Posts About Private Insurance and Health Insurance Marketplaces

As Republicans struggle to come to agreement on how far to go with ACA repeal and what to put in its place, they are confronted with three interlocking math problems: first, how to make their budget numbers add up; second, how to put together a proposal that can command a majority in both the House and the Senate; and third, how to avoid running afoul of public opinion.

Where to Start?

Let's start with the budget problem. The budget reconciliation instruction only requires Congress to save $2 billion over 10 years, which is barely even rounding error in the context of overall federal health spending. It should be easy, right? But the complications begin immediately with the Republican commitment to repeal the taxes that helped pay for the expanded benefits in the ACA.

How to plug that hole? In the good old days of "repeal and delay" (about a month ago), you simply wiped out all of the ACA spending – including both the tax credits for marketplace coverage and all of the Medicaid expansion funds – and made some vague promises about fixing it later, someday, maybe (not!). But “repeal and delay” ran aground on the other two problems – public opinion, which is strongly against it (only 18 percent support this course), and that constituents have not been shy about making their objections known to their members of Congress.

As a result, there aren't enough votes to pass repeal and delay, so GOP leadership is in need of some kind of replacement plan. That replacement plan has to make good on Republican commitments to preserve access to coverage for people with pre-existing conditions and also has to avoid yanking Medicaid coverage (and funding) away from states. But preserving funding for the Medicaid expansion (even if the federal matching rate phases down over time) and creating a substitute for the ACA tax credits, even at reduced levels, eats up some of your savings, so you are still left with a budget hole.

How big a hole depends on how much of the expansion funding is preserved and how adequate are the new tax credits. The greater the funding preserved, the bigger the budget hole. But proposals to shrink the funding have fueled opposition in states that have benefited from the Medicaid expansion, including 16 states with Republican governors. It would also cause the number of uninsured to spike and do little to allay the public's fear that people with pre-existing conditions will again be locked out of the insurance market. 

A notable feature of the recently leaked draft House repeal-and-replace plan is that it tries to address these problems by providing more funding for the Medicaid expansion and for subsidizing private insurance than did previous proposals, such as the one authored by now-HHS Secretary Tom Price. But because at least a portion of the ACA funding is preserved, a sizable budget hole remains, although we don't know how big because no CBO score has yet been made available.

Fixing a Hole?

How is this hole to be plugged? Again according to the leaked plan, there are two additional revenue sources. One, involves cuts to the core Medicaid program; the other involves changes to the tax exclusion for employer-sponsored insurance, in the sphere of the ACA's "Cadillac tax" that places an excise tax on the most expensive health plans. But both of these revenue sources immediately run into trouble with respect to math problems two and three, above. The "Cadillac tax" is wildly unpopular with both the public and in Congress, across party lines. It is not at all clear that a majority of members will repeal the Cadillac tax only to turn around and support replacing it with something that essentially does the same thing.

On the Medicaid front, the House proposal is to continue to provide states with enhanced matching funds through 2019, but only for those beneficiaries who are currently enrolled. New enrollees would receive only the regular match rate. Starting in 2020, states would receive a capped amount for each beneficiary. The proposal calls for this capped payment to grow at the rate of medical CPI plus one percentage point. It's not clear that this adjustment factor saves a lot of money. If not, it then doesn't do much to fill the budget hole (running into math problem one).

The House Medicaid proposal differs significantly from another leaked proposal, this one developed by a number of Republican governors. In particular, the governors do not want to be forced to assume increased risk for the cost of care for beneficiaries who are jointly eligible for Medicare and Medicaid. (The "dual eligibles" account for over one-third of all Medicaid spending.) At the same time, at least some Republican governors seem perfectly comfortable with substantial Medicaid funding cuts as long as they have increased freedom to cut people off of Medicaid and reduce benefits for those who remain. Of course, this would just shift costs onto providers and beneficiaries. In essence, perhaps in an effort to keep senior citizens, people with disabilities and the providers who serve them on the sidelines, the governors' plan boils down to massive eligibility and benefit cuts for non-disabled adults and children.

