Open enrollment to purchase insurance on the exchange through the Affordable Care Act starts Wednesday. Numerous changes have been made, including by the Trump administration, which could lead to a drop in participation across the country and here in Missouri.
Only three companies are offering policies in the Show-Me state; Cigna, Anthem and Centene. Centene is entering the state’s marketplace for the first time, although it has a separate Medicaid managed care contract in Missouri. Cigna and Anthem have proposed major rate increases of 42% and 36% respectively for 2018.
Both have indicated that they have based their proposals on the assumption that a subsidy to cap premiums for low income enrollees will be eliminated in 2018. President Trump announced plans to drop the $7 billion in funding, known as cost-sharing reduction subsidies or CSR’s, in mid-October.
Last week, a federal judge denied a request from 19 state attorneys general to stop Trump’s move. The President has repeatedly threatened to end the payments, calling them insurer “bailouts”. A lawsuit Republicans filed against the Obama administration intended to stop the subsidies is unresolved.
88% of Missouri enrollees on the exchange received the cost-sharing reductions in 2017, which insurers must provide, regardless of whether federal funding continues. Those people receiving the subsidies will likely be protected from rate increases, while those who don’t qualify for them will see the higher premiums in 2018.
President Trump also signed an executive order in the past several weeks which could reduce participation in the health exchange, although it won’t be in effect during open enrollment. It must go before a regulatory review before any portion is implemented, which could take a year.
The order would allow small businesses to pool their purchasing power together into associations that could bargain for cheaper premiums. The associations would also be able to buy plans across state lines.
However, the move could also push people into less regulated plans that offer fewer services or extremely high deductibles. Dave Dillon with the Missouri Hospital Association (MHA) says the provisions of Trump’s executive order have been panned by health providers and insurers as substandard, and an ineffective way to bridge the gap of uninsured people.
“There are elements to what his proposal was that are not necessarily new ideas, but also have not really been fully tested to whether they would be viable alternatives to the existing marketplace,” said Dillon.
The Trump administration has also curtailed several procedures during open enrollment for the exchange that could result in lower participation.
First, the enrollment period itself has been cut in half, from 12 to 6 weeks. It starts November 1st and continues through December 15th, where as in previous years under the Obama administration, it continued through the end of January of the following year.
Also, the website to shop for coverage on the exchange will shut down from midnight until noon nearly every Sunday during open enrollment, which MHA’s Dillon sees as a means to further limit the enrollment widow. “If you take every Sunday out of six weeks, you’ve already eliminated almost a full week.”
The federal Center for Medicare and Medicaid Services (CMS) says maintenance outages are regularly scheduled every year during open enrollment. It says this year’s downtime is planned for the website’s lowest-traffic time periods.
The Trump administration has further announced major cuts to outreach efforts for the exchange. It’s cut advertising by 90%, from $100 million down to $10 million. And it’s cut federal funding for “Navigators”, who assist consumers in navigating the system, by 40%.
CMS announced it was rolling back the open enrollment period in April. In August, it went public with its cuts to outreach.
In doing so, the agency pointed out the $100 million spent on advertising in 2016 was double the total spent in 2015. It noted the campaign was ineffective, resulting in a first-time enrollment decline of 42%, or 500,000 individuals.
In making cuts to “Navigators”, CMS said more than $62 million was spent to enroll fewer than 81,000 people on the exchange. It said 17 Navigators enrolled less than 100 each at an average cost of $5,000 per each enrollee.
The agency noted 78% of Navigators failed to meet their goals, and announced a performance based procedure for renewing grants. It said for the upcoming enrollment period, Navigator grantees will receive funding based on their ability to meet their enrollment goals during the previous year.
MHA’s Dillon thinks the administration is more focused on limiting access to the exchange and is rooting for its failure.
“The administration’s priority is not to create as open an environment for individuals who might enroll,” Dillon said. “And I can’t second guess or judge, other than what they’re saying, which is basically that they have historically said that have historically said that they want this to collapse under its own weight.”
Ryan Barker is Vice President of Health Policy at the Missouri Foundation for Health, a non-profit group that’s heavily involve in outreach concerning the exchange. He says his organization has resources to help offset the marketing and assistance cuts that have been made.
“We do have an annual awareness campaign that has bus ads, and radio, and social media,” said Barker. “We buy Facebook ads to try to let people know that this is still out there. This is still available.”
The Missouri Foundation for Health operates in 85 of the 114 counties in the state with $15 million in financing annually it receives as a charitable organization with ties to the for profit insurer Anthem Blue Cross Blue Shield. It employs consumer assistance counselors that serve the same purpose as the federally funded Navigators.
Just over 244,000 Missourians signed up for coverage through the exchange during the 2017 open enrollment period, a nearly 16 percent reduction from the more than 290,000 who enrolled the year before. Dillon says it’s impossible to predict what the total will be for 2018, given all the changes that have taken place.
“All of this chaos and message that is contrary to the fact the law is, in fact still alive and kicking, may just in and of itself suppress participation. It’s really hard to know.”
Barker with the Missouri Foundation for Health would like to see the numbers keep from depleting too much. “I would hope that we stay above 200,000 enrollments. I think we’re all aiming to keep around the 250,000 (level). We know that there could be up to half a million Missourians that could benefit from the marketplace. It’s an awareness game.”
The Missouri Foundation has a site dedicated to helping individuals connect with consumer assistance counselors to help them find a health care plan on the exchange.