Tagged Open Enrollment

Podcast: ‘What The Health?’ Is Health Care Spending Still The Hungry, Hungry Hippo?

Congress is trying to wrap up its work for the year, but unsettled questions remain about the Children’s Health Insurance Program, the fate of the individual mandate insurance requirement from the Affordable Care Act and other health issues. Meanwhile, outside Washington, major mergers are happening within the health care system and the federal government reports that the rate of increase in health spending slowed in 2016.

This week’s “What the Health?” guests are:

Julie Rovner of Kaiser Health News
Stephanie Armour of The Wall Street Journal
Alice Ollstein of Talking Points Memo
Margot Sanger Katz of The New York Times

They discuss these topics and other health news of the week, including the state of open enrollment for 2018 health insurance.

Among the takeaways from this week’s podcast:

  • The iron-clad promises on health care that Sen. Susan Collins (R-Maine) secured for her vote for the tax bill may be splintering.
  • Although a number of health programs could see funding cut as a result of the tax bill, lawmakers promise that they will protect Medicare.
  • Former Obama administration officials are worried that last-minute insurance enrollment on the federal marketplace could be anemic this year, because the Trump administration has not promoted the law.
  • The merger mania of the past week highlights insurers’ interest in having a piece of the action in other parts of the health care system.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Tonic.Vice.com’s “Why Do People Hate Obamacare, Anyway,” by Julie Rovner

Stephanie Armour: The New York Times’ “Millions Pay The Obamacare Penalty Instead Of Buying Insurance. Who Are They?” by K.K. Rebecca Lai and Alicia Parlapiano

Alice Ollstein: The Washington Post’s “Rep. Trent Franks Of Arizona, Who Asked Staffers If They Would Bear His Child As A Surrogate, Says He Will Resign,” by Mike DeBonis and Michelle Ye Hee Lee.

Margot Sanger Katz: Vox.com’s “Emergency Rooms Are Monopolies. Patients Pay The Price,” by Sarah Kliff.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

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Podcast: ‘What The Health?’ Is Health Care Spending Still The Hungry, Hungry Hippo?

Congress is trying to wrap up its work for the year, but unsettled questions remain about the Children’s Health Insurance Program, the fate of the individual mandate insurance requirement from the Affordable Care Act and other health issues. Meanwhile, outside Washington, major mergers are happening within the health care system and the federal government reports that the rate of increase in health spending slowed in 2016.

This week’s “What the Health?” guests are:

Julie Rovner of Kaiser Health News
Stephanie Armour of The Wall Street Journal
Alice Ollstein of Talking Points Memo
Margot Sanger Katz of The New York Times

They discuss these topics and other health news of the week, including the state of open enrollment for 2018 health insurance.

Among the takeaways from this week’s podcast:

  • The iron-clad promises on health care that Sen. Susan Collins (R-Maine) secured for her vote for the tax bill may be splintering.
  • Although a number of health programs could see funding cut as a result of the tax bill, lawmakers promise that they will protect Medicare.
  • Former Obama administration officials are worried that last-minute insurance enrollment on the federal marketplace could be anemic this year, because the Trump administration has not promoted the law.
  • The merger mania of the past week highlights insurers’ interest in having a piece of the action in other parts of the health care system.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Tonic.Vice.com’s “Why Do People Hate Obamacare, Anyway,” by Julie Rovner

Stephanie Armour: The New York Times’ “Millions Pay The Obamacare Penalty Instead Of Buying Insurance. Who Are They?” by K.K. Rebecca Lai and Alicia Parlapiano

Alice Ollstein: The Washington Post’s “Rep. Trent Franks Of Arizona, Who Asked Staffers If They Would Bear His Child As A Surrogate, Says He Will Resign,” by Mike DeBonis and Michelle Ye Hee Lee.

Margot Sanger Katz: Vox.com’s “Emergency Rooms Are Monopolies. Patients Pay The Price,” by Sarah Kliff.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

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Cost and Quality Health Care Costs Insurance Medicare Multimedia The Health Law

For Marketplace Customers Who Delay, Auto-Enrollment Could Be Nasty Wake-Up

Shopping to update your coverage on the health insurance marketplace may be annoying — didn’t you just do this last year? But letting the exchange automatically renew your coverage instead could be a big mistake. If you don’t like the plan you’re auto-enrolled in this year you may be stuck with it in 2018, unlike previous years when people could generally switch.

It’s all in the timing. This year, the open enrollment period, which started Nov. 1, will end a week from today, on Dec. 15 in most states. On Dec. 16, if you haven’t picked a new plan, the marketplace will generally re-enroll you in the one you’re in this year or another one with similar coverage.

But unlike previous years when the open enrollment period ran through the end of January, this year open enrollment will generally be over by the time you see which plan you’ve been assigned to.

“The deadline catches up with people,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

It’s important to affirmatively pick a plan to make sure you’re getting the right coverage at the best price. Federal tax credits that help pay for premiums are pegged to low-cost silver plans, called benchmark plans. It’s critical that each year you run the numbers to determine how your premium tax credit could be affected by changes in the benchmark plan and how that affects what you will pay out of pocket for coverage. Even if you are assigned to the same plan, your costs could be different next year.

Auto-enrollment doesn’t take premiums or benchmark plan changes into account, said Stan Dorn, a senior fellow at Families USA, an advocacy group.

Last year, 2.8 million people were auto-enrolled. That’s nearly a quarter of the 12.2 million people who enrolled in marketplace plans during the open enrollment period that ran from Nov. 1, 2016, through Jan. 31, 2017.

People whose plans will be discontinued by their insurer next year have a little room to maneuver if they’re auto-enrolled on Dec. 16. Because their plan will no longer be offered, that’s considered a loss of coverage, which triggers a 60-day special enrollment period. They can pick a plan through the end of February.

“But you have to pay the premium [on your existing plan], or you’ll have a gap in coverage,” said Pollitz, a risk that potentially exposes people to a penalty for not having insurance.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

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Challenges Abound For 26-Year-Olds Falling Off Parental Insurance Cliff

Marguerite Moniot felt frustrated and flummoxed, despite the many hours she spent in front of the computer this year reading consumer reviews of health insurance plans offered on the individual market in Virginia. Moniot was preparing to buy a policy of her own, knowing she would age out of her parent’s plan when she turned 26 in October.

Marguerite Moniot recently purchased health insurance on the open market with the help of a health navigator. She and her parents began searching for a policy several months ago, but the details of each plan became too complicated for the family. (Courtesy of Marguerite Moniot)

She asked her parents for help and advice. But they, too, ran into trouble trying to decipher which policy would work best for their daughter. The family had relied on her father’s employer-sponsored plan through his work as an architect for years, so no one had spent much time sifting through policies.

“Honestly, my parents were just as confused as I was,” said Moniot, a restaurant server in Roanoke.

In defeat, just before Thanksgiving, she went with her mother to meet a certified health insurance navigator, buying a policy that allowed her to keep her current doctors.

A new crop of young people like Moniot are falling off their parents’ insurance plans when they turn 26 — the age when the Affordable Care Act stipulates that children must leave family policies.

They were then expected to be able to shop relatively easily for their own insurance on Obamacare marketplaces. But with Trump administration revisions to the law and congressional bills injecting uncertainty into state insurance markets, that task of buying insurance for the first time this year is anything but simple.

The shortened sign-up period, which started Nov. 1, runs through Dec. 15. That window is half as long as last year’s, hampering those who wait until the last minute to obtain insurance.

