Community health centers are reporting mixed progress in getting patients to trade up from bronze to subsidized silver plans during the recent Affordable Care Act open-enrollment period.
An influx in the past year of patients with bronze plans put financial strains on many centers because policyholders could not afford to pay the deductibles, copayments and coinsurance outlays that came with such relatively low-initial-cost plans.
Centers found themselves having to subsidize that care by offering means-tested sliding-scale fees. When the centers, which are not allowed to turn away patients for inability to pay, tried to get the insurers to pay the additional costs, the claims were usually denied and the centers had to write charges off as uncompensated care.
Whether the issue has improved depends on which centers are asked. Those that did more individualized outreach achieved positive results. In some places, consumers simply became more savvy shoppers after a disappointing year with bronze plans, center officials said.
Federal enrollment figures indicate a slight decrease in bronze plan selections. As of Jan. 16, 1.6 million people, or 16.8% of those who obtained coverage through the state and federal exchanges, purchased a bronze plan, according to HHS. That's up from a total of 1.5 million people last year, but down in terms of percentage of total ACA enrollees. In 2014, HHS estimates that 20% of beneficiaries had bronze plans.
In Texas, community health centers say progress was made.
“We're not having the financial concerns that we had last year,” said José Camacho, executive director of the Texas Association of Community Health Centers. “People have become much more sophisticated shoppers. The products they are buying are trending away from the high-deductible products.”
Enhanced education and outreach efforts played a significant part in getting more people to make better plan selections. For community health centers and other navigators working with the low income, the goal for the second open-enrollment period was about quality of time spent with a consumer, not just the quantity of how many people signed up.
“We became more patient after learning from last year of the pitfalls of a family choosing the bronze plan,” said Lonnie Jones, CEO of Women's Health Coalition of Arizona.
Others say the best educating tool was having to live with the pitfalls of a bronze plan. “A number of people came back after living with a bronze plan last year and realized that it wasn't the best fit for them,” said Debbie Berndsen, navigator project director at the Kansas Association for the Medically Underserved, a patient advocacy organization.
More competition in terms of plan options also helped, said Eva Turbiner, CEO of Zufall Health Center in Morristown, N.J. As in Arizona, Medicaid had expanded in New Jersey, but its community health centers in urban areas had a high number of patients in the 139% to 200% federal poverty level range selecting bronze plans last year.
“We're seeing people move away from plans with high deductibles to new offerings that have much better pricing and no deductibles at all for primary-care visits, and that works out great for us,” Turbiner said.
Nationally, there was a 25% increase in issuers participating in the marketplace in 2015. About 91% of consumers will be able to choose from three or more issuers, up from 74% in 2014, according to HHS.
Despite a greater push in outreach about the benefits of choosing a silver plan, some always will opt for a bronze plan, said Jenny Englerth, CEO of Family First Health, a community health center in York City, Pa.
“We are seeing a majority of those we are assisting with enrollment select silver-level plans, the one exception being young adults that are minimally using healthcare services so are primarily driven by premium,” Englerth said.
Other community health centers say their financial predicaments have only grown worse. During the second enrollment, community health centers in Washington state were noticing more non-Medicaid eligible people coming in without insurance. The centers realized that many were not renewing coverage they had obtained last year, regardless of whether it was bronze or silver, said Susan Ward, a spokeswoman for Community Health Network of Washington.
On top of that, some centers struggled to get new people to sign up for plans. Centers found that on average, a family of four earning less than $47,700 a year will pay up to $3,000 of its annual income on premiums, with copays and deductibles on top of that.
“Low-wage workers who earn just over Medicaid income eligibility levels are struggling to buy and keep plans in Washington's Health Benefit Exchange,” Ward said. “One health center estimated that 75% of the people they assisted who were eligible for subsidized coverage on the exchange declined to purchase because it was still too expensive for them.”
The trade group is asking state lawmakers to study the issues of coverage affordability and continuity of care for people in Washington.
What's happening in Washington isn't that surprising, said Sara Rosenbaum, chair of the department of health policy at George Washington University.
“Cost sharing in a silver plan can still be considerable,” Rosenbaum said. “It can still cost $20 to $30 to see a doctor even with subsidies.”
Others are starting to wonder if their centers will be able to survive long term. In Louisiana, not only are community health centers suffering as a result of non-expansion of Medicaid, but they are still seeing a large number of bronze plan enrollees. Also, without Congressional action, they and other centers around the country stand to collectively lose up to 70% of their federal funding by the end of 2015.
“It's a perfect storm,” said Jonathan Chapman, executive director of the Louisiana Primary Care Association.
The trade group launched additional outreach efforts to help better train navigators at it centers about the different tier plans. But for every person who switched out of a bronze plan from last year, a new person who was shopping for insurance for the first time replaced them, he said.
Many of the centers' financial woes could be addressed if the state would expand Medicaid coverage, but there are no plans to do so. A single childless adult making 11% of the federal poverty level makes too much money to be on the state's current Medicaid program, and 75% of the consumers walking through community health centers' doors are under 100% of the federal poverty level, Chapman said.
With a fiscal cliff just ahead, and expansion looking out of the question, “I cannot say with certainty that all of the community centers will remain open,” Chapman said.
Follow Virgil Dickson on Twitter: @MHVDickson