At the Intersection of Health, Health Care and Policy Cite this article as: Tricia A. Brooks Open Enrollment, Take Two Health Affairs, 33, no.6 (2014):927-930 doi: 10.1377/hlthaff.2014.0415
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/6/927.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
Entry Point
Seeking coverage: Sakoun Khanthanoua reads a Maryland Health Connection health insurance Marketplace pamphlet while waiting to speak to a health navigator in Maryland. During the Affordable Care Act’s open enrollment period, consumer demand for help maneuvering the sign-up process outstripped capacity. doi:
10.1377/hlthaff.2014.0415
Open Enrollment, Take Two The Affordable Care Act’s long and rocky first open enrollment period is over. Now the Marketplaces prepare to do it all over again. BY TRICIA A. BROOKS
A
lthough the new health insurance Marketplaces stumbled out of the gate, March enrollment surged past expectations to exceed the original target of seven million enrollees. This milestone symbolized a comeback for President Barack Obama’s signature legislation—the Affordable Care Act (ACA)—but offered little time for celebration. Program administrators
and stakeholders were already preparing for open enrollment round 2, fast approaching on November 15.
Up First—Systems Functionality Website and enrollment system failures and flaws were front and center in the media mania and political posturing that shadowed the Marketplaces’ bumpy debut. While glitches and the need for
Photograph by Andrew Harrer/Bloomberg via Getty Images
troubleshooting are commonplace when new information technology (IT) systems are launched, the extent of the technical difficulties that accompanied HealthCare.gov and many state-based Marketplace IT systems was startling. These websites and their underlying eligibility and enrollment processes were working better by the end of open enrollment, but development work continues on back-end functions and consumer features—such as account transfers to coordinate coverage with state Medicaid agencies and automating the appeals process. The consumer interface is a Marketplace’s online storefront. If it works well and consumers can maneuver the system, they are less likely to get frustrated and abandon the process. So although getting the systems working efficiently from end to end takes priority over adding new functionality over the next few months, certain improvements will go far. These include tweaking the wording of tricky application questions, incorporating help text, and refining notices to be easily understood and to clearly reflect the income used to determine eligibility. For lawfully present immigrants with incomes low enough to qualify for the ACA’s premium tax credits, enrollment was acutely difficult. Marketplaces can address the most significant challenges faced by immigrant families and families with a mix of members who are immigrants and citizens by developing applications in additional languages other than just English and Spanish, and by improving the electronic and alternative processes for verifying identity and qualified immigration status.
Smoothing Out Coordination With Medicaid And CHIP Seamless access to all affordable insurance options—subsidized Marketplace coverage, Medicaid, and the Children’s Health Insurance Program (CHIP)—is a core principle of health reform. The ACA’s “no wrong door” approach to enrollment, regardless of where someone applies, requires meaningful coordina-
June 2014
33:6
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
Health Affa irs
927
Entry Point tion and cooperation between the Marketplaces and state Medicaid and CHIP agencies. To achieve this, each agency must resolve lingering technical kinks that have delayed the daily flow of error-free electronic account transfers between coverage sources. The Centers for Medicare and Medicaid Services (CMS) may also need to flex some muscle to ensure that all fifty states’ Medicaid systems, plus that of the District of Columbia, have fully adopted the ACA requirements for streamlining and coordinating enrollment.
