Insurance exchanges under the Affordable Care Act: How will they affect surgical care?

Health care coverage in the U.S. is characterized by a patchwork of public and private health insurance programs and heavy reliance on employer-sponsored plans. Though longstanding, the private insurance marketplace has been marked by numerous inefficiencies and disadvantages to consumers, including limited competition, hidden costs, and insurers’ ability to exclude high-risk customers through medical underwriting or to limit high-risk coverage through price differentiation.1-4

The Affordable Care Act (ACA) was enacted in 2010 in an effort to reduce the number of uninsured Americans, ensure high-quality coverage for insured Americans, and stem the crisis of rapidly increasing national health care costs. An integral means of addressing these problems involves the establishment of insurance exchanges.5,6 This article describes the potential advantages and consequences of ACA insurance exchanges and explores how their implementation may affect the practice of surgery in the U.S.

History of insurance exchanges

Based on Alain Enthoven’s concept of “managed competition,” an insurance exchange is an organized marketplace for the sale and purchase of health insurance.4,7,8 Exchanges are managed in order to promote access and informed decision making among consumers and to promote efficient risk-sharing mechanisms among insurers; they are competitive in order to reward quality, efficiency, and value among insurers and plans. To date, insurance exchanges have been implemented both in Europe and in the U.S., where they have operated on the federal, state, and industry levels.9,10 Notable examples include the Federal Employees Health Benefits Program (FEHBP), Health Insurance Purchasing Cooperatives (HIPCs) in Texas and Iowa, the Commonwealth Health Insurance Connector Authority (“Connector”) in Massachusetts, and purchasing pools formed by the Connecticut Business and Industry Association and the American Bar Association.4,8,11 Although some exchanges have expanded consumer choice and have dramatically improved consumer access to the insurance marketplace, they have not necessarily reduced premiums.12,13 Furthermore, a number of exchanges have failed outright due to an inability to achieve significant market share and economies of scale, adverse selection within and against the exchanges, and insurance company cherry-picking of healthy consumers to non-exchange plans.14 The ACA includes precautions to reduce the likelihood that its insurance exchanges will be similarly affected.

Insurance exchanges under the ACA

The ACA entails a broad set of insurance reforms in addition to the establishment of exchanges. These reforms include medical loss ratios (MLRs), requiring that 80 to 85 percent of premium revenues be spent on health care services, guaranteed issue, and a ban on medical underwriting.15 The ACA’s “employer shared responsibility” clause incents firms with more than 50 employees to offer affordable, comprehensive plans.16 Similarly, the “individual mandate” requires all Americans to obtain health care coverage of a certain standard or pay a penalty. These reforms have important implications for the function and viability of insurance exchanges and provide essential context for the design of ACA insurance exchanges. (See Table 1.)

Table 1. Insurance Exchanges Under the ACA

Types of ACA exchanges

The ACA establishes two types of insurance exchanges: the American Health Benefits Exchange (AHBE) for individual purchasers and the Small Business Health Options Program (SHOP) for businesses with fewer than 100 employees, although until 2016, states retain the discretion to limit eligibility to businesses with fewer than 50 employees.17 Through AHBE, individuals benefit from economies of scale to access a wider range of plans than otherwise may have been available to them. SHOP provides a similar service for small businesses. Notably, small businesses also have the option to self-insure or to pay for employee benefits through a private trust.14,18

Although some features of insurance exchanges are federally mandated, states have considerable flexibility in their design and implementation.19 States may operate their own exchanges, partner with other states to form a joint exchange, collaborate with the federal government, or rely on an exchange established and run by the U.S. Department of Health and Human Services. States may determine the number of exchanges they will offer, the number of plans included in each exchange (in addition to two federally sponsored plans), and the administrative structure of the exchange (public, private, or semi-private).20 They may merge individual and small group markets, and will ultimately have the option of including large groups (>1,000 employees) in the exchange consumer pool.14,17 Finally, states have discretion regarding the particulars of risk adjustment, the demands placed on insurance brokers and navigators, and any “essential services” beyond those mandated by the federal government.21

Key aims

Whereas the specifics of their design may vary, all ACA insurance exchanges are intended to address a few central aims: increase consumer access to insurance, enhance competition among carriers, stabilize insurance markets, and improve quality and uniformity of insurance coverage plans.