Reminders and help are scarcer than before: The federal government cut marketing and outreach funds by $90 million, and federal funding to groups providing in-person assistance was whacked by 40 percent.

“I think it’s definitely going to be difficult. There’s just additional barriers with [less] in-person help, just fewer resources going around,” said Erin Hemlin, director of training and consumer education for Young Invincibles, an advocacy group for young adults.

Emily Curran, a research fellow at Georgetown University’s Health Policy Institute, said those actions combined with the Trump administration’s vigorous criticism of the health law could further handicap the uphill battle to entice young people to enroll. As of Dec. 2, more than 3.6 million people had enrolled through the federal marketplace, according to the Centers for Medicare & Medicaid Services. The data were not sorted by age.

“There’s already a barrier where young adults are having difficulty understanding what the value of insurance is,” she said. “Coming out … and saying prices are going up, choice is going down and this law is a mess doesn’t really get at the young adult population.”

Trouble Attracting Young Adults 

Before the Affordable Care Act, young adults had the highest uninsured rate of any age group.

The ACA made coverage more affordable and accessible. It allowed states to expand Medicaid to cover single, childless adults. Tax credits to help pay for premiums made plans on the individual market more affordable for people whose incomes fell between 100 and 400 percent of the federal poverty level (between $12,060 and $48,240 for an individual). And young adults were allowed to stay on their parents’ plan until their 26th birthday.

Dominique Ridley signed up for health insurance with the help of a broker. The college student lives with asthma and needs to carry her inhaler at all times. (Courtesy of Dominique Ridley)

In all, the uninsured rate dropped to roughly 15 percent among 19- to 34-year-olds in 2016. Still, young adults have not joined the individual market in the numbers as expected. About a quarter of marketplace customers in 2016 were ages 18-34, according to the Department of Health and Human Services. But that age group makes up about 40 percent of the exchanges’ potential market, according to researchers and federal officials.

If the Trump administration’s moves dampen enrollment, insurers could face additional challenges in attracting healthy adults to balance those with illnesses, who drive up costs.

“When you’re relatively healthy, it’s not something that you’re thinking about,” said Sandy Ahn, associate research professor at Georgetown University’s Health Policy Institute.

But illness does not recognize age. Dominique Ridley, who turned 26 on Dec. 6, knows this all too well.

Ridley has asthma. She always carries an inhaler and sees a doctor when she feels her chest tighten. The student at Radford University in Virginia relies on her mother’s employer-sponsored plan for coverage.

Ridley started peppering her parents with questions about health insurance as soon as she started seeing ads for this year’s open enrollment.

“I don’t want to just go out there and apply for health insurance, and it be all kinds of wrong and I can’t afford it,” she said.

Her parents didn’t have the answers, but her mother linked up Ridley with a friend that runs a marketing company tailored to promoting the Affordable Care Act. Ridley then connected with a broker who signed her up for a silver plan that will cost her less than $4 per month, after receiving a premium subsidy of more than $500 a month.

“If you don’t have health insurance, you don’t have anything,” Ridley said.

A Digital Campaign 

The Obama administration relied in part on partnerships to attract young enrollees to sign up. Last year, it collaborated with national organizations like Planned Parenthood Federation of America and Young Invincibles on a social media campaign called #HealthyAdulting. Emails, according to Joshua Peck, former chief marketing officer for healthcare.gov, were particularly effective for recruitment.

The Centers for Medicare & Medicaid Services, which oversees the marketplaces, said it will focus this year’s resources on “digital media, email and text messages.”

James Rowley sits in front of the counter at Vapology 101, an e-cigarette store in Herndon, Va. Rowley started his own business in 2015 called Virginia Vaping Co., which makes and sells e-cigarette flavorings to stores. (Carmen Heredia Rodriguez/KHN)

Hemlin said the government has not asked Young Invincibles to assist in marketing. Her group will use its own resources to pay for targeted ads on social media to reach the target demographic, she said.

“But obviously we can’t make up for $90 million in advertising” that’s been cut, said Hemlin.

One factor that might compensate is that 20-somethings are facile at shopping online, said Jill Hanken, director of Enroll! Virginia, a statewide navigator program.

“Our job is to make sure they understand to look at provider networks and drug formularies if they have health concerns. But they’re able to do the mechanics of enrollment on their own very often.”

James Rowley, a 26-year-old entrepreneur from Fairfax, Va., is among those who signed up without help. He started his own company two years ago while covered under his father’s health plan. When he turned 26, he signed up for health insurance on his own through a special enrollment period this year. After general enrollment opened this fall, he once again picked a plan.

“I might not 100 percent need it now, but there will come a time where health insurance is important,” said Rowley.

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Brokers Tout Mix-And-Match Coverage To Avoid High-Cost ACA Plans

Health insurance a la carte?

As the Affordable Care Act open-enrollment season moves into its final weeks, some consumers looking for lower-cost alternatives are considering a patchwork approach to health insurance. The products may secure some basic protection but leave patients on the hook for high medical bills.

The idea involves mixing and matching several types of insurance products originally designed to cover the deductibles and other gaps in traditional coverage.

“We have several carriers” from which clients can choose “prescription coverage from one and accident coverage from another and critical illness care from someone else,” said Eric Jans, a Nashville, Tenn., broker.

An entire package, he added, usually costs $900 to $1,000 a month for a family.

Though not new, the tactic is gaining momentum and interest with consumers — particularly in regions of the country with high ACA plan premiums.

And it’s gone national with the online firm eHealth, which launched a set of packages Nov. 1 and promotes them on its website to people who “can’t afford Obamacare.”

The packages won’t exempt people from the IRS penalty under the ACA, experts warn.

And consumer advocates caution the concept falls far short of full coverage.

“We’re seeing increased marketing of these over the past year. It’s a very risky proposition for consumers,” said Betsy Imholz, special projects director for Consumers Union. “Proceed with extreme caution.”

The packages cobble together “fixed-benefit indemnity” plans, also known as “gap coverage” plans, with other types of policies.

Most such “gap coverage” plans are underwritten, meaning they ask about applicants’ health and can exclude people with medical problems, or exempt those conditions from coverage.

These plans pay an often-small per-day or per-service amount toward hospital care, doctor visits and lab tests — for example, $65 for a primary care appointment or $175 for an advanced imaging test.

The packages usually include a prescription drug discount card.

Many also feature a “critical illness policy” that pays a lump sum of between $5,000 to as much as $50,000 if the policyholder is diagnosed with a qualifying illness, such as a heart attack, cancer or stroke. Some also incorporate short-term medical policies, which must be renewed every 90 days.

None provides comprehensive major medical coverage.

The effort to reinvigorate sales of such policies comes as premiums for some ACA plans are rising rapidly, fueled by that ban on rejecting people who are sick, the inability of Congress to agree on efforts to stabilize the market and Trump administration actions that undermine the federal health law.

In some markets, families now face ACA premiums that exceed $20,000 a year.

“There are entrepreneurs all over the insurance industry looking at the fact that people can’t access insurance they can afford,” said Robert Laszewski, an industry consultant based near Washington, D.C.

Detailing The Coverage

The IHC Group, which offers the type of hospital indemnity coverage often included in such packages, provides a hypothetical example of how its plan works. A person in the hospital with pneumonia for five days, two of them in intensive care, would receive a flat payment of $12,250 in total toward that hospital bill.

While that may sound like a lot, the hospital bill, “if you’re on a ventilator and getting antibiotics, could be $12,000 a day,” said Missy Conley, director of consumer claims at Roanoke-based Medliminal, a firm that helps consumers sort out their medical bills.

