"It makes no sense at all – the patient is protected but the rest of the system isn’t and that’s not how it’s supposed to work," the AMA’s Dr. Hoven said.
Much remains to be seen with how the exchanges work, including what kind of clout they will have in negotiating with physicians. Many predict that the exchanges will grow as forces to be reckoned with in the insurance market.
Eventually, they will be able to set quality standards, bar plans that don’t meet certain standards, and limit the sale of insurance outside exchanges, according to Henry Aaron of the Brookings Institution and Kevin W. Lucia of Georgetown University (N. Engl. J. Med. doi:10.1056/NEJMp1308032).
Vermont and Washington, D.C., already prohibit sales of individual policies outside their exchanges.
The insurance exchanges also are expected to expand their reach. They will start offering plans to employers with 51 to 100 workers in 2016, and could be adding larger employers in 2017. Over time, "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 health care delivery system," wrote Mr. Aaron and Mr. Lucia.
Dr. Charles Cutler
Exchanges will vary from state to state
*The Commonwealth Fund has mapped it out, with links to each state's exchange website, details on how each exchange is governed, who serves on the board of directors, and whether and when quality data have to be reported.
*Not every insurer in every state is participating. In some states, only one insurer is offering plans. A list of every insurer and all the plans being offered in every state can be found at The Centers for Medicare and Medicaid Services website. There is also information on insurers participating in the federally-run exchanges at www.healthcare.gov.
Each state exchange is using different ways to get patients enrolled. For the most part, physicians are not being asked to get involved personally; however, the department of Health and Human Services has enlisted physician organizations – such as the AMA, the AAFP, the ACP, and the American Academy of Pediatrics – as "Champions for Coverage," to help spread the word.
Plans offered through the exchanges will have to cover a set of essential benefits. All Medicaid plans have to cover those services as well.
Exchange plans can’t deny coverage or charge higher premiums for preexisting conditions, and premiums can’t be different for men and women. Insurers can still charge more as people age, except in Vermont and New York, which prohibit age-rating by state law.
Plans will be able to offer five levels of coverage, ranging from the least protective and least expensive to the most protective and most expensive: catastrophic, bronze, silver, gold, and platinum. Not every state requires that every level of coverage be offered.
Premiums will be based on income and age. An individual with an income below $45,960 and a family of four with an income below $94,200 will be eligible for some kind of assistance. Tax credits are given directly to the insurance company so that the enrollee doesn’t have to pay the higher premium up front. Out-of-pocket costs will also be limited, depending on income.
The Kaiser Family Foundation has estimated that older Americans, those between 60-65 years, are likely to benefit the most from subsidies.
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*Updated 10/9/13