Ready For Renewals And Reconciliation? If there is any lesson to be gleaned from the Marketplaces’ rocky rollout, it is that thorough system testing is indispensable. HealthCare.gov and the state Marketplaces must be ready before November 2014 to competently and quickly process renewals for seven million people. If they do not, they risk a revived bout of skepticism about the government’s ability to manage such a largescale undertaking. A smoothly functioning renewal system will require extensive consumer testing and subsequent system refinements to avoid further technological mishaps. Renewals will rely on the same eligibility verification tools used for new applications, but the process should be appreciably different. During the enrollment period just completed, enrollees had the option of checking a box to allow the Marketplace to retrieve personal tax data for an end-of-year eligibility review. For the people who chose this option, the process should be automatic, at least in theory. But, considering the reenrollment challenges experienced in Massachusetts’s early health reform efforts, this part of the process bears extra attention.1 For enrollees who did not grant access to their tax data in advance, the Marketplaces will need to obtain authorization before determining eligibility for the upcoming year. Not to be forgotten, the middle of the next open enrollment period will coincide with the first tax season for reconciling premium tax credits provided under the law to help people purchase coverage. This is when people who underestimated their income for 2013 may be asked to pay back a portion of 928
H e a lt h A f fai r s
June 2014
the credit. Marketplaces must formulate an internal and external communications strategy and train navigators and certified application counselors how to respond to reactions from consumers who have to pay back excess tax credits. This is also when the individual mandate’s tax penalty will be assessed for the first time. Those early 2014 tax filers who went without coverage this year will likely feel the pinch of the individual mandate’s tax penalty—1 percent of household income, or $95 per person with a maximum of $285 per family, whichever is higher—for the first time, just as round 2 of enrollment is winding down. It is possible that these costs may spark another enrollment surge among those who were unaware of the penalty and those who have a change of heart about going without coverage.
Getting The Word Out Even after months of outreach and public education at the end of 2013 into early 2014, two key facts about health reform remained largely obscure.2 Fewer than a third of uninsured consumers knew they could get financial assistance to help with premium costs—a message critical in overcoming the pervasive perception that health insurance is unaffordable. Moreover, fewer than one in five knew there was a deadline to sign up for coverage to avoid a tax penalty. And no wonder: Focus groups and surveys of prospective enrollees reveal that the most prevalent source of information about the expanded health insurance options was the news, which was dominated by politics and Marketplace problems. Although there was a notable uptick in awareness toward the end of open enrollment,3 effective public education and outreach remain top priorities. A look back is in order: Why did people who enrolled do so, while others did not? Awareness of and interest in new coverage opportunities are far from universal.4 For example, uninsured adults in their fifties and sixties are more aware of the new coverage options than young adults are. Latinos and African Americans are less aware of the tax penalty for being uninsured than whites are. Understanding how information gaps and barriers to coverage vary among the uninsured, and evolve over time, is critical to developing messages that have the 33:6
power to move consumers to enroll.5 Communications experts agree that targeted tactics and messages are needed to reach disparate groups, including young adults, Latinos, and others who are largely unaware of the new coverage options. Messengers also matter. Research indicates that people are more likely to be influenced by family members, or by someone who is “like them,” than by a celebrity spokesperson.6 During the next open enrollment, a potent tool could emerge if strategists are able to tap the power of word of mouth from first-round enrollees. But for that approach to work, those people must first have a positive experience by gaining value from their coverage. And that condition raises yet another challenge: Lowincome, uninsured people have little experience using insurance. Educating new enrollees on making the most of their new health plans will be crucial to transforming health coverage into actual health care and consumer satisfaction.
Upsizing Consumer Assistance Consumer assistance is available from both inside and outside the Marketplaces through call centers, caseworkers, navigators, and certified application counselors. During open enrollment, consumers’ demand for help maneuvering the multifaceted enrollment process outstripped capacity.7 Even with highperforming IT systems, there will be an ongoing need for robust consumer assistance. Qualifying for financial assistance and picking a health plan is a lot more complex than the straightforward transaction of purchasing a plane ticket on Travelocity.com. And the scope of assistance is not limited to outreach and help during the open enrollment period. Medicaid and CHIP are available for enrollment year-round. People will experience routine life events that qualify them for a special enrollment period or result in eligibility changes. And the need to coach people on using their insurance effectively cannot be overstated; a key test of the law will come as people access health care and decide whether their coverage is a good deal or not.8 Assisters must also be prepared to help consumers through the renewal process. With well-primed systems, re-
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
newing coverage may be a smooth path for those who are satisfied with the plan they selected and have relatively stable family circumstances and income. But those enrollees with eligibility changes or who encounter difficulties using their insurance will want expert guidance before locking themselves into insurance for a second year.
