One provision of the ACA calls for insurance companies to pay out at least 80 percent of the premiums collected in benefits to policyholders. The idea here was to limit what they could spend on administrative costs and retain as profits. The administration says on August 1 that about 8.5 million people will get rebates averaging $100 because their insurance carriers did not spend enough
on medical care. This year’s rebates total about $500 million, compared with $1.1 billion last year, and the administration says the so-called 80/20 rule has forced companies to be more efficient and lower their premiums.
Why the mixed review? While an extra hundred bucks or so is certainly welcome news for those who get it, long-range questions remain. Insurance experts say it’s not hard for the big companies to meet the new 80/20 rule. For small companies, which the administration is counting on to offer competition and lower prices of insurance throughout the system the 80/20 rule may be difficult to comply with. Time will tell.
Cracking down on fraud.
On its website, the government touts the “new tools and resources provided by the Affordable Care Act” that have enabled healthcare fraud and prevention efforts to recover $4.1 billion in 2011 and $10.7 billion over the last three years. The Center for Public Integrity tells a different tale, going forward. In a piece published earlier this month, the Center reported:
Citing massive budget and staff cuts, federal officials are set to scale back or drop a host of investigations into Medicare and Medicaid fraud and abuse even though cracking down on government waste and cutting health care costs have been top priorities for the Obama administration.
It turns out, the Center said, the Office of the Inspector General for the Department of Health and Human Services will lose some 400 employees—auditors, investigators, evaluators—who kept an eye out for Medicare and Medicaid fraud. The agency blamed “expiring funding streams,” and the sequester didn’t help.
Accountable Care Organizations.
Obamacare supporters eager to see lower medical costs as a result of the Affordable Care Act are pinning some of their hopes on accountable care organizations or ACOs—groups of healthcare providers who come together to provide coordinated care that eliminates duplication and theoretically poor care. Obamacare financially encourages them. A year and half ago, the government selected 32 ACOs as pioneers to test the theory that by giving patients better care, the costs would come down. A piece by Kaiser Health News in mid-July tells us that the results so far are mixed at best.
The so-called pioneers managed a gross savings of about $87 million, but only 13 saved enough money to share the savings with Medicare, which was the point of the exercise. Two plans actually owed Medicare money. Nine plans are leaving the three-year program before it ends; most are joining other arrangements that carry less risk. Medicare head Marilyn Tavenner said that “successful Pioneer ACOs have reduced costs for Medicare and improved quality of care for their patients.” But Chas Roades, chief research officer at the Advisory Board Company, a health technology and research consulting firm, said, “Going forward, I think we should temper our expectations about how much money we’re actually going to save through ACOs.”
The next stage of Obamacare is the one that we should watch most carefully, as exchanges set up by the law start selling insurance policies to the unininsured and granting subsidies help people pay for them—the heart of the Affordable Care Act. If people get better insurance for the buck, and decide they can afford the coverage rather than pay the tax penalty, and sign up in droves—that’s a huge hit. But it’s a complicated machine to start up and operate, and reporters need to watch closely. There are bound to be misses and mixed results. Whether they will undermine the success of the law is a big unknown. Neither the Democrats, the Republicans, or the press has a crystal ball.