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Funding For ACA Sign-Up Campaigns Varies Widely From State To State

Kaiser Health News:HealthReform - November 01, 2017

If you buy insurance on your own and have been paying attention to the Affordable Care Act, you’ve probably heard that open enrollment for 2018 plans has just started and the government is spending a lot less money this year to get the word out.

That’s true in the 39 states that rely on healthcare.gov. But circumstances are different in some of the 11 states plus the District of Columbia that run their own ACA websites and marketplaces.

They’re in charge of their own marketing and enrollment assistance programs, so are somewhat immune from Trump administration actions — and inaction — that critics have warned will undermine 2018 individual market enrollment.

“We’re in a very different position than the federal government,” said Allison O’Toole, who runs Minnesota’s exchange, MNsure. “I see a lot of action coming out of Washington designed to destabilize the market and to hinder enrollment. I have the exact opposite goal in Minnesota.”

This story is part of a partnership that includes Minnesota Public Radio, NPR and Kaiser Health News. It can be republished for free. (details)

In its first year of managing the sign-ups, the Trump administration slashed the marketing budget most states rely on for the federally run insurance exchange by 90 percent. The open enrollment period is shorter and healthcare.gov, the federal website, will curb its hours on all Sundays during the sign-up period, except the last one.

A recent analysis by the chief marketing officer of healthcare.gov under President Barack Obama estimated that the marketing cuts alone may reduce next year’s enrollment by at least 1.1 million people.

In contrast, MNsure is planning another all-out annual enrollment push with ads on TV and social media. It will also pay other organizations to help spread the word; for example, MNSure gave $500,000 to Portico Healthnet, a nonprofit healthcare navigator group, for outreach.

The money helps a lot.

“Portico Healthnet was able to staff up — so we have more navigators on staff now to prepare ourselves to meet the needs of the open-enrollment demand,” said Meghan Kimmel, president of the organization, which is based in St. Paul. “We are anywhere we can be where we can talk with people about access to coverage.”

The picture is very different in states like Mississippi, which relies on healthcare.gov, the federal exchange. Open enrollment in these states is shaping up to be much different under President Donald Trump than it was under President Obama.

“We’re still enrolling,” said Ginni Tran, who works as an ACA navigator at Mercy Housing & Human Development in Gulfport, Miss., “but we’re not aggressively outreaching and educating” because there isn’t enough money. Her office helps Gulf Coast seafood industry workers find health plans on healthcare.gov. Cuts to federal enrollment assistance translated to a 70 percent smaller budget for Mercy’s open enrollment activities.

Mississippi’s uninsured rate has fallen to 12 percent but remains tied for third-worst in the United States. Republican Gov. Phil Bryant has staunchly opposed the Affordable Care Act and did not expand Medicaid.

Kimmel and others said what’s happening in states using healthcare.gov underscores the value of Minnesota having its own exchange.

At least one longtime MNsure critic, however, remains unconvinced. State Rep. Greg Davids, a Republican, dismissed the notion that cutting back on the open-enrollment period and slashing the promotional budget will discourage enrollment. He said he favors having the state turn to healthcare.gov, instead.

“We need to get rid of MNsure,” Davids said. “They’re an unnecessary duplicate layer of government that hasn’t worked.”

This story is part of a partnership that includes Minnesota Public Radio, NPR and Kaiser Health News.

Rising Health Insurance Costs Frighten Some Early Retirees

Kaiser Health News:HealthReform - November 01, 2017

Don and Debra Clark of Springfield, Mo., are glad they have health insurance. Don is 56 and Debra is 58. The Clarks say they know the risk of an unexpected illness or medical event is rising as they age and they must have coverage.

Don is retired and Debra works part time a couple of days a week. As a result, along with about 20 million other Americans, they buy health insurance in the individual market — the one significantly altered by the Affordable Care Act (ACA).

But the Clarks are not happy at all with what they pay for their coverage — $1,400 a month for a plan with a $4,500 deductible. Nor are they looking forward to the ACA’s fifth open enrollment period, which runs from Wednesday through Dec. 15 in most states. Many insurers are raising premiums by double digits, in part because of the Trump administration’s decision to stop payments to insurers to cover the discounts they are required to give to some low-income customers to cover out-of-pocket costs.

This story also ran in USA Today. It can be republished for free (details).

“This has become a nightmare,” said Don Clark. “We are now spending about 30 percent of our income on health insurance and health care. We did not plan for that.”

Karen Steininger, 62, of Altoona, Iowa, said her ACA coverage not only gave her peace of mind but also helped her and her husband, who is now on Medicare, stay in business the past few years. But they too are concerned about rising costs and the effect of the president’s actions.

The Steiningers are self-employed owners of a pottery studio. Their income varies year to year. They now pay $245 a month for Karen’s subsidized coverage, which, like the Clarks’, has a $4,500 deductible. Without the government subsidy, the premium would be about $700 a month.