“And that’s just the nursing staff and the room,” she said. “It doesn’t include the physician who pops in or the respiratory therapists.”

Most people have no clue how much big-ticket items like hospital care, chemotherapy or surgery can cost. And it’s hard to get medical providers to disclose their charges. Still, the average cost of a three-day stay in the hospital is $30,000, according to the federal government’s health website, healthcare.gov.

Even with those limitations, some consumers are now eyeing the packages for their sole coverage.

“With [these products], we try to put together carriers that provide something [as] close to major medical as we could get,” said Nate Purpura, eHealth’s vice president of marketing.

Prices vary by carrier, level of coverage and the age and gender of the applicant.

Even with lower premiums, a package might not end up being less expensive than an ACA plan if the consumer has a medical issue or two during the year.

The materials eHealth uses to explain its plans illustrates that point.

It starts by warning consumers that medical insurance packages “may not be the best option” if they have job-based insurance or can afford an ACA plan.

But then it highlights Jane, a hypothetical 28-year-old who says she can’t afford the $350 a month an ACA plan would cost her.

Instead, she gets an eHealth package plan for $230 a month, saving $1,440 in premium for the year.

Unfortunately, Jane has a bike accident, breaks a bone and then a month later needs new glasses.

The example shows that her package of plans paid a total of $17,000 toward the ambulance ride, the hospital costs, her pain medicine and her new glasses. Jane saved $17,000 off total costs incurred of $21,550, the brochure says.

But, what it doesn’t spell out is that she still had to pay about $4,550 for her share of the rest of the tab.

Certainly, she’s better off financially than being uninsured. But, in reality, her package plan cost her $3,110 more than if she had gone with the seemingly more expensive ACA coverage.

“Every dollar you don’t spend on premiums looks like a savings,” said Michael Lujan, co-founder of employer benefit firm Limelight Health in San Francisco, and a board member of the Silicon Valley Association of Health Underwriters. “But let’s say you end up in the hospital with surgery or whatever, you need to weigh that and consider ‘What would my costs be?’”

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Churning, Confusion And Disruption — The Dark Side Of Marketplace Coverage

Cyndee Weston can barely remember the last time she didn’t have to switch health plans during an Affordable Care Act sign-up season. By her count, she has been on five plans in five years.

Every fall, after she has spent months figuring out her insurance plan’s deductibles, doctor networks, list of covered drugs and other fine print, she receives notice that the policy will be canceled as of Dec. 31. Because her job doesn’t come with insurance, “it’s agonizing going through all the plans and trying to compare,” said Weston, 55, who has diabetes and a history of melanoma. “Every year it’s the same scenario: ‘We’re not going to renew your policy.’”

Under the market-based system set up by the ACA, individuals are encouraged to “shop around” each year to find insurance that better suits medical needs and income. In fact — like Weston, a trade association executive in Sulphur, Okla. — they are often forced to do so when plans drop out of the local market or eliminate preferred hospitals and doctors from the network.

The ACA increased the number of Americans with health insurance by 20 million and cut the uninsured rate to about 9 percent.

But the task of finding new insurance annually often undermines the continuity of care for people with ongoing medical needs or chronic conditions. That challenge is immeasurably harder this year as policies change under the Trump administration, spurring unstable networks and turmoil in many state and local markets.

“There’s quite a number of people who are either temporarily uninsured or they move into different plans” each year, said Marianne Udow-Phillips, head of the Center for Healthcare Research & Transformation at the University of Michigan. “And I’m guessing this year that will be much greater, given all the changes that are happening in the marketplace plans.”

Fewer than half of those buying individual coverage in 2014 kept the same plan the following year, according to a Michigan survey done by Udow-Phillips and colleagues. Nearly a third of marketplace enrollees for 2017 were new customers, meaning they had other kinds of coverage before or were uninsured. For the 2018 enrollment season that began on Nov. 1 and ends Dec. 15 in most states, millions of consumers will find themselves switching coverage.

The imperative to shop for insurance affects mostly those who buy insurance for themselves, such as small-business owners and those who are self-employed.

Enrollment for 2018 through online ACA marketplaces has been particularly complicated, due to big premium increases for some plans, the mistaken belief that the health law was fully or partially repealed and the administration’s decision to terminate $7 billion in subsidies.

Many of plans that people relied on for 2017 are being canceled, the result of insurers exiting the marketplaces or redesigning coverage to try to keep premiums down.

Aetna and Humana stopped selling individual marketplace plans for 2018 after losing money on the products. UnitedHealthcare has sharply pulled back. Hundreds of counties have only one marketplace insurer next year, although competition is higher in metro areas.

The average number of carriers selling individual marketplace plans in each state has fallen from five in 2014 to 3.5 next year.

“I wouldn’t call it ideal. It’s what we have,” said Sabrina Corlette, who studies insurance for Georgetown University’s Health Policy Institute. “Ultimately, the consumers have to read the fine print and probably expect that things are going to change from year to year.”

Such instability impedes what was supposed to be the ACA’s other big goal besides coverage expansion. Former President Barack Obama talked of fixing a “broken system” that neglects preventive care, orders billions of dollars in unneeded procedures and shuffles patients among doctors who don’t talk to each other.

The idea was to push insurers to help diabetics improve diets, keep patients on their blood-pressure medication, prevent asthma flare-ups and otherwise improve care and control costs.

Investing in prevention upfront, the thinking went, would pay off for carriers over time as members needed less emergency and inpatient care.

That equation fails when people find themselves with a new policy or a new insurance company each year — or more often.

Insurance churn “is a long-standing problem in the U.S. health care system,” said Benjamin Sommers, a physician and health economist at Harvard’s Chan School of Public Health.

“But there’s a concern that with the ACA you’ve added a whole new layer.” Insurance turnover is especially frequent among lower-income families and those with irregular work.

Unemployed people might be eligible for a plan under Medicaid, which the ACA expanded to most low-income adults in most states. But getting a job and a salary might make them ineligible for Medicaid, bumping them up to a subsidized marketplace plan and a coverage change.

Medicaid, which often comes with its own confusing menu of managed-care plans, generally covers those with the lowest incomes. Subsidized marketplace plans are for medium-income households.

In a 2015 survey by Sommers and colleagues, about a fourth of low-income adults reported they changed coverage during the previous 12 months. That was lower than expected but still problematic, Sommers said.

More than half the switchers had coverage gaps between policies, causing many to report skipped medications and poorer health. Even plan changers with no coverage gap were more likely to swap doctors, to have trouble booking appointments and to seek treatment in the emergency room.

Even though laws in some states allow patients in active treatment to keep doctors from one plan to the next, that’s not a recipe for stable medical relationships or long-term treatment strategies.

“Coming up with the right balance and right approach to a patient’s condition takes time,” said Sommers. “If you wind up with a new set of doctors and new coverage every year, it’s going to make that much harder.”

Cyndee Weston has navigated the shifting ground better than many. For years she has had the same insurer — BlueCross BlueShield of Oklahoma — which has dominated that state’s market for individual plans and is the only marketplace player for 2018.

But even though the carrier is the same and the health law requires insurers to take all comers, canceled plans each year force her to learn a new coverage design, file new paperwork with doctors and worry her primary physician will be dropped from the network.

One year BlueCross “automatically enrolled us into a bronze plan which we didn’t want, so we chose another gold plan,”  Weston said.

Even when insurers stay in a particular market, they often redesign plans from year to year, changing drug coverage or raising out-of-pocket costs to keep premiums as low as possible, Corlette said. As in Weston’s case, that often requires canceling the old plan and having subscribers switch.

