Health Policy Roundup: Recent Trends in Coverage Enrollment and Affordability
January 21, 2022
This event was Part II of the Alliance’s Health Policy Roundup and 2022 Forecast series.
Economic fallout and higher unemployment rates due to the pandemic have raised concerns about health insurance coverage enrollment and affordability in the U.S. Although the national uninsured rate remained mostly unchanged throughout the pandemic (at or around 10–11%), many eligible Americans still do not have coverage. Moreover, even insured consumers are often underinsured, or have difficulty affording all of their health care costs, placing them at significant financial risk if they experience a serious or unexpected illness.
This event highlighted current trends in enrollment, premiums, and out-of-pocket costs in private insurance markets, and presented challenges and opportunities in getting eligible consumers enrolled in appropriate coverage. Panelists also explored coverage affordability and enrollment levers, including potential policy actions at federal and state levels, and how these issues intersect with other national policy conversations, COVID impact, and equitable benefit design.
For additional background information on insurance coverage, please Chapter 2 of the Alliance’s Health Policy Handbook.
Speakers:
- Annette V. James, MAAA, FSA, FCA, Chairperson, Health Equity Work Group, American Academy of Actuaries
- Kevin Patterson, MPA, MURP, Chief Executive Officer, Connect for Health Colorado
- JoAnn Volk, M.A., Research Professor, Center on Health Insurance Reforms
- Elizabeth Wroe, J.D., Principal, Leavitt Partners
- Sarah J. Dash, MPH, President and CEO, Alliance for Health Policy (moderator)
This event was made possible with support from the Commonwealth Fund.
Presentation: Health Policy Roundup: Recent Trends in Coverage Enrollment and Affordability
Event Resources
Key Resources
(listed chronologically, beginning with the most recent)
“State Trends in Employer Premiums and Deductibles, 2010-2020.” The Commonwealth Fund. January 12, 2022. Available here.
“HHS Notice of Benefit and Payment Parameters for 2023 Proposed Rule Fact Sheet.” Centers for Medicare and Medicaid Services. December 28, 2021. Available here.
“No Surprises Act Implementation: What to Expect in 2022.” Pollitz, K. Kaiser Family Foundation. December 10, 2021. Available here.
“Request for Information: Assessing How Common Practices and Methods Used by Health Actuaries and Health Plans Affect Health Disparities.” American Academy of Actuaries. October 29, 2021. Available here.
“How Insurance Marketplace Regulators Can Help Consumers Enroll in Better Coverage.” RAND Corporation. August 2, 2021. Available here.
“Coverage and Affordability in the Private Insurance Market.” Alliance for Health Policy. July 9, 2019. Available here.
Additional Resources
(listed chronologically, beginning with the most recent)
“Findings About the Dual-Eligible Consumer Experience.” Arnold Ventures. January 12, 2022. Available here.
“How Medicare Advantage Plans Can Support the United States’ Reinvestment in Health.” Gilfillan, R., Berwick, D., Kronick, R. Health Affairs. January 10, 2022. Available here.
“State “Easy Enrollment” Programs Gain Momentum, Lay Groundwork for Additional Efforts to Expand Coverage.” Schwab, R., Giovannelli, J., Lucia, K., Corlette, S. The Commonwealth Fund. August 3, 2021. Available here.
“State Efforts to Standardize Marketplace Health Plans Show How the Biden Administration Could Improve Value and Reduce Disparities.” Giovannelli, J., Schwab, R., Lucia, K. The Commonwealth Fund. July 28, 2021. Available here.
“As the Pandemic Eases, What is the State of Health Care Coverage and Affordability in the U.S.?” The Commonwealth Fund. July 16, 2021. Available here.
“How States Can Build on the ACA to Improve Affordability and Lower Health Care Costs.” Center for American Progress. July 15, 2021. Available here.
“Fixing the ACA’s Family Glitch.” Health Affairs. May 20, 2021. Available here.
“Making Employer-Sponsored Insurance More Affordable.” Health Affairs. May 17, 2021. Available here.
“Health Coverage by Race and Ethnicity, 2010-2019.” Kaiser Family Foundation. July 16, 2021. Available here.
“Changing the “Family Glitch” Would Make Health Coverage More Affordable for Many Families.” Urban Institute. May 11, 2021. Available here.
“The Enrollment Coalition.” Leavitt Partners. 2021. Available here.
“The Benefits and Limitations of State-Run Individual Market Reinsurance.” Giovannellli, J., Volk, J., Schwab, R., and Curran, E. The Commonwealth Fund. November 11, 2020. Available here.
“Unpacking Colorado’s New Guidance on Transgender Health.” Keith, K. The Commonwealth Fund. November 10, 2021. Available here.
“State-Based Marketplaces Gear Up to Implement the American Rescue Plan.” Corlette, S. and Schwab, R. The Commonwealth Fund. April 20, 2021. Available here.
“Updating the Essential Health Benefit Benchmark Plan: An Unexpected Path to Fill Coverage Gaps?” Corlette, S. and Ario, J. State Health and Value Strategies. September 11, 2020. Available here.
“States Work to Make Individual Market Health Coverage More Affordable, but Long-Term Solutions Call for Federal Leadership.” Giovannelli, J., Volk, J., and Lucia, K. The Commonwealth Fund. January 15, 2020. Available here.
Experts
Speakers
Annette James, MAAA, FSA, FCA
NovaRest, Principal
Annette@novarest.com
Kevin Patterson, MPA, MURP
Connect for Colorado Health, Chief Executive Officer
executivedirector@connectforhealthco.com
JoAnn Volk, M.A.
Center on Health Insurance Reforms, Research Professor
Joann.Volk@georgetown.edu
Elizabeth Wroe
Leavitt Partners, Principal
Elizabeth.Wroe@leavittpartners.com
Experts and Analysts
Thomas Barker, J.D.
Foley Hoag, Founder, Co-Chair, Medicaid and CHIP Payment and Access Commission (MACPAC)
tbarker@foleyhoag.com
Linda Blumberg, Ph.D.
Urban Institute, Institute Fellow
lblumberg@urban.org
Kate Bundorf, Ph.D.
Sanford School of Public Policy and Duke Margolis Center for Health Policy, J. Alexander McMahon Professor of Health Policy and Management
Kate.bundorf@duke.edu
James Capretta
American Enterprise Institute, Senior Fellow
jcapretta@aei.org
Sara R. Collins, Ph.D.
The Commonwealth Fund, Vice President of Health Care Coverage and Access
Src@cmwf.org
Cynthia Cox, MPH
Kaiser Family Foundation, Vice President for the Program on the ACA
ccox@kff.org
Philip Ellis, Ph.D., MPP
Ellis Health Policy, Inc., President
phil@ellishealthpolicy.com
Edmund F. Haislmaier
The Heritage Foundation, Preston A. Wells, Jr. Senior Research Fellow
Ed.Haislmaier@heritage.org
Mark Hall, J.D.
Wake Forest Law, Director of Health Law and Policy Program and Fred D. and Elizabeth L. Turnage Professor of Law
hallma@wfu.edu
David Kendall
Third Way, Senior Fellow for Health and Fiscal Policy
dkendall@thirdway.org
Nadereh Pourat, Ph.D.
UCLA Fielding School of Public Health, Professor for Department of Health Policy and Management
pourat@ucla.edu
Sara Rosenbaum, J.D.
George Washington University Milken Institute of Public Health, Harold and Jane Hirsh Professor of Health Law and Policy, Founding Chair
sarar@gwu.edu
Government
Jessica Farb
U.S. Government Accountability Office, Managing Director of Health Care
FarbJ@gao.gov
Christie Peters
HHS Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Director, Division of Health Care Access and Coverage
Christie.Peters@hhs.gov
Jeff Wu
Centers for Medicare and Medicaid Services, Deputy Director for Policy at the Center for Consumer Information and Insurance Oversight
Jeff.wu@cms.hhs.gov
Stakeholders
Laura Colbert, MPH
Georgians for a Healthy Future, Executive Director
lcolbert@healthyfuturega.org
Paul Fronstin, Ph.D.
Employee Benefit Research Institute, Director of Health Research and Education Program
frontsin@ebri.org
Julie Goon
Anthem, Senior Vice President of Public Affairs
Julie.goon@anthem.com
Meg Murray
Association of Community Affiliated Plans, Chief Executive Officer
mmurray@communityplans.net
Jodi A. Ray, M.A.
Florida Covering Kids & Families, Director
jray@usf.edu
Lori Shoaf
Blue Cross Blue Shield Association, Managing Director of Federal Relations
Lori.Shoaf@bcbsa.com
Joel White
Council for Affordable Health Coverage, President
Joel.White@cahc.net
Transcript
This is an unedited transcript.
0:04
Hello everyone, and thank you for joining today’s briefing on recent Trends in Coverage: Enrollment and Affordability, part of the Alliance for Health Policies, 20 22 Policy Roundup Series. I’m Sarah Dash, president and CEO at the Alliance. For those who are not familiar with us, welcome, We’re a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
0:30
Today’s briefing is brought to you in partnership with the Commonwealth Fund, and you can join today’s conversation on Twitter using the hashtag. I’ll help live and join our community at all Health Policy, as well as on Facebook and LinkedIn.
