The Affordable Care Act's health insurance exchanges, or marketplaces, opened for enrollment on October 1, 2013. That was the plan anyway (see more in past posts here and here). Although it was expected there would be glitches in the initial weeks, and even months, the implementation of this crucial component of the law has encountered more problems than anyone expected. Those problems have led to proposed solutions that bring with them the potential for new problems. As with much of the public discussion surrounding the ACA, it is not easy to keep track of all the new developments and decipher facts from political rhetoric. This post will address some of the issues that have been receiving a lot of attention, and identify what, if any, implications they have for the profession of occupational therapy. and State Exchanges

The combination of substantial federal grant funding in the ACA for states that created and operated their own health insurance exchanges, as well as the tendency for states to want to take advantage of the flexibility provided to them by the federal government, led many to believe that most states would have state-run exchanges right now. It didn't turn out that way. For a variety of reasons, the federal government is operating all or part of about three dozen states' insurance marketplaces. And it hasn't gone well. is the portal through which consumers are supposed to be able to access their states' federally-facilitated insurance marketplaces, shop for health plans, and see if they qualify for subsidies. However, the launch on October 1st greeted consumers with substantial wait times, if they were able to access the site at all. While interest was significant (reportedly millions of unique visitors attempted to access the site in October), and volume was initially blamed for the problems, it became clear that the underlying technology was simply not ready for the task at hand. The federal government acknowledged the problems and has since been attempting to resolve them, with the goal of making function as it was intended for the majority of users by December 1st. While open enrollment extends to March 31, 2014, originally the deadline for consumers to enroll so that their coverage would begin January 1, 2014 was December 15, 2013. That date has been pushed back to December 23rd, but if the site is not mostly operational by next week, it may be difficult for the backlog of consumers to enroll in time for coverage to start on the 1st of January. Read more here from the Washington Post.

In contrast, many of the state-run health insurance marketplaces are functioning relatively well, although there are exceptions. In fact, while there are about half as many state-run marketplaces, enrollment through them has far exceeded enrollment through Although up to the minute data is not available, nationally it appears at least 200,000 people have selected a private marketplace plan and over 500,000 have been determined eligible for Medicaid or the Children's Health Insurance Program. More than half of those known to have selected a private plan are from just three states (California, New York, and Washington) that are all running their own exchanges. See your state's enrollment numbers here. The Congressional Budget Office has estimated that 7 million people will acquire private marketplace coverage, and 9 million people will newly enroll in Medicaid, in 2014.

Technology glitches and low enrollment in the initial months of a new program like this are not unprecedented. The launch of the website for Medicare Part D also encountered significant problems and delays. And enrollment in exchange plans when Massachusetts implemented its own health care reform law skewed towards the end of the enrollment period. That said, the possibility that enrollment in private marketplace plans will be lower than expected seems real. 

Cancelled Individual Market Plans and the "Fix"

Substantial press coverage has been devoted to the subject of cancellation notices being sent to beneficiaries of insurance plans that were purchased in the "individual market." Such plans cover a relatively small portion of the population (about 5% in most states), but in total, this group still numbers in the millions nationally. Although the focus of the controversy has been on past statements President Obama made about people being able to keep their coverage, the reality is that those who understood the effect of the ACA knew individual market plans would be canceled. That was largely attributable to the fact that all plans in the individual market have to cover "essential health benefits" starting in 2014 (see more about the implications for OT of the EHBs here and here), unless they are "grandfathered" plans. It wasn't until was open for enrollment and failed to provide easy access to information about new consumer options that the plan cancellations became as big a problem as it turned out to be.

The Obama Administration's expectation was that most people in the individual market would fall into one of two categories. The first would have their plans canceled, but be pleased to find new options on their state's health insurance marketplace. The second would be able to maintain coverage in their existing plans, because they met the requirements to be grandfathered. Although there were inevitably going to be people who fell into neither category, that group was expected to be quite small. As it turned out, with not functioning well, people whose plans were canceled were often unable to easily see the new options available to them. In addition, some people who were able to examine their new options have faced higher premiums, and understandably have been disappointed that they must pay more, even if they are receiving more comprehensive coverage (although that issue is more complicated than how it is often described). As a result of all these factors converging, President Obama announced a "fix" recently. The federal government has chosen to allow states to permit health insurance companies to continue to offer plans through 2014 that would have otherwise needed to be canceled, only to those individuals and families who already have them. Keep in mind that not only states will have to decide whether to allow this, but insurers will have to decide whether they wish to continue those plans as well. Some states and insurers have already announced their decisions, but there remain many unknowns. Information about your state may be available here

Apart from the logistical challenges of implementing the "fix," it has raised questions about whether the group of people who will wind up purchasing coverage through their states' marketplaces will be a more expensive group. In other words, will healthy people maintain their existing plans, and sick people buy marketplace plans that have to meet the requirements of the ACA? The technical way to describe this concern is that marketplace "risk pools" will experience "adverse selection," which will cause insurers to lose money, because the premiums they established expected more healthy people to purchase marketplace plans. The implication of this potential effect of the "fix" is that next year, insurers will increase their premiums for 2015 to account for what happened in 2014, which would only make the problem worse, or cause a "death spiral." Even apart from the "fix," there was always a concern that not enough young and healthy people would purchase marketplace plans, and reports so far indicate enrollment of that demographic is likely lower than is ideal. Although this type of analysis is necessary, it is probably too soon to assume the worst. For one thing, at least some states won't implement the "fix." Even in states that do implement it, it's not clear what the risk pool will look like by the time open enrollment is over -- there are a lot of young, healthy people to balance the risk pool who are uninsured and therefore can't keep their existing plans, because they don't have any plans. However, the most likely reason there won't be a death spiral is because it was always known that adverse selection was a risk that the marketplaces would face, and the ACA includes provisions to protect against it (called risk corridors and reinsurance -- if you're a real health policy nerd and want to know more about that, read here). 

What does this all mean for OT? 

The most likely implication for OT that comes from all these developments is that it's possible, and probably likely, that fewer people will be newly insured next year. Therefore, the pool of potential new consumers of OT services will be less than was expected in 2014. However, assuming the ACA survives its problematic first open enrollment period, then the real effect for OT is that it will just take longer to fully benefit from the ACA's coverage expansions. 

The most significant challenge we have identified during open enrollment that directly impacts OT practitioners and consumers has been little discussed. The problem we've identified when evaluating marketplaces and the plans sold on them (to the extent we've been able to access the information) is that information about coverage of rehabilitative and habilitative services, and the cost-sharing related to that coverage, is inadequate. In addition, in some cases, the coverage itself seems to fail to comply with the essential health benefit requirements. AOTA is working with state OT associations, and other allied organizations to attempt to address these problems. 

For more information on related issues and AOTA's advocacy efforts, check out this webinar from earlier this month. For a variety of perspectives on health insurance marketplaces, the Alliance for Health Reform hosted a panel discussion last week (resources available here and video here). I can actually be seen asking a question of the panel at 1:16:50 related to our concern about inadequate availability of information for consumers.