Increased access

To expand access to coverage, ACA exchanges are designed to streamline enrollment and help ensure affordability for a range of consumers. Exchanges must offer centralized, online mechanisms for plan enrollment and are responsible for determining purchasers’ eligibility for plans and subsidies. They must coordinate with other federal institutions, including the Centers for Medicare & Medicaid Services (CMS) and the U.S. Treasury Department, to ensure that consumers receive the maximum possible assistance in the form of tax credits and/or cost-sharing subsidies.2,22

Enhanced competition

ACA exchanges are designed to promote competition between insurers.23 As they aim to expand consumers’ choice of plans, ACA exchanges must also offer independent “navigator” programs to educate and guide consumers through the plan selection and purchasing process.3 Furthermore, exchanges must categorize and rate plans based on actuarial equivalence data, thus presenting consumers with an intuitive indication of cost and value. The goal is improved market efficiency based on robust consumer choice.

In these and other ways, ACA exchanges attempt to resolve many impediments to competition that have traditionally characterized the marketplace. By offering consumers a range of options, exchanges could solve the previous problem of lack of accessible substitute products. By educating consumers and offering them broader plan selection, they could increase what was previously a limited ability to leverage coordinated consumer pressure for higher quality plans. By facilitating direct cost and value comparisons across plans and by enforcing eligibility criteria for plans included in the exchange (for example, MLRs and justified premium increases), they could limit health insurance companies’ ability to pass costs directly to the consumer.2 These changes are intended to help contain and reduce costs.

Market stabilization

ACA insurance exchanges are designed to stabilize insurance markets through effective risk-spreading and risk-adjustment mechanisms.24 ACA-specific mechanisms (see Table 2) include transitional risk insurance, in which the federal government reimburses insurers a portion of the cost of previously uninsured patients, and transitional risk corridors, in which insurers contribute to a common fund to reimburse plans with unexpectedly high costs.25 In addition, the ACA allows for ongoing risk adjustment, such as the diagnosis-based risk assessment already implemented for Medicare Advantage plans. These risk assessments inform adjustments in federal reimbursement and guide direct monetary transfers between insurance companies with more and less healthy enrollees.24

Table 2. Mechanisms of Risk Spreading and Risk Adjustment

Broader reforms under the ACA also are intended to stabilize insurance markets. For instance, guaranteed issue reduces the likelihood of cherry-picking as a means of distorting consumer risk pools, and the individual mandate incents low-risk consumers to participate in the market and effect risk-spreading. Exchange guidelines go further.24 Limited enrollment windows for AHBE plans encourage individuals to enroll at the beginning of the year, instead of waiting until they realize they may need medical services. Similarly, the SHOP requirement that employers select a coverage tier is meant to reduce adverse selection when employees select a particular plan. In addition, ACA exchanges permit “price rating” of plans only within a narrow range and according to a limited set of consumer characteristics, to help offset the anticipated costs of higher-risk consumers. Indeed, insurers may adjust premiums based only on age, tobacco status, family composition, location, and other variables. Many of the particulars of these adjustments, such as age bands and the premium increases assigned to them, remain in the purview of individual states.17,26

Quality of coverage

The final central aim of the ACA and of ACA insurance exchanges is higher-quality insurance coverage. To this end, insurance exchanges are responsible for certifying all participating qualified health plans (QHPs). Under federal law, QHPs must offer “essential services” across 10 categories of care and do so through a robust network of “essential providers” who can provide their services without unreasonable delay.27 These networks also must demonstrate particular attentiveness to the needs of disadvantaged populations.28

States also may set their own quality standards above those of the federal government. Indeed, each state must select a “benchmark plan” that defines its essential benefits and sets the standard for all public and private plans.29 Of note, these standards do not apply to grandfathered plans for individuals and small and large groups, nearly half of which may fall short of the federal standards for new programs as of 2014.30

Finally, even among eligible plans, insurance exchanges have full discretion over which plans to include in the exchange. State exchanges may operate as a certifying organization and clearinghouse for all QHPs or as “active purchasers” that contract and/or negotiate premiums with limited number of QHPs.8,31 Among those exchanges that choose the latter model, admission to the exchange and access to the large body of consumers it represents is seen as powerful leverage for creating high-quality, affordable plans.

Predicted impact

Insurance exchanges and the ACA are anticipated to have a dramatic effect on health care coverage in the U.S. The ACA is predicted to expand insurance coverage to an additional 30 million Americans by the year 2022, although some 30 million people will likely remain uninsured.32 Exchanges are also predicted to significantly reduce but not eliminate ethnic and racial disparities in insurance coverage.33 Similar results have been observed in previously implemented state exchanges.13 The manner by which individuals achieve coverage may also change, as large firms may choose to refer employees and retirees to the individual exchange for insurance coverage instead of offering them a unique benefits plan.34

Much regarding the future of exchanges, however, remains unknown. Not all states have decided on the structure and offerings of their insurance exchanges, and those that have indicate that there will be wide variation across jurisdictions (see Table 3).31 In addition, there are significant threats and challenges to the successful implementation of ACA insurance exchanges, including low rates of consumer and insurer participation, interrupted coverage, adverse selection, and runaway costs.