0:45
Today’s briefing, which will be 90 minutes, includes a question and answer session. At the end of our speaker presentations. Please be active participants and get your questions ready, You will see a dashboard on the right side of your web browser, with a speech bubble icon. That has a question mark. You can use that to ask your questions at any time, and we’ll collect the questions and address them as many as possible during the broadcast.
1:07
Finally, you can also chat about any technical issues you’re having, and somebody will try to help you. So, to start today’s conversation, I am very pleased to invite doctor Sarah Collins to join us on screen, to offer some opening remarks, as well as recent data on coverage and affordability, and enrollment trends. Doctor Collins as Vice President for Health Care Coverage and Access at the Commonwealth Fund, In her role, she leads the Fund’s National Program on Health Insurance, and has overseen several important national surveys on Health insurance coverage, in addition to authoring numerous reports, issue briefs, and journal articles on health insurance coverage and policy. Sarah, welcome. It’s great to see you.
1:49
Thank you, Sarah. And on behalf of the Commonwealth Fund, I’d like to thank the Alliance for convening this briefing today, and the panelists for taking time to share their expertise.
2:01
I’m going to just share a few data points from some recent research on trends and affordability in private health insurance.
2:11
Next slide, please.
2:13
Employer coverage continues to be the backbone of the US. Health insurance system, ensuring more than 160 million workers and their families. Health care cost growth is the primary driver of growth in private insurance premiums and by extension. What people and their families in employer plans contribute to their premiums as well as the …, that base, over the last decade and most years and in most parts of the country. These costs have risen more quickly than the incomes of working families, which means these costs are taking up a larger share of household budgets.
2:49
Last week, we released a study that found that premium contributions and deductibles for people enrolled in employer plans amounted to an average of 11.6% of US median income in 20 20, up from 9.1% a decade earlier.
3:06
Next slide, please.
3:08
In 37 states, average premium contributions and deductibles amounted to 10% or more of median income.
3:17
In 20 28, up from 10 states in 2010, these costs range as high as 90% of median income in Mississippi.
3:26
Next slide, please.
3:28
Years of research has shown that cost sharing when someone uses their insurance and their deductibles, are critical determinants of people’s access to healthcare.
3:38
High out of pocket costs and deductibles lead to delayed or avoided care and medical debt when people do get care.
3:46
The Commonwealth Fund has created a measure of underinsurance, which measures the amount of someone’s out of pocket spending, excluding premiums and deductibles relative to their income.
3:57
The biggest growth in the share of people who are under insured over the last decade has occurred in employer plans. This is the turquoise line on the chart or the gray line on this, on this, on this chart.
4:10
About one quarter of people in employer plans are under insured by our measure, this is up from 19% in 20 20.
4:18
But you can see that the under insured rates continue to be high in individual market, despite the reforms of the Affordable Care Act.
4:26
About 2 or 5 people are under insured.
4:30
The ACA has cost sharing subsidies help a lot, but there are limited to various to lower income enrollees in the marketplaces.
4:39
A lot of people in this market simply have really high deductibles and I’ll stop there and turn it back over to Sarah. Thank you.
4:50
Great.
4:50
Thank you so much, Sarah, for those opening framing remarks and that really helpful data that you shared. So, and I’m looking forward to hearing more of your thoughts in our Q and A So.
5:06
OK, whoops, I wasn’t sharing my webcam, sorry, guys. You would think after three years of this, we would have figured it out. But now, I’m pleased to introduce our expert group of panelists for today’s event. JoAnne Volk is a research professor, founder and co-director of the Center on Health Insurance Reforms are sure at Georgetown University’s McCourt School of Public Policy. At CHIR, she directs an author’s research and provides technical assistance on State and Federal regulation and legislation governing private health insurance, including health insurance marketplaces established under the ACA. Kevin Patterson serves as Chief Executive Officer of Connect for Health Colorado, and previously worked in the public sector as Chief Administrative Officer and Interim Chief of staff to Governor John Hickenlooper. Kevin graduated with a BA and teaching from Sam Houston, State University and holds both the Masters of Public Administration and Masters Urban Regional Planning from the University of Colorado at Denver.
6:03
Annette James and Chairperson of the Health Equity work group at the American Academy of Actuaries has over 25 years of senior level actuarial experience in both the private and public sectors in addition to her service in the American Academy of Actuaries Health Equity work group. Ms. James is currently a member of the Board of Directors of the American Academy of Actuaries, a member of the Health Practice Council of the American Academy of Actuaries as well as Chair of the Health Committee of the actual Actuarial Standard Sport. So if you’re looking at being an actuary as a career choice, I think Ms. James had a lot to a lot to share with you and we’re looking forward to your comments today. And finally, last, but very much, not least, we are thrilled to introduce Elizabeth or Liz Wroe, who is a principal at Levitt Partners, where she develops and manages complex multi sector alliances and advises firm’s clients on the impact of Federal and state health care issues.
6:59
She also provides strategic counsel to emerging business investment and technology players in the healthcare sector, and, as you will hear, and as we’ll be sure to discuss, list was also a senior member of the Health, Education, Labor, and Pensions Committee staff under Adjuvant Alexander. So, welcome, Liz!
7:18
So, we’re going to start with you. Can you lay out, for us, you know, what, what are the current trends in enrollment, where their opportunities to, not only enroll eligible beneficiaries in coverage, but also to potentially make coverage more affordable.
7:35
Joanne, I’m looking forward to your remarks.
7:38
Yes, thank you, Sarah. This is a timely convening. This is one week coming off of a historic open enrollment period for healthcare dot gov, and some state based marketplace. They’re still going strong. Kentucky is still open until the end of this month, in Maryland, through the end of February. But to date, fourteen point two million people have enrolled in marketplace coverage, including 10 million through healthcare dot gov, and four point two million through the 18 state based marketplaces. Most are returning customers, not new enrollees, but the six month coven SDP. That was an effect last year brought a new consumers. States had some challenges in getting out the word on the new enhanced premium tax credits available under the American Rescue Plan Act, and the additional targeted assistance for the unemployed. But together, state based marketplaces and the FFA brought into zero point eight million new enrollees last year during the special enrollment period.
8:36
So how did we get here with that, those, those big numbers. For one thing, the administration significantly increased funding for Navigator assistance, quadruple the number of navigators that are available to help people enroll in coverage and spent $100 million on advertising for the … special enrollment period. In 202012 of the Van 13 … opened up their marketplaces for their own covered Special Enrollment period when healthcare dot gov remain shuttered. And its states have been experimenting with novel ways to reach the eligible, but uninsured. one path that I want to talk about a little bit today, is, to leverage the tax filing process to notify individuals of their eligibility for marketplace subsidies. Are Medicaid, Maryland, was a state.
9:23
That first adopted this program there, Easy enrollment program, uses state tax filing forms to ask Marylanders if they want to share their insurance status, income, and other relevant information to receive an eligibility determination for Medicaid in subsidized marketplace plans.
9:40
The marketplace will then notify those taxpayers of their eligibility for coverage and, if applicable, offer them the opportunity to enroll in a marketplace plan outside of the Open Enrollment period. Of course, Medicaid is open year round for enrollment. In the first year, that program, 20 20, 60,000 people share their data, and most of those, 53,000 were deemed eligible for Marketplace subsidies or Medicaid, a much smaller share enrolled in coverage, just over 4000 people. But the program predates the enhanced subsidies under the American Rescue Plan Act, so it’s, you know, affordability was still a barrier for people enrolling at that point. But it may be a successful strategy for reaching those who have proven harder to reach, because of those who did enroll.
10:27
23% of marketplace enrollees were black, compared with fewer than 17%, who enroll during open enrollment period, and a disproportionate share were younger release ages 18 to 34 40 percent compared to 28% during a regular open enrollment period. Other states are implementing their own version of this, Colorado Pennsylvania in Washington, Have something, In effect, and in California plans. to implement their own version of this. That goes a step. further, Their marketplace plans to automate marketplace enrollment for people losing Medicaid. And the new process, which will take effect later this year, will automatically enroll those who are eligible for Marketplace subsidies into the lowest cost silver plan available.
11:11
Or the same managed care plan they had as Medic as a Medicaid employee. In Raleigh.
11:17
Looking ahead, healthcare dot gov will be back with the same expanded open enrollment in effect this year, running through January 2015, which is longer than we’ve had in recent years. Plus a new monthly opportunity for low-income individuals to sign up for coverage, with the new SDP for those under 150% of poverty.
11:39
In the months ahead, States will be working on the unwinding of a public health emergency in which people remained continuously enrolled in Medicaid.
11:48
Once that ends, there’ll be new redetermination of their eligibility and it will present enormous outreach and enrollment challenges to be sure that people coming off of Medicaid make their way to marketplace plans with the appropriate subsidies. Projected 15 million people will be terminated from Medicaid when we unwind this current continuous enrollment program, And it’s estimated that about one third of those will be eligible for advanced premium tax credits.
