHPs),” there will be an increasing opportunity to “spread the word.” Public administrators and private managers are both being given new opportunities for verbal and written networking—to point out how QHP insurance coverage has replaced earlier plans with marginal and restrictive coverage.

There is also an opportunity for administrators to promote the fact that, under the ACA, pre-existing conditions cannot be used to deny coverage.

The availability of better insurance coverage—that is available to all citizens and legal residents, often with subsidies—can serve as the foundation for efforts to encourage more individuals to enroll and obtain protection.

Even young adults can be encouraged to sign up, if advocates can prepare reasonable explanations of how health insurance fits into the real-world circumstances of those who are only beginning to build lives and careers. The multiple demands on young adults must be recognized if  the purchase of health insurance is to be put forward as being of sufficient value to make compromises elsewhere. It is difficult for people of all ages to evaluate the value of protection against events that are of low probability, but can have a large impact on life when they occur.

However, on a negative note, enrollees in health plans may develop complaints over the limited number of policies health_insuranceavailable due to insurance-company caution; narrow provider networks that can limit choice; and substantial deductibles that can lead to major out-of-pocket expenses when care is needed.

Administrators will need to deal with such challenges openly and directly. One strategy may be to help individuals understand why the positive features of the ACA are available only because of these negative aspects of the Act.

In some situations, and in some states, it may also be important for administrators to explain the options available under the new “adult” category introduced for Medicaid, for individuals with income under 138 percent of the Federal Poverty Level (FPL). Both older and younger individuals may find this to be an important message.

There are also some other difficult issues for administrators to face with respect to the ACA.

The Health Care System is now more complex, with expanded linkages among governmental agencies, providers, employers and individuals. Many individuals may experience “social pain” when trying to cope with these linkages, and administrators may have to look for ways to reduce this pain and improve coping skills. Classes in “how to get care under the ACA” may have a place.

There may also be significant “reality conflicts” between advocates for the ACA and young adults who are living in a very different world, trying to build lives and careers under financial pressures. Administrators will need to explore ways to bridge into this “reality space,” to make the case that limited resources should be used for health insurance instead of for other pressing demands, and that coverage through the ACA can help improve overall “life plans.”

Finally, many individuals may react to the ACA with some alienation due to the regimentation associated with the Act. Standard forms and procedures often seem to be impersonal and unpleasant intrusions on the feeling of personal “self-identity.”

It may be difficult for administrators to help individuals learn to make use of the best features of the ACA. Support will be needed to help potential applicants deal with long and complex forms and with ACA sign-up and service procedures that seem burdensome.


This is installment #16 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.


One thought on “ACA Administrative Issues for 2014

  1. In the Public Health volume 127 (November 2013) (p. 973-974) written by F. Sim and P. Macki, Editors for Public Health, a premier peer reviewed journal of the Royal Society for Public Health (UK), the two editors embedded a rather nasty section criticizing the U.S. federal government shutdown as dangerous to the health of the American population and irresponsible governing. Well, I had to address that editorial with a rather long Letter to the Editors offering them a bit of an American History and Government lesson.
    I wrote; “America gets criticized a lot and certainly America deserves a lot of criticism; however, we have broad shoulders, and we can take it. I remain convinced that I have to answer what seems to be an embedded sidebar in the editorial since the criticism may not be totally accurate. Sim and Macki do not approve of the implementation process of the Affordable Care Act (ACA) or what is lovingly known here as Obamacare. The editors were “’astonished when the House of Representatives effectively closed down America.’” Well, not so fast. Yet, they continue to state that “’there seems to be no American equivalent to the British notion of unparliamentary behavior and most of us on this side of the Atlantic (UK) are not used to this kind of conduct in government, played out with apparent complete disregard for the well-being of the U.S. population.’” Yes, the federal government was shut down but not for the first time in history and most certainly not for the last. I know of no reported casualties during these shutdowns.”
    Further, I wrote; “America can handle the criticism. We have lived with international bad press for over 200 years. However, when the British criticize our political behavior, you understand the reality that the American version of federalism and the checks and balances that were put in place by the unruly Americans of colonial times were established as a response to your own King George. Personally, I never believed that any of King George’s taxes and other laws that originated in London without representation from the colonies were all that egregious or unfair; he just lacked people skills in how he implemented them. In response, Americans wanted a system of government that was both messy and complex and decentralized and would prevent a similar version of King George. We have a purposefully designed an often adversarial relationship between our presidents and our congress, and even an adversarial relationship between the two houses of congress with the Supreme Court waiting for the dust to settle before they step in and render a new law unconstitutional and everyone has to start over again. Even our presidents are not directly elected by a popular vote. We have an Electoral College that can, if they desire, elect whomever they want as president regardless of who gets the majority of popular votes. We can also impeach our president if he is really bad. Alexander Hamilton made it clear he never wanted to see a charismatic demagogue elected and that included Aaron Burr. Hamilton knew he himself could never run for president because he was not born in America. The jury is still out on President Obama; however, if it is proven that he was born in Kenya, what a constitutional crisis that would occur if that news breaks out. Of course, the American fourth estate, the press, is always on alert for political bad acts because the next available Pulitzer Prize has their name on it. In reality, when our politicians get into a pissing contest, most Americans just watch the news from the sidelines and go about their business. We can all do without the federal government for a brief spell; it’s almost a relief. Indeed, government employees who are furloughed during the shutdown may complain bitterly about being sent home; but, secretly enjoy the unpaid vacation (and most of them would be back paid anyway when they returned).
    A federal government shut down never endangers national security or other critical services; they are exempt. You may not be able to go on a tour of the White House but both the Secret Service and the federal police force are all on duty; so is the president even though we may wish he was furloughed. The reason is that we also have state and local governments that serve the public; and we have private sector enterprises that remain open for business. Further, public health is not the same as health care delivery such as a hospital emergency department; and public health programs are not all federal—indeed, many public health agencies are state and locally funded and managed. In fact, federal public health programs may be temporarily shut down but there is little or no direct risk to any seriously ill persons who need immediate medical care. The brinkmanship of a government shutdown is more about show than substance so no one is endangered. The president and the speaker of the house are just two roosters ruffling their feathers and crowing at each other while the press writes their stories. Life goes on in America; I assure you.
    My final point on describing political behavior – Great Britain has had its share of moments of indecision and argumentation. Two of the greatest leaders in world history of the 20th century were arguably Winston Churchill and Margaret Thatcher and maybe the addition of Tony Blair in distant third place. And, each of these leaders staged their own form of political circuses playing brinkmanship. Luckily for all of us, Churchill badgered FDR to getting us into World War II (along with the help of the Japanese) or America would today be a nuclear wasteland (the Nazis would have perfected the A-bomb, a multi-stage V2 rocket to carry it, and jet powered bombers capable of getting here from a defeated Britain). And, you all would be speaking German unless you were Jewish or Black and in that case, you would not be speaking at all given Hitler’s plans for you.
    In my view, Great Britain and America are probably the only two countries holding the world’s door open to the light since I believe we are quite possibly on our way into a new Dark Ages and it may be our two countries that will hold on to a thin thread of civilization until a new Renaissance emerges, if it ever does. So, we need to sleep tight together each night to protect whatever is left of the world. That means stop overreacting to an American president desperately seeking a legacy before his time in office expires.


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