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ACA: Status of marketplace implementation

The "Patient Protection and Affordable Care Act," shorthanded as the ACA and as this series of reports will refer to it, has the potential to reshape health care in America. Expansion of medical insurance coverage, a move toward more integrated care delivery and significant changes in the financing of health care are among the expectations of ACA legislators and regulators. The Association's primary focus has been the law's potential effects on dentistry and the delivery of dental services to patients. The first three ADA News Q-and-A articles were published Aug. 5 and 19 and Sept. 2 and are posted online at ADA.org.

This report continues an examination of the ACA and looks at the status of marketplace implementation and, for the first time, addresses member questions on ACA implementation. Questions may be directed to the dedicated email address healthreform@ada.org.

Marketplace implementation, effect on health insurance coverage

The Congressional Budget Office—a nonpartisan arm of the federal government that conducts impartial analyses—estimates that in the first full year of implementation (2014) 7-9 million people will enroll in coverage through individual and small group marketplaces.

Those numbers will grow to some 24-29 million by 2023.

The CBO projects that by 2023 some 7 million fewer individuals will have employment-based coverage as a consequence of ACA implementation but that employer-provided coverage will remain in place for about 162 million people. Medicaid and the Children's Health Insurance Program are expected to grow from about 34 million to 47 million during this same time period.

Marketplace implementation: How is it going?

Depends on who's talking. There is universal acknowledgment that there will be a great many "glitches" as states and the federal government attempt to open the door to enrollees. Some are calling it a "train wreck" and others see the process of implementation continuing to move forward if only because there is no way to stop it.

There is general agreement that there are a great many challenges to implementing the ACA.

Challenges to timely and complete implementation

The trick is to find the uninsured, get them signed up (especially the young, healthy uninsured) and have the exchange infrastructure fully functioning. People can enroll in health plans as late as Dec. 15 for plans that begin coverage on Jan. 1.

But the Oct. 1 deadline (when people should be able to begin enrolling) is virtually upon us.

U.S. Health and Human Services Secretary Kathleen Sebelius acknowledged that efforts to reach consumers have been uneven.

In general terms, states that are building their own marketplace, such as Maryland, have done better in identifying the uninsured and providing people (navigators and others) to help guide consumers through the purchasing process.

Private, nonprofit organizations, such as Enroll America, are trying to step up and help identify the uninsured through outreach efforts in various states.

The challenges of having the information technology systems in place and properly running by Oct. 1 or even by Jan. 1, 2014, cannot be overstated.

Different data systems, such as those for Medicaid and CHIP, have to be integrated with the exchange-generated information; real time eligibility decisions (e.g. Medicaid, tax credits, and so forth) will have to be made. For example, according to the Office of the Inspector General at the Department of Health and Human Services, the federal data hub that must be running before the exchanges can open will not be designated as "secure" until Sept. 30, the day before the exchanges are scheduled to open.

The administration's delay in implementing the employer mandate will affect coverage, at least in the short term. According to the Congressional Budget Office, about 1 million fewer individuals are expected to enroll in employer sponsored coverage because of the one-year delay in applying noncompliance penalties on large businesses (50 or more full-time employees).

CBO estimates about half of those people will remain uninsured for 2014, while the others will obtain coverage through the exchanges or low-income government programs.

Some states running their own exchanges are finding it difficult to meet the deadline. For example, Oregon's exchange will open Oct. 1 but consumers will not be able to access the exchange online until the end of the month. 

ACA: Members' questions

I am a 61 year old retired dentist.  Under the ACA requirements, am I required to purchase dental insurance by Oct. 1, 2013?

No. In fact no one is required to purchase adult dental coverage under the terms of the ACA. The only requirement to purchase dental coverage applies to children's dental coverage and that is limited. Specifically, those individuals purchasing coverage in the individual and small group markets outside the exchanges will have to buy children's dental coverage.

Will the ADA discuss how the ACA will affect different entities within dentistry, such as small and large group private practices, community health centers (such as federally qualified health centers) and tribal dental clinics?

Regardless of practice setting, the effect of the ACA on dentists and their patients will vary state to state.

Expansion of dental coverage will be influenced by many factors, including the types of plans participating in the marketplace and in the individual and small group markets outside the marketplace, the relative success of navigators and others in educating consumers regarding dental coverage and the state's decision to expand or not to expand the Medicaid program to cover adults.

The effect of the ACA will vary in some cases depending on the practice setting. Beginning in 2015, employers with 50 or more employees will have to offer health coverage for their employees; employers with fewer than 50 full time employees do not.

The ACA amends the Fair Labor Standards Act by creating a requirement that by Oct. 1 all employers covered by the FLSA (which includes dental offices) will have to furnish each of their employees a notice that informs the employees that there are new health insurance marketplace coverage options available.

U.S. Department of Labor notices designed for this purpose are available for printing:

• One notice is for employers who offer a health plan to some or all employees;

• A second notice is for employers who do not offer a health plan.

Dentists in community health centers are much more likely to experience a change in their work environment because of the increased emphasis on collaboration across disciplines within and outside the clinic.

For example, the ACA authorized grants to establish the Community-Based Collaborative Care Network Program to provide comprehensive, coordinated and integrated health care services (as defined by the HHS secretary) for low-income populations.

A network could include hospitals that meet defined criteria and all federally qualified health centers in a given geographic location. The grants could be used to assist low-income individuals to access and appropriately use health services, enroll in health coverage programs, provide case management and transportation, expand capacity (including telehealth, after-hours services or urgent care) and provide direct patient care services.

The ACA also relies on an expansion of public programs (like Medicaid) to address the uninsured, underserved population, which is the population targeted by public clinics. Depending on a given state's decision concerning expansion of the Medicaid program, clinics could find that a higher percentage of their patients have dental coverage in the future.

Regarding tribal or Indian Health Service dental clinics, the U.S. Government Accountability Office in a September 2013 study estimates that most American Indians and Alaska Natives potentially will be eligible for expanded or new coverage options under the ACA.

The GAO recommended that outreach to tribal leaders be increased so the leaders are aware of their members' coverage status.

On the other hand, recent funding cuts due to sequestration have reduced the funding available for such outreach activity. Patients using these dental programs will likely continue to face access to care challenges that go beyond the ACA.

I work in a federally qualified health center, and we are trying to prepare our dental department for some of the effects of the ACA. Especially in public health, is there a chance of a reimbursement system based on health outcomes?

It is very difficult to predict at this time if there will be changes in the FQHC reimbursement system to accommodate reimbursements based on outcomes.

At the present time, most FQHCs are paid on a per-encounter basis. As discussed in some detail in an earlier Q-and-A, the ACA established a pilot program called the Medicare Shared Savings Program, which encouraged the formation of accountable care organizations.

In general terms, ACOs are entities comprised of health care providers (e.g. hospitals, physicians, home health agencies and others) who collaborate to provide coordinated care to a defined population for a bundled payment.

While most of the ACOs to date are Medicare-centric, there are ACOs that focus on the Medicaid population. In Oregon, for example, CCOs (equivalent to ACOs) must coordinate physical, mental, behavioral and dental health care for people eligible for Medicaid or dually eligible for Medicare and Medicaid. CCOs will be required to publicly report on quality metrics, including those related to dental care.

Please send your ACA implementation questions to the dedicated email address healthreform@ada.org.