A new survey reveals confusion among county governments over the Affordable Care Act because of delays or changes to the law, but a slim plurality say the law hasn’t yet affected them.

Forty-two percent of respondents in the National Association of Counties’ (NACo) 2014 health benefits survey said the complexity of the law most contributed to their difficulties responding to it. But 35 percent of counties said the law hasn’t yet affected them. Some 34 percent of respondents said the law is already affecting them or will affect them in the future.

The survey, conducted in March, follows a similar 2009 questionnaire of the same counties. It provides a look into the business of covering the health care of an estimated 2.5 million employees who are insured through county governments. 

Among the counties that did say the law is already affecting them or will in the future, cost increases could be attributed to ACA provisions that took effect before the law came fully online in 2014, such as required coverage for young adults up to 26 years of age and the removal of lifetime caps on benefits deemed essential under the law, according to NACo. 

Perhaps the two provisions of the law with the biggest implications for county governments are the mandate for larger employers to offer affordable health coverage to most employees and a tax on plans with more generous benefits that goes into effect in 2018. 

The so-called employer mandate has been delayed and altered by the Obama administration. It now will apply in 2015 to employers with more than 100 employees and in 2016 to those with between 50 and 99 workers. Employers will face penalties if their workers go to an insurance exchange and qualify for federal assistance for health coverage because their employer’s plan cost them more than 9.5 percent of their income.  

NACo reported that some counties are “acutely aware” of the 40-percent tax on health plans that exceed $10,200 in annual value for an individual. While the tax doesn’t go into effect until 2018, some counties are already planning changes to their health plans to avoid the tax. If the so-called “Cadillac tax” went into effect today, it would hit at least 6 percent of respondents, NACo found. In California, Sonoma County estimated the tax would increase premiums for employees and retirees by an estimated $4.1 million annually.

Other findings from the survey include:

  • The percentage of counties offering full coverage to even part-time employees doubled from eight percent to 16 percent.
  • Between 2009 and 2014, average monthly premiums for county health plans increased by 20 percent
  • More than 80 percent of counties now offer at least one wellness program, up from 59 percent
  • Sixty-eight percent of counties offered health benefits to retirees in 2014, far higher than the 2013 national average of 28 percent for employers with more than 200 workers
The report can be found here,