Why 2014 may be a make-or-break year for health reform

2014 is shaping up to be a critically important year in determining whether the country moves forward or backward on expanding health insurance to 30 million uninsured persons and providing better consumer protections for many millions more. This is the year when the biggest changes made by the Affordable Care Act (ACA) go fully into effect, and what happens over the next 12 months may seal the law's fate.

If it is successfully implemented in 2014 so that millions of Americans get coverage that they can afford and that they like, the ACA will be here to stay. If implementation falters so that millions of Americans either can't get coverage or don't like the coverage they get, then the ACA's unpopularity (already high) will grow, making it vulnerable to major rollbacks in the future, although outright repeal is almost inconceivable for the rest of President Obama's term in office.

2014 will be a year of competing narratives. Republicans will highlight every instance of implementation problems, people being forced to pay higher premiums, and people losing their current health insurance to make the case that the ACA is a failure and must be repealed. Democrats will highlight every instance of implementation successes, people paying lower premiums, and people gaining coverage to make the case that the ACA is a success and must be retained. But other than more oversight hearings convened by House Republicans to highlight problems with the law, Congress for the most part will not be where the action is when it comes to the ACA's present and future.

Instead, the action will be on the state and local levels. Will the states running their own exchanges be able to operate them effectively and get people to enroll? Right now, it is a mixed bag. Some states, like California and Kentucky, seem to be doing a good job signing people up, while others, like Oregon and Maryland, have had great difficulties in getting their exchanges up and running.

How many state insurance commissioners will agree to the Obama administration's request that people be given another year to sign up for a qualified replacement plan if their individual health insurance plans were canceled because they didn't meet federal standards? How many more states will agree to expand Medicaid to cover everyone with incomes up to 138% of the federal poverty level?

Will the federally run healthcare.gov exchange, which covers the majority of states, work out its remaining technical and implementation snafus and successfully sign up enough people, with the right mix of young and old?

March 31 is the deadline for enrolling in a qualified plan to avoid the ACA's penalty of $95 or 1% of taxable income, whichever is greater. How many people will have signed up for coverage, either through an exchange plan or Medicaid? Will enough younger people sign up in the exchange plans to offset the costs that insurers will incur in enrolling older and sicker people?

What will people experience once they enroll? Will the millions signing up for Medicaid be able to find physicians who will see them? Will the people who sign up for an exchange plan be happy with their coverage, which by law must include free preventive services, no exclusions or higher premiums for having a preexisting condition, no annual and lifetime limits on coverage, and guaranteed coverage of 10 categories of “essential benefits,” including physician visits, hospitalizations, maternity benefits, and prescription drugs? Or will they find that the premiums and deductibles and co-payments are too high for their needs? How many will object to paying for benefits they feel they don't need or want? How many will find that their preferred physicians and hospitals aren't in their health plan?

It is too early to say what will happen on these and other questions. But after several months where the problems with the federal website made enrollment nearly impossible for many who wanted coverage, the most recent enrollment trends suggest that the ACA is beginning to deliver on its promise of providing access to affordable coverage for many millions, especially the previously uninsured. As of Jan. 1, at least 9 million people were covered because of the ACA, including 3.9 million people who were newly enrolled in Medicaid, 2.1 million who were newly enrolled in state and federal exchange plans, and another 3 million adults up to age 26 who were covered by their parents' plans.

This is not to suggest that everything is hunky-dory with the ACA. Far from it. The initial federal rollout was a disaster. Many states are still struggling to implement it. Too many poor people are being left out because their states haven't gone along with the Medicaid expansion. Many people have real concerns that the deductibles are too high, the drug formularies are too restrictive, and the numbers of physicians and hospitals participating in many of the plans available through the exchanges are too limited. Medicaid payment rates historically have been so low that many physicians are unwilling to see more enrollees.

ACP is advocating to address each of these potential concerns. We are seeking legislation if possible, such as urging Congress to extend a provision of the ACA, set to expire at the end of 2014, that pays primary care physicians and some medical subspecialists no less than the Medicare rates for services provided to Medicaid enrollees, and regulatory and administrative fixes if legislation isn't politically feasible.

But even with all of the questions remaining, the rising demand for ACA coverage suggests that if you build it (a way for people to qualify for coverage they can afford), they will come—by the millions.