Timothy Jost reviews what four years have brought us

Implementing Health Reform: Four Years Later

By Timothy S. Jost
Health Affairs, January 2014

Despite enormous potential, the Affordable Care Act has been plagued by controversy and confusion from day one.

Looking Ahead

It is likely that more complaints will be heard once people actually use their ACA coverage. Many exchange carriers are offering limited provider networks. Narrow networks allow insurers to reduce premiums as they exclude the most expensive providers and negotiate steep discounts with those who remain. Consumers will like the low premiums but will be unhappy to learn that their doctors are not available and shocked to discover charges from out-of-network specialists when they go to in-network hospitals.

Consumers may also be surprised by the magnitude of cost sharing under ACA plans. Bronze plans may have $6,000 deductibles, and silver plans can have deductibles of $2,000 or more. Even at these levels, of course, cost-sharing obligations will be lower than many policies found now in today’s nongroup market. But this is not free care, or anything close to it.

Millions of low-income Americans in states that refuse to expand Medicaid will find themselves too poor to receive any help. This is, of course, not the fault of the ACA but rather of its opponents. But the public may not grasp this distinction.

Other problems will also attend the implementation of the 2014 reforms, and all will be widely reported. Employers may continue to reduce employees to thirty hours or otherwise try to avoid offering health insurance to their employees. Insured and self-insured plans will bear part of the cost of expanding coverage and reinsuring high-cost enrollees in the individual market, increasing their costs. Finally, public outrage is sure to hit the headlines again when tax filing time arrives in 2015 as some individuals will be assessed the penalty for remaining uninsured, while others will face a repayment demand for overpaid premium tax credits.

Going forward, one of the most important challenges facing the ACA will be whether its benefits become apparent quickly and dramatically enough to offset the problems that are currently dominating the news coverage of the health reform law. Even more important may be the question of how much it will matter that the greatest beneficiaries of the ACA are likely to be low-income Americans, who are less likely to be politically active than many of the higher-income Americans who will be adversely affected by higher insurance premiums and taxes.

In the end, the most important fact is that the ACA addresses a real and dramatic problem: nearly fifty million uninsured Americans. Its opponents in Congress have failed to put forth any credible proposal to address this problem since the law was enacted. As disruptive as it may in fact be, the ACA does address this problem. If it succeeds, America will be a better place. If it fails, it is unlikely that another solution will be forthcoming any time soon, perhaps not for another generation.


By Don McCanne, M.D.

Timothy Jost is one of the most astute, objective analysts and observers of the unfolding of the Affordable Care Act. We should listen to him when he describes the negative impact that ACA will have on moderate- and higher-income Americans. They will be especially unhappy with their loss of choice of physicians and hospitals because of the narrow or ultra-narrow networks, and they will be greatly displeased with out-of-pocket costs that are much greater than they previously experienced.

Although Jost suggests that the determination of the success or failure will be based on how successful the enrollment of the 50 million mostly lower-income uninsured Americans will be, it is more likely that those with incomes above 400 percent of the federal poverty level who will be bearing the full costs of their insurance, directly or through wage concessions, will consider the shift in employer-sponsored plans toward narrow networks and high cost sharing to be a failure of policy.

Although Jost also discusses the positive features of ACA, they do not offset the negative since we did not have to accept such a compromised system.

Although he suggests that another solution is unlikely for a generation, once the politically active people with good jobs and decent incomes realize what happened and what they could have had, the demand for single payer Medicare for all will move the process much earlier. At least for their benefit, and for the benefit of all U.S. residents, we hope so.