Q&A: What's next for the Affordable Care Act?

The next open enrollment period for the Affordable Care Act (ACA) begins Nov. 15. What can we expect to happen over the next year? And how many more uninsured Americans will gain access to care?

Princeton University's Woodrow Wilson School of Public and International Affairs discussed these questions and more with Heather Howard, director of the State Health Reform Assistance Network and a lecturer in public affairs at the Wilson School.

Question: According to federal figures, about 7.3 million people are enrolled in health plans being sold through the ACA. How many more people do you expect to enroll in 2015?

Answer: Initially, the Congressional Budget Office projected 7 million people to enroll in the exchanges over the course of 2014. Taking early technical problems into consideration, the agency later amended that number to 6 million. After exchange technology stabilized, there was a late surge of enrollees at the end of open enrollment, many of whom were motivated by the impending deadline. In spite of the challenges, enrollment ultimately exceeded the expectations of many experts. The last-minute push to enroll also demonstrated the significant demand for affordable coverage throughout the country.

The Department of Health and Human Services now estimates that between 9 and 9.9 million people will be covered through the marketplaces by the end of 2015, including those who renewed their coverage from this year. The difficulty in attaining this goal is that, in addition to ensuring that all of the consumers who previously gained coverage re-enroll, exchanges will be faced with the added challenge of trying to reach the remaining uninsured, who in many ways represent a harder-to-reach population.

Q: Based on enrollment data, who has yet to enroll? Will these individuals be a focus in the coming year?

A: As they approach the second open enrollment period, exchanges face many of the same challenges as last year, in addition to new ones. Much has been made of the fact that during the initial open enrollment period, many of the "low-hanging fruit" — those most motivated to sign up for coverage — were already reached. This leaves behind an uninsured population for whom there may be significant knowledge gaps with regard to the availability of financial assistance for coverage, and for whom the in-person assistance has not been effective.

Simultaneously, one of the most significant issues currently facing the exchanges is the process by which they will re-enroll those who signed up during the initial open enrollment period. While many exchanges have implemented processes by which consumers are able to re-enroll automatically, in many cases it may not benefit them to do so, as premiums or incomes may have changed. Exchanges are now reaching out to enrollees to encourage them to review their options before re-enrolling. This will ensure that the cost and coverage are still right for them. Finally, all of this work will need to be accomplished within a condensed timeframe, as the enrollment period has decreased from six months to three months.

Q: Besides the obvious benefits of adding more enrollees (improved health, reducing the number of uninsured), what are the other benefits of high enrollment numbers? For example, will a larger number of enrollees keep premiums in check?

A: One of the most obvious benefits of enrolling more people in affordable health coverage is the decrease in the uninsured rates in areas of the country where people have desperately needed access to affordable coverage. In Kentucky, for example, the uninsured rate in the state has fallen from 20.4 percent to 11.9 percent as a result of the state's decision to expand its Medicaid program and the success of its state-based health insurance exchange. In Oregon, the uninsured rate has fallen from 14 percent to 5.1 percent. The affordability of the plans offered on the exchanges is indeed largely dependent on who is enrolled in those plans. More healthy people enrolled in the exchanges — a more diverse risk pool, in other words — means lower premiums for everyone. That's why states work so diligently to reach young people. In addition, strong enrollment in the first year has induced more insurance carriers (such as UnitedHealth Group) to enter the market, and we know that when insurance companies compete, consumers win.

Q: Increasing access to health coverage is central to the ACA. In what ways does the law focus on decreasing health care costs?

A: There are several ways in which the ACA attempts to control health care costs, which have risen consistently for years. Some examples include the development of accountable care organizations, which are designed to improve the efficiency of care through the shifting of risk, Medicare payment penalties to hospitals for excessive amounts of patient readmissions, and increased transparency and accountability requirements of insurers. A recent report by the Office of the Actuary at the Centers for Medicare and Medicaid Services showed historically slow health care spending growth nationally in 2013. While it's too early to attribute all of these gains to the ACA, the slowing growth of health care spending nationally is a positive sign, and there are certainly ways in which the ACA is addressing this issue.

Q: How might the new congressional balance of power affect the ACA?

A: The elections clearly weren't good news for the ACA. Yet while the ACA remains important to some voters, polling suggests that it was not the highest priority issue for a majority of Americans. And recent polling data also show that most Americans don't favor repeal but would prefer changes to the law. Considering how central the law is to the president's legacy, it is extremely unlikely that it would be repealed, even given a new Republican-controlled Congress.

Instead, I think that we are likely to see Republicans in Congress try to scale back certain aspects of the law, such as the employer mandate and 30-hour work week. Some of the ACA's threatened provisions (such as the individual mandate) are crucial affordability mechanisms, however, and attempts to remove them may face significant consumer opposition, as well as a presidential veto.

Certainly, some of the more popular aspects of the law, including insurance reforms that prohibit insurers from denying coverage based on pre-existing conditions, are not likely to be affected by the new balance of power in Congress.

Q: How might the recent announcement by the Supreme Court that it will hear a case challenging subsidies on the federal marketplace potentially alter the future of the ACA?

A: On Nov. 7, the U.S. Supreme Court declared that it would hear King v. Burwell, similar to the Halbig case we spoke about in July. These two challenges to the ACA dispute the availability of tax credits to individuals who enroll in coverage through the federal exchange.

In the immediate term, this announcement will not have any impact on this year's open enrollment period, as the court won't make its ruling on the case until next summer, but the decision could have significant ramifications after that. Within the 34 states that rely on the federal platform, this year more than 80 percent of enrollees selected plans with tax credits. If the court rules against the administration, all of those subsidies would be in jeopardy. That means that through 2016, 7.3 million people could lose out on financial assistance, rendering health insurance unaffordable for most.

If the court were to rule against subsidies on the federal marketplace, some states that had initially been hostile to ACA implementation could face added pressure from constituents and their health care industries to establish a state-based marketplace, in order to maintain access to financial assistance. The most likely outcome of a court decision striking the subsidies is deepening divisions between states that have embraced the ACA and those that have not — with significant consequences for residents of the latter. A ruling in favor of the plaintiffs would take us back to a health system that looks more like the pre-ACA status quo — a patchwork of access and fairness — that the law tried to address by creating a national floor of affordability.