Especially if the votes aren't there for tackling the tax-exclusion, then the Medicaid cuts would have to be deeper – much deeper – than what is laid out in either of the leaked draft proposals.  And benefits would likely be even skimpier both for Medicaid beneficiaries and in the private market. An analysis of the replacement plan based on documents released by Speaker Ryan suggests that millions would lose coverage. Such draconian cuts in health coverage would spark even more public outcry and could erode support in both the House and Senate, even though one House leader called a decline in coverage "a good thing" (again, see math problems two and three, above).

All in all, once the "original sin" of repealing the ACA taxes is committed, solving all three "math problems" – i.e., finding a way to make the budget numbers work while keeping a majority of support lined up in both the House and the Senate and not enraging the voters – adds up to a monstrous headache for Speaker Ryan and Leader McConnell. (Sad!)  Perhaps that's why former House Speaker Boehner predicts that the Republican effort to repeal most of the ACA will ultimately fail.

Let's hope he is right.

Transitioning between Medicaid and Marketplace coverage can create health care potholes for consumers, placing them in harm’s way. Transitioning coverage can be further complicated by challenges with health literacy and health insurance literacy – or understanding how to use health information to make informed health care decisions. Case in point: Connecticut.

July 31st marked the expiration of Connecticut’s Transitional Medicaid Assistance (TMA) option for parents whose Medicaid eligibility was reduced in the 2015 state budget. The transitional Medicaid program assists low-income families’ transition from Medicaid over one year. This experience shines light on two key issues facing consumers who transition between Medicaid and Marketplace coverage—understanding how to select and use health insurance and how to fit health insurance into family budget.

Why were these parents on TMA? In 2015, Connecticut reduced the Medicaid eligibility limit of parents from 201 to 155 percent Federal Poverty Level ($31,140 for a family of three). This resulted in “rollbacks” of parents from Medicaid to Marketplace eligibility. Affected were a small number of parents who were eligible for Medicaid through a category other than income, and the remaining parents who had become ineligible for Medicaid based on income and were poised to lose their coverage—about 14,000 parents. Connecticut Voices for Children led a successful advocacy campaign in 2015 to protect this group of parents from being dropped from Medicaid by highlighting parent’s legal access to Transitional Medicaid Assistance (TMA).

So how did it go? About 41 percent of those eligible enrolled in Marketplace plans, leaving over 8,000 uninsured. It also exposed a more complex set of issues.  Lingering problems remain for low-income consumers—health literacy and plan affordability. These are two longstanding pre-ACA factors that influence the success of a consumer-focused health agenda—not just in Connecticut, but in all states.   


Meeting consumers where they are….and sticking with them.

Connecticut’s effort to transition this group of parents from Medicaid to Marketplace coverage reveals the need for ongoing health literacy support. The literacy required to move from a public to private platform for health coverage is significant and can create confusion—even for veteran enrollment assistance workers. Health literacy is beyond understanding basic health insurance terminology—it is empowering consumers to be active partners in their health decision making, resulting in better health. In Connecticut, advocates supported this initial translation work through the development of their own flyers with clear, plain language instructions for low-income consumers. Advocates shared these resources broadly through their networks as a way to augment those of the Marketplace. Access Health CT also directed its energy and resources toward holding enrollment fairs.

While there are other initiatives to support health literacy underway in Connecticut, in some communities, the outreach and literacy work is largely unfunded. Over the long term, health literacy support and the advancement of broader goals around health improvement cannot be attained without dedicated resources.

Connecticut’s experience is an important reminder that if we really want to reach and improve the health of the “hard-to-reach,” we need assets inside communities to communicate an authentic message that inspires folks to enroll—and use their insurance coverage to improve their health. But is that enough? Even when community partners are heavily involved in outreach and enrollment efforts to aid with the transition, challenges still arise with helping consumers switch coverage in ways to allow them to continue accessing needed care.

