The Wild Card: State Insurance Exchanges

Greg Young, government relations manager at Medical Mutual of Ohio, says the payer has been analyzing the Patient Protection and Affordable Care Act since it was signed into law in March 2010 and is ready to implement its requirements.

But what’s uncertain going forward is if the act when implemented will actually lower premiums, and if payers, providers and the federal government can couple with I.T. systems to enable the data exchange required to manage the health of the millions in, and millions joining, the national health care system.

“The great debate is whether this is actually going to lower premiums,” he says. “We’re simply not sure at this point. There are different answers to that, but it seems those answers via estimates have been on strictly partisan lines.“

The real wild card, he says, is the varying definitions of what constitutes “essential” benefits for insurance products that will be offered on state insurance exchanges (click here for recent HDM commentary). The Institute of Medicine and the Department of Health and Human Services were supposed to define those benefits to enable apple to apple comparisons across the states, but “they basically punted that issue until 2016, and for the next two years are going to let states define essential benefits. And that’s going to create problems in the marketplace.”

Medical Mutual of Ohio operates in four states--Georgia, Indiana and South Carolina, along with Ohio--which will make it easier for it to address those essential benefit variations than health insurers that are offering products in all 50 states, Young says.

But the I.T. complexities of sharing data with the state exchanges will be daunting, Young says, on top of the current demands to establish information exchange with providers and federal agencies. A particularly difficult challenge will be collecting and analyzing data to come up with a mutual definition of “quality” amongst stakeholders, he says.