12:16
We, each year, are going to be writing about the California experience, and fielding a survey of SPM directors in the months ahead to get their thoughts on these challenges and others.
12:27
Turning now to affordability another major barrier to getting the eligible, but on an enrolled, into coverage. I’m going to have to start by recognizing what the American Rescue Plan Act has meant for marketplace premiums. People with incomes under 150% of poverty pay no premiums and people with incomes above that pay much less than they have in the past. But also, extends subsidies to those who had previously fallen on the other side of the cutoff, or cliff at 400% of poverty. So that no one now has to spend more than 8.5% of their income on a plan. This is an effect.
13:05
Um, still, the enhanced subsidies have made it possible for people to buy, up to Richard Gold and Platinum plans, in addition to the crushing subsidies for those under 250% of poverty, and there was targeted help for the unemployed, as I mentioned. Through 2021, it’s no longer in effect. People claiming unemployment insurance qualified for zero premium marketplace plans.
13:28
About 200,000 people enrolled in this provision, and 34,000 of those are people who would not have been eligible, because they were in a coverage gap. State and Medicaid coverage gap states that they were newly eligible for coverage with substantial subsidies because of the unemployment insurance program. There are other programs I’m going to talk about today, that we’ve done some research on, and I’m gonna share some resources when this is done. that.
13:54
I know the lion’s share the various posts that talk about the states that have done these programs, and provide more detail, but there are some states that have provided their own state funding to beef up subsidies. California has their own program to enhance the tax credits for those under 400% of poverty and extended premium tax credits to those above 400% of poverty going up to 600%. Beginning in 20 20, Massachusetts and Vermont also subsidized premiums and Minnesota subsidizes coverage for those not eligible for premium tax credits, Medicaid, or their basic health plan.
14:32
Another tool that states have used to tackle affordability of coverage is standardized plans, which sets cost sharing for targeted services. To provide pre deductible coverage for key services and prioritize co-pays or co-insurance to make access to care more affordable. eight states plus the District of Columbia have standardized plans. Colorado will use them beginning in 20 23, and the administration has proposed to require standardized plans be available. So, health care dot gov, beginning in 20 23, with the Notice of Benefit and Payment Parameters rule, that’s out for comment, right now.
15:06
Do you see, is using their standardized plans to target lower cost sharing, to treat diseases that disproportionately impact DC Residents of color? Diabetes and cardiovascular disease. And collar, Colorado will follow suit when they roll out their plans.
15:20
Um, in the coming year, and standardized plans are part of the Washington and Colorado Public Option programs. And as previously noted, ARPA extended premium tax credits to those with income above 400% of poverty. Prior to ARPA states relied on state run re-insurance programs to lower premiums for subsidized individuals’. 14 states have re-insurance programs that offset ensure costs for high cost to individuals, and have used 13 32 waivers to pull down Federal savings in premium tax credits to help fund those programs alongside their own state funding.
15:54
And finally, states have opportunities to improve how coverage works by adjusting what is covered under their essential health benefit benchmarks.
16:01
States have used some flexibility allowed under the federal rules to update their benchmarks to improve coverage most recently, Colorado Clarified and affirmed coverage for gender affirming care.
16:14
Beginning in 20 23, plans must cover medically necessary care to treat gender dysphoria, and it requires insurers to be more explicit and more comprehensive in their coverage.
16:29
Previously five states similarly updated their essential health benefits benchmarked to improve coverage specifically to respond to the opioid crisis. In Michigan, New Mexico, Oregon, and Illinois, and South Dakota updated their benchmark plan to cover ABA therapy for Autism Spectrum disorders. This has made possible under the flexibility to allow states to update their benchmark plan so long as the generosity of the benchmark does not exceed the most generous of the 10 benchmark plan options they had to choose from. So it’s actually proven to be a tool to enhance coverage in those states looking ahead. You know, one thing that Congress is debating now is realigning the firewall the employer firewall that keeps people who have employer sponsored coverage from accessing premium tax credits. If their coverage is considered affordable or end meets minimum value, currently, the bar is still set.
17:27
Requiring premiums be no more than 9.83% of household income, and there’s a proposal to lower that to match the 8.5% cap on premium contributions in the marketplace so that more people could clear the firewall and get out of affordable player coverage to access pay in tax credits. And finally, there’s still hope that there’ll be a fixed to what’s called the family glitch that prevents dependence from accessing premium tax credits, regardless of whether or not their own coverage is affordable. If the self only coverage for the employee and the family is considered affordable under that firewall test, the family cannot access coverage.
18:12
six million people are denied premium tax credits under that rule, and there’s hope that there’ll be, and adjustment to that interpretation, so that people can access premium tax credits when they have unaffordable dependent coverage.
18:26
And that’s a quick overview of some of the activity in the states to reach the eligible, but uninsured. And to improve the affordability of coverage.
18:37
Thank you so much, Joanne. And that was definitely a tour de force. Let me, let me ask you. First of all, I hope this is all written down somewhere, so people can see where this menu of options may be, But I really, really appreciate this. I want to ask you, before we, before we, shift to another presentation, you mentioned a lot about the states and the state based marketplaces. Like, just for those who might be kind of a little bit newer to the trajectory here, Are there big differences between, like, what can happen in states with a state based marketplace, as opposed to states that have the federally facilitated marketplace?
19:14
Like, are there any major parallels or overlaps? Or can you say, a little bit about the different levers that are available from a policy perspective?
19:23
State based marketplace has have much more autonomy to, to set their rules and to do their own outreach and enrollment.
19:32
So, for example, as I said, during the first year of coven, the state based marketplace is all, But the Idaho marketplace enacted their own state special enrollment period to allow people to enroll in coverage outside the open enrollment period.
19:46
So where people could have coverage during the pandemic, the feds refused to open up the marketplace, even for states that were relying on healthcare dot gov, there were governors calling on healthcare dot gov to be opened in the same way.
20:00
So, in that case, states have flexibility to open up the marketplaces where the States for lying on healthcare dot gov for sort of stuck with a federal decision, they also run their own outreach and enrollment programs.
20:12
So, you know, Lanier’s, where they made, prior to the current administration there, were substantial cuts, 90% funding, cuts in navigator funding, and 80% cuts in advertising.
20:25
And though they do their own advertising, they really said they sort of wrote on the, on the, the wings of the, the Federal Advertising Program.
20:33
And then they sort of also experienced difficulties in getting the word out when there was less funding from the federal level. But nonetheless, they do fund their own advertising and enrollment assistance. And has been more, you know, have really tried to be creative about how to reach eligible. But not enrolled, including some phone calls in some cases, and other programs, Like I said, leveraging the tax system or other programs like unemployment or family benefit programs that find people who might be eligible for marketplace subsidies.
21:04
Mean, thanks for that additional context. And so now, I will turn to it and that James and Joanne has done a great job of sharing a lot of the mechanisms by which people can get coverage went a little bit into HBs. And so, and that was so pleased to have you here, tell us more about how premiums, how plan benefit designs actually impact affordability and how? And how is that affecting the health equity conversation. So not, I’ll turn it over to you. Thanks, for joining us.
21:36
Thank you so much, Sarah, and thank you so much for inviting me to this panel.
21:43
Before we go into, Can we get the next slide?
21:47
Before we go into premiums and how DOD to me, they’d like to spend a moment talking about what an actuary is because I don’t want to presume that everyone knows whether that truly is, what they do and so for the purpose of level setting, so that starts, Let’s stop there.
22:08
So actuaries typically spend a lot of time analyzing risk and modeling the financial impact of those events based on the likelihood of just scenarios and actuaries.
22:22
Traditionally have worked in insurance, all lines of business, my property, and casualty insurance.
22:30
They also work in non traditional industries such as financial services, the environment and issues, such as climate change.
22:40
So let’s look at the health actuaries and how we fits into the health ecosystem.
22:46
So, um, actuaries, Bluetooth headphones they work with to determine premiums intersect reserves. Those are the traditional roles of actuaries.
22:59
Uncertain reserves is really a way to ensure that the sufficient funds synthesized to meet its obligations. We also work with how tons of other issues are often in the room when a lot of discussions and decisions. Regarding designing the benefits, care management programs, provide a contracted arrangements, provided that boots and so on.
23:26
So we usually provide the quantitative analysis to support those decisions.
23:33
Actuaries also work with federal and state governmental agencies, and so we’re talking about Social Security, the Department of Labor, CMS, the Center for Medicare and Medicaid citizens.
23:47
And they manage social programs and develop regulations and legislation.
23:55
Uh, full disclosure, I myself work with this as a regulated and sleep, the vision of insurance in Nevada for many, many years.
24:06
And we’re also involved in the aspects of.
24:11
For example, actuaries are often employed by providing groups with pharmaceutical companies and pharmacy benefit managers and so on and so, hopefully that gives you a little bit of background as to what an actuary is and how we fit into.
24:31
The health ecosystem.
24:33
So, next one.
24:36
So let’s look at Southern health premiums. They are generally three components. The first is is the largest.
24:44
That’s the cost of benefits for the individual or small group market.
24:51
This portion is required to be at least 80% of the people and premiums are set on a project basis. So this portion is the expected level of leaves.