Rhode Island illustrates that when you roll back the parent population from Medicaid to Marketplace coverage as they did in 2014, it is challenging to enroll consumers in coverage even with robust outreach and enrollment efforts. For parents, Marketplace plans are unfamiliar and have a more limited benefit package that lacks important supports like transportation and access to in-network clinics or providers.  Further, plans and networks are not aligned across platforms. Consumers’ knowledge of cost-sharing structures and risk-based insurance products offered in Marketplaces is limited. Additional support is needed to help consumers integrate private coverage into their household budget and access additional social service programs that address their financial stability beyond health care coverage. Community partners can play a key role in supporting consumers in this process, connecting them to existing networks of social service partners and working to ensure consumers have ongoing access to affordable, robust coverage.

The road ahead.

The long-term success in Connecticut will be measured during the next enrollment period when enrolled parents are asked to renew their Marketplace plans. Access Health CT understands the importance of assessing consumer experience. Over the coming months, it will conduct focus groups to learn what outreach strategies worked well and whether or not parents are utilizing their new plans. This will be important data to share with community partners so that all stakeholders can work together to improve consumer experience and support consumers in their effort to reach optimal health.

We have much work to do in protecting low-income consumers from high-cost coverage. High on the list are designing Marketplace products that meet the unique needs of low-income consumers and continuing to push for investment in outreach and enrollment and ongoing interactions between enrollers and consumers to promote increased health literacy for all.  As health system stakeholders pave the road for healthy communities, advocates can play a key role in ensuring consumers avoid health care potholes and have seamless access to needed services and supports to keep themselves and their families financially secure and healthy over the long run.

The Affordable Care Act’s (ACA) Essential Health Benefits (EHB) completely changed health coverage by requiring health plans on the individual and small-group market to cover the same ten benefits without discrimination. These 10 essential categories of benefits range from general—office visits and hospital care – to more specific population focused requirements, including pediatric care, mental health and substance use disorder services. However, CMS, health plans and state regulators have experienced challenges bringing this robust standard to life resulting in inconsistent implementation across states.

A recent report by the American Occupational Therapy Association (AOTA) found some concerning issues with the coverage of the rehabilitation and habilitation services and devices EHB found in the marketplace. While the report finds that only a minimal percentage of plans were counted as discriminatory, about a third of plans combined their rehabilitation benefit with their habilitation benefit. Combining rehabilitation with habilitation coverage can restrict consumers with disabilities who utilize this benefit and who are inherently at risk of discriminatory benefit design, health treatment and health disparities. CMS has recognized this issue and has required plans to keep the benefit limits of rehabilitation and habilitation services separate starting January 2017.

Beyond the benefits analyzed in the AOTA report, the recently finalized Section 1557 rule gives examples of other benefit design practices that CMS has recognized as discrimination, including arbitrary age limits and placing medications on the highest cost-sharing tiers. Nonetheless, Section 1557 still leaves a lot of room to determine discriminatory benefit design on a case-by-case basis. Therefore, robust monitoring and enforcement of EHB standards (and other relevant federal rules) plays an important protective role to ensure that consumers get the full benefits promised to them.

Making the health coverage feedback loop work better

AOTA’s report can be a handy resource to check states’ marketplace plan coverage of rehabilitation and habilitation services and devices. On a broader level, its findings suggest a need for a more systematic way to monitor benefit design and take corrective action – such as strengthening the feedback loop between consumer assisters, consumers, advocates, state departments of insurance and the Office of Civil Rights (when the issue is based on discrimination); improving the consumer complaints process; and, sharing findings of discriminatory benefit design.

As more and more people gain coverage through the marketplaces, it is critical that they, especially the most prone to discrimination, get the care they need. Fulfilling the promise of the ACA’s 10 EHBs not only ensures that people with health conditions and disabilities have access to coverage, but also that they are no longer excluded from necessary and effective treatments on the basis of their health status. While Section 1557 provides the regulatory framework to protect consumers, consumer advocacy is still a key ingredient to truly make non-discriminatory benefit design a reality.

Amidst the noise of insurance companies deciding whether or not to sell on the Affordable Care Act’s (ACA) marketplaces and proposed rates “doom,” the Commonwealth Fund released a new report that paints a brighter picture of the ACA and its marketplaces. Using insurer’s filings for the 2016 plan year, the report compares ACA-compliant plans on and off the marketplaces to better understand how effectively the marketplaces promote value for consumers.

