Andrew Bindman: ACA's Impact at State and National Level

Andrew Bindman, MD, professor in the UCSF Department of Medicine and the UCSF Philip R. Lee Institute for Health Policy, worked as a staff member in Congress to help draft provisions in the Affordable Care Act (ACA).

He currently is involved in implementing the law and evaluating its impact as a senior advisor to the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services in Washington and as the director of the California Medicaid Research Institute in California. Here, Bindman discusses the rollout of the state health exchanges from a national perspective.

Q. Recent polls show that many Americans don’t understand the Affordable Care Act, including the health insurance exchanges, and are uncertain how they will benefit. Is that a concern?

The ACA is a very large law with hundreds of provisions, so it isn't surprising that many Americans don't fully understand it. Different aspects of the law are relevant for different groups of people. What is most important is that Americans have an ability to understand the parts that are relevant for them.

Health insurance exchanges, or marketplaces, are one of the new ideas in the law. Marketplaces have the potential to simplify the search for health insurance and to create competition among sellers of health insurance, but they are not intended to be the method by which the majority of Americans will obtain insurance coverage. These marketplaces will have open enrollment starting Oct. 1, 2013, through March 31, 2014, with a start date of the coverage beginning as early as Jan. 1, 2014.

State and federal officials are supporting a number of organizations to help spread the word and to serve as navigators to help those who could benefit from the marketplace to understand how to use it. For those who want to get a jump start, they can find information on the California Marketplace, called Covered California.

Q. How do the health insurance exchanges work with Medicaid and Medicare?

The marketplace does not apply to those covered by Medicaid (what we call Medi-Cal in California), Medicare, or who obtain their health insurance coverage from an employer.

Health insurance exchanges are designed as a marketplace for individuals seeking to purchase private insurance for themselves and their family. 

It is estimated that about 25 million Americans will be eligible to purchase health insurance from a marketplace and as many as 20 million of those are expected, based on their income, to qualify for a federal subsidy to help them and their family purchase their health insurance through a marketplace.

Individuals who are eligible for Medi-Cal or Medicare are ineligible for the federal subsidy to purchase health insurance through a state or federal marketplace.  

Q. What do you think consumers need to know and/or misunderstand about the exchanges? 

Not all health plans available for individuals to purchase today will be available beyond 2013 or for purchase through marketplaces. In some cases, these plans will be terminated because they do not meet the minimum standards of health insurance coverage that will be applied to health plans beginning in 2014.

Beginning in 2014, individuals may elect to purchase private health insurance outside of a marketplace; however, the available information about plans and prices from California's marketplace (Covered California) suggests that most individual consumers of health insurance will be able to save money by purchasing it through the marketplace.

Q. Do you think the exchanges will make the health care market more competitive? 

There are a few key aspects of health insurance exchanges that will promote competition in the health insurance marketplace. 

First, consumers purchasing a health plan through a marketplace are given assurances that these plans meet basic standards for quality, consumer protections and provider availability.

Second, marketplaces require that health insurance products be categorized according to standards that will allow consumers to do simple comparison shopping. By providing information about the plans' quality, benefits, providers, premiums, co-payments and deductibles in a side-by-side manner using simple terms, marketplaces can help consumers to make the sorts of choices they make when shopping for other products.

Finally, individuals eligible to purchase health insurance through a marketplace are guaranteed the opportunity to purchase the plan they choose – plans cannot refuse to provide coverage based on an individual's pre-existing condition.

Q. What do you see as the future of the health insurance exchanges, especially for states that opted out of establishing ones this year?

Each state can choose to create and run its own marketplace. Many experts around the country regard California as a leader in how it has set up its marketplace to support consumer choice and buying power.

States that do not choose to create and run their own marketplace can either partner with the federal government to run some marketplace functions or have a marketplace established and operated by the federal government.

The ACA requires that there be a marketplace for all eligible Americans in all 50 states and the District of Columbia. States that do not initially choose to create and run their own marketplaces, may revisit that decision based on the experience of the states that do so, but it may become more challenging for them to establish their own marketplace because the federal resources the ACA made available for them to do this will expire.