25:02
So actuaries will estimate the expected level of claims, and it reflects the cost of providing services, nets of patient cost sharing. And so it’s impacted by many different things is impacted by the extent of the network visit, the merrimack provider. Reimbursement rates, what type of utilization management protocols, please.
25:31
As well as the types of benefits that are, oh, great.
25:37
The second bucket is what I call the non bank expenses, and that’s administrative and taxes and fees.
25:46
It includes things like premium thoughts, salaries and so on, the cost of administering claims and other expenses.
25:59
And the food bucket is premium, intense and risk. And this is usually the smallness of the three.
26:06
And but the one thing to note here is, as uncertainty increases, this bucket will increase with not necessarily a decrease in the other two buckets.
26:19
So, for example, with that, this is where a lot of, of insurers added some risk margin to there premiums to reflect the fact that there was a lot of uncertainty as to what the impact would be.
26:38
So, next slide.
26:43
So, now I’m going to talk a little bit about trends, and Joanne talked a lot about some of the things I was gonna cover here.
26:52
So, I am happy to expand on anything on this slide in the queue it needs.
27:00
But, what what I’m seeing is an increased focus on health equity issues.
27:07
As we all know, the pandemic shown a bright light them health disparities. And so, both from the government perspective see governments as well as health plans and employers. We’ve seen a lot more emphasis on health equity issues and attempt to address disparities. On the next slide, I will give a brief summary of what the group of us New student this week.
27:34
There’s also I’m seeing a an increased focus on behavior.
27:41
Again in response to what’s to the pandemic of what we’ve seen with behavioral health, utilization increasing during the pandemic.
27:52
A lot of, it’s definitely focusing on behavior, so the thought ability are always areas.
28:06
There’s a lot of focus on, as far as, you know, to do, consumers have access to healthcare and health insurance, and, of course, affordability.
28:18
Uh, as far as equitable design, Joanne talked about the interest in some of those funds, and we’re also seeing interest in benefit designs.
28:33
Focused on certain sub segments of the population.
28:37
Next one.
28:42
So move on to talk a minute about what the actuaries are doing and to have equity space. So the American Academy of Actuaries established and we’ve been all 20 20.
28:55
So that, as actuaries, we can add our voices to the conversation in a meaningful and appropriate way and as I mentioned before, actuaries often have a seat at the table when many decisions.
29:11
So our main focus is to work on solutions by Foos taking an introspective view of the common analytical practices better used by actuaries in the context.
29:27
So in other words, when this sitting at the table, obvious things that we can do differently to enhance of equity, there, there’s therefore bullet points here, and I’ll focus on the first two. These represent four phases.
29:46
Right now, the first phase, we’re in the space, which are identifying, actually, we just finished different space, identifying and monitoring actual data sources and methods that may contribute to health and these.
29:59
So, we spent a lot of time trying to identify the right questions to ask, and as a result of the inquiries, we publish five sessions, We will now start in the second phase of doing an analysis. To see what exists in research. What research exists, where there may be gaps to.
30:23
two, have additional research, and in this regard, we sent out the Request for Information, and it’s due by February 15th, so if any one in the audience has information that may be helpful to the areas of inquiry, I’d be very interested in hearing from you.
30:46
Next slide, would have to give an example of how we’re looking at health equity.
30:54
And this example focuses on benefit designs, and the common benefit design strategies that are used today, and how they may impact these.
31:04
So in this picture, we have individuals and families, at the top of the page, attempted to access the healthcare system, which is shown at the bottom of the page, And in the middle, we show some benefits design features inside of event stuffing area.
31:18
These features I intended to discourage overuse of services.
31:25
Listen, we’re exploring what does some of these design features it actually creates, or perpetuated barriers to access with disadvantaged communities, and result in under utilization, bagels do. So as we look at the fencing area, some of the questions we’re exploring on the right-hand side.
31:47
Cost prohibitive, but they inadvertently discourage appropriate to space it and populations on the left. The reauthorization and pre certification processes increase reluctance to seek needed services in some communities due to the invasive nature.
32:06
And in the middle, put it to network design, actually discourage appropriate use of medical services and results improve the utilization, especially if first tier providers are not readily accessible to disadvantaged.
32:22
So as I’ve indicated, these are some of the of questions that we’re exploring regarding benefit design and health equity. And we’re actually looking at similar questions in each of the other areas that we’re exploring, right in the pricing, provided contracting and development.
32:44
As well as population population care management.
32:52
Next one.
32:55
So, I mentioned that the five issue briefs that we have published, and these there are links to each of these.
33:04
And we also, as I said, uh, we just issued a request for information to solicit input, exist in an ongoing usage that made up the work that we’re doing. It’s because it’s important for us to collaborate.
33:25
Um, and finally, if you have any questions, here is the person to contact.
33:32
And I’m happy to answer any questions in the few of these.
33:40
Great. Thank you so much. I really appreciate the thoroughness of your presentation. And we do have a question from the audience. I would love to ask if and follow up. And this is, I’m just gonna read it. It’s fairly technical. But the request is whether you could address the question of what a risk margin is. And the questioner says, it’s often misunderstood, is just a kicker for-profit. Can you share more about what, what that is, and sort of how, how to act or a balanced this, this, you know, tough job of, kind of projecting the future. And sort of like trying to get it right, but maybe not always getting it right. So a lot packed in there, but that is from our audience. So that’s a great question. So much. It really reflects the amount of insurgency and it’s, it’s not, uh.
34:37
You articulate it correctly. A lot of people think it’s, it’s just additional profit.
34:43
That’s not the intent.
34:45
The intent is that when you put checked, when you protect anything, any protect cause, there is uncertainty.
34:54
And, there is a range of uncertainty that’s implicit in that protection.
35:03
If there is additional uncertainty that probably as a result of regulations, or legislation’s, or something like open, that is really difficult to predict. And, it was not contemplated when the initial projections have done. Or is it the insurgency became more empowering after?
35:34
Know, the initial protections. And then there is, the risk margin is added to reflect that.
35:46
Thank you very much, Very helpful. So, it’s fair to say the more uncertainty, the greater the risk margin, and you’ve gotta kind of adjust accordingly.
35:55
Absolutely, and the higher the premiums, and then the higher Yes.
36:00
Yes, indeed. Well, thank you so much, and I look forward to the Q and A And now, I will turn to Kevin Patterson, Kevin, who runs a state based marketplace in Colorado.
36:14
and I think, you have a tough job of, trying to explain all this to the public and to your customers. All this wonky stuff. So, we’re really looking forward to your presentation on how this actually works in practice in your state.
36:35
Yes, sir. Thank you. Really appreciate the opportunity to be with you all today.
36:40
The meeting, right before was a lot of this conversation with our health insurance affordability fund, where I’m working with our Commissioner of Insurance, to actually put up some state subsidies.
36:53
We’ve been able to roll out a cost share reduction for a targeted population, and we’re looking to expand that into the family glitchy, and possibly those that are regardless of immigration standards.
37:04
So, they can also come up with a number of different health affordability choices, that would give them the ability to have state funds that help them.
37:13
But in terms of what we do at the connect for our Colorado, we, of course, implement the Affordable Care Act for our state.
37:24
You know, the thing that has been, the biggest challenge, especially lately, is just when decisions are getting made, and especially at the federal government, or not. And, and, not just about what the policies are, but when it happens, really has a huge impact on our ability to move and try to respond very quickly to a change at the federal level. The great thing about being a state based marketplace is that we are able to use a lot of flexibility. Joanne talked about to do a number of the different programs that we are actually in the middle of right now. Of course, she talked about the …
38:05
ASAP that we did last year, We extended that at the request of a County Metro County, here, and around Denver that wanted us to give folks enough time because they were they noticed that Folks are getting Layoff Notices and we were able to, to move that time for.
38:22
We’ve spent a much of last year in some sort of special enrollment plan that was happening.
38:29
And we’ve just issued a new disaster special enrollment plan that is allowing folks that from the fires up in Boulder County to make sure that they can actually put their lives together and still have time to come through and give them another 60 days, because there may be documents that they can’t find right now.
38:49
And so we wanted to make sure that we expanded that and for folks that are concerned about the latest surge we’re seeing in our hospitals and ICU beds.
38:59
We have, in fact, added a tax time special period for this current year. We’ve been working with our Department of Revenue at the State of Colorado. We’re really excited about that opportunity to get two additional folks that will come through whether they are Medicaid eligible for the marketplace.
39:18
We’re able to get them a health affordability plan that helps them with their, with just a simple check, up a box, although the work they’re doing that is not simple. We also have been working on standardized plans with the Division of Insurance.
39:34
There is a state bill that came last year that is moving that process through joy, and also talked about our benefit design, adding a gender affirming care. We’re actually quite quite proud of that.
39:49
I think the other thing that we have been seeing a good bit of is because we are a state that is involved in re-insurance we’ve been able to keep reductions in the individual market.
40:00
On average, 20%. We’ve been able to say, folk’s two years in a row.
40:04
We also are seeing that our individual market rates have become extremely competitive to group rates, and especially for really small businesses.
