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Broker Websites Expand Health Plan Shopping Options While Glossing Over Details

Some websites consumers use to buy their own health insurance don’t provide full information on plan choices or Medicaid eligibility, and appear to encourage selection of less comprehensive coverage that provides higher commissions to brokers, according to a report released Friday by the left-leaning Center on Budget and Policy Priorities.

These direct-enrollment broker websites — including eHealth, ValuePenguin, GetInsured.com and some named after the insurance carriers they represent — are not the state-based marketplaces or the federal exchange, known as healthcare.gov.

The commercial sites promise more options to consumers shopping for health insurance. They can offer Obamacare plans, for instance, as well as lower-cost but less comprehensive plans, such as short-term policies and other types of coverage that don’t meet the federal Affordable Care Act’s requirements.

About 42 percent of enrollments for 2018 ACA plans were arranged through sales agents or brokers, with many of them relying on such alternative websites to enroll their clients, noted the report.

But consumers who use alternative portals, the report warned, don’t have the same shopping experience as applicants accessing state or federal marketplaces. That’s because government sites must provide full information on all available ACA choices and cannot steer consumers to non-ACA plans. The government marketplace also is responsible for accurately processing applicants’ eligibility for Medicaid or premium subsidies. The commercial sites generally don’t have those responsibilities.

Two years after sharp financial cuts by the Trump administration for enrollment outreach and funding for navigators and other assistants helping people sign up for ACA plans, the administration encouraged consumers to seek out brokers for help.

For next year’s enrollment period, it is considering changing the rules to allow federally funded navigators to also use the alternative websites to enroll consumers.

There are differences among the alternative websites. “Not all entities have these problems,” the report concludes. “But the program lacks safeguards to protect consumers from harm.”

It found that some direct enrollment websites:

  • Use default settings, chat boxes and other design methods to highlight alternatives that earn the web brokers higher commissions, such as low-cost, short-term insurance plans, which cover less and can reject people with preexisting conditions.
  • Either fail to inform or provide inaccurate assessments of whether applicants or their family members might qualify for Medicaid or premium subsidies to help them get coverage.
  • Fall short of providing full information on premium costs and deductibles for all the plans available in a region.

The commercial websites are “under-policed,” said report author Tara Straw, a senior policy analyst at the center.

The administration, she said, should more closely monitor website design and how well the sites inform consumers of their potential eligibility for government assistance in purchasing coverage.

Because of the drawbacks, consumers who use some of these websites are at a disadvantage, lacking the ability to adequately comparison shop, the report warned.

As a result, some may choose non-ACA plans, such as short-term insurance, which may not be their best option. Others may be discouraged from applying for coverage at all if the websites inaccurately indicate they might not qualify for a subsidy or Medicaid.

“That’s the problem,” said Straw. “The websites can say, ‘We’re telling people to complete the application [to assess subsidy eligibility],’ but who is going to do that when they’re showing all the plans at the unsubsidized price?”

Comparison shopping on some of the websites is limited.

An example outlined in the report focuses on Duval County, Fla., where the eHealth website shows a list of ACA policies described as “17 of 17 plans” available. Each of those 17 shows the costs of premiums, deductible amounts and other details. At the bottom of the screen, however, eHealth lists the names of 32 additional plans available from Florida Blue, the state’s largest insurer, without any specifics on cost and coverage.

If consumers stopped there, they would not know that on Florida Blue’s website they could find 15 plans that are less expensive than the lowest-cost plan listed on eHealth, according to the report.

“Without visiting multiple websites, consumers would have difficulty finding and comparing their plan options,” the report said. “This is the type of fractured shopping experience the marketplace is designed to remedy.” It noted, however, that one web broker, HealthSherpa, did list all 49 plans available in Duval County.

An eHealth spokeswoman countered that the website makes it easy for consumers to get additional information on available plans it may not sell directly.

“When they get to the bottom of the page, they see 32 additional plans available through the federal marketplace, with a hyperlink directly to that marketplace,” said eHealth’s Lisa Zamosky.

To avoid having to visit multiple sites, Straw offered consumers simple advice: “Go to healthcare.gov.”

Understanding Loneliness In Older Adults — And Tailoring A Solution

For years, Dr. Linda Fried offered older patients who complained of being lonely what seemed to be sensible guidance. “Go out and find something that matters to you,” she would say.

But her well-meant advice didn’t work most of the time. What patients really wanted were close relationships with people they care about, satisfying social roles and a sense that their lives have value. And this wasn’t easy to find.

We need “new societal institutions that bring meaning and purpose” to older adults’ lives, Fried recently told a committee of the National Academies of Sciences investigating loneliness and social isolation among older adults. (Fried is a geriatrician and dean of the Mailman School of Public Health at Columbia University.)

The committee’s deliberations come amid growing interest in the topic. Four surveys (by Cigna, AARP, the Kaiser Family Foundation and the University of Michigan) have examined the extent of loneliness and social isolation in older adults in the past year. And health insurers, health care systems, senior housing operators and social service agencies are launching or expanding initiatives. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

Notably, Anthem Inc. is planning a national rollout to Medicare Advantage plans of a program addressing loneliness developed by its subsidiary CareMore Health, according to Robin Caruso, CareMore’s chief togetherness officer. UnitedHealthcare is making health navigators available to Medicare Advantage members at risk for social isolation. And Kaiser Permanente is starting a pilot program that will refer lonely or isolated older adults in its Northwest region to community services, with plans to eventually bring it to other regions, according to Lucy Savitz, vice president of health research at Kaiser Permanente Northwest. (KHN is not affiliated with Kaiser Permanente.)