“Each year, we assess our plan offerings and make any necessary adjustments to best meet our members’ anticipated health care needs,” BlueCross Oklahoma spokeswoman Melissa Clark said via email.

After Weston’s primary physician left the plan’s network this year, she’s had trouble finding a new one, although the insurer said its physician list has not changed significantly.

“I take some medications, and I worry that if I go to a new doctor they’ll change my medication or it won’t be covered,” she said.

A few weeks ago, she got a new notice from BlueCross saying her current plan is canceled as of Dec. 31. So she’s shopping again.

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Facebook Live: A Status Check On Obamacare Enrollment

As of today, Dec. 5, only 10 more shopping days remain for consumers who buy their own Affordable Care Act health insurance on the federal exchange and in most state marketplaces. So how is it going? What are the numbers so far? What are the market trends? And how has the enrollment experience been for consumers? This live chat features KHN senior correspondent Julie Appleby answering these and other questions.

For more in-depth conversations with KHN reporters, check out our Facebook video archive.

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‘I’ve Never Been This Busy’: As Marketplace Deadline Nears, Navigators Feel The Pinch

When Monica Spalding got the renewal letter from her health insurance company with premium details for the upcoming year, she couldn’t believe her eyes. The insurer estimated that the share of the monthly premium that she and her husband would owe for their marketplace silver plan would go up from the current $28 a month to $545.

She immediately called Sharon Barker, a health insurance navigator with Family and Children’s Service in Nashville, Tenn., with whom she and her husband had worked this year to buy a marketplace plan after relocating from California to take care of her husband’s ailing parents. They sat down with Barker at their local library and showed her the letter.

Barker helped them run the numbers to determine that their premium tax credit next year will be much higher than the insurance company’s estimate, more than making up for the premium increase. The couple’s share of the monthly premium for 2018 will actually go down, Barker showed them: from $28 to $0.

“That’s why we need these navigators,” Spalding said. “If I didn’t have Sharon, I would have just paid that increase.”

Other consumers may not find a navigator at the ready when they want to enroll. This year, the federal Centers for Medicare & Medicaid Services, which oversees the federal health insurance marketplace, slashed federal funding for navigator groups to $36.8 million, a 41 percent average cut. Some groups fared far worse than others did.

In Tennessee, Family and Children’s Service, the state’s largest navigator grantee, received a 15 percent cut to its $1.8 million grant. It had to put plans to hire a couple of navigators on hold, but its 22 navigators enrolled 2,082 people in marketplace plans and Medicaid or the federal-state Children’s Health Insurance Plan in November, said Sandy Dimick, the navigator program director. The organization is on track to meet its goals for the open enrollment season, she said.

But with outreach funding tight, Dimick said, she’s worried about the people they’re not seeing. This year, many insurers raised 2018 premiums significantly to make up for the federal government cutting off reimbursements for cost-sharing subsidies that insurers must cover under the law. Consumers who get federal tax credits to help cover the cost of their premiums won’t generally have to pay more out-of-pocket, because that subsidy should cover the difference. But, like the Spaldings, many may not realize that.

“People are going to get those insurance letters and see the premium increase, and they won’t come in,” she said. “They won’t go for coverage because they’ll think they can’t afford it.”

In addition to the navigator cuts, the federal government also cut the advertising budget for open enrollment from $100 million to $10 million, creating additional challenges for navigator groups.

In Florida, navigators are tapping “social influencers” to get the word out about open enrollment, including paying pro football player Julius Thomas of the Miami Dolphins to appear in a video public service announcement that is running in some television markets and on social media, said Jodi Ray, director of Florida Covering Kids & Families at the University of South Florida in Tampa. That $4.9 million navigator program covers the entire state and took a 15 percent funding hit this year.

In Ohio, outreach is just one of many services that has been squeezed. Faced with a 71 percent cut to its $1.7 million navigator grant this year, members of the consortium of nine nonprofits that made up the state’s largest navigator program voted not to provide services this year. Last year, that group, the Ohio Association of Foodbanks, helped nearly 10,000 people find health insurance.

Other groups are doing what they can to step into the breach. Kami Perritt typically works as a patient advocate for a group of federally qualified health centers called Hopewell Health Centers in rural southeastern Ohio. But during the marketplace open-enrollment period, Perritt shifts gears and works as a certified application counselor, traveling between Hopewell’s primary care offices in eight counties to meet with people who’ve made appointments to sign up for health insurance.

This year, the increase in demand for enrollment help has been “incredible,” Perritt said. She routinely skips lunch to fit everyone in, and she estimated she’s doubled or tripled the number of people she works with, depending on the site.

“I’ve never been this busy,” she said. “It’s crazy.”

In addition to the shortage of enrollment assisters, the open-enrollment period for federal marketplace states is six weeks shorter this year than last, running from Nov. 1 to Dec. 15.

The issues haven’t changed, though. In addition to reviewing the available plans, many people have special concerns they need help with. Sometimes it’s young adults who turned 26 and can no longer be on their parents’ family plan, or people who need to update their income and premium tax credit details, as the Spaldings did in Tennessee. Some people have application glitches that have to be addressed to prove their income or immigration status.

So far, Perritt said, she’s been able to accommodate all the requests for her help. But she’s had to eliminate the enrollment clinics she used to run at county libraries to answer questions and sign up consumers.

The Latino HealthCare Forum in Austin, Texas, took a 95 percent hit to its federal navigator funding, from $254,000 to $13,600. It was able to replace most of the cut with funding from the city and a foundation, said Jill Ramirez, the group’s chief executive officer. Because the enrollment period is six weeks shorter this year than last, staffers have been able to concentrate resources in that smaller window, and are exceeding last year’s enrollment pace.

The group did make some changes, however. “In the past few years, walk-ins were welcome, but we can’t do that anymore,” Ramirez said. Now, people have to schedule appointments in advance for a set number of slots. “We’re not going to help fewer people, but people will have to wait longer to see us.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

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Language Barriers, Aversion To Credit Stall Coverage For Some Vietnamese

ARLINGTON, Texas — Bích-Thu “Lisa” Pham has become a familiar face at this Vietnamese community center, setting out her Affordable Care Act insurance materials in a small office several afternoons each week. She also holds enrollment sessions at local Vietnamese shopping centers and near Vietnamese-owned nail salons, and every Sunday morning she assists members of her own Vietnamese congregation in Fort Worth who want to sign up for coverage.

Lisa Pham, a Vietnamese-speaking health insurance marketplace navigator, helps fellow Vietnamese-Americans sort through not only their ACA options, but also whether they qualify for other public health programs, such as Medicaid. (Laura Buckman for KHN)

She’s a “rock star” in her ability to get Vietnamese residents in the greater Fort Worth area insured, said Daniel Bouton, who directs health services at Community Council of Greater Dallas, the nonprofit organization that receives federal funding to assist northeast-central Texas consumers sign up for ACA coverage.

It’s an important mission in Texas, where the Vietnamese uninsured rate runs nearly twice the national rate. Dallas-Fort Worth is home to the fourth-largest Vietnamese population in the U.S., with nearly 72,000 residents, and the Houston area ranks third, with nearly 104,000 residents, according to a Census Bureau analysis of 2010 data.

Nationally, 7.7 percent of Vietnamese residents were uninsured as of 2016 versus nearly 20 percent in 2010 prior to the ACA, according to an analysis of Census Bureau data by the Asian & Pacific Islander American Health Forum, a nonprofit advocacy organization. (Among all Americans, the uninsured rate last year was 8.8 percent.)