Supporting Navigators And Other Assisters Funding for navigators and community health center enrollment counselors in the thirty-four states served by the federal Marketplace was only slightly more than double the amount allocated to consumer assistance in California and New York alone.9 All state-based Marketplaces, as well as the five states that partnered with the federal Marketplace to manage consumer assistance, had substantially more resources dedicated to outreach and consumer assistance than the states that relied solely on the federal Marketplace. States with a state-based or consumer partnership Marketplace, which collectively represent 37 percent of the uninsured eligible population, accounted for 67 percent of spending on consumer assistance.10 The federal government has yet to announce how much money in the next round of grants it will award to navigators or community health centers, which received $67 million and $208 million, respectively, but consumer groups are not optimistic that it will exceed the total funding awarded for year 1. Regardless of the amount, Marketplaces can implement more nimble policies and take steps to strengthen the assister network infrastructure. To boost enrollment and retention and stretch limited assister resources, Marketplaces should consider adopting some or all of the following strategies:11 (1) Award grants to lead organizations responsible for coordinating the consumer assistance effort at a state or regional level and directing
The health insurance Marketplaces are here to stay, although it will take time for them to mature.
Call centers will build expertise faster and improve the quality of service if they can structure dedicated units to serve niche populations, such as immigrants or the self-employed, or to specialize in certain aspects of coverage, such as health plan comparison and selection.
Thinking Ahead resources to the places and populations most in need. (2) Make multiyear grants to promote retention of experienced assistance professionals. (3) Dedicate an expert team to provide technical and policy support to assisters, who are generally more knowledgeable than call center staff. Doing so will help detect training gaps, identify systemic issues, and advance problem resolution. (4) Create an assister web portal to improve the efficiency of application assistance, while enabling the Marketplace to more readily conduct oversight. (5) Embrace policies that support assisters in developing ongoing relationships with consumers. Assisters are currently hampered by limitations on or confusion over policies relating to phone assistance and maintaining consumer records for follow-up and retention.
Structuring More-Effective Call Centers Applicants, consumer groups, and assisters alike were frequently frustrated by the limited policy expertise of call-center representatives and their heavy reliance on scripts that often missed the mark. Common complaints included long hold times and staffers’ inadequate knowledge of Medicaid, which underscores the need for additional capacity and training. As call centers downsize following the initial open enrollment period, retaining the best and brightest staffers is a must. But ramping up again in the fall will inevitably mean bringing more inexperienced representatives on board.
The health insurance Marketplaces are here to stay, although it will take time for them to mature. Technology-based innovations—such as mobile apps or a more comprehensive online plan comparison feature—will be key to continually improving the consumer experience.12 If Marketplaces were to set up a testing version of their “live” IT systems for policy and consumer groups, they could tap a cadre of experts to supplement their technical resources. Engaging external partners would expand troubleshooting capacity, provide independent corroboration of system performance, pinpoint ways to enhance the consumer experience, and ensure that each phase of system development is good to go. Beyond enhanced technology, outreach, and consumer assistance, a host of “product-related” improvements would be helpful to consumers. These include standardizing plan benefits, strengthening network adequacy standards, and using Marketplaces’ purchasing power to leverage lower prices and higher quality. In all of these decisions, if policy makers put the best interests of consumers first and if they design Marketplaces and coverage options that work for consumers, it should be possible to achieve something that has eluded the United States for decades: nearuniversal access to affordable health care. ▪
Tricia A. Brooks ([email protected]) is a senior fellow at the Georgetown University Health Policy Institute, in Washington, D.C.
