Two health policy groups brought the leaders of 85 public exchange assister programs together for a conference this summer and discovered something shocking: Managers of the assister programs found that getting poor, uninsured people insured is difficult.
Assister program managers took note of the challenges “associated with helping consumers match their health and financial needs to plan characteristics.”
Analysts at the Kaiser Family Foundation and the Robert Wood Johnson Foundation organized the assister program manager roundtable, in June, to see what was happening at the country’s 4,400 Patient Protection and Affordable Care Act (PPACA) exchange assister programs.
Originally, when policymakers designed the exchange system, they thought the new, standardized qualified health plans (QHPs) would sell themselves. Brokers and agents had to fight to get any opportunity to sell QHPs.
PPACA called for exchanges to offer a nonprofit Navigator program, or ombudsman program, to provide low-income people and people unfamiliar with private insurance a little independent technical support. Once the U.S. Department of Health and Human Services (HHS) and states with state-based exchanges began thinking seriously about enrollment, and realized that the PPACA Navigator provision requirements made hiring Navigators difficult, they created other types of exchange helpers, or “assisters,” to provide a stripped-down version of the services that licensed agents and brokers have traditionally provided to consumers enrolling in health plans, without the involvement (or expense) of producer sales commissions.
At one point, for example, Nevada was hoping it could get uninsured people enrolled in QHPs for $35 per buyer helped by a live human.
Brokers themselves estimated — even before the exchange enrollment systems opened for business and system glitches began wasting enrollers’ time — that helping an intelligent, well-organized consumer enroll in QHPs with a smoothly functioning enrollment system would take a minimum of 30 to 45 minutes of agency time, at a minimum cost of about $50 per hour. Brokers warned that helping unsophisticated consumers with complicated profiles could take far longer.
Here are five startling conclusions assistance program managers came to after actually “facilitating enrollment” in QHPs.
1. A QHP enrollment process and plan design system that was difficult for insurance companies and veteran insurance producers to understand was difficult for low-income, uninsured consumers to understand.
The assister program managers said assisters faced “huge” insurance literacy barriers, with consumers having a hard time understanding basic concepts such as “deductible,” let alone the new PPACA cost-sharing reduction subsidy program.
Assisters tried to translate terms such as “advanced premium tax credits” into terms that seemed easier for consumers to understand, such as referring to the tax credit as a “monthly discount coupon.”
2. For assisters, getting complete, accurate, up-to-date information about exchange rules and procedures was a headache.
Groups for exchange agents and brokers have complained that the Centers for Medicare & Medicaid Services (CMS) — the HHS agency that supervised the entire PPACA exchange system and managed operations at the HHS-run exchanges — sent regular e-mail newsletters to the nonprofit exchange helpers but not to licensed producers.
The assisters told the policy groups that figuring out what was going on with exchange program rules was no picnic for them, either. They said they ended up having to check HealthCare.gov, the Regtap technical assistance portal, other CMS websites, and sites maintained by private organizations.
“Participants suggested that it would be helpful to have a single, reliable, up-to-date compilation of guidance summarizing evolving rules and regulations that would be posted online so all assister programs could access it,” the policy group analysts write.
3. Well-meaning, energetic assisters who wanted to help clients with enrollment or coverage use problems often had no way of knowing about the problems.
In some cases, the assisters said, the consumers or assisters made a mistake, or an exchange asked for more documentation to back up something in an application. Often, the notices from an exchange were hard to understand, or submitting an appeal or extra information was difficult.
In other cases, the consumers received notices from the exchange, but the assisters had no idea that there was a problem.
The assisters who showed up for the roundtable conference said exchanges should send copies of notices about problems to the assisters as well as to the consumers, or at least tell the assisters that the exchanges have sent notices to the consumers.
4. Real clients often have complicated problems.
The assisters said their clients often needed legal advice about immigration law or the tax implications of using PPACA exchange subsidy programs.
The assisters said they and their clients need more training, and more access to tax and immigration law specialists.
5. Exchange assister programs typically pay too little for exchange programs for the programs to keep good workers or to go door-to-door to get the attention of the most isolated uninsured people.
One state, for example, had an 80 percent turnover at its call center because of the low pay level.
If the workers in the assister program are viewed as “temporary, poorly remunerated, and not yet professionalized,” they may lack the stability to develop expertise and connections in their communities, assisters told the policy groups.