“What if we make more money and get less of a subsidy or just if the premiums increase a lot?” Karen Steininger asked. “That would be a burden. We’ll have to cut back on something or switch to cheaper coverage.”

The experiences of the Clarks and the Steiningers point to an emerging shortfall in the ACA’s promise of easier access to affordable health insurance for early retirees and the self-employed. Rising premiums and deductibles, recent actions by the Trump administration, and unceasing political fights over the law threaten those benefits for millions of older Americans.

“These folks are rightly the most worried and confused right now,” said Kevin Lucia, a health insurance specialist and research professor at Georgetown University’s Health Policy Institute in Washington, D.C. “Decisions about which health plan is best for them is more complicated for 2018, and many people feel more uncertain about the future of the law itself.”

At highest risk are couples like the Clarks who get no government subsidy (which comes in the form of an advanced tax credit) when they buy insurance. That subsidy is available to people earning up to 400 percent of the federal poverty level, or just under $65,000 for a couple. Their income is just above the amount that would have qualified them for a subsidy in 2017.

Premiums vary widely by state. Generally, a couple in their late 50s or early 60s with an annual income of $65,000 would pay from $1,200 to $3,000 a month for health insurance.

Premiums rose an average 22 percent nationwide in 2017 and are forecast to rise between 20 and 30 percent overall for 2018.

In an analysis released this week based on insurers’ rate submissions for 2018, the Kaiser Family Foundation found that individuals and families that don’t qualify for a subsidy but are choosing plans on the federal marketplace face premiums 17 to 35 percent higher next year, depending on the type of plan they choose. (Kaiser Health News is an editorially independent program of the foundation.)

A similar increase would be expected for people who also buy on the marketplaces run by some states or buy directly from a broker or insurance company.

The substantial premium increases two years in a row could lead fewer people to buy coverage.

“I’m really worried about this,” said Peter Lee, CEO of Covered California, the exchange entity in that state. “We could see a lot fewer people who don’t get subsidies enroll.” He said that California has taken steps to mitigate the impact for people who don’t get subsidies but that “consumers are very confused about what is happening and could just opt not to buy.”

There are already signs of that, according to an analysis for this article by the Commonwealth Fund. The percentage of 50- to 64-year-olds who were uninsured ticked up from 8 percent in 2015 to 10 percent in the first half of 2017. In 2013, the figure was 14 percent.

Indeed, the ACA has been a boon to people in this age group whether they get a subsidy or not. It barred insurers from excluding people with preexisting conditions — which occur more commonly in older people. And the law restricted insurers from charging 55- to 64-year-olds more than three times that of younger people, instead of five times more, as was common.

The law also provided much better access to health insurance for early retirees and the self-employed — reducing so-called “job lock” and offering coverage amid a precipitous decline in employer-sponsored retiree coverage that began in the late 1990s.

Only 1 in 4 companies with 200 or more workers offered any kind of coverage to early (pre-65) retirees in 2017 compared with 66 percent of firms in 1988, reported the Kaiser Family Foundation. And the vast majority of small firms never did offer such coverage.

Overall, before the ACA became law, 1 in 4 55- to 64-year-olds buying coverage on their own either couldn’t get it at all because of a preexisting condition or couldn’t afford it, according to AARP.

“The aging but pre-Medicare population was our major reason to support the ACA then and it still is now,” said David Certner, director of legislative policy at AARP. “This group benefited enormously from the law, and we think society and the economy benefited, too.”

Just how many 55- to 64-years-olds have been liberated from job lock by the ACA has yet to be fully assessed. But recent data show that 18 percent of people ages 55 to 64 who were still working in 2015 got coverage through the ACA marketplaces, up from 11.6 percent in 2013, according to an analysis for this article by the Employee Benefit Research Institute.

Also, a report released in January 2017 by the outgoing Obama administration found that 1 in 5 ACA marketplace enrollees of any age was a small-business owner or self-employed person.

A bipartisan effort is underway in Congress to provide dedicated funds to woo enrollees to healthcare.gov and help state agencies explain changes in the law for 2018 triggered by the Trump administration. But the fate of the proposed legislation is uncertain.

The Clarks said they’ll look carefully at options to keep their premiums affordable in 2018.

Said Don Clark, “If we get to a point where we have a $10,000 deductible and pay 40 percent or more of our income for health insurance, I’m not sure what we’ll do. We can’t afford that.”

Timeline: Roadblocks To Affordable Care Act Enrollment

Kaiser Health News:HealthReform - November 01, 2017

President Donald Trump’s decision last month to cut off payments to insurers for discounts they provide to some low-income people who buy individual health coverage was big news. But it was far from the first time the president and his administration have sought to deter enrollment on the insurance marketplaces set up by the Affordable Care Act.

Enrollment for 2018 plans begins Nov. 1 and runs through Dec. 15. Over the course of the year, the administration has announced a variety of changes that affect sign-ups:

Jan. 20, 2017:

(Chip Somodevilla/Getty Images)

On his first day in office, Trump issues an executive order to “minimize the unwarranted economic and regulatory burdens” of the health law. It includes instructions to agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden.”

