The Patient Protection and Affordable Care Act, and Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation

The goal of exchanges and related policies in the Affordable Care Act is to make affordable health insurance available to individuals who do not have access to affordable employer-sponsored coverage. There is no explanation of how this is supposed to make people's lives better.

The outcome to be measured is the number of individuals who will now have affordable insurance coverage. This is not specified, but is implicit in the NPRM. There is no explanation of how this is supposed to make people's lives better.

Risk corridors encourage health insurance issuers to offer QHPs through exchanges during the first three years of their operation by ensuring that all issuers share the risk associated with initial uncertainty in the pricing of QHPs. Reinsurance protects health insurance issuers from the risk of high-cost individuals, reducing issuers' need to accumulate precautionary savings and lowering premiums. Risk adjustment plays a similar role by reducing the advantages of the selection of healthy individuals with low risk by a plan. This cannot be said to be a theory as such, since it consists of mainly asserted material.Risk corridors encourage health insurance issuers to offer QHPs through exchanges during the first three years of their operation by ensuring that all issuers share the risk associated with initial uncertainty in the pricing of QHPs. Reinsurance protects health insurance issuers from the risk of high-cost individuals, reducing issuers' need to accumulate precautionary savings and lowering premiums. Risk adjustment plays a similar role by reducing the advantages of the selection of healthy individuals with low risk by a plan. This cannot be said to be a theory as such, since it consists of mainly asserted material.

HHS does not attempt to isolate benefits associated with each particular provision of Affordable Care Act. Instead, HHS discusses evidence on the benefits of affordable health insurance coverage, which is the objective of Exchanges and related provisions of the Affordable Care Act. HHS focuses on studies of the expansion of Oregon's Medicaid program that expanded access to uninsured adults and a 2002 Institute of Medicine report that found insurance coverage improves health outcomes of insured. The Oregon study focused on indigent persons and may not be representative of wider populations. Benefits are seen in terms of numbers insured.

HHS admits its estimates are based on a predictive economic model subject to fundamental uncertainty. With limited previous data and experiences, there is greater uncertainty in estimating the impacts of implementing the Affordable Care Act and the exchanges than in estimating the implications of modifying a previously existing program. Many behavioral variables are not measurable (expected income, changes in health risk, cultural norms, etc.) and changes in economic conditions or productivity would affect predictions. HHS also acknowledges uncertainty about how the Affordable Care Act will affect employer-sponsored insurance. No details on how such uncertainties might affect outcomes are provided, and there is no critical awareness of the likely impact of uncertainty.

The RIA states that the number of uninsured Americans is rising due to lack of affordable insurance, barriers to insurance for people with preexisting conditions, and high prices due to limited competition and market failures. The RIA does not explicitly discuss what these market failures are and confuses equity with efficiency.

HHS argues millions of people without health insurance use health care services for which they do not pay, shifting the uncompensated cost of their care to health care providers. Providers pass much of this cost to insurance companies, resulting in higher premiums that make insurance unaffordable to even more people. In reality there are many possible causes of these problems.

Little is provided since there is no model of optimal insurance coverage, just that there are too few insured individuals; no convincing empirics are offered.

There is no real discussion since there is no attempt to determine how many uninsured result from market failure compared with how many from efficient reasons for not buying insurance.

Two alternatives are discussed: 1) a uniform standard for operations of exchanges and 2) a uniform standard for certifying health insurance coverage. Not much is done with the alternatives, but they are enumerated.

It is very narrow, since they represent modest variation of the Affordable Care Act.

It is a qualitative assessment with little detail.

Not really: the baseline appears to be that used by the CBO, but this is not adequately discussed.

Some costs are identified, but without quantification.

It identifies outlays for reinsurance and risk adjustment, and grants authority for start-ups, financial year 2012–16. Little detail is provided.

It makes some assertions but makes no attempt whatsoever to identify price changes, other than that insurance rates should fall overall.

The HHS uses the CBO's assumption that employer-provided insurance will increase, but cites another study that estimated a reduction. Little discussion is provided.

In the NPRM (but not the RIA) costs are estimated using two discount rates (3 percent and 7 percent), but there is no range of estimates attempting to deal with any other uncertainty. There is really nothing here.

No, there is an accounting statement with costs and benefits, but no assessment of alternatives. Benefits are not quantified.

No alternatives are listed, although there is a general discussion.

Some social groups are identified, such as lower-income users, providers, and insurers.

It identifies the currently underinsured as beneficiaries. It asserts that "everyone" appears to gain. There is a little discussion of small versus large employers.