Problems, perceptions likely to dampen ACA enrollment

By Dana Beezley-Smith, Ph.D.
December 2, 2014



Problems, perceptions likely to dampen ACA enrollmentAs the Affordable Care Act’s (ACA) second enrollment campaign begins, federal officials are tamping down expectations. “We never had to have re-enrollment and open enrollment together,” new Health and Human Services (HHS) Secretary Sylvia Burwell told reporters. “It will not be perfect.”

Cecelia Munoz, Domestic Policy Council director, asked for support from attendees at a Kaiser Family Foundation (KFF) event, confessing that “this year’s going to present new challenges that we didn’t have to face last year.”

While last year’s campaign ran from October through March, this year’s open enrollment starts Nov. 15 and lasts only three months. Since Americans may be preoccupied with holiday activities, some worry that many won’t attend to enrollment applications and secure coverage that starts in January.

The Congressional Budget Office anticipates 13 million individuals will enroll in 2015 exchange plans. Assuming all current buyers re-enroll, officials need to persuade several million more to sign up.

Those who declined coverage last year may be more difficult to convince. Complicating enrollment efforts may be public opinion of the law itself and exchange plans in particular.

Although negative judgment of the ACA hovered at 53 percent throughout the year, a recent Gallup poll finds increasing numbers claiming they’ve been harmed by it — 27 percent, up from 19 percent — at the year’s start and only 16 percent reporting benefits. The majority, 54 percent, say they haven’t yet been affected by the law, but that number declined from 70 percent in January.

Health media firm Morning Consult’s recent survey suggests consumers have become less attracted to exchange policies. Forty-seven percent of respondents said they are “not at all likely” to buy an exchange plan, up from 28 percent a year ago. “Voters’ stated likelihood of buying insurance decreased across all categories from 2013 to 2014. The drop in interest in the exchanges could present a challenge.”

Negative press about ACA plans could explain some Americans’ ambivalence about signing up. A number of enrollees, many among the millions experiencing policy cancellations last fall, publicly complained about high premiums and deductibles, loss of doctors and hospitals, limited drug formularies and high out-of-network expenses. Government-subsidized exchange participants despaired when their children were forced into Medicaid.

In a Wall Street Journal op-ed, Ralston College President Stephen Blackwood described his mother’s ACA coverage. “On Feb. 12, just before going into (yet another) surgery, she was informed by Humana that it would not, in fact, cover her Sandostatin, or other cancer-related medications,” he wrote. “Obama Care made my mother’s old plan illegal, and it forced her to buy a new plan that would accelerate her disease and death.”

The Associated Press reported that many ill enrollees are facing other drug coverage problems. “Some plans are requiring patients to initially pay 30 percent or more of the bill for drugs that can cost several thousand dollars a month.” An analysis by Avalere Health found that the bulk of exchange plans require significant out-of-pocket burdens for vital medicines.

“A key component of the ‘patient protection’ offered in the ACA is access to not just affordable overall insurance, but specifically to affordable prescription drugs,” said HealthHIV Executive Director Brian Hujdich. “The Avalere study reveals that high out-of-pocket costs are concentrated among the most vulnerable patients.”

AP also reported that “some of the nation’s best cancer hospitals are off-limits,” depriving patients of “the most advanced treatment, including clinical trials of new medications.”

Some hardships will be addressed in 2015 policies. HHS now permits patients to request off-formulary medications from insurers when “suffering from a serious health condition” or “in a current course of treatment using a non-formulary drug.” Although the federal enrollment site, HealthCare.gov, will not display drug formularies and provider lists, insurers are encouraged to share this information on their commercial websites. Provider networks must now include 30 percent of “essential community providers,” those serving low-income and traditionally medically underserved populations.

Re-enrollment considerations

Federal enrollees are automatically re-enrolled in their plans if they don’t make changes by Dec. 15. Although HHS encourages buyers to auto-renew, KFF’s Karen Pollitz advises a careful review of options. Policy benefits, premiums and subsidy allowances will vary every year. Insurer mixes are changing in many states, and 2015 plans are likely to offer even tighter provider networks. Actuarial firm Milliman reports that those auto-renewing could face “net premium contribution increases of 30 percent to near 100 percent.”

Continued technical issues

The Government Accountability Office continues to report weaknesses in the security, privacy and functionality of HealthCare.gov. Numerous outlets report that the “back end”— relaying enrollment information to and paying insurers — is still under construction. However, Kevin Counihan, the site’s new CEO, told Bloomberg News he’s confident about the “front end” that interfaces with consumers, predicting Americans will become “raving fans.”

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