Sustaining the marketplace for a healthier America

As the third Affordable Care Act (ACA) open enrollment season draws to a close, more than 11 million Americans have signed up for coverage and are enjoying the peace of mind that comes with having health insurance.  For that reason, I am proud to have supported the law, but only with continued improvement can we help secure its future success.

We now have a system in place where everyone, including those with pre-existing medical conditions, can gain access to coverage.  This is transformative given that prior to the ACA, millions of Americans were uninsured.  As of last year, the rate of uninsured reached its lowest in decades – roughly 10 percent according to the National Center for Health Statistics.

{mosads}The declining rate of uninsured is significant as it is critical to the ACA’s success.  To ensure the affordability of healthcare services, we must help individuals not only access health insurance coverage, but also stay covered. 

Instead, our current regulatory framework seems to be having the opposite effect.   

For example, there are over 30 “special enrollment periods” – more than that of any other federal government program, including Medicare Advantage.  Rightfully so, these periods are intended to help individuals seek coverage outside of the normal enrollment period due to certain qualifying life events, such as relocating or losing prior coverage.  However, there is little oversight in place to ensure that special enrollment period requirements are satisfied. The unintended consequence is that special enrollment periods enable individuals to only seek coverage when they need care the most – a more costly proposition for the patient and the health care system.

While special enrollment periods should be allowed for clearly defined circumstances and hardships, reducing the number of special enrollments and, importantly, better enforcement of the requirements of these periods, would encourage individuals to stay insured with less interruption.  Not only does this help balance the system, it enables people to get the preventive services and care management they need to remain healthy.

Fortunately, the Centers for Medicare & Medicaid Services (CMS) is already taking an important first step to help address these concerns.  CMS is eliminating six special enrollment periods that are either no longer needed or subject to abuse.  And while CMS intends to more closely examine the utilization of special enrollment periods, the agency should consider adopting approaches used in, for example, Medicare Advantage and the Federal Employees Health Benefits Program, to implement a common practice of enrollee verification across federal government programs.

The marketplace will also require greater opportunity for innovation.     

So far, consumers have had ample coverage choices and plan offerings in the marketplace.  It is important that we continue to encourage this level of access to meet individuals’ unique health care needs.  Some level of uniformity is necessary to lessen confusion for individuals seeking coverage and to enable individuals to make meaningful comparisons in the marketplace.  However, the benefits of standardization should not outweigh the importance of consumer choice. 

Striking the right balance between innovation and market consistency will be necessary to incent individuals to become insured, while allowing health plans to respond to the needs of consumers.  

Likewise, in this time of health care reform, states have truly become the incubators of alternative payment and delivery models, meeting the needs of their local health care markets.  States should continue to play a role in setting the rules that best serve their patients and providers.  To that end, federal regulators should work with the National Association of Insurance Commissioners (NAIC) to implement policy that gives state regulators the flexibility they need to ensure that health care networks are appropriate for their state’s environment.

The Affordable Care Act has demonstrated great potential for establishing a high quality, affordable health care market.  Now is the time to leverage that progress and ensure its sustainability by removing barriers that discourage market participation and incentives that make it easier to not seek care.

As envisioned by the law, let’s, instead, continue to build a stable, enduring system that fulfills the ACA’s promise of a healthier America for everyone.

Daschle served in the Senate from 1987 to 2005. He was majority leader from 2001 to 2003. He is the founder and CEO of The Daschle Group, which represents stakeholders across the healthcare industry.