What’s Next for Health Care

By Robert Pear for  The New York Times

WASHINGTON — The first open enrollment period for health insurance under the Affordable Care Act has just ended, and consumers, insurers and federal officials now face many immediate chores and challenges that will help determine if the law works as intended.

Many questions about the law’s potential impact on the health care system remain, and here are some preliminary answers.

Q. How many people have actually paid for the insurance plans they selected?

A. The Obama administration has been reluctant to provide data, saying it did not have solid figures because consumers pay premiums to insurance companies, not to the government.

The Blue Cross and Blue Shield Association said Wednesday that 80 percent to 85 percent of people buying its products on insurance exchanges had paid by Feb. 1. That is consistent with reports by other insurers.

If 15 percent of the 7.1 million people signing up fail to pay premiums, that would reduce the number gaining coverage to six million.

The federal government says it will probably need a couple of weeks to tabulate data on the age and other demographic characteristics of new policyholders.

Q. Will premiums shoot up next year?

A. Several insurers have said they will probably seek double-digit increases in premiums next year. However, at least four factors may counter this impulse.

Competition, which could be intensified by the entry of more insurers into the market in some states, will tend to hold down premiums. Consumers showed a strong preference for the lowest-cost health plans this year.

Federal and state officials can negotiate with insurers if they believe proposed prices for 2015 are excessive. Even if new policyholders this year are sicker and older than insurers expected, they may not use as much health care as experience suggests. Many of the new policies have high deductibles, which will discourage overuse of health care by people eager to avoid high out-of-pocket costs.

In addition, the law has several mechanisms intended to stabilize premiums for several years. If one insurer enrolls a disproportionate number of sick people, the government and other insurers will help defray the costs.

Q. Will more states expand Medicaid?

A. Congress tried to require states to expand Medicaid, but the Supreme Court ruled in 2012 that states could opt out, and about half have done so.

Andrea Maresca, director of federal policy at the National Association of Medicaid Directors, said that some of these states might expand Medicaid if they could work out an “alternative approach,” tailored to their needs, with the federal Department of Health and Human Services.

Among the states to watch, she said, are Indiana, Tennessee, Utah and Virginia.

Some states may try to follow Arkansas, which decided to expand Medicaid by buying private coverage for poor people through the new insurance marketplace.

In many parts of the country, new beneficiaries may have difficulty finding doctors willing to accept new Medicaid patients.

“Nothing in the Medicaid provisions of the Affordable Care Act, by itself, cures the underlying shortages of primary care physicians and specialists who accept Medicaid,” said Sara Rosenbaum, a professor of health law and policy at George Washington University.

Community health centers will play a crucial role. The law provides $11 billion over five years to expand these clinics. In addition, most states have contracts with insurance companies or other entities that are supposed to manage care for Medicaid beneficiaries and connect them to doctors.

Q. Will more states create their own insurance exchanges?

A. Caroline F. Pearson, who follows state developments as a vice president of Avalere Health, a research and consulting company, said it was unlikely in the near future. “Given all of the information technology challenges in 2014, including persistent problems for some state-based exchanges, I expect most states to continue relying on HealthCare.gov next year,” she said.

Q. What comes next?

A. Thousands of people started applications for insurance but were unable to finish them before the deadline on Monday. The government will allow extra time for some who encountered error messages or “other system errors” on HealthCare.gov. Officials have not said how long this grace period will last. Nor have they said whether they will require people to submit documents or other evidence showing they tried to enroll.

Insurers are already developing 2015 rates. For most states in the federal exchange, insurers are supposed to submit their proposals to the Obama administration in June. The government will review the proposals and send “correction notices” to insurers in July, then review the “corrected applications” in August and September, and make final decisions by mid-October.

The federal government and some states may try to force insurers to expand their networks of doctors and hospitals, though insurers say such changes could increase costs.

The next open enrollment period begins on Nov. 15, just 11 days after the midterm elections, and runs through Feb. 15, 2015.

The Congressional Budget Office estimates that enrollment in private plans through the federal and state exchanges will triple in two years, reaching 22 million by 2016, an ambitious goal for the administration.

Q. Will employers cut back their commitment to health insurance for employees?

A. The answer, in short, is unclear. Employers, which provide coverage to more than 150 million people, say they desperately need the White House to provide more clarity and certainty about their obligations.

Under the law, larger employers are generally required to offer coverage to full-time employees, defined as those who work at least 30 hours a week, on average, or the employers may have to pay penalties. The administration has delayed the requirement, but it will hit many employers in 2015 or 2016.

The 30-hour rule will require employers to insure many employees who have not received health benefits in the past. Some employers say the law creates incentives for them to reduce the work hours of some employees to avoid the cost of providing them health benefits. The White House sees no evidence of a trend in this direction.

One of the fastest ways for the administration to expand coverage would be to persuade more businesses to offer insurance to employees. To date, the administration’s outreach to employers has lagged. Small businesses have been unable to buy insurance online for their employees through the federal marketplace, but the administration promises they will be able to do so this fall.