The good news: Enrollment in marketplace plans continues to increase, and the report suggests plans offered on the marketplace have lower overhead costs and a slower rate of premium increases as compared to those outside of the marketplace.

The less good news: Premium savings on the marketplaces are likely attributable to the rise in enrollment in plans with closed or very narrow networks.

Insurers selling marketplace plans spend 2.5 percent less on administrative costs.

The ACA requires insurers selling ACA-compliant plans to use a certain portion of premium payments for paying medical claims and advancing quality – known as the medical loss ratio (MLR). The remaining funds from premium payments may be allocated to profits and overhead costs (i.e. salaries, marketing and broker and agent commissions). One benefit of the MLR is quite tangible – insurance companies must issue rebate checks to consumers if they fail to comply with the rule. While it is not entirely clear why marketplace plan administrative costs are lower, the report suggests that the marketplace structure itself might be the key, perhaps due to increased competition and sales efficiency.

2016 premium increases were lower for marketplace plans, but at what cost?

Certainly news of keeping premiums at bay is notable. However, as the report indicates, a closer look at the data suggests that the ability of marketplace plans to keep premiums lower is linked to increased enrollment in narrow-network plans. While plans providing out-of-network care both on and off the marketplaces were more expensive and experienced a decrease in enrollment, only the marketplace plans experienced an enrollment spike in narrow or closed network plans (37 percent in 2016). At face value this might indicate that price-sensitive consumers are simply choosing a plan that is the most affordable. However, until state and federal regulators figure out how to systematically protect consumers from falling prey to inaccurate provider directories and surprise out-of-network bills, the tradeoff for lower premiums might prove more costly in the end.


As we near November, the ACA and its marketplaces will undoubtedly be under a microscope. Certain findings in this report should give ACA proponents a little relief – marketplace enrollment continues to grow, threats of adverse selection between the individual markets remain unrealized, and we’re continuing to make progress on realizing the ACA’s goals of increasing coverage and lowering costs.

The ACA is here to stay, and the forecasters of doom are wrong again. That doesn’t mean the law is perfect. It’s time to turn toward building the foundation to make coverage and care more affordable for more people.  

Despite political opposition to the Affordable Care Act at the highest levels of state government, Florida led the nation as the state with the most people gaining new health insurance through the Affordable Care Act. However, for Floridians with coverage, being insured has not completely provided assurance against exorbitant and unfair surprise medical bills. Stories in Florida newspapers and national media have highlighted the problem of “balance billing” for out-of-network services to people who thought they were covered. Fixing this problem for consumers became a focus of both opponents and advocates of the Affordable Care Act, resulting in Florida’s enactment of one of the strongest consumer protections against unfair out-of-network balance bills in the nation. The law exempts consumers from being held responsible for out-of-network rates in emergency and non-emergency situations if they’re denied opportunities to receive treatment by in-network providers.

As a statewide consumer health advocacy organization, Florida CHAIN is advocating to improve health insurance through state regulation and oversight of carriers. CHAIN has a seat, appointed by the Insurance Commissioner, on the Florida Health Insurance Advisory Board (FHIAB). For the past two years the CHAIN representative has recommended to the Board that the Insurance Commissioner propose and support legislation that protects consumers from out-of-network balance billing.

Despite the optics, the political will in Florida this year was strong to address high-health care prices. The Florida House and Governor remain unyielding in opposition to expanding Medicaid in conflict with the Florida Senate, which seeks to cover the expansion population with a waiver approach. This intra-legislature disagreement led to myriad health care-related bills in 2016 designed by the House in a charade that lowering costs, mostly through deregulation, would fix the health care access problem for more than three million uninsured Floridians. The bills to prevent out-of-network balance billing were a part of the pretense.

We took advantage of the unique political climate that positioned consumer advocates alongside our anti-ACA ‘surprise bedfellows’ in support of protections from unfair surprise medical bills. Using our proposal to the FHIAB, the Insurance Commissioner recommended legislation that prohibited balance billing and helped increase our visibility with other state agencies. When the Florida Insurance Consumer Advocate (ICA) convened a Balance Billing Forum, she invited CHAIN to present the consumer perspective along with industry speakers.