Table 3. Insurance Exchange Design: States’ Choices

Consumer nonparticipation

Insurance exchanges face the risk that too few consumers will participate to achieve large risk pools and ensure exchange viability.35 Potential causes of consumer nonparticipation include low health literacy, the complexity of exchange offerings, the limited utility of actuarial data in guiding individual consumers to the most appropriate plan, and prohibitive costs.11,15,36

The ACA’s individual mandate is a key mechanism for promoting consumer participation in insurance exchanges. For most individuals, the consequence of noncompliance is a tax penalty, set at the higher of two values: $695 per adult in 2016, indexed to inflation thereafter with lesser fees for children and an overall cap on family penalties, or 2.5 percent of the household income.37 However, a number of groups are exempt from the individual mandate or from the penalty. Such groups include individuals whose premiums would exceed a certain share of their income (8 percent in 2014).37 Furthermore, enforcement of the penalty for uninsured individuals is limited to action by the Treasury to collect through income tax returns, without authorizing additional mechanisms such as liens. In effect, non-filers or filers who are ineligible for an income tax refund are unlikely to be penalized, thus diminishing the incentive effect of the mandate. Finally, some groups (including large employers) are expressly excluded from participation in the exchanges, regardless of whether they are legally required to purchase or provide insurance coverage.38 Although exchange navigators and insurance subsidies are intended to promote consumer participation in exchanges, nonparticipation is a salient risk to exchange viability, and the rate of consumer participation remains to be seen.

Insurer nonparticipation

Insurance exchanges are also vulnerable to low rates of insurer participation.35 Insurance companies may choose not to participate if risk-adjustment strategies are poor and if they maintain a sufficient number of consumers in grandfathered plans. Access to a large pool of potential customers and careful, ongoing risk adjustment are intended to encourage insurer participation. In fact, it is estimated that by 2021, the insurance industry will collect $205 billion in additional premiums, certainly incentivizing insurers to participate.39

Interrupted coverage

Under the ACA, as noted, the expansion of insurance coverage will not reach all Americans. This unmet need is attributable in part to disruptions in coverage for those at the cusp of Medicaid eligibility, who may “churn” between Medicaid and exchanges due to income fluctuations and calculation errors.40 This risk is particularly salient in states that intend to delay or refuse Medicaid expansion, in light of the U.S. Supreme Court’s ruling that states need not expand Medicaid eligibility, as was initially mandated under the ACA.32

Adverse selection

Adverse selection represents a formidable challenge to insurance exchanges as it does to the insurance market in general.24 Under the ACA, this risk may be exacerbated by grandfathered plans, which may offer limited coverage at favorable prices for healthy consumers, and by the possibility that small business may choose to self-insure as long as their employees are healthy.14,26 As discussed previously, the ACA’s precautions to reduce adverse selection include the individual mandate and a range of risk-adjustment mechanisms. Within SHOP, employer selection of coverage tier may also reduce the risk that primarily less healthy individuals will purchase more generous coverage.11


Health care costs remain a major concern; insurance exchanges can only control spending if they are administratively efficient, if the marketplace is competitive, and if adverse selection is prevented effectively. The ACA’s expansion of coverage may increase the likelihood of moral hazard and overconsumption of health care services by a larger patient population, although the law is expensive, regardless. Indeed, the cost of expanding coverage through the ACA is estimated at $1,168 billion from 2011 to 2022 (down from $1,252 billion before the U.S. Supreme Court ruling on Medicaid).32 By the year 2021, 50 percent of all U.S. health expenditures may be paid for by the local, state, or federal government.41 At press time, a $1.2 trillion budget sequester had taken effect on March 1. The impact of sequester spending cuts on ACA insurance exchanges was unclear: although Medicare cuts are restricted to 2 percent of the program budget and Medicaid and CHIP are exempt, funding for exchanges is not.42

Impact on surgeons

It is difficult to predict the precise impact of the ACA on surgeons and surgical practice, though it is possible to foresee effects on the surgical workforce, procedure reimbursement, and surgeon autonomy. Of note, much of the anticipated impact of the ACA is due not only to insurance exchanges but to broader changes required under the law.

