Janesville, Wis. — Everyone agrees the Affordable Care Act exchanges need more people to sign up for coverage to make those marketplaces more stable. A larger number of enrollees -- especially a higher percentage of younger and healthier people -- would help convince nervous insurers to continuing selling plans in the exchanges and would moderate premium increases.
But as I was reminded on a reporting trip here last week, many Americans haven't enrolled because they find the health insurance and healthcare system complex and confusing – before, during, and after they sign up for coverage. A surprisingly large number still don't know about the financial assistance available to them under the law. And many fall into one of a number of coverage chasms that continue to exist. When talking to people who badly need insurance but lack information about the ACA's benefits, it's hard not to become an amateur enrollment assister.
That's why healthcare providers and ACA supporters believe much greater efforts are needed to educate consumers about their insurance options and offer them in-person help in signing up for coverage. “There is a persistent perception that coverage is out of financial reach and people don't know that financial help is available,” said Jennifer Sullivan of Enroll America, which has led efforts to get more Americans covered under the ACA. “We have found that in-person assistance is one of the critical factors for so many people in whether they sign up.”
Yet for this year's upcoming open enrollment, the CMS announced Tuesday that it is awarding $4 million less than last year -- $63 million -- in grants to organizations providing in-person navigation assistance to connect people to health coverage in the 34 states where the federal government runs the insurance exchange. These grants are particularly important in states like Wisconsin that haven't set up their own insurance exchanges and whose Republican elected leaders have made little or no effort to promote ACA enrollment.
Christopher, a tall 28-year-old wearing shorts and a T-shirt who declined to give his last name, was standing outside the Rock County Job Center in Janesville last Wednesday afternoon when I asked him about his healthcare situation. He spoke with frustration about how he recently had lost his Medicaid coverage, known as BadgerCare in Wisconsin. That happened because he got a full-time job grossing about $1,300 a month – a little over the state's minimum wage of $7.25 an hour – and his income is now too high to qualify.
Wisconsin has not expanded Medicaid coverage to low-income working adults like Christopher with incomes up to 138% of the federal poverty level because Republican Gov. Scott Walker opposes the ACA, which provides enhanced federal funding for state Medicaid expansions. For a single person, BadgerCare eligibility cuts off at $990 a month, the federal poverty level.
Christopher's employer doesn't offer coverage. He's been uninsured since July 1. As a result, to save money, he has been taking his psychiatric and other medications every other day rather than daily. He worries this puts him at increased risk of suffering another psychotic episode.
He checked with an enrollment assister and was told it would cost him $117 a month to buy a subsidized plan on the exchange, which he said he can't afford. Plus, he believes he would have to pay a high deductible and coinsurance before he could receive benefits.
Katherine Gaulke, executive director of the Wisconsin Association of Free and Charitable Clinics, sees these misinformation problems all the time. In an interview at the Health Care Network, a free clinic in Racine, just south of Milwaukee, Gaulke described how her member clinics have to spend lots of time helping clients navigate the insurance system. Clients often are intimidated by high plan deductibles and copays, or get scared when they receive a big medical bill in the mail and then don't refill prescriptions or go for follow-up visits.
“We try to teach patients it's better to be insured than uninsured, particularly with the ACA's cap on out-of-pocket costs,” Gaulke said.
Alison Sergio, executive director of the Racine clinic, said some of her clients get lost when they mistakenly go to Healthcare.com, a private insurance website, rather than HealthCare.gov, the official ACA information and enrollment site. Then they get inundated with solicitations from insurance brokers and often aren't told about subsidized coverage options on the ACA exchange.
That's exactly what happened to John Erickson, a 59-year-old Kenosha resident who retired from his factory job for health reasons last year and needed health insurance. “I went on the Internet and got slammed with a million emails from all these companies,” he said.
After wandering in the insurance wilderness for a while, he learned he could sign up for ACA coverage for $743 a month. “There was no way I could afford it,” he said. He then contacted Molina Healthcare, which assisted him in signing up for a Molina plan through the exchange. He gets a $511 monthly tax credit, reducing his out-of-pocket premium cost to $232. “I was happy as hell when I heard about the premium subsidy.”
Experts say stepping up public education and outreach to boost ACA enrollment will be key to stabilizing the exchange markets. Chris Jennings, an outside health policy adviser to the Democratic presidential nominee Hillary Clinton's campaign, said that's a major part of Clinton's plan, along with additional subsidies to consumers, tougher cost controls and continued delivery system reforms. “The combination of these steps should increase enrollment, stabilize the marketplace, reduce premiums, and convince more plans to enter the market because there will be more and healthier customers,” he said.
When I informed Christopher last week that at his income level he would qualify for generous subsidies to defray his deductible and coinsurance expenses, he looked surprised. He knew nothing about the ACA's cost-sharing reductions. I suggested he contact the local navigator group, Covering Wisconsin, to learn more about that financial assistance. He said he would. “I guess I'm going to have to find a way to pay that $117 a month premium,” he said.