Ferd MitchellA number of “adjustments” in implementation of the Affordable Care Act (ACA) have been introduced in recent months to deal with operational and political problems associated with the transition from the “old” U.S. healthcare system to the new version that is emerging.

All of these adjustments will affect hospital planning and strategies.

Postponement of the large-employer mandate to 2015 has allowed employers to continue with “old” plans, change to new plans that do not meet the requirements of qualified health plans (QHPs), or offer no plans at all during 2014—without penalty. To the degree that employers take this opportunity to “back away” from the ACA requirements, employees may experience reduced group insurance coverage. Some employees may shift to the purchase of coverage through the new health insurance exchanges.

Cheryl Mitchell

Political guarantees to allow individuals to keep prior existing plans for 2014 may be effective in some states, depending on decisions by insurance commissioners and insurance companies.

Some people with cancelled individual policies are now to be able to obtain hardship exemptions for 2014, again allowing the ramp-up to the QHPs to be delayed.

Because of sign-up problems, high-risk pools have also been continued into 2014 to prevent these individuals from losing all coverage.

And some insurance companies also continue to offer inadequate mini-med plans, despite the likelihood that individuals purchasing such plans will still remain liable for the individual penalty.

Precedents established during this “penalty-free” year may have long-term impact on employer decisions, as companies observe and evaluate exchange operations during 2014. The combined effect may be to reduce QHP coverage during 2014, and perhaps for the longer term.

And if employers begin to reduce their support for group health insurance for employees, hospitals may be less influenced by employers when business decisions are made.

Any slow migration away from company-based insurance toward exchange-based coverage for employees will begin to weaken the organizational interdependence between hospitals and companies.

Hospitals may find that many of the problems associated with previous insurance policies remain unfixed for 2014, as QHPs are deferred.

All of these changes will tend to slow down the shift to QHPs, forcing hospitals to continue to cope with existing problems. The result of these adjustments will generally be to slow down the transition to an ACA-based healthcare system, while potentially weakening some of the linkages among organizations in the system.

Throughout 2014, there is likely to be a growing sensation of slowing implementation of the ACA, combined with more organizational shifts being driven by the slowdown. The slowdown will have positive features, including more time for individuals and organizations to adjust to changes in the ACA. But at the same time, the slowdown may have negative impacts, as implementation momentum is lost and ACA “drift” is allowed to develop.

The ties that have been tightening among organizations may also be allowed to “relax” somewhat, preventing the desired integration activities from moving ahead as intended.

Hospital managers will have to decide whether to “push hard” to “stay ahead of the curve,” expecting a return to rapid implementation in 2015, or to ease off on the rate of change and allow a certain amount of drift to develop.

Such strategies should be prepared with full recognition of the ways in which interested groups will likely react to such changes, and with accommodations included to produce the desired results even with these reactions considered.  

Ferd H. Mitchell is an attorney, Mitchell Law Office, Spokane, Wash., and a member of HFMA’s Washington-Alaska Chapter.

Cheryl Mitchell is an attorney, Mitchell Law Office, Spokane, Wash.

A new edition of a book by the authors details how organizational reactions to the ACA may be evaluated.

Publication Date: Friday, February 07, 2014