As a consumer advocacy organization, we stood firm on our goal to hold consumers harmless when they have no opportunity to choose an in-network provider. Our one-page brief for stakeholder groups and legislators highlighted that the consumer should not be party to any dispute resolution process. Despite a wide chasm in the design and definitions of a payment resolution process between providers and payers with no middle ground in sight, we successfully advocated for a “clean bill” that only addressed the consumer protections.

Our allies at Consumers Union worked to mobilize a groundswell of email and phone action from Florida constituents urging their legislators to “pass a bill – clean.” State media reported on the bills and the advocacy by highlighting consumer stories we referred to them as the bills made their way to the finish line.

Advocating through our seat on the state advisory board, working with close allies and key stakeholders, and taking advantage of the media’s interest in the issue helped move this legislation from a bill into a law that will protect 11.5 million Floridians with private insurance from the financial distress of unfair surprise medical bills.

Laura Brennaman PhD RN, Policy and Research Director at Florida CHAIN

Recently, UnitedHealth Group signaled they will be exiting Affordable Care Act (ACA) marketplaces in several states following losses they sustained because too many sick people are buying their plans and using their insurance.

UnitedHealth seems to have learned what many people at the bottom of the health care delivery system have known all along: Those who haven’t had insurance often need it the most. UnitedHealth is in good company, though, as many players selling plans in the marketplace seem to have underestimated the pent-up demand for medical services. Thus, they priced themselves a little too competitively, while also ending up with significantly sicker enrollees than they had anticipated. The attitude coming from UnitedHealth seems to be to cut their losses (insured people) and maybe come back in when the market’s more palatable and they have plans that stand to make them more revenue.

UnitedHealth seems to be a victim of the law’s success. It turns out that the people who had been locked out of access to affordable insurance prior to implementation of the ACA, perhaps due to a pre-existing medical condition, lack of steady income or working for an employer who doesn’t offer it, haven’t been getting the regular (now free, thanks to the ACA) preventive maintenance their bodies need. As a result, they need a little – or in some cases, a lot – more of a tune-up now that they can actually afford to purchase and use insurance. 

These sick Americans have posed a problem for a company like UnitedHealth, the nation’s largest health insurer, who cited losses in the markets of $720 million last year, or 0.46 percent of their annual revenue.

At this point, it feels like UnitedHealth is trying to signal three horn blasts from the Wall. Unfortunately, the threat they face is not an undead army threatening peace throughout the world, but actually a chronically ill, severely underserved population whose threat seems to mainly consist of making a very minor dent in United’s $157.1 billion in 2015 revenue

I can only imagine that insurers like United were salivating at the pool of 12.7 million new potential customers who purchased health insurance through marketplaces. After all, economic theory tends to hold that a bunch of new customers = $$$$$$. And while I’m not sure that’s exactly how it’s spelled out in “The Wealth of Nations,” it does hold that this great new economic market created by the ACA is taking its time in getting settled as insurers get accustomed to who marketplace consumers are, what they need and how companies can best provide it while still making significant amounts of money.

It has certainly not been smooth sailing, but it turns out the ACA isn’t going anywhere. The positive things it has done – covering people with pre-existing conditions, allowing young people to stay on their parents’ plans longer and capping out-of-pocket expenses – are too darn common-sensical and liked(!) for even critics of the law to propose abolishing.

And while debating topics like the Congressional undermining of “risk corridor adjustment” payments speaks to the wonk in all of us, it speaks to the practicality of none – especially the thousands of affected patients and their families impacted by UnitedHealth leaving the market who may, once again, be looking for good insurance. 

Martin Luther King, Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Thankfully, he was a little more optimistic in saying, “The arc of the moral universe is long, but it bends towards justice.” I hope that the arc of history is long enough for UnitedHealth to regret not offering insurance to hardworking families.