The effectiveness of these programs and others remains to be seen. Few have been rigorously evaluated, and many assume increased social interaction will go a long way toward alleviating older adults’ distress at not having meaningful relationships. But that isn’t necessarily the case.

“Assuaging loneliness is not just about having random human contact; it’s about the quality of that contact and who you’re having contact with,” said Dr. Vyjeyanthi Periyakoil, an associate professor of medicine at Stanford University School of Medicine.

A one-size-fits-all approach won’t work for older adults, she and other experts agreed. Instead, varied approaches that recognize the different degrees, types and root causes of loneliness are needed.

Degrees of loneliness. The headlines are alarming: Between 33 and 43 percent of older Americans are lonely, they proclaim. But those figures combine two groups: people who are sometimes lonely and those who are always lonely.

The distinction matters because people who are sometimes lonely don’t necessarily stay that way; they can move in and out of this state. And the potential health impact of loneliness — a higher risk of heart disease, dementia, immune dysfunction, functional impairment and early death — depends on its severity.

People who are severely lonely are at “high risk,” while those who are moderately lonely are at lower risk, said Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University.

The number of people in the highest risk category is relatively small, as it turns out. When AARP asked adults who participated in its survey last year “How often do you feel lonely or isolated from those around you?” 4 percent said “always,” while 27 percent said “sometimes.” In the University of Michigan’s just-published survey on loneliness and social isolation, 8 percent of older adults (ages 50-80) said they often lacked companionship (a proxy for loneliness), while 26 percent said this was sometimes the case.

“If you compare loneliness to a toxin and ask ‘How much exposure is dangerous, at what dose and over what period of time?’ the truth is we don’t really know yet,” Periyakoil said.

Why it matters: Loneliness isn’t always negative, and seniors shouldn’t panic if they sometimes feel this way. Often, loneliness motivates people to find a way to connect with others, strengthening social bonds. More often than not, it’s inspired by circumstances that people adjust to over time, such as the death of a spouse, close family member or friend; a serious illness or injury; or a change in living situation.

Types of loneliness. Loneliness comes in different forms that call for different responses. According to a well-established framework, “emotional loneliness” occurs when someone feels the lack of intimate relationships. “Social loneliness” is the lack of satisfying contact with family members, friends, neighbors or other community members. “Collective loneliness” is the feeling of not being valued by the broader community.

Some experts add another category: “existential loneliness,” or the sense that life lacks meaning or purpose.

Dr. Carla Perissinotto, associate chief for geriatrics clinical programs at the University of California-San Francisco, has been thinking about the different types of loneliness recently because of her 75-year-old mother, Gloria. Widowed in September, then forced to stay home for three months after hip surgery, Gloria became profoundly lonely.

“If I were a clinician and said to my mother, ‘Go to a senior center,’ that wouldn’t get at the core underlying issues: my mother’s grief and her feeling, since she’s not a native to this country, that she’s not welcome here, given the political situation,” Perissinotto said.

What’s helped Gloria is “talking about and giving voice to what she’s experiencing,” Perissinotto continued. Also, friends, former co-workers, family members and some of Perissinotto’s high school buddies have rallied around Gloria. “She feels that she’s a valuable part of her community, and that’s what’s missing for so many people,” Perissinotto said.

“Look at the older people around you who’ve had a major life transition: a death, the diagnosis of a serious illness, a financial setback, a surgery putting them at risk,” she recommended. “Think about what you can offer as a friend or a colleague to help them feel valued.”

Why it matters: Listening to older adults and learning about the type of loneliness they’re experiencing is important before trying to intervene. “We need to understand what’s driving someone’s loneliness situation before suggesting options,” Perissinotto said.

Root causes of loneliness. One of the root causes of loneliness can be the perception that other people have rejected you or don’t care about you. Frequently, people who are lonely convey negativity or push others away because of perceived rejection, which only reinforces their isolation.

In a review of interventions to reduce loneliness, researchers from the University of Chicago note that interventions that address what they call “maladaptive social cognition” — distrust of other people, negativity and the expectation of rejection — are generally more effective than those that teach social skills or promote social interactions. Cognitive behavior therapy, which teaches people to recognize and question their assumptions, is often recommended.

Relationships that have become disappointing are another common cause of loneliness. This could be a spouse who’s become inattentive over time or adult children or friends who live at a distance and are rarely in touch.

“Figuring out how to promote quality relationships for older adults who are lonely is tricky,” Holt-Lunstad said. “While we have decades of research in relationship science that helps characterize quality relationships, there’s not a lot of evidence around effective ways to create those relationships or intervene” when problems surface.

Other contributors to loneliness are easier to address. A few examples: Someone who’s lost a sense of being meaningfully connected to other people because of hearing loss — the most common type of disability among older adults — can be encouraged to use a hearing aid. Someone who can’t drive anymore and has stopped getting out of the house can get assistance with transportation. Or someone who’s lost a sibling or a spouse can be directed to a bereavement program.

“We have to be very strategic about efforts to help people, what it is they need and what we’re trying to accomplish,” Holt-Lunstad said. “We can’t just throw programs at people and hope that something is better than nothing.”

She recommends that older adults take mental stock of the extent to which they feel lonely or socially isolated. Am I feeling left out? To what extent are my relationships supportive? Then, they should consider what underlies any problems. Why don’t I get together with friends? Why have I lost touch with people I once spoke with?

“When you identify these factors, then you can think about the most appropriate strategies to relieve your discomfort and handle any obstacles that are getting in the way,” Holt-Lunstad said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.