College of Health Solutions experts weigh in on the state of ACA marketplaces and how system is faring in Trump administration

Reduced federal marketing dollars, a shortened enrollment period and regularly scheduled website blackouts are just a few of the recent actions taken by the Trump administration that may discourage Americans from obtaining health insurance through the Affordable Care Act (ACA) marketplaces.

In Arizona, ACA plans provide health care coverage to roughly 155,000 people.

But despite repeated attacks over the years, the ACA has demonstrated “unexpected resiliency,” according to Swapna Reddy, clinical assistant professor, and Matthew Speer, faculty research associate, of the College of Health Solutions at Arizona State University. As open enrollment approaches, ASU Now spoke with Reddy and Speer to learn what the administration’s recent decisions mean for health care access, affordability and coverage.

Question: Open enrollment begins Nov. 1. How are the ACA marketplaces faring?

Swapna Reddy

Reddy and Speer: Despite repeated efforts by the federal administration to undermine the ACA, many consumers will see a noticeable decrease in marketplace premiums in 2019. According to a recent study by the Centers for Medicare and Medicaid Services, national premiums are expected to drop 1.5 percent and some states, including Arizona, should experience a reduction of almost 10 percent. This is a notable development because most ACA state marketplaces have witnessed consistent increases in premiums since 2014.

Arizona notoriously experienced the loss of most of its insurance carriers and, in 2017, saw a 117 percent increase in premiums. As such, it was often referred to as "ground zero" in the 2016 presidential election, representing all that was flawed in the ACA.

Although each of Arizona’s 15 counties saw only one insurance carrier selling ACA plans in 2018, four companies have filed to sell ACA marketplace plans in Maricopa County in 2019 and three are expected in Pima County.

This reversal of premiums in Arizona, and also nationally, represents a likely correction in marketplace premiums as many insurers initially underpriced their plans and had difficulty providing ACA-required comprehensive coverage for populations in need of health care. In addition to reductions in premiums, many states are enjoying new or returning insurance carriers entering their state marketplaces, which once again increases competition and choice for consumers.

Q: What changes to the ACA need to occur to better serve the health needs of the population?

Matthew Speer

Reddy and Speer: At the core of this issue, people need comprehensive health coverage that is affordable and accessible. Individuals who are still not able to afford the premiums but do not have other options for coverage are not being served.

The aforementioned improvements in the ACA marketplaces nationally and in Arizona are encouraging. Greater competition in the marketplaces benefits consumers because it increases choice and helps to control costs. Arizona’s marketplace would benefit from continuing to attract insurance carriers to the state.

Maintaining plans that provide comprehensive coverage is vital to meeting the needs of the population. “Bare bones” plans tend to be less expensive but also offer less coverage. Based on experiences with similar types of coverage prior to the passage of the ACA, we know that this approach often does not meet the needs of patients and leads to higher costs for consumers and the larger health care system when the care is uncompensated. We should be encouraging the proliferation of plans that offer comprehensive health care coverage.

While millions of people nationwide have gained coverage through the expansion of Medicaid under the ACA, 17 states have elected to forgo this optional expansion as of June 2018. In those 17 states, roughly 2.2 million people fall into the gap in coverage encompassing those that are too poor to qualify for tax credits yet still ineligible for Medicaid.

Although marketplace premiums across the board are generally expected to fall and more insurance carriers are flooding markets with additional plans, many nonexpansion states like Texas should expect to see modest increases in their premiums. This effectively widens the coverage gap. This is especially critical in large states like Texas, where more than 1 million people enrolled in marketplace coverage in 2018.

Q: Are there efforts underway by lawmakers to dismantle any aspects of the ACA?

Reddy and Speer: The most notable efforts include removing the tax penalty associated with the ACA's unpopular individual mandate provision; drastically reducing federal marketing budgets for ACA enrollment; offering low-cost "bare bones" plans as competition; reducing the open enrollment period when consumers can shop for and enroll in coverage by 45 days; defunding cost-sharing reductions; and most recently, a decision to conduct scheduled maintenance on the healthcare.gov website for 12 hours almost every Sunday of the upcoming enrollment period. Each of these serve as major barriers or disincentives for consumers.

Additionally, still pending is a lawsuit filed in February by 20 state attorneys general contesting the legality of the ACA in the wake of the individual mandate repeal. If successful, the suit would dismantle popular consumer protections central to the ACA, such as the exclusion of pre-existing conditions from coverage consideration. Recent repeal-and-replace efforts from the House also included amendments that would allow states to request waivers that would essentially nullify the pre-existing conditions protection.

Despite these efforts, the ACA has demonstrated an unexpected resiliency as we enter a new enrollment period, which runs from Nov. 1 through Dec. 15, 2018. The changes in premiums, insurance carrier participation and continued interest in enrollment is reflective of the national need for comprehensive health coverage for millions of Americans and their families.

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