Trump ad­min­is­tra­tion cre­ates tough slog for po­ten­tial ACA en­rollees

Modern Healthcare - - News - By Shelby Liv­ingston

Con­sumers in­ter­ested in buy­ing in­sur­ance cov­er­age on the Af­ford­able Care Act ex­changes are con­fused, un­pre­pared and mis­in­formed.

That’s ac­cord­ing to des­ig­nated nav­i­ga­tors who help peo­ple sign up for cov­er­age on the ACA’s in­sur­ance mar­ket­place. They have their work cut out for them this year.

Many con­sumers don’t know that open enrollment kicks off Nov. 1. Some aren’t even aware the ex­changes ex­ist any longer, hav­ing been in­un­dated with mes­sages from law­mak­ers that the mar­ket­place is im­plod­ing.

“Are they still go­ing to be able to af­ford to use their care? Is the tax credit go­ing to help them, be­cause they’re hear­ing things about a dou­ble-digit in­crease to pre­mi­ums?” said Shelli Quenga, di­rec­tor of pro­grams for the Pal­metto Pro­ject, South Carolina’s lead nav­i­ga­tor group, re­gard­ing the type of ques­tions nav­i­ga­tors are re­ceiv­ing. “There’s a lot more con­fu­sion.”

That un­cer­tainty, cou­pled with a se­ries of ac­tions the Trump ad­min­is­tra­tion has taken in the months lead­ing up to open enrollment, means the fifth open-enrollment pe­riod is shap­ing up to be the most chal­leng­ing since the ACA was im­ple­mented.

That’s been the ex­pe­ri­ence at nav­i­ga­tor group Florida Cov­er­ing Kids & Fam­i­lies at the Uni­ver­sity of South Florida. “Last year, con­sumers were com­ing in more in­formed and more pre­pared to do what they need to get cov­er­age,” said Jodi Ray, di­rec­tor of the pro­gram. “Now it’s like it’s been a huge set­back.”

The com­bi­na­tion of con­fused con­sumers, higher pre­mi­ums and a fed­eral ad­min­is­tra­tion that would like to see Oba­macare dead leads many ex­perts to be­lieve enrollment will fal­ter, cre­at­ing fi­nan­cial headaches for hos­pi­tals and in­sur­ers. In­sur­ers alone will have to eat $1 bil­lion in costs this year be­cause the Trump ad­min­is­tra­tion scrapped cost-shar­ing re­duc­tion sub­si­dies.

“I don’t think any­body thinks enrollment is go­ing to go up this year,” said Kather­ine Hemp­stead, who di­rects the Robert Wood John­son Foun­da­tion’s work on health cov­er­age. Still, she said, there’s a “core of this mar­ket that re­ally, re­ally, re­ally needs health in­sur­ance and doesn’t have an­other place to get it, so I think there’s a floor on how much it could drop.”

For its part, the fed­eral govern­ment hasn’t set an enrollment goal as the pre­vi­ous ad­min­is­tra­tion did. “Our tar­get this year is to have a seam­less open enrollment for con­sumers. The numbers we think will take care of them­selves,” CMS Deputy Ad­min­is­tra­tor Randy Pate said in a state­ment emailed by a spokesper­son. In 2017, 10.3 mil­lion peo­ple got cov­er­age through the ex­changes.

If fewer peo­ple sign up for cov­er­age and they be­come unin­sured, that spells trou­ble for hos­pi­tal fi­nances. Un­com­pen­sated care at hos­pi­tals fell to $35.7 bil­lion in 2015, its low­est point since 2007, thanks to fewer unin­sured pa­tients. “If you now have a sit­u­a­tion where enrollment is go­ing to go down, while I don’t think it’ll nec­es­sar­ily be felt im­me­di­ately by hos­pi­tals ... if more folks be­come unin­sured, it will soon there­after have an im­pact,” said Dan Grau­man, CEO of con­sul­tancy Ver­alon.

This year’s enrollment pe­riod was dras­ti­cally short­ened from three months to 45 days, though some state­based mar­ket­places have ex­tended their dead­lines.

Those with cov­er­age this year through Health­Care.gov will be auto-en­rolled into a plan un­less they choose an­other, and, un­like in pre-

vi­ous years, they won’t have time to switch if they don’t like what’s se­lected for them, nav­i­ga­tors said. That’s be­cause auto-enrollment hap­pens at the end of the enrollment pe­riod, Dec. 15.

That makes it more im­por­tant for con­sumers to ac­tively en­roll, but fund­ing for mar­ket­ing and out­reach was slashed to $10 mil­lion from the $100 mil­lion al­lo­cated pre­vi­ously, so in­for­ma­tion is sparse.

Nav­i­ga­tor grants also were sharply re­duced, lead­ing some groups, like the Pal­metto Pro­ject, to can­cel out­reach events. More­over, the Trump ad­min­is­tra­tion will take Health­Care.gov off­line for main­te­nance for what may be 12 hours nearly ev­ery Sun­day dur­ing open enrollment. The ad­min­is­tra­tion said the amount of down­time is in line with pre­vi­ous open-enrollment pe­ri­ods.

“We’ve al­ways had con­fi­dence that the con­sumers best in­ter­est drove the sys­tem and we don’t have that con­fi­dence this year,” Quenga said.

