With Oba­macare’s fate in the bal­ance, there’s some good en­roll­ment news

Modern Healthcare - - NEWS - By Shelby Liv­ingston

En­roll­ment on the Af­ford­able Care Act’s fed­eral mar­ket­places dropped al­most ev­ery­where this year, amid the Repub­li­can push for the health­care law’s re­peal and the wide­spread sen­ti­ment that the in­sur­ance ex­changes were go­ing un­der. But Utah was a bea­con of hope for Oba­macare sup­port­ers.

The po­lit­i­cally con­ser­va­tive state added 21,000 mem­bers dur­ing the 2017 open en­roll­ment pe­riod that ended Jan. 31, the most of any state us­ing the fed­er­ally op­er­ated mar­ket­place, Health­Care.gov. Utah’s to­tal en­roll­ment reached more than 197,000, a 12.3% in­crease over last year. Only one of Utah’s 29 coun­ties saw an en­roll­ment drop.

The Utah Health Pol­icy Pro­ject, which helps peo­ple sign up for cov­er­age, said much of the growth is con­cen­trated in the fast-grow­ing, fam­i­ly­fo­cused sub­urbs of south­ern Salt Lake County and Utah County. These com­mu­ni­ties have a high pop­u­la­tion of mem­bers of the Church of Je­sus Christ of Lat­ter-day Saints. It’s not un­com­mon for some fam­i­lies to have seven or eight kids, said Ja­son Steven­son, the non­par­ti­san or­ga­ni­za­tion’s ed­u­ca­tion and com­mu­ni­ca­tions di­rec­tor and ACA pol­icy leader.

And thanks to the struc­ture of the ACA’s sub­si­dies, which are based on both in­come and fam­ily size, many of these mod­er­ate-in­come fam­i­lies re­ceived fi­nan­cial help to pur­chase in­sur­ance. Un­der the ACA, a fam­ily of eight with a six-fig­ure house­hold

in­come can qualify for fi­nan­cial as­sis­tance on the ex­changes, Steven­son said. Chil­dren un­der the age of 18 ac­count for 25% of Utah’s ex­change en­roll­ment—the high­est rate in the na­tion.

These fam­i­lies count on health in­sur­ance and build it into their bud­gets. “Utahns love a good deal,” Steven­son said. “If you have a fam­ily of five or six kids, you are cut­ting coupons. The ACA is the best coupon you can find.”

In the face of ACA re­peal,

ex­change en­roll­ment in many states de­clined as ex­pected. To­tal en­roll­ment in the fed­eral and state-based ex­changes dropped by 500,000 peo­ple to 12.2 mil­lion in 2017. On the sur­face, those num­bers seem to tell a story of the mar­ket­places’ demise.

But that’s not ac­tu­ally the case. In some states, such as Utah, the ex­changes are work­ing just fine and en­roll­ment has jumped to their high­est lev­els yet. Many states held steady, give or take a few per­cent­age points. And in the state where en­roll­ment fell steep­est, it’s likely peo­ple switched to Med­i­caid and re­ceived cheaper cov­er­age, health in­sur­ance ex­perts say.

“There’s a much big­ger con­cern if there’s a pre­cip­i­tous de­cline (in en­roll­ment), which could be the sign of things spi­ral­ing out of con­trol. And that’s not the case in the vast ma­jor­ity of the coun­try,” said Larry Levitt, se­nior vice pres­i­dent of the Kaiser Fam­ily Foun­da­tion.

An­other bright spot on the map, ru­ral South Dakota, grew en­roll­ment by al­most 14% over last year to just over 29,600 peo­ple. The state has seen steady growth in the past three years.

The Com­mu­nity Health­Care As­so­ci­a­tion of the Dako­tas, which runs the state’s Get Cov­ered South Dakota web­site, said out­reach and mes­sag­ing were huge fac­tors. Face­book ads, brochures and pre­sen­ta­tions at com­mu­nity hos­pi­tals and health cen­ters helped boost en­roll­ment.

“There’s been a real ded­i­cated ef­fort,” said the as­so­ci­a­tion’s CEO, Shelly Ten Napel. It also helps that 88% of the state’s ex­change mem­bers re­ceive premium sub­si­dies to help off­set any in­creases in plan rates. Av­er­age bench­mark pre­mi­ums be­fore fi­nan­cial as­sis­tance were fac­tored in in­creased by 39% this year in South Dakota, ac­cord­ing to HHS data.

Mean­while, in Louisiana, en­roll­ment plum­meted by 33% over 2016. That’s the largest de­cline in en­roll­ment by per­cent­age of any Health­Care.gov state. But it’s likely be­cause ACA plan mem­bers switched to Med­i­caid for cheaper in­sur­ance when the state ex­panded the pro­gram last year.

The ACA al­lows states to ex­tend Med­i­caid to adults with in­comes up to 138% of the fed­eral poverty level. Louisiana’s Demo­cratic gov­er­nor, John Bel Ed­wards, last year took the Obama ad­min­is­tra­tion up on that of­fer. Louisiana— his­tor­i­cally one of the poor­est and most unin­sured states in the na­tion— be­came the first state in the Deep South to ex­pand Med­i­caid.