40:15
We’ve never really took off in terms of the Old Shot Program.
40:20
Small business plan they had for the AC ate, a lot of compliance that was required for that. And a lot of a small mom and pops are just trying to make payroll and not trying to figure out how to do it complicated tax credit.
40:33
But we are seeing a number of those folks, especially after covert, where businesses were just trying to stay open, moving their employees into the individual market and understanding, especially after the American rescue plan really increased the size of those subsidies.
40:48
You know, it makes a really big difference to folks that are making 16, 17, $18 an hour to, actually have a health insurance plan that they can pick.
40:56
that, is a full HB, In some cases, maybe a little bit better plan that they maybe were able to get from a very, very small employer that’s trying to kick in bits and pieces of money. So, you know, those are things that I think are really important for us to think through.
41:13
We have been using our flexibility to try to help as many different folks with state funds and dealing with growth and really just responding to what our customers are asking us to do.
41:26
And I think that’s the additional benefit as we really can be responsive to customers working through our brokers. And assisters and are certified application centers. And hospitals and doctors clinics to make sure that we’re able to catch people when they need care and get them some sort of assistance when they can get around a huge doctor Bill or a hospital bill that they can cut out, and again, cutting our medical bankruptcies and more than half in the state of Colorado. So, with that, I’m happy to take any kinds of questions and participate in the conversation with the rest of my panel. Colleagues.
42:01
Thank you so much, Kevin. And I’m really glad you mentioned small businesses, too, because I think, from the days from the days, I think I was working on the state based health policy and campaigns back in 2005 and I know way before that’s, you know, insurance for small businesses that have been a real, a real challenge. We didn’t have an audience question that I’d love to ask and follow up. And this might lead right into Liz’s presentation as well. And there was a, there was a specific question about a couple of provisions here, So let me, let me read the question.
42:35
The questioners concerned that lowering the employer responsibility requirement without indexing to 8.5 to 8.5% of income would be harmful to the small group market and had some concerns about the impact of removing the the firewall or the family glitch. Is.
42:55
Do you have a sense of what, what that would do to the small group market, or, like, when you, when you think about the relevant consultations of federal policy for a small group market in your state.
43:09
Yeah, you know, when we see this movement, It’s from really small businesses. It’s usually 10 and fewer.
43:16
And I am using that mom and pop example, because those are the folks that we’re really looking at. You know, they don’t have the same requirement, and what you end up with is a lot of folks that are eligible, but not enrolled, but they’re not getting picked up.
43:29
That way, because people are assuming there, they have a job, and they did get employer sponsored care. So, I think it’s a pocket of uninsured that we really don’t talk about and focus on enough for these really small businesses, And so, that’s why I’m seeing a good bit of that movement, and I think that’s the way that you deal with the concern that I’m hearing the question.
43:50
Alright. Well, thank you so much. And we’ll look forward to more discussion in the Q and A And so, now, Liz, thank you so much for joining us. And I understand you have some slides, and you have been working with an enrollment coalition, specifically focused on taking some very practical steps on eligibility moment, So we look forward to hearing your thoughts.
44:14
Great, Well, thanks. It is fantastic to be here, and, particularly with this great group of presenters. It’s just been really helpful for some fantastic information. We’re gonna go through these slides really quickly, because I actually want to get to the panel discussion, just because I think it’s going to be fantastic. So, we can go through this first slide here. Kind of what I tried to do was think about it. You know, a lot of our work at one of our partners is done at the federal policy level, our federal policy firm, as well as help run stakeholder coalitions. So, really tried to think about what are some of the themes that we’re seeing kind of in Federal policy and advocacy and then amongst stakeholders.
44:55
And so three things we’re going to just briefly identifiers kind of trends or items that we’re watching is the potential for coverage cliffs, basically action forcing events, and Federal legislation, that could have a significant impact on enrollment or could also kind of carry along with it other policy changes around enrollment. The second piece would be to kind of what Sarah mentioned, what are some stakeholders doing? You know, are there areas for consensus among a number of different enrollment strategies. And then finally, this has come up a lot so far today is, you know, this coverage or migration with the individual employer markets, and looking that over the long term.
45:41
So if we take the next slide, as they’ll say this, Kevin, I think made a comment about kind of one of the things that can be challenging is both Federal Action and inaction as well as the schedule.
45:56
And so, one of the things that, you know, we have dealt with in Congress, and I was on both the Health Committee and the Budget Committee during both the Affordable Care Act, and then, later on, through some efforts in 20 17, just that try to stabilize the individual market.
46:11
Know, sometimes there’s not a very good understanding at the congressional level that you can’t just flip a switch on a number of policies, and particularly, when we’re talking about kind of insurance market. The fact that states have deadlines, They have plans in places, you know, health plans have a process that they go through for setting rate, setting premiums and setting plans. And so, it’s really important, I think, for a number of these issues to try to not wait to the 11th hour to talk about them.
46:44
Unfortunately, Congress has a tendency to wait until the 11th hour to address some of these issues. And so, you know, one question we get quite a bit is, you know, is there going to be legislative action on enrollment strategies for outside of, you know, ACA expansion, Whenever you want to talk about some, whether it’s program improvements or changes?
47:06
And, you know, I think we’ve seen, for a long time, politically, this focus on kind of ACA expansion or repeal, and, replace, frankly, that you had policymakers kind of on either side of the spectrum, but not that many policymakers, kind of in the middle, trying to figure out operationally, how to make the current system better. And so I think some of the deadlines that we’re looking at that are going to be really impactful is, number one, you know, what happens when the ACA subsidy expansion that was part of the American rescue plan. What happens when that sunset, at the end of this year, you know, does that create a moment for potentially Congress to step in and expand those subsidies?
47:51
Or, you know, inapt other policies, in addition, to try to address enrollment, as we saw the proposed Build Back Better Act would extend those subsidies through 2025. I think that’s an interesting timeframe. If you look, you also kind of like the Medicare trust fund, that’s a webinar for another day, but you have the Medicare Trust Fund fortunate asset depletion around that same time. And so, do you kind of create this, these Cliff moments, where you’re forcing federal policymakers to actually have to look at some of these items? So, we all know, kind of, we’re in a little bit of a waiting game right now as to what’s going to happen both with the build back better apps or even legislatively over the next couple months. But I think it’s, it’s hard to ignore the fact that this larger federal policy landscape does have some impact on the ability to make headway.
48:47
Not on the next slide. You know, one of the things that we’re also seeing is, you know, maybe it’s because of that lack of consensus at the congressional level on some areas on enrollment that you’re starting to see and not really start.
49:02
And I think it’s been there for quite some time, but really seeing a lot of stakeholders at the federal and state level, working together to try to address enrollment. And particularly the enrollment of people that are currently eligible for plans or subsidies that are enrolled in and trying to get a sense of, you know, what are some of those barriers? And what are some of the strategies where you can see some consensus? So some of the issues where we’ve started to see some consensus bubble up. Again, they’re all, you know, challenging issues.
49:34
But, you know, really having a focus on improving data analysis to address health disparities, you know, making sure that plans can actually collect the information that’s going to be really helpful in measuring whether or not, you know, benefit design is actually helping address health disparities.
49:52
And move forward on health equity, agents, and brokers. I think it’s interesting. I think some people would be surprised to see this terminal west of consensus.
50:00
I think there is definite consensus that agent, agents and brokers have a role to play and enrollment. But I think there’s also an acknowledgement that, you know, any of the different players or sisters need to be working under certain standards.
50:15
So I think there’s a place where you could see, you know, an enhanced role, maybe for agents and brokers, again, with oversight and making sure that, you know, everything’s being done in a way to help, obviously, enhance enrollment and qualified health plans.
50:32
A lot of conversation we’ve heard about is and what’s going to happen at the end of the public health emergency and young with Medicaid redetermination. So we know there’s a lot of conversations happening in that space.
50:46
Another area where I think we’re seeing a lot of discussion is, how do you leverage investments across multiple programs? So that’s essentially, you know, how can you leverage enrollment investments on, you know, the side of Ag Department versus HHS? So at a state level, you know, whether somebody’s applying for a snap benefit, also applying for Medicaid, having leverage some of those investments.
51:10
Whether it’s on the technology side, data, storage so that you’re streamlining enrollment in a really efficient way.
51:18
Another issue that has bubbled up and frankly wasn’t woman I was really familiar with until recently, was consumer notification and consumer communication. And just making sure that plans have the ability or to reach out to consumers, whether it’s through text messages or phone calls, to help if there’s been any kind of drop in enrollment.
51:40
And then finally, this is a much more structural policy option.
51:44
I think there’s a lot of different ways that you could approach Islam, but I think, particularly after the individual mandate was repealed.
51:53
There’s been a lot of focus on auto enrollment as potential enrollment strategy, and whether that’s a federal program or, you know, federal standards with state implementation, completely state auto enrollment options.
52:07
You know, I think there’s a number of policies there, you know, really worth thinking through.