J une 201 4
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NOTES 1 Raymond AG. Lessons from the implementation of Massachusetts health reform. Boston (MA): Blue Cross Blue Shield of Massachusetts Foundation; 2011 Mar. 2 PerryUndem Research/ Communication. The uninsured midway through ACA open enrollment [Internet]. Washington (DC): Enroll America; 2013 Dec [cited 2014 Apr 21]. Available from: https://s3.amazonaws .com/assets.enrollamerica.org/ wp-content/uploads/2014/01/ Perry_Undem_Uninsured_ Survey.pdf 3 Kaiser Family Foundation. Kaiser health tracking poll: March 2014 [Internet]. Menlo Park (CA): Kaiser Family Foundation; 2014 Mar [cited 2014 Apr 21]. Available from: http://kaiserfamily foundation.files.wordpress.com/ 2014/03/8565-t2.pdf 4 Garrett B, Clemens-Cope L, Hempstead K, Anderson N. Who
930
H e a lt h A f fai r s
among the uninsured do not plan to look for health insurance in the ACA Marketplaces? Washington (DC): Urban Institute; 2014 Mar. 5 PerryUndem Research/ Communication. Checking in on enrollment: communicating to uninsured consumers midway through open enrollment [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2014 Jan [cited 2014 Apr 21]. Available from: http://www.rwjf.org/ content/dam/farm/reports/ surveys_and_polls/2014/ rwjf410426 6 Undem T, Perry M. Findings from a national study on enrolling in health care coverage [Internet]. Washington (DC): Enroll America; 2013 Feb [cited 2014 Apr 21]. Available from: https://s3 .amazonaws.com/assets.enroll america.org/wp-content/ uploads/2013/11/UndemPerry_ 2_14_03.pdf
June 2014
33:6
7 Radnofsky L, Dooren J. Long waits as health insurance deadline nears. Wall Street Journal. 2014 Mar 30. 8 Horsley S. With enrollee goal met, Obamacare still faces political trial. Morning Edition [Internet]. Washington (DC): National Public Radio; 2014 Apr 5 [cited 2014 Apr 21]. Available from: http:// www.npr.org/2014/04/05/ 299240252/with-enrollee-goalmet-obamacare-faces-its-realroad-test/ 9 Brooks T. Assister types abound: but will navigators and assisters be plentiful enough? Say Aaah! [blog on the Internet]. 2013 May 17 [cited 2014 Apr 21]. Available from: http://ccf.georgetown.edu/ all/assister-types-abound-butwill-navigators-and-assisters-beplentiful-enough/ 10 Polsky D, Weiner J, Colameco C, Becker N. Deciphering the data: state-based marketplaces spent
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
heavily to help enroll consumers. Princeton (NJ): Robert Wood Johnson Foundation; 2014 Apr. 11 Asian Pacific Island American Health Forum, Center on Budget and Policy Priorities, Community Catalyst, Enroll America, Families USA, Georgetown Center for Children and Families, National Health Law Program. Recommendations for improvements to the federal navigator and certified application counselor programs [Internet]. Washington (DC): Georgetown Center for Children and Families; 2014 Mar 28 [cited 2014 Apr 21]. Available from: http://ccf.georgetown.edu/wpcontent/uploads/2014/04/CCIIONavigator-Recommendations.pdf 12 Brooks T, Kendall J. Consumer assistance in the digital age: new tools to help people enroll in Medicaid, CHIP and exchanges. Princeton (NJ): Robert Wood Johnson Foundation; 2012 Jul.
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/6/927.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
Entry Point
Seeking coverage: Sakoun Khanthanoua reads a Maryland Health Connection health insurance Marketplace pamphlet while waiting to speak to a health navigator in Maryland. During the Affordable Care Act’s open enrollment period, consumer demand for help maneuvering the sign-up process outstripped capacity. doi:
10.1377/hlthaff.2014.0415
Open Enrollment, Take Two The Affordable Care Act’s long and rocky first open enrollment period is over. Now the Marketplaces prepare to do it all over again. BY TRICIA A. BROOKS
A
lthough the new health insurance Marketplaces stumbled out of the gate, March enrollment surged past expectations to exceed the original target of seven million enrollees. This milestone symbolized a comeback for President Barack Obama’s signature legislation—the Affordable Care Act (ACA)—but offered little time for celebration. Program administrators
and stakeholders were already preparing for open enrollment round 2, fast approaching on November 15.
Up First—Systems Functionality Website and enrollment system failures and flaws were front and center in the media mania and political posturing that shadowed the Marketplaces’ bumpy debut. While glitches and the need for
Photograph by Andrew Harrer/Bloomberg via Getty Images
troubleshooting are commonplace when new information technology (IT) systems are launched, the extent of the technical difficulties that accompanied HealthCare.gov and many state-based Marketplace IT systems was startling. These websites and their underlying eligibility and enrollment processes were working better by the end of open enrollment, but development work continues on back-end functions and consumer features—such as account transfers to coordinate coverage with state Medicaid agencies and automating the appeals process. The consumer interface is a Marketplace’s online storefront. If it works well and consumers can maneuver the system, they are less likely to get frustrated and abandon the process. So although getting the systems working efficiently from end to end takes priority over adding new functionality over the next few months, certain improvements will go far. These include tweaking the wording of tricky application questions, incorporating help text, and refining notices to be easily understood and to clearly reflect the income used to determine eligibility. For lawfully present immigrants with incomes low enough to qualify for the ACA’s premium tax credits, enrollment was acutely difficult. Marketplaces can address the most significant challenges faced by immigrant families and families with a mix of members who are immigrants and citizens by developing applications in additional languages other than just English and Spanish, and by improving the electronic and alternative processes for verifying identity and qualified immigration status.