Mar­ket­place en­roll­ment dropped by more than 70,500 mem­bers, while the state’s Health De­part­ment said Med­i­caid en­rolled 400,635 new mem­bers.

“Utahns love a good deal, and if you have a fam­ily of five or six kids you are cut­ting coupons. The ACA is the best coupon you can find.”

JA­SON STEVEN­SON The Utah Health Pol­icy Pro­ject’s com­mu­ni­ca­tions di­rec­tor and ACA pol­icy leader

“That’s not a sig­nal that the mar­kets are desta­bi­liz­ing,” Levitt said. “There’s a big shift from the mar­ket­places to Med­i­caid. It’s sim­ply put­ting Louisiana on the track of the other states that have al­ready ex­panded Med­i­caid.”

The same trend oc­curred in 2015 when In­di­ana and Penn­syl­va­nia ex­panded their Med­i­caid pro­grams and sub­se­quently ex­pe­ri­enced de­clines in ACA en­roll­ment.

It’s not a bad deal. Stud­ies have shown that states that ex­panded Med­i­caid to low-in­come peo­ple had lower mar­ket­place pre­mi­ums. Lower-in­come in­di­vid­u­als are typ­i­cally less healthy than those with high in­comes. By mov­ing them to Med­i­caid, the fed­eral ex­change is “a smaller mar­ket but prob­a­bly a health­ier one,” Levitt said.

Among all the states us­ing the fed­er­ally op­er­ated Health­Care.gov plat­form, 9.2 mil­lion peo­ple en­rolled, com­pared with 9.6 mil­lion the year be­fore. About 3 mil­lion peo­ple en­rolled in states that op­er­ate their own mar­ket­places, down from 3.1 mil­lion. En­roll­ment dropped in most coun­ties. Last year, en­roll­ment in­creased nearly ev­ery­where.

It’s not hard to see why fewer peo­ple signed up in 2017. On the cam­paign trail, Pres­i­dent Don­ald Trump promised vot­ers he would re­peal for­mer Pres­i­dent Barack Obama’s sig­na­ture health­care law. Un­sure of whether the ex­changes or the in­di­vid­ual man­date re­quir­ing peo­ple to buy cov­er­age would be around much longer, many would-be health­care shop­pers sat out this open en­roll­ment, ob­servers say.

The Obama ad­min­is­tra­tion pushed hard for peo­ple to sign up for cov­er­age. Then Trump took his foot off the gas. His ad­min­is­tra­tion pulled ad­ver­tise­ments and out­reach emails meant to en­cour­age peo­ple to en­roll on Health­Care.gov dur­ing the fi­nal week of open en­roll­ment, when large num­bers of peo­ple typ­i­cally choose plans. One re­cent Health Af­fairs study showed that re­peated tele­vi­sion ad­ver­tise­ments are linked to in­creases in health in­sur­ance en­roll­ment.

At the same time, con­sumers may have de­cided not to en­roll be­cause of premium sticker shock or be­cause their health in­surer stopped sell­ing plans. Many health in­sur­ers, in­clud­ing Unit­edHealth Group, Hu­mana and Aetna, have scaled back their par­tic­i­pa­tion or ex­ited the in­sur­ance ex­changes, cit­ing fi­nan­cial losses. Some in­sur­ers, how­ever, have man­aged to turn a profit.

Con­sid­er­ing the many ob­sta­cles con­sumers faced, it’s “re­mark­able” that some states man­aged to en­roll more peo­ple this year even with the “in­cred­i­bly neg­a­tive rhetoric” and the fact that open en­roll­ment took place right af­ter the pres­i­den­tial elec­tion, said Sab­rina Cor­lette, a health in­sur­ance ex­pert at Ge­orge­town Univer­sity.

It’s a safe bet that en­roll­ment in the ex­changes will de­cline even more next year if the House Repub­li­cans’ bill to re­peal the ACA passes. The Amer­i­can Health Care Act would get rid of the in­di­vid­ual man­date and tweak the premium tax cred­its so they are based on age, rather than in­come. The tax cred­its will be less gen­er­ous for many older, low-in­come Amer­i­cans. The bill would also slash Med­i­caid fund­ing and phase out the en­hanced fed­eral fund­ing for the Med­i­caid ex­pan­sion.

The Con­gres­sional Bud­get Of­fice es­ti­mates that 24 mil­lion peo­ple will lose in­sur­ance over the next decade if the leg­is­la­tion is en­acted.

The Utah Health Pol­icy Pro­ject ex­pects that re­peal­ing the ACA will cause many Utahns to drop their in­sur­ance. The bill would al­low in­sur­ers to charge a 30% premium penalty for one year for in­di­vid­u­als who have let their cov­er­age lapse.

So Steven­son said his or­ga­ni­za­tion is now ad­vis­ing peo­ple to main­tain cov­er­age be­cause the con­se­quences are much higher. “Get things done now while you can, be­cause we don’t know what’s go­ing to hap­pen,” he ex­plained.

He’s also con­cerned that the Utah Health Pol­icy Pro­ject won’t have time to fo­cus on im­prov­ing health­care qual­ity and bend­ing the cost curve. “If this bill does be­come law, we are go­ing to have to try to pro­tect peo­ple from los­ing their cov­er­age.”

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