But the rate among Vietnamese Texans is 14.2 percent, although that is a steep drop from 27.4 percent in 2010.

In California, which has the nation’s two largest metropolitan Vietnamese communities, the rate was 16.6 percent in 2010 and 4.2 percent last year.

Along with sometimes limited English-speaking proficiency, signing up Vietnamese-Americans can involve other challenges, including in some cases a lack of credit history, said Cathy Phan, who has worked on ACA enrollment in the Houston area for the Asian American Health Coalition-Hope Clinic. Part of the ACA’s verification process includes running a check with a credit reporting agency, she said.

“We see that a lot — especially with newly immigrated Vietnamese community members,” Phan said. “Over in Vietnam, everybody still uses cash. I think the general cultural mentality is you don’t really want to go into debt — you want to avoid it as much as possible.”

‘It’s My Duty’

Throughout the year, Pham makes the Vietnamese community center east of Fort Worth one of her regular stops. The center, which offers meals, a game room and prayer rooms, serves as a hub for resources about local services. People have learned to seek her out there, said Pham, an ACA navigator since 2013.

The 67-year-old Pham, who moved to the United States in 1975, jokes that her husband is lobbying her to follow in his footsteps and retire. She’s held various jobs through the years, including as a software engineer and a translator at a local hospital, along with raising three children. To work as a federal navigator, a paid full-time position, she completes certification training annually.

In that role, she signs up uninsured residents across Fort Worth and Arlington. She particularly enjoys using her bilingual skills to help fellow Vietnamese-Americans sort through not only their ACA options, but also whether they qualify for other public health programs, such as Medicaid.

“I see a lot of people, they don’t speak English and they don’t know what’s going on,” Pham said. “I feel like it’s my duty to share [information] with them.”

On a recent November afternoon before her appointments began, Pham gave a short spiel to potential clients about the federal health law, including this year’s condensed sign-up period.

One of her appointments was with Mua Thi Nguyen, a 61-year-old thyroid cancer survivor. Nguyen had been reluctant to switch from her individual private insurance policy, worried that she wouldn’t have sufficient access to cancer specialists if the malignancy returned. But her income dropped and her premium reached slightly more than $1,000 each month, Nguyen explained, speaking some English and some Vietnamese.

After running the numbers, Pham showed Nguyen that she qualified for significant federal subsidies that would bring her monthly premiums to $422 for a “gold”-tier plan and $73 a month for a “silver” plan that included no deductible. Nguyen, uncertain about which policy to select, opted to go home and mull over her options.

Pham (left) speaks with client Mua Thi Nguyen at the Vietnamese community center in Pantego, Texas, on Nov. 8, 2017. (Laura Buckman for KHN)

Signs Of Funding Strain

The Trump administration severely reduced federal funding for outreach and navigator services this year. Bouton’s group took an 18 percent cut, receiving $1.8 million compared with $2.2 million last year to serve the 56-county region, which stretches east to the Louisiana border and north to Oklahoma.

The choice was made to retain as many navigators as possible, and slash the marketing budget, Bouton said. So, this year, the operation has 35 navigators, including two new Vietnamese speakers, compared with a total of 40 previously. There’s no radio advertising for the 2018 enrollment season, and no ads in local movie theaters, he said. Thus, Vietnamese-targeted marketing has been eliminated as well, including advertising in a local newspaper and printing new promotional placards in Vietnamese.

Another funding casualty has been the Fort Worth ACA enrollment office, which closed this fall. That worries Pham. Some of her Vietnamese clients had become accustomed to going there and might not have transportation options to reach other sites such as the community center, she said.

Pham and other Texas navigators have only six weeks, through Dec. 15, to sign up people through the federal ACA exchange.

Their counterparts serving the more sizable Vietnamese communities in California aren’t facing similar constraints. California operates its own state exchange and enrollment there stretches through Jan. 31, which was the deadline for the federal exchange last year.

Leaders at two California-based groups providing health services to Asian communities said they were concerned that recent reports in San Francisco and other areas about detention and deportations by U.S. immigration officials of Vietnamese and Cambodian immigrants might have a chilling effect.

“We’re still at the very beginning of this sign-up, so we’ll see how it plays out,” said Thu Quach, director of community health and research at Asian Health Services in Oakland, Calif. “But we know from the past, that anytime there’s concern that there are policies that target immigrants, it’s caused a lot of impact in the community around signing up for anything.”

They don’t speak English and they don’t know what’s going on. I feel like it’s my duty to share [information] with them.

Lisa Pham

Bilingual Outreach

Bilingual navigators, such as Pham, can bridge a critical communication divide. Nationally, 46 percent of Vietnamese have limited English proficiency, meaning they speak the language less than “very well,” according to Census data analyzed by the Asian & Pacific Islander American Health Forum.

An individual’s comfort level with English also can influence which ACA plan he or she selects. In the Houston area, Vietnamese residents sometimes are willing to pay higher premiums for access to more Vietnamese-speaking physicians, said Phan, with the Hope Clinic.

At the Vietnamese community center here earlier this month, a 61-year-old woman walked in asking about ACA coverage. Hong Vu, who spoke very little English, told Pham that she’d been insured until a few months before, when her husband had suffered a stroke and she quit her job to care for him.

Vu passed her Social Security card and other paperwork across the desk. But since Vu didn’t have a credit history, Pham couldn’t immediately establish an account. Instead, she took photos of Vu’s documents to forward to federal officials.

Several days later, after Vu’s identity had been verified, she returned to the community center to discuss insurance plans, Pham said.

Vu qualified for “bronze” plan coverage for herself, which after subsidies would cost $115 a month. Unsure whether she could afford the premium, Vu decided to talk it over with her husband.

Vu did end up getting the coverage, meeting Pham at another enrollment session at a Vietnamese shopping plaza. “She worried about if she gets sick in the future,” Pham said, “so that’s why she said she wanted to have the peace of mind.”

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Middle-Class Earners Weigh Love And Money To Curb Obamacare Premiums

Anne Cornwell considered two drastic strategies in her quest to get affordable health insurance premiums last year for herself and her retired husband.

One was divorce. Another was taking a 30 percent pay cut. She chose the latter.

That maneuver slashed the Chattanooga, Tenn., couple’s premiums from exorbitant to economical. Instead of $2,100 a month — the amount she had been quoted for 2017 — their premiums are just $87 monthly, her lost income more than compensated for by qualifying for insurance subsides.

Cornwell’s solution — completely legal — reflects how a growing number of Americans are incorporating strategies for affording health insurance into financial planning, adapting money and salaries to yield better choices — much as people place money into 401(k) plans to save for retirement while reducing their tax

Her solution and others like it may resonate with other Americans who are now buying 2018 health plans on the individual market, through the Affordable Care Act’s online marketplaces or outside them. Double-digit premium price hikes are forecast for many plans, a trend that has accelerated since President Donald Trump announced his administration would not pay some ACA subsidies to insurers.

Open enrollment in the 39 states using the federal marketplace started Nov. 1 and ends Dec. 15 for coverage that starts Jan. 1. Enrollment dates vary in other states.

The vast majority of enrollees in Obamacare plans will not pay the higher premiums, since modest incomes make them eligible for another type of government-paid subsidy that will hold their premiums flat or close to it.

But upper-middle-class people like Cornwell and her husband are expected to pay full price, feeling the blunt force of what experts and health economists agree are unbearable escalations.

Some people may qualify for ACA subsidies through less extreme measures than those taken by Cornwell, such as shifting money into tax-preferred savings account, such as a 401(k), and lowering their taxable incomes, said Frank Caccavale, an accountant from Staten Island, N.Y. But when that is not sufficient, he counsels clients to do what Cornwell did: “This is your only option. You have to take a pay decrease.”