Smoothing Out Coordination With Medicaid And CHIP Seamless access to all affordable insurance options—subsidized Marketplace coverage, Medicaid, and the Children’s Health Insurance Program (CHIP)—is a core principle of health reform. The ACA’s “no wrong door” approach to enrollment, regardless of where someone applies, requires meaningful coordina-
June 2014
33:6
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
Health Affa irs
927
Entry Point tion and cooperation between the Marketplaces and state Medicaid and CHIP agencies. To achieve this, each agency must resolve lingering technical kinks that have delayed the daily flow of error-free electronic account transfers between coverage sources. The Centers for Medicare and Medicaid Services (CMS) may also need to flex some muscle to ensure that all fifty states’ Medicaid systems, plus that of the District of Columbia, have fully adopted the ACA requirements for streamlining and coordinating enrollment.
Ready For Renewals And Reconciliation? If there is any lesson to be gleaned from the Marketplaces’ rocky rollout, it is that thorough system testing is indispensable. HealthCare.gov and the state Marketplaces must be ready before November 2014 to competently and quickly process renewals for seven million people. If they do not, they risk a revived bout of skepticism about the government’s ability to manage such a largescale undertaking. A smoothly functioning renewal system will require extensive consumer testing and subsequent system refinements to avoid further technological mishaps. Renewals will rely on the same eligibility verification tools used for new applications, but the process should be appreciably different. During the enrollment period just completed, enrollees had the option of checking a box to allow the Marketplace to retrieve personal tax data for an end-of-year eligibility review. For the people who chose this option, the process should be automatic, at least in theory. But, considering the reenrollment challenges experienced in Massachusetts’s early health reform efforts, this part of the process bears extra attention.1 For enrollees who did not grant access to their tax data in advance, the Marketplaces will need to obtain authorization before determining eligibility for the upcoming year. Not to be forgotten, the middle of the next open enrollment period will coincide with the first tax season for reconciling premium tax credits provided under the law to help people purchase coverage. This is when people who underestimated their income for 2013 may be asked to pay back a portion of 928
H e a lt h A f fai r s
June 2014
the credit. Marketplaces must formulate an internal and external communications strategy and train navigators and certified application counselors how to respond to reactions from consumers who have to pay back excess tax credits. This is also when the individual mandate’s tax penalty will be assessed for the first time. Those early 2014 tax filers who went without coverage this year will likely feel the pinch of the individual mandate’s tax penalty—1 percent of household income, or $95 per person with a maximum of $285 per family, whichever is higher—for the first time, just as round 2 of enrollment is winding down. It is possible that these costs may spark another enrollment surge among those who were unaware of the penalty and those who have a change of heart about going without coverage.