ACA cov­er­age out­look

Health in­sur­ance pre­mi­ums are set to rise in most states. An anal­y­sis of states us­ing the fed­er­ally op­er­ated mar­ket­place by con­sult­ing firm Avalere found that the av­er­age sil­ver plan pre­mium will go up 34% in 2018 to about $743 each month. Bronze plans will rise 18% and gold plans will in­crease by 24%.

In Iowa, where just one in­surer, Med­ica, is sell­ing plans, the av­er­age sil­ver plan pre­mium will rise 69% to $1,001 a month in 2018. On the other end of the spec­trum is Alaska, where sil­ver pre­mi­ums will fall by 22% to $996. Alaska also has a sole ex­change in­surer, Pre­mera Blue Cross and Blue Shield. Its rates will drop be­cause of the state’s rein­sur­ance pro­gram cre­ated un­der a 1332 waiver.

Most in­sur­ers raised their rates in part to make up for the po­ten­tial loss of fund­ing for cost-shar­ing re­duc­tion sub­si­dies. The Trump ad­min­is­tra­tion de­cided to scrap the CSR pay­ments, and a state-led le­gal ef­fort to force the ad­min­is­tra­tion to con­tinue them failed.

In­sur­ers in many states loaded pre­mium in­creases at­trib­ut­able to the loss of CSR pay­ments onto sil­ver plans only. The se­cond-low­est-cost sil­ver plan in each area is known as the bench­mark plan, and it helps de­ter­mine the amount of a per­son’s pre­mium tax credit, which is an­other form of fi­nan­cial as­sis­tance avail­able for con­sumers with in­comes up to 400% of the fed­eral poverty level. So if the sil­ver plan pre­mium in­creases, so does the tax credit a per­son re­ceives.

Be­cause 84% of con­sumers on the ex­changes re­ceive pre­mium tax cred­its, they will be pro­tected from those pre­mium hikes. For some, switch­ing to a bronze or gold plan will save them money. But ex­change cus­tomers that get no fi­nan­cial as­sis­tance, or those in states that spread the “CSR sur­charge” across all types of plans, may bear the brunt of the sharp in­creases.

$1 bil­lion hit

In­sur­ers will also lose money. They are still re­quired to re­duce out-of­pocket ex­penses for cus­tomers who qual­ify for sub­si­dies, even if the fed­eral govern­ment doesn’t pay them back. An­a­lysts say in­sur­ers’ 2017 fourth-quar­ter earn­ings will likely take a hit. The Na­tional As­so­ci­a­tion of In­sur­ance Com­mis­sion­ers said end­ing the CSRs will cost in­sur­ers $1 bil­lion this year alone.

“There’s noth­ing that in­sur­ers can do at this point to com­pen­sate for the fact that CSRs will not be paid out for the re­main­der of the year,” Avalere Se­nior Vice Pres­i­dent El­iz­a­beth Car­pen­ter said.

Some plans are in­creas­ing out­reach to boost enrollment. Health Care Ser­vice Corp., a Blues af­fil­i­ate, rolled out TV and ra­dio ads to let mem­bers know of the short­ened enrollment pe­riod.

Still, large swaths of the coun­try are dom­i­nated by a sin­gle health plan, and a lit­tle more than half of the peo­ple in 39 Health­Care.gov states are pro­jected to have just one in­sur­ance op­tion.

Health in­sur­ers have re­treated from the ex­changes in droves. En­tries paled in com­par­i­son to the num­ber of ex­its the mar­ket­place has ex­pe­ri­enced. There are 1,500 county-level mar­ket­place ex­its for the 2018 plan year, and just 200 en­tries, ac­cord­ing to the Robert Wood John­son Foun­da­tion.

Na­tion­ally, for-profit in­sur­ers have largely fled the mar­ket­places. Unit­edHealth Group was the first, with Aetna and Hu­mana fol­low­ing suit. An­them slowly ex­tri­cated it­self from ex­changes in many of the 14 states where it sold plans in 2017, and now ex­pects to re­duce its ex­change mem­ber­ship by 70% next year. This year, An­them served 900,000 ex­change mem­bers.

Med­i­caid man­aged-care in­surer Cen­tene Corp. is the newly crowned king of the mar­ket­place, with more than 1 mil­lion ex­change mem­bers. Cen­tene CEO Michael Nei­dorff has long said that it’s “busi­ness as usual” for the in­surer. Ad­di­tion­ally, Cigna Corp. in 2018 will of­fer ACA plans in six states. Molina Health­care will exit ex­changes in Utah and Wis­con­sin and keep sell­ing plans in seven other states.

With the ex­o­dus of na­tional in­sur­ers, not-for-profit com­mu­nity health plans—many of them Blue Cross and Blue Shield-af­fil­i­ated plans—and provider-spon­sored re­gional plans are hold­ing court over the mar­ket­place. Most of those in­sur­ers see it as their mis­sion to of­fer cov­er­age to the low-in­come, and they have re­mained com­mit­ted to the ex­changes.

Some na­tional in­sur­ers, in­clud­ing Blues-af­fil­i­ated An­them, have in­di­cated that they’d be will­ing to re-en­ter the mar­ket in cer­tain ar­eas in 2019 if it starts to sta­bi­lize.

Dur­ing open enrollment for 2017 plans, a nav­i­ga­tor helps a cus­tomer en­roll in health cov­er­age through the ACA in­di­vid­ual in­sur­ance ex­change at the Uni­ver­sity of South Florida’s Mar­shall Stu­dent Cen­ter.

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