Cornwell hit upon her solution on her own after a month of poring over spreadsheets.

“When I saw what the premium was going to be in 2017, I had to sit down. I was shocked,” Cornwell said of the $2,100-a-month figure — for a plan that didn’t even cover care until they’d each spent a $6,500 deductible. The couple simply couldn’t afford it.

Cornwell, 62, made $80,000 a year as a project manager for a small consulting firm that doesn’t offer health insurance. Her husband, Donald Donart, 63 and a cancer survivor, receives Social Security and a small pension, bringing their pretax household income to $92,000. Finding insurance required radical action.

Between 5 and 7 percent of Americans with insurance — about 17.6 million — buy it on the individual market. Of those, 7.5 million, or nearly half, don’t get subsidies, according to insurance industry consultant Robert Laszewski. Many in this latter group are professionals who work for small companies or have jobs where they work solo, for themselves.

When Cornwell saw that premiums for 2017 would rise by hundreds of dollars a month — double what they’d paid in 2015 — the couple looked hard at the options:

Should they get divorced and file taxes separately so Donart’s lower income would qualify him for cheaper insurance? Too impractical because of Tennessee’s legal requirements, Cornwell decided.

Should they form a business that paid Cornwell a lower salary than she was making? That would have taken too long.

Donart was ready to go without insurance for a year until they could figure out something else. But Cornwell worried about his cancer history, and both have chronic health conditions.

Under Obamacare, subsidies are available for people whose annual incomes are from 100 percent to about 400 percent of the federal poverty line. For 2017, that was $16,020 to $64,080 for a family of two.

So, Cornwell sat down to figure out how to reduce their income to qualify.

Four spreadsheets later, Cornwell asked her boss to reduce her hours by 30 percent, dropping her pay by $24,000 a year. She became a part-time hourly employee — at $56,000 a year. The couple now qualified for a $27,000 subsidy that made up for Cornwell’s lost income.

Their subsidized premium was so low that they upgraded to a better silver-level plan, which carried a lower deductible than the bronze plan they had passed up.

Katy Votava, president of goodcare.com, a consulting firm that advises people about health care costs, suggests people use a financial planner for taxes and health care. “The anxiety, the uncertainty and the culture is so high, it gets in the way of people making solid decisions,” she said.

She generally doesn’t recommend the radical approach of drastically cutting salaries, although that may work in some cases. Instead, she tells clients to contribute as much pretax money as the IRS allows — and as they can afford — each year into tax-advantaged retirement and health savings accounts. That reduces taxable income, which determines whether someone qualifies for a subsidy and how much.

In 2018, people can contribute up to $18,500 a year to a 401(k) retirement account. If they are older than 50, they can put in $6,000 more — a total of $24,500 annually. Health savings accounts, which can be used to pay eligible medical and dental expenses, provide a similar tax break. Neither was an option for Cornwell, whose small employer doesn’t offer those kinds of benefits.

Cornwell and her husband were satisfied with the subsidized plan they had this year. But she is deeply frustrated by the system and the somersaults she had to turn to make it financially viable. “This is when I should be maximizing income and putting it away … but we’re going the other way,” Cornwell said.

She said that she and her husband are looking ahead, running down the clock until they turn 65 and qualify for Medicare.

They intend to keep the same health plan in 2018 and are approaching this year’s open-enrollment event with anticipation instead of dread. Their insurer has told them to expect much higher premiums. But, according to healthcare.gov’s calculator, they’ll also get a much higher subsidy.

That will drop their monthly premium to zero.

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Desperate For Coverage: Are Short-Term Plans Better Than None At All?

When one of Cindy Holtzman’s clients told the Woodstock, Ga., broker he was considering dropping his Affordable Care Act plan because next year’s cost approached $23,000 for his family of four, she suggested a new option: a back-to-back set of four, 90-day short-term plans, which would effectively give them a modicum of medical coverage for 2018.

An Obama administration rule limited short-term coverage to three months at a time because it was meant as a stopgap between more substantial policies. But several insurers, including big players Golden Rule and National General, now are sidestepping that rule by packaging three or four consecutive 90-day plans, with a one-time medical review upfront.

“I’m not pitching this to replace Obamacare, but when you’re telling me you’re going to get nothing,” Holtzman said, “I want to throw this into the arena.”

As premiums rise and some middle-class families feel they can’t bear the costs of a more secure Obamacare plan with its coverage guarantees, brokers and agencies have unveiled a slew of alternatives.

Interest has grown after the Trump administration stopped paying insurers subsidies they use to lower deductibles for lower-income ACA policyholders, which caused premiums to rise. The administration has also signaled it will soon loosen restrictions for alternative coverage, including ending the rule that limits short-term plans to 90 days.

But advocates warn shoppers to carefully read the fine print and understand what they’re buying. The plans might not cover what you think.

Most short-term coverage requires answering a string of medical questions, and insurers can reject applicants with preexisting medical problems, which ACA plans cannot do.

Because short-term plans fall short of ACA standards, policyholders are considered uninsured and face an IRS tax penalty, which could be hundreds of dollars for an individual or thousands for a family.

“If you absolutely cannot afford [an ACA-compliant plan] — and you are sure you are healthy — look at other plans. But they all come with the caveat that if you get sick, they won’t give you much coverage,” said Joel Ario, a former Pennsylvania insurance commissioner and now a managing director at Manatt Health Solutions, a consulting firm.

To keep premium costs low, the policies set annual and lifetime caps on benefits. Many don’t cover prescription drugs, and most exclude coverage for maternity care, preventive care, mental health services or substance abuse treatment.

Also not covered are preexisting conditions, defined as anything treated — or for which a “prudent person” should have sought treatment — during the previous 12 months to five years, depending on the insurer.

Insurers can also bar coverage for any condition a patient develops after their initial enrollment period, even if they want to sign up again for another term with the same insurer.

Broker Kelly Rector in O’Fallon, Mo., cautions consumers: “Even if they’re healthy enough to get on the plan now, but have a heart attack in a month, they won’t be able to reapply and will be out of coverage for the rest of the year,” until the next ACA open enrollment.

Sold by a wide range of insurers, the plans usually pay a percentage of the cost for medical care, after the policyholder pays a deductible, which can range from $1,000 to $10,000 or more per contract term.

Already, insurers have begun offering plans that seem to anticipate that the Trump administration will restore the ability to hold short-term plans for 364 days.

National General’s package, for example, guarantees “eligibility for three more consecutive plans.” However, on those packages and similar ones offered by other insurers, the deductible resets every 90 days, so the patient would be on the hook for that amount every three months. That means a $5,000 deductible could grow to $20,000 if the policy were kept for the full year.

Premiums vary by insurer and other factors, including age, the deductible and how much coverage the plan provides.

Holtzman says a National General plan for her 46-year-old client, his wife and two children in Georgia with a $2,500 deductible every 90 days would cost $1,348 a month.

That’s appealing when compared with his current ACA plan, Holtzman said, for which the premium would be about $1,900 a month next year, with a $3,000 annual deductible.

Still, if the family enrolled in a different ACA plan than his current coverage, the differences narrow.

The least expensive ACA plan in his area would cost his family $1,335 a month, according to government website healthcare.gov, which is about the same as the short-term plan by National. The ACA plan has a bigger annual deductible — $13,600 for his family — but the gap dwindles if someone falls ill and the family ends up meeting the deductible under the short-term plan in each of the four consecutive terms.