52:12
And so, one of the stakeholder, no activities that are out there, have to give it a little bit of a plug, that we work with them at Lovett Partners. But we help run an enrollment coalition, and as you can see here, this just gives an example of just a really broad group of stakeholders that have come together to work on some of these issues. So, think it just gives you a sense that, you know, one of my former bosses used to say that, you know, when you looked at Congress, sometimes it was, like, split screen TV, you know, on one side and one channel, or one side of the screen, It was all the fighting and, you know, the debate.
52:46
While on the other side, there are people actually getting stepped up. And so I think this is just to show that While yes, there’s a lot of focus on, you know, areas of disagreement within ACA policy. There’s a lot of area where you’ve got folks sitting around the table, trying to get things done.
53:02
Then finally, just kind of, you know, when we think about other themes that we’re looking on, if you go to the next slide.
53:09
one of the things that we’re, you know, paying attention to and obviously don’t have any answers yet is just kind of the coverage migration that we’ve been seeing over the last, you know, year two.
53:19
And really kind of the impact of … 19 on sources of health coverage. You know, we know that job losses obviously lead to some shifts and employer sponsored coverage, but if it’s not clear yet, kind of how permanent those shifts are going to be.
53:32
If we’re in a post pandemic world, if the employment situation improves, you know, our folks that are in the individual market likely stay there or, you know, do we think that there’s going to be some type of chime back into the employer market?
53:46
We’ve also seen, you know, a way to appropriate some employee employers really taking an enhanced role in that kind of health and wellness of their employees.
53:57
So that’s whether or not, you know, there were some companies that provided, you know, cobra subsidies when they had to lay off additional focus hyper subsidies when they had to pay off employees.
54:09
We’ve seen, you know, some employers create wellness clinics or, you know, help with vaccinations and masks. So it’s been really interesting to see how some employers have kind of responded in the pandemic and really taken responsibility for their employees’ health and well-being.
54:28
It was already mentioned before what kind of potential legislation to weaken the ACA employer sponsored coverage firewall.
54:36
I think that certainly a federal policy area that people are watching closely and the employer sponsored coverage space, and how that plays out, I think, will just be another factor in this story of kind of the role of a large employer sponsored coverage.
54:51
Then, finally, I would just saying, you know, Annette mentioned this, and I thought her presentation was really, really helpful. There’s a lot of large employers that are looking at health benefit design as a way to address health, equity, and social determinants of health.
55:06
And, again, stepping into this role of, you know, there are large purchasers of health care coverage, but also health care services, So they’re in a unique position. Whether it’s kind of demanding, diversity, equity, inclusion. training of the providers that they work with are, again, really assessing their benefits. There’s a lot that employers, large employers can do, utilize in their flexibility to be a little bit of a testing ground, and some of these areas. So, again, I think we don’t have, you know, hard answers yet, but I think this will be over the next year to, one of the things that we’re going to be looking at is, you know, Are we starting to see, you know, more for migration away from large employer sponsored coverage? Or is this kind of, you know, maybe, a shorter term trend, because of some of the factors that we want.
55:57
So, happy to, to get into the panel and talk further, and really appreciate the opportunity to meet here.
56:04
Great, thank you so much, Liz. And so, while the other panelists are turning their cameras back on, and I’ll invite Sarah Collins to rejoin us so many questions for you. Listen and follow up.
56:19
What a really incredibly helpful and clear presentation, I just want to ask you since you serve and then on the note of large employers and the sort of you know shifts that Covert has brought about I’m really curious from your perspective if you if you think Like where is the status of The conversation around employer? Employers is like, hasn’t caught up to the changing landscape around like the gig economy.
56:46
You know, like, I mean, how many of us have have, you know, the privilege of, like sitting in our houses and working from home, and ordering from DoorDash or Grubhub, for instance, or whatever. So I’m just curious, like, how you think some of the shifting workforce landscape as factoring in and what impact do you think if any that will have on disparities?
57:08
Yeah, I think it’s interesting, because I think it will have an impact, and, is having an impact. And, I think, again, this concept of, we’ve always thought about churn. Oftentimes, we’re kind of the term between Medicaid and individual market, and I think now we may have more churn also with kind of the large employer market and then the individual market. You know, I think it’s been interesting. Some employers that we work with are so really committed and feel very strongly about the role of the employer, and healthcare and health insurance.
57:40
I think there are some others that still think it’s really important that they’re kind of more open to thinking about other ways of delivering that, whether it’s, you know, giving somebody a subsidy to go into an individual market, or doing something that’s more portable, that you can take with you. So, I still think it’s a really interesting time, because I would have said, you know, 3 or 4 years ago, I think it would have been a very hard, hard and fast. We liked status quo. You know, we’re not really touching it, but I think the facts on the ground economically have changed and that has forced more of these conversations, frankly, more than any other political debate has.
58:20
Yeah, thank you. So, very, very practical considerations, well. Thank you all for your incredibly helpful overview and excited to get into the Q and A So we’ve got questions coming in, and we’ve got about half an hour left in our, in our panel discussion to get to that. So.
58:39
So, let me let me start on a really practical note on with the latest question that just came in. I’m going to talk about this family glitch, which seems like it’s been around forever. Was mentioned, this is a question that says, it was mentioned that six million people are affected by the family glitch. They know of a Colorado high school teacher who’s paying 14% of family income for health insurance. Their employer offers family insurance, but only helps to pay for the the employee’s health insurance, not for the, The husband and kids, obviously serious financial burden for them.
59:12
What do you think, you know, is the prospect of fixing art or changing that?
59:21
Let me just start with you, since I didn’t watch this, And yeah, Well, I’ll let others chime in.
59:26
It’s interesting. I feel like it’s politically. But on the list of, like, every time, someone’s about to do something in this space, kind of, on the list of things that, I think there’s bipartisan support for. I think we’re, where it’s gotten challenging, is within some of the most recent legislation. As everybody knows, They’re trying to come up with priorities on where they’re going to spend money.
59:49
And so, I think, that’s really, I think, politically, where it is, is it’s just an issue of competing priorities.
59:56
Yeah, and I wanna get to a broader question about those competing priorities, but let me ask if others have a thought to that. Kevin …
1:00:06
said that it was a, the questionnaire specific about your state, do you have a thought about that, as well?
1:00:12
I do. I think what’s interesting on the family glitches if you look around, especially as public sector employees typically fall into this category more than others and so whether you’re in a large urban dish, urban area or a small, rural community, it’s probably one of your top 2 or 3 employers as well. And so the ability to get to that many people that to actually give them the ability to actually get care, I mean, these are folks that are teachers. Janitors bus, driver. I mean, these aren’t folks making a whole heck of a lot of money, anyway, and so, their families is like, you know, hey, great, I have insurance, but you have to go explain to your significant other in kids that you know. Go, you, go figure it out. Is a very difficult conversation for households to happen. And so, I think I’m actually a little more optimistic on that, one than I am on a number of other things right now. But, I do think that there is a way to figure that one out.
1:01:06
Because I think the benefit to it is going to be larger than most people would estimate.
1:01:11
Yeah, and I, if I may, I do wanna point out, there is a, you know, the administration has a unified agenda of rules that they hope to tackle a plan to tackle at some point. And there’s a hint that this is on that agenda. There is a regulatory fix here. It doesn’t have the same outcome as if there were a legislative fix. But you could interpret the affordability test to allow for consideration of what it would cost for those dependencies to get care and measure affordability against that instead of, you know, what it costs for the employee only to enroll.
1:01:41
And so the family would end up in two different places of coverage, the employee would remain with the employer plan, the dependence would be free to go to the Marketplace Premium tax credits. But it’s one area that states like Colorado and others that. when they think about people that that are falling through the cracks there, they’re thinking of ways that they can devote state dollars to that. And you know clearly if it was address at the federal level, those state dollars will be freed up to to reach other populations.
1:02:09
Also, lift our in our in our analysis of employer premiums, average premiums that people are paying an eight states. The average premium relative to income is exceeds at 8.5% threshold, So that’s an average of crossing on family plans.
1:02:24
So the, both lowering the threshold to 8.5 and fixed. And it worked with really, potentially help a lot of?
1:02:36
Great, thank you. And I have a question about, there’s a, there’s a, there’s a question from our audience about, about another provision. And so I wanna ask that question, and not one is directed at James. And it’s whether you’ve considered or if, the, actuarial considerations? of the, the tax credit provisions that were in the Build Back Better Act that would be focused on low-income populations. And particularly kind of this question around like how our actuaries thinking about the challenges potentially sending premiums for marketplace plans. If the bill that better were enacted, that would allow individuals with incomes below the poverty level, are currently ineligible for the subsidized marketplace coverage to gain access. So you know, for example, and 12 states that haven’t taken up the Medicaid Expansion.
1:03:29
How are you thinking about questions of pent up demand? Would use?
1:03:33
You know, expect that to be substantial if that coverage gap population became eligible for marketplace subsidies. And then, lastly, very it’s a multipart question. What health equity issues, do you think we would then be, would then be affected. So you’ll take, you can write a whole essay on it, after that. Thanks for taking a stab at that. That great question.
1:03:57
OK, that is a great question and you know, I was, I was, keeping it in my brain. And then you went to, to further and further questions. So I’m gonna start with a pent up demand question. Because that is certainly something that.
