The Affordable Care Act is a massively complex piece of legislation, more than 2,000 pages long. Rules and regulations to implement the ACA are already in the tens of thousands of pages with many more to come. Some of the components of the bill have already been cancelled, modified, or postponed: long-term care insurance, multiple offerings of SHOP insurance in the exchanges in 2014, IRS determination of an individual’s eligibility for subsidies in 2014, and the recently announced postponement of enforcement of the employer mandate until 2015.
At the heart of implementation of the ACA lies the healthcare exchange (now being called a “marketplace”). Twenty-seven states have elected not to create a state-run exchange, and will default to a federally facilitated version. All exchanges are supposed to be functional on Oct. 1 for applications, and begin actual activities on Jan. 1, 2014. A look at the functions of the exchange and the necessary coordination between agencies indicate that a daunting task lies ahead.
Some of the key functions to be performed by the exchanges include: income verification (although self-reporting will be used in 2014), control of tax credits, payment of subsidies, determination of eligibility (including citizenship and residency), enrollment, listing of insurance offerings, and coordination with Medicaid and CHIP. In order to perform these functions, coordination will be necessary with numerous governmental agencies including: HHS, CMS, IRS, the Treasury Department, Social Security, Homeland Security, the VA, the Defense Department, the Office of Personnel Management, and the Peace Corps.
Many of the databases needed to coordinate care, though the exchanges do not currently exist. Of even greater concern is the necessity for coordination among all of the governmental agencies involved. After many years of attempting to develop an integrated medical record for joint use by the Department of Defense and the VA, that project was abandoned earlier this year. If these two organizations with a common patient base (military) were unable to develop a unified system, it does not bode well for integration of the diverse organizations which must work together through the exchange.
Like all major pieces of social legislation, there are flaws in the ACA which must be corrected. However, a recent Kaiser poll indicated that 43 percent of those polled support the ACA, while 35 percent have an unfavorable opinion. Also, 45 percent of the population knows nothing about the exchanges. With the polarization of our government in Washington, the prospect for bipartisan modification to the ACA seems impossible. A rocky road lies ahead.
Dr. Forney Fleming heads up the Healthcare Management master’s program at UT Dallas. He joined the university after decades of working as an orthopedic surgeon.