Getting The Word Out Even after months of outreach and public education at the end of 2013 into early 2014, two key facts about health reform remained largely obscure.2 Fewer than a third of uninsured consumers knew they could get financial assistance to help with premium costs—a message critical in overcoming the pervasive perception that health insurance is unaffordable. Moreover, fewer than one in five knew there was a deadline to sign up for coverage to avoid a tax penalty. And no wonder: Focus groups and surveys of prospective enrollees reveal that the most prevalent source of information about the expanded health insurance options was the news, which was dominated by politics and Marketplace problems. Although there was a notable uptick in awareness toward the end of open enrollment,3 effective public education and outreach remain top priorities. A look back is in order: Why did people who enrolled do so, while others did not? Awareness of and interest in new coverage opportunities are far from universal.4 For example, uninsured adults in their fifties and sixties are more aware of the new coverage options than young adults are. Latinos and African Americans are less aware of the tax penalty for being uninsured than whites are. Understanding how information gaps and barriers to coverage vary among the uninsured, and evolve over time, is critical to developing messages that have the 33:6
power to move consumers to enroll.5 Communications experts agree that targeted tactics and messages are needed to reach disparate groups, including young adults, Latinos, and others who are largely unaware of the new coverage options. Messengers also matter. Research indicates that people are more likely to be influenced by family members, or by someone who is “like them,” than by a celebrity spokesperson.6 During the next open enrollment, a potent tool could emerge if strategists are able to tap the power of word of mouth from first-round enrollees. But for that approach to work, those people must first have a positive experience by gaining value from their coverage. And that condition raises yet another challenge: Lowincome, uninsured people have little experience using insurance. Educating new enrollees on making the most of their new health plans will be crucial to transforming health coverage into actual health care and consumer satisfaction.
Upsizing Consumer Assistance Consumer assistance is available from both inside and outside the Marketplaces through call centers, caseworkers, navigators, and certified application counselors. During open enrollment, consumers’ demand for help maneuvering the multifaceted enrollment process outstripped capacity.7 Even with highperforming IT systems, there will be an ongoing need for robust consumer assistance. Qualifying for financial assistance and picking a health plan is a lot more complex than the straightforward transaction of purchasing a plane ticket on Travelocity.com. And the scope of assistance is not limited to outreach and help during the open enrollment period. Medicaid and CHIP are available for enrollment year-round. People will experience routine life events that qualify them for a special enrollment period or result in eligibility changes. And the need to coach people on using their insurance effectively cannot be overstated; a key test of the law will come as people access health care and decide whether their coverage is a good deal or not.8 Assisters must also be prepared to help consumers through the renewal process. With well-primed systems, re-
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
newing coverage may be a smooth path for those who are satisfied with the plan they selected and have relatively stable family circumstances and income. But those enrollees with eligibility changes or who encounter difficulties using their insurance will want expert guidance before locking themselves into insurance for a second year.
Supporting Navigators And Other Assisters Funding for navigators and community health center enrollment counselors in the thirty-four states served by the federal Marketplace was only slightly more than double the amount allocated to consumer assistance in California and New York alone.9 All state-based Marketplaces, as well as the five states that partnered with the federal Marketplace to manage consumer assistance, had substantially more resources dedicated to outreach and consumer assistance than the states that relied solely on the federal Marketplace. States with a state-based or consumer partnership Marketplace, which collectively represent 37 percent of the uninsured eligible population, accounted for 67 percent of spending on consumer assistance.10 The federal government has yet to announce how much money in the next round of grants it will award to navigators or community health centers, which received $67 million and $208 million, respectively, but consumer groups are not optimistic that it will exceed the total funding awarded for year 1. Regardless of the amount, Marketplaces can implement more nimble policies and take steps to strengthen the assister network infrastructure. To boost enrollment and retention and stretch limited assister resources, Marketplaces should consider adopting some or all of the following strategies:11 (1) Award grants to lead organizations responsible for coordinating the consumer assistance effort at a state or regional level and directing
The health insurance Marketplaces are here to stay, although it will take time for them to mature.
Call centers will build expertise faster and improve the quality of service if they can structure dedicated units to serve niche populations, such as immigrants or the self-employed, or to specialize in certain aspects of coverage, such as health plan comparison and selection.
Thinking Ahead resources to the places and populations most in need. (2) Make multiyear grants to promote retention of experienced assistance professionals. (3) Dedicate an expert team to provide technical and policy support to assisters, who are generally more knowledgeable than call center staff. Doing so will help detect training gaps, identify systemic issues, and advance problem resolution. (4) Create an assister web portal to improve the efficiency of application assistance, while enabling the Marketplace to more readily conduct oversight. (5) Embrace policies that support assisters in developing ongoing relationships with consumers. Assisters are currently hampered by limitations on or confusion over policies relating to phone assistance and maintaining consumer records for follow-up and retention.