1:04:16
You know, is a concern when when trying to price with these changes in population.
1:04:22
because one of the, the inputs to the Premium level is, of course, the risk pool and what the risk pool looks like.
1:04:31
And so a lot of new, new members into the risk pool raises the question of what that new risk pool will look like once these these people enter. And then, it’s also a question not test, or the better bill, but also, on the, when the public health emergency, and a lot of people get off the Medicaid rules and boon to the financial markets. So, that’s a question that it depends is the beyond the answer. It depends on the mix of people that come in, and, quite frankly, the risk pool.
1:05:18
Oh, the risk pool impact really depends on who are these people.
1:05:25
Are they not only their status and their sense of the mind, but also where do they lie on the in them, because they are the eligible for subsidies.
1:05:40
So, the impact on us is great for those who are unsubsidized, all right. Oh, or marginally subsidized than for the folks that heavily subsidized.
1:05:57
When I talk about say, I’m talking about the cost to the consumer, because most of the cost will be taken up by the subsidies.
1:06:06
I also wanted to, to kind of piggyback off of what we were talking about before, as far as no states are taken up.
1:06:18
Um, I find that recently, a lot of states, now, having a lot of activity around what can they do, in addition to what the federal government is doing as far as subsidies, and not just In the past, a lot of the focus has been on premium subsidies and given additional premium subsidies to, to those over the federal poverty level.
1:06:48
Now, the focus has shifted with AARP, the focus has shifted, too, um, sharing subsidies where the focus is now, on, what can states do to make the out of pocket expenses a little more affordable for all the consumers.
1:07:10
So I think they I don’t know if I tackled the whole question. But, yes, I am.
1:07:20
Yeah, if there’s something I didn’t tafel, but do you want me to dress? I’d be happy to.
1:07:28
Great. Thank you so much. And just a reminder to our audience, that our panelists have graciously shared their contact information. That’s an expert list that we have shared with you on our website. And that also includes a number of other experts and stakeholders in this, in this area. In case folks have questions about these or related issues. All right. I want to ask this sort of tradeoffs question before we move on to the next round, and we’re getting some great audience questions. And you know, Liz, like, you, you really talked about.
1:08:06
It’s a matter of priorities and tradeoffs. And in all of these policies, right, like we’re kind of talking about this tradeoff between consumer affordability and when they pay out of pocket and their families, our pocket, and then what is coming from largely they’ve been talking about federal budget, although Joanna, of course, also mentioned that some states have chosen to sort of enhance subsidies.
1:08:28
I mean, Liz, you’ve been, you’ve been in those rooms where the debates are happening. I mean, do you see this as just, like, how fundamental is this to challenge challenges, to finding consensus? How do you see policy makers, you know, particularly on it, hopefully by partisan basis, like ever ever addressing it?
1:08:48
That the fundamental tradeoff between, you know, tax, tax payer, public taxpayer dollars, going into subsidies versus what, what individual households and individuals are.
1:09:00
Yeah, I would say it’s a challenge.
1:09:02
I think that, as I mentioned before, I think all of all of the different health policy issues that I’ve worked on, these issues are, are very different because of the politics surrounding the Affordable Care Act, and it is amazing to me, having been on the **** during that time. I listen, I worked for a Senate Republicans during that time. So it’s not. So, I understand, you know, during that time, the policy concerns, it still shocks me that today, though we’re still operating from our perspective. We’re kind of still at the loggerhead stuff like that, your forwarder or you’re against it.
1:09:38
And in, I think, it was 2016, when you started to see thought on, cost sharing subsidies weren’t going to be paid, And you started to see some counties that are likely to not have insurers on the market. You started to see a little bit of a panic of some, I think, Republicans in Congress, with an understanding that no, private insurance in their district was actually not a good app. And you saw them kind of band together. and then, you know, some situation has changed, and there was no longer at this moment. So, I think there has to be a confluence of things and then it gets hard.
1:10:16
When either party is talking about doing something through reconciliation, it becomes this, like, kind of, in our big, political moment, it becomes a lot harder to have some of these real-world conversations. But the conversations are ongoing, and so I think affordability, to me is really kind of the next real theme.
1:10:37
Both individual market employer market, really addressing people’s out of pocket costs, I think, is gonna really dominate, you know, almost everything that Congress does on healthcare in the next two years. So I think in the confines of that affordability conversation, I think there’s definitely room, you know, for some consensus, and to move forward.
1:10:59
Thank you so much, Kevin, from the State Policymaking perspective, you know, how do you see this, and what you’re hearing from families every day?
1:11:10
Where do you see us or pass through here?
1:11:15
Oh.
1:11:18
It’s tough. I mean, you know.
1:11:22
one, we have combined federal tax credits and health insurance to create this Frankenstein. Right. This, this, this very complicated monster that families are supposed to figure out. And then we say, we explain everything and federal poverty level numbers.
1:11:41
People don’t know what that means, They’re trying to figure out how to work per hour.
1:11:44
We converted everything that we send out, especially like the restaurant workers, Other folks that we know work hourly jobs to what the hourly rate is for all of that to try to figure out, because they know how much they make an hour.
1:11:57
They don’t know how much they make year, because they don’t know how many hours they’re going to work.
1:12:01
And so, really trying to change this conversation in a way that the average person can understand what their choices are.
1:12:10
And a lot of the work that we’ve been doing is trying to make those choices more, reasonable for them to figure out, because, you know, the great thing. In Colorado, we added almost 100 new plans on the exchange. Bad news is we added almost 100 new plans on the exchange, and it’s just tough for folks to kinda figure out how to wade through all of that.
1:12:31
And so we’re trying to ask 3 to 5 questions upfront to kind of limit that what they need to see so they can say, OK, I can handle this number of choices that are close to me that have the farm, the pharmaceuticals. I’m looking for the doctor, the network, whatever they’re whatever they define. And so I think we, with all this conversation we have about, all this stuff is moving around us.
1:12:55
Not to lose sight of what the customer needs to know, to make a decent decision for their families To actually get the dead gum health insurance and use it.
1:13:04
Yeah, Thank you. And that leads, right into the next question, actually, which is, around this idea of choice, And, of course, you know, we often talk about consumer choice, is something people really like as a, kind of a core value. But then also, obviously, like, you have to help people navigate those choices. We have a question, which is, can the speakers talk more about standardized plans and sort of, you know, Hey, I thought there already were standardized plan. We already have, like, the gold, silver, or bronze, et cetera, levels.
1:13:36
Can you, can you give them a little bit more specificity about what, what you mean by standardized plans?
1:13:43
And Kevin, I don’t know if you want to start off with that and then I’ll turn to to Joanne and to Sarah and Annette and literally oh no, I’m putting to Joanne on that one. I will be on it. I’ll be on a diatribe it won’t be helpful.
1:14:02
So, yes. I mean, I think there is some level at a basic level level of standardization with the metal with them, you know, that it was intended to make it easier for people to do apples to apples comparisons. I’m looking at the silver level and looking at the gold level, but this takes it a step further to really lock in cost sharing for particular services. And in many cases, as I said, make more services available without having to meet the deductible. Primary care.
1:14:26
Behavioral health are often services made available before the deductible with standard plans to set cost sharing for other services and to prioritize co-pays or co-insurance, which it’s easier for consumers to understand what their out of pocket costs are. When they’re looking at a dollar number instead of 20% of some unseen, no cost that may show up on their bill one day. And they used to be in the healthcare dot gov marketplace as an option for insurers. What the feds are proposing now is to require it of all insurers that are offering to HPS and the Health and healthcare dot gov. And, as I said, states have been doing this for, for some years now, and it’s both to help with that decision making, but also to make coverage more affordable and people to know more easily understand what their out of pocket costs are.
1:15:10
It does, as proposed in the Federal rule, dramatically increase the number of plans because the rule is for every … you offer in a metal level or product type like HMO. You also have to add standard plan. And so, they’ve also asked for comment on whether or not they should limit the number of plans, if they should require meaningful difference so that there aren’t these minor differences between plans that consumers can actually distinguish between.
1:15:35
and they’ve also propose to tighten the de minimis variation on a deep plan. So as 70% plan can actually be anywhere from 66 to 72, that proposing to sort of bring up the bottom end of that. So it has to vary between 70 and 72%, and that’s a narrower variation when you’re looking at a silver Plan.
1:15:56
Thanks. And so, just to clarify, you’re talking about, first of all, this, the percentages you just mentioned, you’re talking about actuarial value. Yeah. Correct, OK. And then the role you’re talking about is the proposed notice of benefit and payment parameters that was released, I believe, honest, say, December 23rd, or something like that, of last year. So.
1:16:15
So that’s an active rulemaking and progress. I think someone earlier had also asked like what’s going on at the federal level. That is something and we can send around that link for those who are interested in some bedtime reading, the notice of Benefit payment parameters.
1:16:30
And then lastly, Julia, just for those who are kind of maybe a little newer to health insurance terms, this idea of co-pay versus co-insurance like $20 versus 20%, right, like a flat, a flat co-pay versus a co-insurance, and OK. Anyone else want to chime in on that? That question of standardized? And I’m not sure how helpful it would be, but what the thing is with standardized plans.