Efforts To Close The Coverage Gap Inch Forward With Brighter Days Likely Coming

Despite the health, economic and fiscal benefits of closing the coverage gap for people who fall between state Medicaid eligibility levels and eligibility for subsidized Exchange coverage, 2016 has been a tough year to get new states to take advantage of federal funding with efforts coming up short in Idaho, Nebraska and South Dakota (so far, though there is still hope for later in the year). But support for closing the gap remains strong with important votes taking place in New Hampshire and Arkansas to continue their expanded Medicaid programs and an important procedural milestone occurring in Louisiana, where the House has taken steps to approve the financing needed to make  the expansion recently approved by Governor Edwards successful.

The logic of refusing federal funds is purely political and the costs of refusal are becoming clearer all the time. Refusal to do the right thing is provoking anger among state residents as political leaders in Tennessee and Florida have discovered. With 2017 perhaps offering a more favorable political environment and continued strong support from key interest groups and the general public, look for renewed momentum in the months ahead.

Health Care Is Not Crowding Out The Other Stuff We Need

It seems like the recent news on the health care spending front is mostly good, with spending growth still running well below historic averages. But recent growth in health care employment has prompted the usual hand-wringing about crowd-out. Here are two reasons why that anxiety is misplaced. First, it ignores the universal tendency of richer countries to devote more of their total economy to health care – because they can. Think about it. Imagine you are an anthropologist and you visit some remote island where the entire economy is subsistence agriculture, with maybe one medicine woman doing a little part-time doctoring. Then, they get much more efficient at farming (perhaps because you violated the Prime Directive on your previous trip) that allows them to devote more effort to other things. When you come back you now find that 20 percent of the population is now engaged in providing medical care so you file an emergency report back home saying that the populace is in danger of starvation because health care is growing so fast it is crowding out agriculture...

Still not convinced? Then consider this: the U.S. is practically the lowest taxed country in the Organisation for Economic Co-operation and Development (OECD) with only Mexico and Chile and lower. Our struggle to finance human needs in this country is a result of political choices, not economic constraints. The "health care crowd out" argument is a political argument masquerading as an analytic one that is often unwittingly advanced by people who actually do not support the agenda of economic austerity. Don't fall for it. Not to say that we should waste money on inefficient or over-priced health care and speaking of which...

Another Week, Another Drug Pricing Outrage

Drug companies continue their price-gouging ways as yet another report shows that the industry routinely hikes the price of existing medications far faster and higher than any conceivable increase in production costs could justify. While a few outliers have drawn the most media attention, the problem is actually widespread and underscores the need for stronger action by government to keep medications available and affordable.

The ACA Has Done A Lot, But There Is A Lot More To Do

A new report from Gallup shows that, thanks to the ACA, the uninsurance rate in the U.S. has dropped to the lowest rate since they began tracking eight years ago. However, there is still a lot of room to make more coverage gains. A recent Robert Wood Johnson Foundation/Urban Institute report found that nearly half of the remaining uninsured are currently eligible for subsidized coverage in some form and an even greater number would be added if more states closed the coverage gap. But many people, especially in communities of color, are unaware that they or members of their family may be eligible for financial help. Fortunately, there is at least one easy way to spread the word. The IRS could notify families that qualify for the earned income tax credit and don't have employer sponsored coverage that they are likely eligible for financial assistance and direct them to enrollment assisters who could help them get coverage.


Actually, he has done no such thing. Opposition to the ACA may be Senator Cruz’s signature issue. His willingness to bring the federal government to a grinding halt in order to grandstand on the issue earned him a lot of notoriety. But when it comes to “replace,” the candidate remains vague at best. The reason probably has to do with the fact that an alternative along the broad lines that Senator Cruz has supported—inter-state sale of insurance, increased use of Health Savings Accounts—would cause millions of people to lose their coverage. It would also reintroduce discriminatory practices that have been outlawed by the ACA and impose large financial losses on families and on the health care industry, which has lately been one of the main engines of employment growth since the recession . That’s not a very attractive policy platform. Meanwhile, fellow candidate John Kasich offered implicit criticism of his opponent’s greatest claim to fame, calling efforts to repeal the ACA while President Obama was still in office “a big joke” and promises to do so “stupid.” (No fooling.)

