By BETSY TAYLOR
Financial specialist Kevin Roberts at St. Vincent's Medical Center in Jacksonville, Fla., is on the front line of the nation's health insurance exchanges, the marketplaces where people can shop for health insurance plans under the Affordable Care Act.
He meets with patients trying to figure out how they're going to pay for care. The first week the exchange opened, in between his work assisting patients in need of Medicaid or charity care, he met with 11 people to help them enroll for insurance on the website of the federal exchange: no luck. "I was 0 for 11," he says. But, in the next two weeks at the medical center, part of St. Louis-based Ascension Health, things improved a bit. Roberts was able to help people create accounts online. A few enrolled on the spot for new health insurance; some went home to shop and compare plans.
Along the way, Roberts is educating patients, many of whom are low-income or have no income, about health insurance. "They don't know 'deductible.' 'Premium' — I've had patients who haven't known what that's meant," he says. The work is part of the rollout of the health insurance exchanges, which began Oct. 1 across the U.S. The launch was marred by far-reaching technical problems with the website of the federal exchange, healthcare.gov. Federal officials maintain the website will be fixed by the end of this month; and, in the meantime, some consumers are turning to phone calls and paper applications to start the process to get coverage.
But some states, like Washington and Kentucky, fared much better from the outset with their own state-run exchanges and websites.
Touch points Across the country, CHA members are holding public information sessions and staffing insurance service centers, sending out explanatory letters to patients who are uninsured and recruiting volunteers to educate others about buying insurance through the exchanges. They're also working to better understand what all the changes will mean for their patients and for facility or system finances, with different states responding to the law in different ways.
A central component of the ACA was the expansion of Medicaid so more low-income people could receive health care.
However, a Supreme Court ruling last year allowed states to choose if they would expand Medicaid.
In Florida, where Roberts works, the state declined to expand Medicaid or build a state-based exchange, so individuals are being directed to the federal site where they can receive income-based premium subsidies and enroll for insurance.
But because Florida did not expand Medicaid, many poor uninsured adults fall into a coverage gap. They earn too much to qualify for Medicaid in Florida but not enough to qualify for marketplace premium subsidies. Those with incomes below
100 percent of poverty cannot get subsidies for insurance purchased on the exchange.
Outreach and assistance efforts At many ministry hospitals, health insurance enrollment has become a higher-profile issue in recent months as staff and volunteers geared up to assist patients through the exchanges.
Saint Joseph Regional Medical Center–Health Insurance Services, a for-profit company which is part of Livonia, Mich.-based CHE Trinity Health, opened two insurance service and information centers, one in the lobby of Saint Joseph Regional Medical Center in Mishawaka, Ind., and the other at the Marshall County Community Resource Center in Plymouth, Ind. Managers and associates are licensed insurance agents who take "a proactive approach to helping people with their health insurance," says Sondra Gardetto, manager for Health Insurance Services.
At the hospital, a lobby kiosk provides a spot where people can access the healthcare.gov website on their own; separate insurance offices provide a place where patients can meet with Health Insurance Services staff, who are also certified by the Centers for Medicare and Medicaid Services to help people enroll through the federal exchange. (Indiana opted not to create a state-based exchange.)
Certified enrollment counselors staff an insurance education center in the lobby of Providence Health Center's Women and Newborns Center in Waco, Texas. The hospital is part of Ascension Health. Texas, the state with the highest rate of uninsured residents, declined to expand Medicaid or set up a state-run exchange. Texans are enrolling through the federal exchange. In late October, because of the federal exchange difficulties, Jana Whitaker, Providence's vice president of marketing and volunteer services, says counselors were temporarily directing patients to fill out paper applications or apply by phone at (800) 318-2596.
Providence also created a website, providence.net/marketplace, to provide straightforward answers to questions as foundational as: what is health insurance?
"We're trying to help change a culture of people who haven't had insurance," she notes. It isn't easy, but, "we know we're doing the right thing," she says.
Providence is training volunteers to reach out into the community. Among the volunteers are university students, who can connect with young adults, whose participation is considered to be important to the actuarial soundness of the pricing of exchange-based insurance products.
Fielding calls, sending letters Bob Fletcher, patient registration manager of PeaceHealth St. John Medical Center in Longview, Wash., assists members of the public in securing health insurance through the Washington Healthplanfinder, Washington state's health insurance marketplace. In the early weeks of October, he answered questions from people trying to understand the health insurance marketplace and how to enroll in the state's expanding Medicaid program or purchase commercial insurance through the exchange.
PeaceHealth, St. John's parent, planned to send out roughly 30,000 to 40,000 letters to charity care patients and private pay patients with significant balances owed. New insurance won't reduce charges already incurred, but PeaceHealth believes these patients would be interested in learning about coverage options that could expand their access to health care and improve their economic security. "I think that's really in keeping with our Catholic mission, reaching out to the most vulnerable," Fletcher says.
Making the numbers work At St. Claire Regional Medical Center in Morehead, Ky., financial counselors assist patients enrolling through Kentucky's state-based exchange, called Kynect. As Catholic Health World went to press in late October, the enrollment pace at the medical center had been "a little slow," says Chris McClurg, St. Claire vice president of finance. "It's not like a fire sale on iPhones," he says.
By October's end, Kentucky was among the 25 states that said yes to expanding Medicaid.
McClurg notes as systems try to forecast demand for services and revenues, many are advocating for delays to scheduled reductions in the Medicare and Medicaid Disproportionate Share Hospital programs, which provide support for hospitals serving Medicaid beneficiaries, low-income Medicare beneficiaries, the uninsured and underinsured. McClurg says such delays would be a help, preserving a safety net for patients in the short term as hospitals adapt to changes in health care financing.
Delay in DSH reductions sought During negotiations leading up to the passage of the ACA, hospitals went along with significant cuts in DSH payments based on the assumption that there would be a reduction in hospital uncompensated care as the number of uninsured declined significantly. However, based on Congressional Budget Office data, it's now estimated that health care coverage will be extended to 25 million people, rather than earlier projections of about 32 million due to the 25 states not participating in the Medicaid expansion, and uncertainty about the uptake in commercial insurance coverage through the exchanges. Because of this, hospitals treating disproportionate shares of uninsured, low-income patients will see cash flow reduced in ways that ACA framers hadn't intended.
CHA is among the organizations supporting the DSH Reduction Relief Act of 2013, legislation that would delay scheduled reductions to the Medicare and Medicaid Disproportionate Share Hospital programs for two years, lessening the adverse impact on hospitals trying to care for vulnerable populations.
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