1:17:01
And Joanne mentioned, you know, some of the concerns.
1:17:10
Yeah, some of the concerns. one is that she said is that you add more plans, That’s not helpful.
1:17:20
The other thing is that, I think we all know that health is local, and so the extent to which these standardized plans reflect what the needs are, or the specific circumstances of an area, even within the state.
1:17:38
I think that would make it more more helpful to, to the Emily population.
1:17:48
The use of standardized plans in the states that have implemented has been quite low.
1:17:56
And in those states where they limited the number of lines, The number of non sunday nights glance, that’s where you see more effective teeth.
1:18:08
So, those are some considerations.
1:18:10
And as far as as health equity, the, uh, it’s not clear that adding standardized plans would help.
1:18:24
The goals of health equity.
1:18:26
Unless it is done in a way to, to focus on the inequities and where the benefit design would, will the change in the design would impact health equity. So, so, those are some things that states are starting to think about standardize lands in the markets.
1:18:48
Those are some things that may be considerations. Millimeter. Hmm, I want to ask you that have an impromptu question here, which is just, I mean, it just, it feels like sometimes this conversation is, is like, you know, the government is setting standards where the federal or state, you know, the health insurance plans. And, you know, we haven’t talked about the rural providers at all, but then we’re trying to explain it to consumers.
1:19:12
Like, is anyone making an effort to actually ask people, know the end user, the consumers, like what they think, and what would actually be useful and clearer to them, and then trying to incorporate that into the design. I don’t know if anyone wants to try to respond to that, but I am curious if there have been efforts along those lines?
1:19:33
I can’t speak to the kind of direct outreach to consumers. I will say that in and kind of the confines of our kind of enrollment coalition work. There’s a number of different kind of patient advocacy groups that are engaged in that work. And I think in general, I have to say, I think the administration has been really open and interested in hearing from people that are kind of on the front lines about what works and what doesn’t work. And so all of us also put a plug that, you know, whether it’s commenting on the notice and benefit payment, permanent roles for other opportunities to really engage with policymakers.
1:20:08
I think it’s really important, because particularly at a time when a lot of policy makers aren’t hearing really profitable ideas, I just think it’s so important that they’re hearing from people on the ground about what is and isn’t helpful.
1:20:26
Thanks.
1:20:27
Early, early stage efforts really struggled with, from, you know, displaying standard plans in a way that consumers could find them. I mean, this is not directly your question about what consumers want in that specific plan design. But, even just the presentation of them, I know, was not well done in the beginning, and I think states have really evolved from there. And the Feds are asking, as part of this proposed rule, what should we be keeping in mind about display and in helping consumers understand what this standard plan is and how to find them?
1:20:57
Thank you. And I saw Kevin kind of nodding, nodding along to that, as well. Anything you wanted to add, or?
1:21:05
Yeah, I think sometimes, we, we think, we know what the customer wants, but when we ask them, we actually find out what we didn’t think to ask. And I think, you know, we’ve learned a lot of that on how we’ve just done changes in our plan design, and how we’re making changes to the shopping platform.
1:21:21
And I think, you know, going back to something I said a little earlier, you know, if people don’t really understand this whole structure, you know, making an assumption of what we think, because we know the policy really well, is a pretty dangerous place for us to start.
1:21:35
So, I think, making sure that we have as much effort to talk to them, the customer about what they care about, and then finding a way to translate that into the language we’re used to and framing it in that way. It’s got to be the has, it just has to be the way that we start.
1:21:51
Yeah. Thank you. Sarah Collins, I want to bring you into the conversation.
1:21:55
And I’m curious like with your researchers eye and ear like, what are you, what are you thinking is important to look for as as you sort of think about.
1:22:06
Yeah.
1:22:08
I think calculating these trends, but I mean, you’ve been looking at this now for at least 10 years, if not like many, many more and then sort of tracking this stuff. I mean, from a from a researcher’s I like, What’s, what’s popping for you in this conversation?
1:22:23
No, I agree. The standardized plans as such a, it’s such an important thing to do and particularly focus on stock deductible exclusions and making it easier for consumers to choose.
1:22:34
But I think that the part that we haven’t addressed and what we really need to address is the fact that people are facing really high deductibles. And a lot of these, and a lot of a lot of these class, an individual market, the cost sharing subsidies are fantastic, but they’re only for people. under 200% of poverty.
1:22:51
Are 250, but that even between 2 and 250 years is very high.
1:22:56
Deductibles are pretty high, so we really have to get at that. There are bills in Congress to extend the subsidies further up the income scale, but it’s a, it’s a, it’s a big issue, and then it’s an issue and employer plans to end.
1:23:11
The one thing I do want to point out to, just just just as a reminder to the audience, is, where are these costs come from?
1:23:17
You know, when we talk about the tax financing, and then the and then what consumers pay, this is really a problem of health care cost growth, and, and, and, and it’s if we continue to see excessive growth in healthcare costs, which is primarily driven by provider prices.
1:23:37
We’re always going to be in this situation where we’re trying to decide how much taxpayers pay of this ever larger bill and how much consumers have to pay out of pocket. So, I think there’s just some overarching cost issues here. The public plan public option debate gets at that. But it’s, a, it’s a, it’s a, it’s a hard issue. And it’s one we’re going to continue to grapple with when we talk about affordability or underlying drivers with us.
1:24:06
Yeah.
1:24:10
Just it just reminded me, I mean, putting that together with the standardized plans and co-pays, and, you know, we’ve heard from states where they have co-pays. They may have to adjust them the next year, because the cost increase behind it. If you do a co-insurance, just the consumer’s cost grows with the underlying cost growth.
1:24:26
But though consumers prefer the co-pay, this unrelenting trend in cost growth means that states that have standardized plans have to go back and tweak them year to year, because what was but fit in the math of it. Actuarial value one-year with $20 co-pay no longer works the following year.
1:24:44
Yeah, thank you. And I wanna ask just one question that came in, from the audience. that gets a little bit to this question of under Underlying Costs. And it’s for a net. Are you looking at the actuarial impact of coven delayed treatment? So, for example, those non coven related things that haven’t been treated. Are you looking at the high death rates among seniors? What are the actuarial impacts of that? as well as Long coven? And how are you beginning to think about that?
1:25:10
Yeah, that’s a really good question. So, so that is something that we are looking at.
1:25:16
We know that the data is not conclusive right now, it’s still evolving and it depends on on the different areas of the country. You have different different impacts, but that is something that I think.
1:25:35
Health plans, I’m going to have to factor into their cause.
1:25:39
You know, Because because we don’t know what the impact of them is, we don’t know the extent of it yet.
1:25:51
And you know the, when it’s when **** it was mainly impacting the elderly.
1:26:02
one could say that the timeframe for that was, is really sure.
1:26:08
But now the qubit is impacting younger and younger people timeframe, for the impact and they tend to be really significant.
1:26:20
So that’s, we’re looking at that, but quite frankly, we don’t have enough data yet to understand, all, know exactly what that means. But that is something that’s very troubling.
1:26:34
And then you mentioned the the foregone play here. We’re seeing increases in mortality incidence in certain areas, or when reasons, and part of that is the for them.
1:26:52
And so, you know, that, that is also very troubling. Whoops.
1:27:00
Exactly. What does that look like?
1:27:03
Oh, um, how deep is that impact? How long is that, is that impact them?
1:27:13
That does not, that’s not helpful for trying to manage the boss out there.
1:27:21
But those are things that we’re looking at and we don’t honestly, we don’t have any answers, right?
1:27:27
Yeah. Thank you. And I suspect we’ll be spending quite a few of the next several years really unpacking and and trying to better understand the impact of this pandemic and as we are, as we hopefully turn the corner and emerge from it.
1:27:44
But, but certainly, silver fires. Very good data and objective look and thoughtful discussion, including from people like yourselves. You have been amazing panelists today. Thank you so so much. We have just one minute left, so we don’t have time for any more substantive questions, but we are so grateful to Kevin. Patterson, Director of Colorado Health Benefit Exchange, Liz Row of Levitt Partners and that James American Academy of Actuaries and Joanne Vault from CER Center on Health Insurance Reforms at Georgetown and Sarah Collins from the Commonwealth Fund. We are grateful for your partnership really grateful for your incredibly thoughtful remarks, and I hope that our audience has taken away some some new learnings from this. Again, you’ll be able to watch a recording of this discussion on our website as soon as it’s the technology.
1:28:46
She is ready, and the materials will be on our website at all health policy dot org, So please take time to complete the brief evaluation survey you’ll receive and share your thoughts with us. as well as your wishes for future topics for us to cover, and join us next Friday, January 28th, for the next event on our in our Health Policy Roundup series, focusing on state policy analysis and priorities and get a better sense of what’s been going on in the states. So, again, thank you. This concludes today’s webinar on recent Trends in Coverage enrollment Affordability, Joanne, Patrick and Atlas, Sarah. Thank you for joining us today.
1:29:27
Thank you. Thank you.