Consumer advocates say an ACA plan would cost the family more upfront but would include benefits for any preexisting conditions and would cover more, noting the short-term plan does not include coverage for prescription drugs and excludes benefits for chronic pain, congenital conditions and immunodeficiency disorders.

“People should be aware,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “There’s a huge variety of plans out there — from true bottom feeders that are going to take your money and don’t provide any protection to legitimate products that are designed to meet a short-term need.”

Her advice: Find a reputable broker, read the fine print “and look for caps on amounts that they will pay per service, which can leave you holding the financial bag if you have to go to the hospital.”

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Podcast: ‘What The Health?’ Taxes, Medicare And The Year-End Mess

Weeks ago, the tax bill under consideration in Congress became a health bill, too. But now it could also trigger major cuts to the Medicare program.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Paige Winfield Cunningham of The Washington Post discuss how a little-known law prohibiting federal deficits could force big cuts to Medicare and many other defense and domestic programs if the tax bill passes as currently configured in the House and Senate.

Among the takeaways from this week’s podcast:

  • A possible delay in negotiating a year-end spending bill puts the fate of the Children’s Health Insurance Program in doubt. States are starting to run out of money for the program, whose federal authorization expired Oct. 1.
  • A Senate committee heard from Alex Azar, a former drug company executive and President Donald Trump’s nominee to head the Department of Health and Human Services. Much of the discussion was about what he might do to contain drug prices.
  • The National Academy of Medicine issued its own recommendations about how to make drugs more affordable, including the idea of letting government programs negotiate with drugmakers and possibly limit which drugs the government would pay for.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: ProPublica’s “A Hospital Charged $1,877 to Pierce a 5-Year-Old’s Ears. This Is Why Health Care Costs So Much,” by Marshall Allen.

Joanne Kenen:  The Atlantic’s “No Family Is Safe From This Epidemic,” by James Winnefeld.

Paige Winfield Cunningham: The Washington Post’s “597 days. And still waiting,” by Terrence McCoy.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

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Putting Money Where Its Mouthpiece Is: Calif. Outspends U.S. To Market Obamacare

The marketing blitz is on.

Californians are getting barraged with online pop-up ads, radio spots and television commercials, all aimed at persuading them to sign up for Affordable Care Act health plans during this year’s open-enrollment season.

Covered California, the state’s Obamacare exchange, is wielding a monster marketing budget that devotes $45 million to ads, including $18 million for TV and $8 million for radio. The agency is so flush with marketing dollars that it also spent $100,000 for a dozen freshly painted murals across the state, most of which have nothing directly to do with health insurance enrollment.

Covered California’s marketing riches contrast starkly with the advertising budget for the federal health insurance exchange, healthcare.gov. The feds have slashed ad dollars to $10 million, down from $100 million last year.

The huge discrepancy reflects conflicting attitudes toward the ACA, commonly known as Obamacare, said Gerald Kominski, director at the University of California-Los Angeles Center for Health Policy Research.

“A $10 million advertising budget for healthcare.gov, which supports exchanges in 30-something states, is … in keeping with the goal of this administration to destroy the ACA,” he said. “California’s budget reflects a different approach to the ACA, which is that it is an important source of insurance.”

Other health care experts say marketing is not the best use of money now that the exchanges are a known commodity, especially in California. They suggest the dollars could be better used for things like reducing premiums.

“It’s a waste of taxpayer money,” said Sally Pipes, the president and CEO of the Pacific Research Institute in San Francisco, which advocates for free-market policies.

“All of this money being used on murals and bus tours and TV ads, etc., it’s not going to change the number of enrollees that much. It would be better to save money and reduce taxes so that people have lower tax burden.”

California is one of 11 states, plus the District of Columbia, that operate their own health insurance exchanges. The remaining 39 states use the federal healthcare.gov site.

In addition to cutting its ad budget, the federal government reduced grants for “navigators,” individuals and organizations that help people enroll, to $37 million, down from $63 million last year. Covered California will devote $6.5 million to navigators. It’s not a perfect measure, but judging purely by population, these investments in navigators do not seem significantly different.

Altogether, Covered California plans to spend $111.5 million on marketing in 2017-18, which includes navigators, ads, staff salaries and more.

Covered California leaders and consumer health advocates say the agency’s sizable marketing budget is necessary because of recent federal moves to undercut the Affordable Care Act. The Trump administration shortened the enrollment period to 45 days in most states and stopped paying insurers to provide a subsidy that helps many low-income consumers with their out-of-pocket medical costs.

“It sounds like a lot … but it’s a very legitimate expenditure,” said Betsy Imholz, director of special projects for Consumers Union.

The federal government’s $10 million investment in advertising is “ridiculously inadequate” by comparison, she said. Covered California will spend that amount on online ads alone.

There have been so many policy flip-flops in Washington, D.C., and so much misinformation that some people may be confused about whether the law is even in place anymore, she said.

Their confusion is magnified by the fact that consumers nationwide may be served by different Obamacare exchanges with different rules.

For instance, Californians who purchase their individual insurance through Covered California or on the open market will continue to have three months, until Jan. 31, 2018, to enroll in plans for next year. People who purchase their plans through healthcare.gov have until Dec. 15.

Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, said the feds’ advertising cuts simply reflect the needed transition from promoting the exchange as a new option to maintaining it as an established program.

“Growing awareness is not going to magically get desired people to enroll,” he said.

The U.S. Department of Health and Human Services (HHS), which runs the federal exchange, explained that it cut advertising in part because it did not seem to be working to boost first-time enrollment. For 2017 plans, first-time enrollment declined by 42 percent and total enrollment fell by 500,000 people to 12.2 million. Covered California has about 1.4 million enrollees.

HHS plans to use its smaller budget on digital media promotion like YouTube videos and targeted ads on search engines, called search advertising. It will also focus on emailing and calling healthcare.gov consumers directly to remind them of the Dec. 15 deadline.

So far, neither the confusion nor the smaller advertising investment seems to have stopped people from signing up. About 1.5 million people had selected healthcare.gov plans as of Nov. 11, which represents a stronger start than last year, when about 1 million people picked plans during the first 12 days.

In California, 48,000 new consumers had signed up for exchange plans as of Nov. 14, slightly ahead of the same period last year, when 39,000 consumers picked plans. These figures don’t include existing enrollees who renewed their plans.

Kathy Hempstead, a senior adviser at the Robert Wood Johnson Foundation, said Covered California usually performs better than others in enrollment, which probably has something to do with its marketing efforts. “Covered California has become a brand,” she said. “Healthcare.gov hasn’t.”

Peter Lee, Covered California’s executive director, said he believes that spreading the word about open enrollment creates a risk pool that includes both healthy and sick people.

“Yes, marketing costs money, but marketing means more people sign up, and the people that sign up are healthier and help lower premiums,” he said.

Covered California commissioned this Sacramento mural as part of its marketing and outreach efforts to promote the open-enrollment period for 2018 coverage. (Ana B. Ibarra/California Healthline)

Advertising likely helped lower premiums by 6 to 8 percent in 2015 and 2016 because it helped create a more balanced risk pool, according to a recent marketing report produced by Covered California.

Covered California’s $111.5 million marketing budget is nothing new. Last year, it spent $99 million on marketing, and $122 million the year before that.

This year, as in some previous years, Lee paraded across the state in a colorful charter bus promoting the start of open enrollment. He touted the 12 new murals, and echoed the primary message of Covered California’s ads: Life can change in an instant due to unexpected injuries, such as falling off a ladder.