Structuring More-Effective Call Centers Applicants, consumer groups, and assisters alike were frequently frustrated by the limited policy expertise of call-center representatives and their heavy reliance on scripts that often missed the mark. Common complaints included long hold times and staffers’ inadequate knowledge of Medicaid, which underscores the need for additional capacity and training. As call centers downsize following the initial open enrollment period, retaining the best and brightest staffers is a must. But ramping up again in the fall will inevitably mean bringing more inexperienced representatives on board.
The health insurance Marketplaces are here to stay, although it will take time for them to mature. Technology-based innovations—such as mobile apps or a more comprehensive online plan comparison feature—will be key to continually improving the consumer experience.12 If Marketplaces were to set up a testing version of their “live” IT systems for policy and consumer groups, they could tap a cadre of experts to supplement their technical resources. Engaging external partners would expand troubleshooting capacity, provide independent corroboration of system performance, pinpoint ways to enhance the consumer experience, and ensure that each phase of system development is good to go. Beyond enhanced technology, outreach, and consumer assistance, a host of “product-related” improvements would be helpful to consumers. These include standardizing plan benefits, strengthening network adequacy standards, and using Marketplaces’ purchasing power to leverage lower prices and higher quality. In all of these decisions, if policy makers put the best interests of consumers first and if they design Marketplaces and coverage options that work for consumers, it should be possible to achieve something that has eluded the United States for decades: nearuniversal access to affordable health care. ▪
Tricia A. Brooks ([email protected]) is a senior fellow at the Georgetown University Health Policy Institute, in Washington, D.C.
J une 201 4
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NOTES 1 Raymond AG. Lessons from the implementation of Massachusetts health reform. Boston (MA): Blue Cross Blue Shield of Massachusetts Foundation; 2011 Mar. 2 PerryUndem Research/ Communication. The uninsured midway through ACA open enrollment [Internet]. Washington (DC): Enroll America; 2013 Dec [cited 2014 Apr 21]. Available from: https://s3.amazonaws .com/assets.enrollamerica.org/ wp-content/uploads/2014/01/ Perry_Undem_Uninsured_ Survey.pdf 3 Kaiser Family Foundation. Kaiser health tracking poll: March 2014 [Internet]. Menlo Park (CA): Kaiser Family Foundation; 2014 Mar [cited 2014 Apr 21]. Available from: http://kaiserfamily foundation.files.wordpress.com/ 2014/03/8565-t2.pdf 4 Garrett B, Clemens-Cope L, Hempstead K, Anderson N. Who
930
H e a lt h A f fai r s
among the uninsured do not plan to look for health insurance in the ACA Marketplaces? Washington (DC): Urban Institute; 2014 Mar. 5 PerryUndem Research/ Communication. Checking in on enrollment: communicating to uninsured consumers midway through open enrollment [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2014 Jan [cited 2014 Apr 21]. Available from: http://www.rwjf.org/ content/dam/farm/reports/ surveys_and_polls/2014/ rwjf410426 6 Undem T, Perry M. Findings from a national study on enrolling in health care coverage [Internet]. Washington (DC): Enroll America; 2013 Feb [cited 2014 Apr 21]. Available from: https://s3 .amazonaws.com/assets.enroll america.org/wp-content/ uploads/2013/11/UndemPerry_ 2_14_03.pdf
June 2014
33:6
7 Radnofsky L, Dooren J. Long waits as health insurance deadline nears. Wall Street Journal. 2014 Mar 30. 8 Horsley S. With enrollee goal met, Obamacare still faces political trial. Morning Edition [Internet]. Washington (DC): National Public Radio; 2014 Apr 5 [cited 2014 Apr 21]. Available from: http:// www.npr.org/2014/04/05/ 299240252/with-enrollee-goalmet-obamacare-faces-its-realroad-test/ 9 Brooks T. Assister types abound: but will navigators and assisters be plentiful enough? Say Aaah! [blog on the Internet]. 2013 May 17 [cited 2014 Apr 21]. Available from: http://ccf.georgetown.edu/ all/assister-types-abound-butwill-navigators-and-assisters-beplentiful-enough/ 10 Polsky D, Weiner J, Colameco C, Becker N. Deciphering the data: state-based marketplaces spent
Downloaded from content.healthaffairs.org by Health Affairs on May 28, 2015 at Univ of Connecticut Health Center/L.M. Stowe Library
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