Created by the Patient Protection and Affordable Care Act, the exchanges are newly created markets where 24 million Americans will buy health coverage within a decade, the Congressional Budget Office projects.
States can require all insurance sold to individuals or small businesses to be sold inside the exchange, creating a robust market, they wrote. States also may authorize the exchange to pick and choose which insurers may participate in the market. Exchanges could present comparative price and quality information for consumers; require health plans to include financial incentives for members to use high-value providers; and encourage or require new payment and delivery models such as accountable care.
An exchange that is “supportive and sympathetic” to accountable care would help promote use of the payment model, Aaron said in an interview.
But first, exchange operators must get the new markets up and running, Aaron and Lucia said. The immediate operational challenges that face exchanges are significant.
Another obstacle is that a large percentage of Americans remain unaware of the exchanges. A Kaiser Family Foundation survey last month found that one in three had heard nothing about the exchanges, though there are signs more people have become aware of them since advertising and public education campaigns have gotten underway in recent weeks.
Exchanges must develop and test enrollment software, educate the public and train new workers, the authors said.
“I think that's really where the attention has to go,” Aaron said.
Some problems will inevitably occur, he said. “If you have millions of people being enrolled, you're going to have thousands of mistakes.” Reform law foes may find more ammunition in those mistakes, he said. But Massachusetts' reform model, on which the law is based, has demonstrated that broad political support can lead to successful efforts to find solutions.
An initial focus on operations is critical to prevent an unfavorable experience that will turn customers away, Aaron said. Just as good mortgage advice from a financial adviser might bring a customer back for retirement planning, so will a smoothly run exchange win repeat business, he said. Early success will help to establish the exchanges as “well-entrenched, accepted and attractive.”
“Mundane administrative tasks will occupy the exchanges for the first year or two,” the authors wrote. “But the exchanges are an instrument of enormous potential power. Political resistance may inhibit the use of this instrument. But over time, as the initial administrative glitches are ironed out, we believe that the exchanges will be seen as a means for promoting a competitive insurance market in which consumers can make rational decisions and that they will become an instrument that can reshape the healthcare delivery system.”
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