Discriminators Gonna Discriminate

At the same time, the insurance industry has not turned over a new leaf and embraced the ACA’s rule prohibiting discrimination against sick people. In the past they have used practices such as placing all HIV medications on the most expensive cost-sharing tier to try to discourage sick people from enrolling. More recently, many insurers have adopted the practice of manipulating insurance broker commissions to discourage sales to people who might have higher medical claims. The takeaway is that while the ACA creates the opportunity to eliminate discriminatory industry practices, vigilance and aggressive enforcement continue to be necessary to make that promise a reality.

More On The Insurance Industry Front: How Much Did It Cost To Produce That Report?

This week the Blue Cross Association issued a report with the surprising finding that if you stop discriminating against sick people in the sale of insurance, then more sick people will get coverage. While ACA opponents will no doubt find fuel for fresh attacks in the report’s findings, most observers consider the results unremarkable. If anything, the surprise is that premiums have been lower than most forecasters originally projected.

Drug Prices

Another week, another example of drug companies preying on sick people by raising the price of an already existing medicine. While there can be no doubt that there is still a long slog ahead, the pressure to do something about drug companies’ abuse of their monopoly power is growing. Most recently, the American College of Physicians issued a call to rein in drug prices including endorsements of measures such as allowing reimportation, federal drug price negotiation and requiring manufacturers to be transparent about research, marketing and production costs.

And for some good news…

The New Hampshire Senate joined their colleagues in the House to retain full coverage of low-income adults in that state preserving coverage for 48,000 people. In Florida, legislators sent a bill to Governor Scott providing protections for consumers against surprise medical bills. Let’s hope Scott signs the bill (or allows it to become law) and that success in Florida motivates other states to act as well.

Over the past three years, advocates across the country have celebrated the plummeting number of uninsured people while working to identify and address the remaining challenges and barriers that health care consumers face. While early evidence found  most people who signed up for health insurance were able to find a doctor and get a timely appointment for primary care with relative ease, advocates noticed some concerning trends: provider networks were narrowing and provider directories, the main tool that consumers use to find out information about which doctors are in their plan, were error-ridden.

These trends were not limited to one state or region, and setting new model network adequacy standards and consumer protections became a priority at the National Association of Insurance Commissioners (NAIC), which issued its network adequacy model act this past fall.

At Georgians for a Healthy Future, concerns about network adequacy and provider directory problems came onto our radar during the first open enrollment period when consumers began contacting their enrollment assisters with network issues. Health care provider associations in Georgia also expressed concerns about network adequacy. Last year, a national report found that Georgia had the highest percentage of narrow networks, or networks with a very limited number of health care providers, of any state at 83 percent.

In 2015, the Georgia Senate created a study committee to explore issues around provider and consumer protections, including network adequacy. I was honored to be appointed to this committee to bring the consumer perspective to the process. Additionally, our Health Policy Analyst Meredith Gonsahn researched these issues in detail and delivered testimony and policy recommendations during the study committee process. The committee’s final report referenced concerns about provider directory inaccuracies and recommended a careful review of the NAIC model act. While the Legislature did not have the appetite to take on network adequacy in all of its complexities this year, we knew these important consumer issues had the attention of policymakers.

We did not want to lose this momentum. So as consumer advocates we thought carefully about the steps that health care consumers take when they review their options, select a health plan, and seek to access a medical provider through that plan. We kept coming back to provider directories as the first step. Consumers can easily obtain information about premiums, deductibles, and benefits when shopping for insurance. However, finding information about provider network size and composition is more challenging, and provider directories are the primary tool available for that information. Unfortunately, a secret shopper survey we conducted found three-quarters of directory listings contained at least one error and one in five providers listed in the directory weren’t even in the network. 

Model language about improving provider directory accuracy and usability was included in the NAIC act, and our friends at Families USA put a spotlight on promising practices from a range of states to help clean up provider directories and make them useful tools for consumers. In the fall of 2015 we began to draft legislation here in Georgia that included accuracy provisions such as requiring provider directory audits, usability provisions such as requiring directories to be searchable, and a protocol for protecting consumers when they rely on inaccurate information contained within a directory.