One mural painted outside an AltaMed clinic in East Los Angeles features people dancing, running and exercising around a doctor. A mural painted outside La Familia Counseling Center in Sacramento shows a woman holding a bowl above her head, out of which flow children riding bikes and a basketball player.

How much the murals, the tour bus or the television ads will help cut through the confusion, let alone increase enrollment, is unclear.

“I don’t know if marketing will be able to address how complex this open enrollment will be,” said Kevin Knauss, an insurance agent in the Sacramento area.

Kaiser Health News senior correspondent Anna Gorman contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Marketplace Confusion Opens Door To Questions About Skinny Plans

Consumers coping with the high cost of health insurance are the target market for new plans claiming to be lower-cost alternatives to the Affordable Care Act that fulfill the law’s requirement for health coverage.

But experts and regulators warn consumers to be cautious — and are raising red flags about one set of limited benefit plans marketed to individuals for as little as $93 a month. Offered through brokers and online ads, the plans promise to be an “ACA compliant, affordable, integrated solution that help … individuals avoid the penalties under [the health law].”

Such skinny plans — sold for the first time to individuals — come amid uncertainty over the fate of the ACA and whether President Donald Trump’s administration will ease rules on plans for individuals. Dozens of brokers are offering the plans.

“The Trump administration is injecting a significant amount of confusion into the implementation of the ACA,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute. “So it doesn’t surprise me that we would have arrangements popping up that might be trying to take advantage of that confusion.”

Apex Management Group of the Chicago area and Pennsylvania-based Xpress Healthcare have teamed up to offer the plans, and executives from both companies say they don’t need approval from state regulators to sell them. They are selling the policies across the country, although their websites note one state — Massachusetts — where the plans are not offered.

David Shull, Apex’s director of business development, said “this is not insurance” and the plans are designed to meet the “bulk of someone’s day-to-day needs.”

Legal and policy experts have raised concerns that the new plans could leave buyers incorrectly thinking they are exempt from paying a penalty for not having coverage. Additionally, they say, plans sold to individuals must be state-licensed — and one regulator has already asked for an investigation.

“Generally speaking, any entity selling health insurance in the state of California has to have a license,” Dave Jones, the Golden State’s insurance commissioner, said earlier this month. “I have asked the Department of Insurance staff to open an investigation with regard to this company to ascertain whether it is in violation of California law if they are selling it in California.”

Asked about a possible investigation, Apex owner Jeffrey Bemoras emailed a statement last week saying the firm is not offering plans to individuals in California. He also noted that the individual market accounts for only 2 percent of the company’s business.

“To be clear, Apex Management group adheres closely to all state and federal rules and regulations surrounding offering a self-insured MEC [minimal essential coverage] program,” he wrote. “We are test marketing our product in the individual environment, if at some point it doesn’t make sense to continue that investment we will not invest or focus in on that market.”

Price-Tag Appeal, But What About Coverage?

The new plans promise to be a solution for individuals who say that conventional health insurance is too expensive. Those looking for alternatives to the ACA often earn too much to qualify for tax subsidies under the federal law.

Donna Harper, an insurance agent who runs a two-person brokerage in Crystal Lake, Ill., found herself in that situation. She sells the Xpress plans — and decided to buy one herself.

Harper says she canceled her BlueCross BlueShield plan, which did meet the ACA’s requirements, after it rose to nearly $11,000 in premiums this year, with a $6,000 annual deductible.

“Self-employed people are being priced out of the market,” she said, noting the new Xpress plan will save her more than $500 a month.

The Xpress Minimum Essential Coverage plans come in three levels, costing as little as $93 a month for individuals to as much as $516 for a family. They cover preventive care — including certain cancer screenings and vaccinations — while providing limited benefits for doctor visits, lab tests and lower-cost prescription drugs.

There is little or no coverage for hospital, emergency room care and expensive prescription drugs, such as chemotherapy.

Harper said she generally recommends that her clients who sign up for an Xpress plan also buy a hospital-only policy offered by other insurers. That extra policy would pay a set amount toward in-patient care — often ranging from $1,500 to $5,000 or so a day.

Still, experts caution that hospital bills are generally much higher than those amounts. A three-day stay averages $30,000, according to the federal government’s insurance website. And hospital plans can have tougher requirements. Unlike the Xpress programs, which don’t reject applicants who have preexisting medical conditions, most hospital-only coverage often does. Harper says she personally was rejected for one.

“I haven’t been in the hospital for 40 years, so I’m going to roll the dice,” she said.  And if she winds up in the hospital? “I’ll just pay the bill.”

About 100 brokers nationwide are selling the plans, and interest “is picking up quick,” said Edward Pettola, co-owner and founder of Xpress, which for years has sold programs that offer discounts on dental, vision and prescription services.

Caveat Emptor

Experts question whether the plans exempt policyholders from the ACA’s tax penalty for not having “qualified” coverage, defined as a policy from an employer, a government program or a licensed product purchased on the individual market.

The penalty for tax year 2017 is the greater of a flat fee or a percentage of income. The annual total could range from as little as $695 for an individual to as much as $3,264 for a family.

Trump issued an executive order in October designed to loosen insurance restrictions on lower-cost, alternative forms of coverage, but the administration has not signaled its view on what would be deemed qualified coverage.

Responding to questions from KHN, officials from Apex and Xpress said their plans are designed to be affordable, not to mimic ACA health plans.

“If that is what we are expected to do, just deliver what every Marketplace plan or carriers do, provide a Bronze, Silver Plan, etc. it would not solve the problem in addressing a benefit plan that is affordable,” the companies said in a joint email on Nov. 14. “Individuals are not required to have an insurance plan, but a plan that meets minimum essential coverage, the required preventive care services.”

Bemoras, in a separate interview, said his company has been selling a version of the plan to employers since 2015.

“As we see the political environment moving and wavering and not understanding what needs to be done, the individual market became extremely attractive to us,” Bemoras said.

Still, experts who reviewed the plans for KHN said policies sold to individuals must cover 10 broad categories of health care to qualify as ACA-compliant, including hospitalization and emergency room care, and cannot set annual or lifetime limits.

The Xpress/Apex programs do set limits, paying zero to $2,500 annually toward hospital care. Doctor visits are covered for a $20 copayment, but coverage is limited to three per year. Lab tests are limited to five services annually. To get those prices, patients have to use a physician or facility in the PHCS network, which says it has 900,000 providers nationwide. Low-cost generics are covered for as little as a $1 copay, but the amount patients pay rises sharply for more expensive drugs.

“I’m very skeptical,” said attorney Alden J. Bianchi of Mintz Levin, who advises firms on employee benefits. “That would be hard [to do] because in the individual market, you have to cover all the essential health benefits.”

The details can be confusing, partly because federal law allows group health plans — generally those offered by large employers — to provide workers with self-funded, minimal coverage plans like those offered by Apex, Bianchi said.

Apex’s Shull recently said in an email that the firm simply wants to offer coverage to people who otherwise could not afford an ACA plan.

“There will be states that want to halt this. Why, I do not understand,” he wrote. “Would an individual be better off going without anything? If they need prescriptions, lab or imaging services subject to a small copay, would you want to be the one to deny them?”

Some consumers might find the price attractive, but also find themselves vulnerable to unexpected costs, including the tax liability.

Harper, the broker who signed up for one of the plans, remains confident: “As long as Xpress satisfies the [mandate], which I’m told it does, my clients are in good hands. Even if it doesn’t, I don’t think it’s a big deal. You are saving that [the tax penalty amount] a month.”

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Cost and Quality Insurance States The Health Law