The same day, officials at the Department of Health and Human Services begin removing information on how to sign up for coverage from the healthcare.gov website, even though enrollment for 2017 policies lasts until the end of the month.

Jan. 26, 2017: Use Our ContentThis KHN story can be republished for free (details).

HHS officials abruptly pull funding for outreach and advertising for the last days of 2017 enrollment. That is usually when healthier people traditionally enroll. Some of the advertising and outreach continues, but that’s largely because it is too late to cancel advertising purchased and scheduled by outgoing Obama administration officials.

One former Obama-era official later estimates nearly a half a million fewer people enrolled as a result of the cuts to outreach and advertising.

Feb. 15, 2017:

The Trump administration proposes new rules, backed by the insurance industry, cutting the 2018 open enrollment period in half and making it more difficult for people to buy insurance outside that six-week window. Insurers say the rules would reduce the number of people who “game the system” by waiting until they need care to sign up for coverage. These rules are finalized in April.

The Internal Revenue Service also announces it will not reject 2016 tax returns for failure to include information on individual tax filers’ health insurance status. This is a reversal of plans to step up enforcement of the individual mandate, which requires most individuals to demonstrate they have insurance coverage or pay a fine. (In October, that policy was reversed again for the 2018 filing season; meaning the IRS would be more strictly enforcing the mandate.)

March 13, 2017:

HHS Secretary Tom Price sends a letter to each state saying the department is eager to help them unleash state innovations for the insurance marketplaces to “alleviate the burdens” of the ACA. He says HHS is eager to see ideas from the states for bringing down premium prices through new insurance pools that would help cover the costs of high-risk enrollees.

May 4, 2017:

President Donald Trump stands in the Rose Garden on May 4 after House Republicans mustered just enough votes to pass their health care bill. (Andrew Harrer/Bloomberg via Getty Images)

The House narrowly passes the American Health Care Act, its version of a “repeal and replace” measure for the health law, but the bill has no support in the Senate. Despite that, Trump says at a celebration in the White House Rose Garden that not only was the House bill “a great plan,” but also, of the underlying health law, “it’s dead. It’s essentially dead.”

June 7, 2017:

HHS launches a series of videos on its YouTube channel detailing the problems people are having with the Affordable Care Act.

A screenshot from YouTube of an HHS video, part of a series that detailed the problems people are having with the Affordable Care Act.

July 29, 2017:

As the Senate heads for its ultimately unsuccessful effort to overhaul the health law, Trump threatens to stop funding the cost-sharing reduction (CSR) payments. These reimburse insurers for discounts that they are required by the ACA to offer to some low-income exchange enrollees to help them afford deductibles and other out-of-pocket costs. The payments were the subject of a lawsuit filed by the House against the Obama administration, with the House charging that Congress had not provided a specific appropriation and therefore the administration was making the payments illegally.

Aug 14, 2017:

HHS officials make clear that they will not be working with local groups on enrollment efforts for the sign-up period starting Nov. 1.

Aug 31, 2017:

HHS officials announce that the advertising budget will be cut 90 percent for the coming enrollment season and programs that provide help to people signing up will be cut by 41 percent. Officials tell reporters on a call that the programs are ineffective and people are already aware of the health law logistics, something public opinion polls suggest is not the case.

Sept. 22, 2017:

During a conference call with community groups, HHS officials announce the federal enrollment website healthcare.gov will be shut down for as much as 12 hours every Sunday except one during the six weeks of open enrollment. Officials say the time is needed for site maintenance, although such maintenance took far fewer hours during the Obama administration.

Sept. 27, 2017:

Trump officials instruct HHS regional directors and staff not to participate in state events to promote enrollment. An HHS official tells BuzzFeed that enrollment events “are organized and implemented by outside groups with their own agendas, not HHS.”

Sept. 29, 2017:

Oklahoma withdraws its request for a waiver from federal rules that would have allowed the state to create a “reinsurance” program that it estimated could have reduced premiums in the state by more than 30 percent. The proposal followed Price’s April letter inviting states to seek changes, and state officials said they had been led to believe a waiver was forthcoming. But it failed to materialize. State officials say the delay would keep the program from launching in time for the 2018 plan year.

Earlier, Trump administration officials said Minnesota could institute a similar program, but that the state was also going to lose nearly $370 million in funding for a separate health law program serving those with low incomes. Other states that are ultimately frustrated by the waiver process include Iowa and Massachusetts.

Oct. 12, 2017:

During the day, Trump signs an executive order pushing federal officials to make it easier for people to purchase insurance that does not meet the regulatory standards of the Affordable Care Act.

Late that night, he follows through on his threat to cut off the cost-sharing reduction payments to insurers. “The bailout of insurance companies through these unlawful payments is yet another example of how the previous administration abused taxpayer dollars and skirted the law to prop up a broken system,” says a statement from press secretary Sarah Huckabee Sanders.

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