When the 2016 legislative session began in January, we identified a bill sponsor who championed this legislation and brought all stakeholders to the table to ensure it was something that could garner the necessary support. To inform this process and engage other community partners and advocates, advocates held a policy forum in February to release recommendations on network adequacy and provider directories and discuss the legislation. As the bill moved through the General Assembly, state regulators lent support to the legislation and it received attention in the local media.

Moving this bill across the finish line involved negotiation among multiple parties and support from our partners in the advocacy community. We were also fortunate to have a dedicated legislative champion and continued engagement from the DOI. Still, there are elements of the bill that may need to be clarified when rules are promulgated this summer or even in next year’s legislative session. Nevertheless, a strong piece of consumer protection legislation sparked by consumer health advocates passed both the state House and Senate overwhelmingly and now heads to the governor for his signature.

Cindy Zeldin Executive Director, Georgians for a Healthy Future

It was a beautiful spring day to be in a conference room, but inside, people’s energy did not wane.

I felt like I was in a room of scientists – listening to presentations, brainstorming ideas, evaluating new approaches – all with the goal of improving their results. 

These “scientists” were not looking to cure cancer – but what they were doing could be just as important to someone’s health. They were enrollment assisters, discovering the best ways to get the people of Missouri health insurance coverage. They came from all over the state, brought together by Dara Taylor, Carrie Rogers and Wells Wilkinson, the Community Catalyst staff who help create and support a community of enrollment assisters as part of the Expanding Coverage Initiative of the Missouri Foundation for Health.

As specialists, enrollment assisters take on the hardest cases:  people who speak English as a second language, individuals with disabilities, or those who live in remote communities without internet access. They take the complex rules of the ACA and make them understandable to regular people.   

Fully engaged, the assisters were passionate about their work because they understand it makes a difference in people’s lives. Patty Hendren, an enrollment assister from Randolph County Caring Community Partnership, told a story of how she helped a farmer get health insurance just a day before his house burned down, leaving his daughter with severe burns. The next day he had a heart attack and was rushed to the hospital. But because this family had health insurance, they could get the care they needed and did not need to worry about the medical bills.

For me, this meeting was a flashback. I have worked in health advocacy for 30 years. What I remember most are the stories of helping people. Over 20 years ago, Florence Allen called to ask for my help. Her son was the innocent bystander of a gang shooting. He was brought to a major teaching hospital in Boston with a stomach wound and had surgery that required a colostomy. He was discharged after three weeks with instructions to return in a month to have his colostomy closed. When he returned, he was told he owed $3,000, which he could not afford. Uninsured, he went a year with a colostomy he did not need despite the fact he could have been enrolled in a program that would have covered the hospital bill. The colostomy bag was removed three days after he got assistance through Massachusetts’ free care pool, which, while helpful, offered a short-term fix rather than insurance coverage.

Over the last 20 years, we have made a lot of progress in providing health coverage to people. The ACA has helped 20 million people gain insurance. But it’s not a perfect law. For some, it is not easy to sign up, choose a health plan and stay insured. There are loopholes, complex rules, and physical and emotional barriers that need to be addressed. This is why enrollment assisters play such a critical role. Given that the ACA is a federal law, you would think the government would support enrollment assistance to help guide consumers through these challenges. Unfortunately, that is not the case.  Federal financial support for enrollment assistance is built into the Affordable Care Act. However, the amount distributed over time is variable. It will not be enough to sustain the growing capacity needed not only to help consumers gain health insurance coverage, but also to learn how to use their coverage.

In Missouri, the Missouri Foundation for Health has stepped up to the plate by investing in outreach, education and enrollment through support of the Cover Missouri Coalition and on-the-ground enrollment assistance. The foundation understands the vital role assisters play.

It is ironic that while we spend billions of dollars supporting cancer research and the training of medical professionals, this other vital function that saves lives by connecting people to health coverage is severely underfunded.



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