Workforce issues

The ratio of general surgeons to overall population in the U.S. has declined in recent decades, and this trend has fueled concern that the country is facing an impending shortage of surgeons, particularly in rural areas.43,44 Indeed, estimates of surgeon shortages for the year 2030 range from a 9 percent shortage for general surgeons to 39 percent for thoracic surgeons, with deficits predicted in at least seven surgical specialties.45 Although the effect of an aging population has been incorporated in assessments of surgical workforce adequacy, the impact of increased insurance coverage and service use under the ACA has received limited attention.46,47 Nonetheless, it seems likely that the already strained surgical workforce will come under increasing pressure as 30 million Americans acquire health insurance coverage.

Safety net institutions

Safety net institutions, including most academic medical centers, and particularly those mandated to serve uninsured populations, face mounting challenges as private and for-profit hospitals and enterprises such as outpatient surgery centers seek to more aggressively court privately insured patients.48 This trend is facilitated by accountable care organizations (ACOs), bundling demonstration projects, and other arrangements that strongly incentivize participating providers and institutions to keep insured patients within their own networks. These safety net institutions will continue to absorb the costs of caring for Medicare, Medicaid, uninsured, and indigent populations.49 These costs may be all the more significant because “disproportionate share payments”—federal payments to institutions that care for a large number of uninsured patients—are slated to decrease under the ACA.48


Under the ACA, physician and hospital reimbursement will change in several ways. Reimbursement is expressly shifted toward primary care through efforts such as the Primary Care Incentive Program (PCIP). Although fee-for-service will remain the dominant model, cost-bundling, global payments, and new “pay-for-performance” models—including the value-based modifier (VBM), which would adjust physician reimbursement based on benchmarked measures of quality, cost, and patient satisfaction—are on the horizon.

In addition, the ACA creates or advances a number of programs that provide incentives and penalties for compliance or noncompliance, respectively, including the Medicare Electronic Health Records Incentive Program and the Physician Quality Reporting System. The ACA also calls for the establishment of the Independent Payment Advisory Board to make recommendations on Medicare payment, which may inform private plans’ standards for coverage and reimbursement. Concurrently, CMS is actively re-evaluating reimbursement for “potentially misvalued codes,” such as gastrointestinal scoping.50 Finally, the federal government’s recently announced plan to sponsor insurance plans through state exchanges may effect de facto standards for all private plans in terms of services, consumer premiums, and provider reimbursement.

Surgeon autonomy

The ACA may have an effect on surgeon autonomy, both in terms of clinical decision making and the administration of a surgical practice. Growing regulatory demands, including the incentivized use of electronic medical records, might place a significant financial burden on smaller practices in addition to requiring practice adaptations by individual surgeons. Furthermore, ACOs, as outlined in the ACA, are intended to further integrate providers both horizontally (across physician specialty) and vertically (physicians and hospitals) with the goals of improving quality and limiting cost. This provision may foster or necessitate closer working relationships between surgeons and nonsurgeons but is also expected to result in changed patterns of specialist referral and will likely affect practice in other ways.51 Additionally, the Patient-Centered Outcomes Research Institute (PCORI) will promote and fund comparative clinical effectiveness research; eventually, this research will help establish an evidence-based standard of care to which surgeons and other providers could be held accountable.52 Of note, the PCORI is expressly prevented from conducting cost-effectiveness analyses or funding research projects that include a cost-effectiveness component.52,53


Insurance exchanges as envisioned and implemented under the ACA represent a sea change in insurance coverage in the U.S. The potential benefits of ACA insurance exchanges include increased patient access to insurance coverage and greater competition between insurance providers. However, the threats to successful implementation, such as adverse selection and the potential fiscal consequences of expanded coverage, warrant continual reassessment.

The ACA and insurance exchanges will likely continue to encounter political challenges. Already, dozens of attempts to repeal the ACA have been made in the U.S. House of Representatives, and it is possible that similar efforts will continue for years to come. In addition, politics at the state level might well trump federal activity on exchanges, as the states are under deadlines to determine whether they will create exchanges of their own. Reflecting the role of state politics in this matter, of the 18 states and the District of Columbia who have declared they will implement their own exchanges, 16 have Democratic governors and/or state legislatures. Of the 25 states that have decided not to implement exchanges, all have Republican governors and/or state legislatures.54 The law itself is likely to be amended and revised over time, including the particulars regarding health insurance exchanges. There may be important opportunities for surgeons to become involved in these developments. For instance, the ACS and other professional organizations might advocate for certain procedures to be included in state or federal essential benefits or might help guide states’ selections of benchmark insurance plans.

As the ACA is implemented and reformed, much research is needed regarding the impact of insurance exchanges on surgical practice, including the effects on individual surgical specialties, surgeons practicing in public and private settings, and rates and reimbursement of elective and urgent procedures. The impact on both patients and surgeons is likely to be considerable, and continued engagement in the development and implementation of state exchanges is imperative.


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