Ready or not, the online insurance Exchange that is an "Obamacare" mainstay for making health care accessible and affordable to the uninsured will be opening for business very soon.
On Oct. 1, by law, the Exchange (which is now being called the Marketplace) will start enrolling as many eligible Americans as possible in health plans offered on its website for coverage effective Jan. 1, 2014. In Tennessee, some 500,000 of the state's estimated 800,000 uninsured are being targeted by outreach efforts to choose from an array of plans being offered "Travelocity style" by the five insurance companies that have opted to do business on the Marketplace. (Three others are offering dental-only plans.)
Lamentably, that doesn't include the 300,000 Tennesseans in direst need: namely, those with incomes below 100 percent of the federal poverty line ($11,500 for an individual, $23,840 for a household of four). Obamacare provided for their coverage instead by expansion of the joint federal-state Medicaid program at purely federal expense through 2016. But Gov. Bill Haslam has spurned Tennessee participation in the Medicaid expansion, as have many other Republican governors who remain opposed to Obamacare.
Haslam has called instead for letting the nearly $2 billion a year in attendant federal funding go instead to pay for insuring those with low incomes on the Marketplace. However, his "private option" plan begs sticky questions such as the extent to which those covered would be subject to out-of-pocket expenses for things like deductibles and co-payments that Medicaid law stipulates can only be "nominal."
Even if these get resolved, it's highly unlikely that Haslam will call the special session of the state Legislature that would be needed to approve a plan before year end. So those most in need of help will remain without it when coverage starts on Jan. 1.
Just accommodating the 500,000 uninsured Tennesseans who will be eligible for coverage will be a formidable undertaking. Surveys indicate that a majority of them aren't yet aware of the existence of the Marketplace, let alone how to make use of it. And when they start to, there's the question of whether its systems have the capacity to process all the applicants without buckling.
Each state had the option of forming its own Exchange, and if Tennessee had done so, it would have qualified long since for upwards of $50 million in federal implementation grants to make ready for the fall enrollment period and the January coverage start. But Haslam, again along with most other Republican governors, opted not to. So Tennesseans are dependent on a federally run Exchange, which Washington's own Government Accountability Office has found to be slow on the uptake.
This month, a consortium of community service organizations is finally due to get a $1.5 million federal grant for training and supporting what are known as "Navigators" to guide the uninsured through the Exchange enrollment process. But it remains to be seen whether they will be sufficient to the task.
Fortunately, the state is blessed to have a Navigator consortium headed by a Memphis-based non-profit, Seedco, that has long experience helping disadvantaged people in coping with the rigors of various governmental assistance programs. And a number of foundations, most notably the Baptist Healing Trust in Nashville, have chipped in with resources to support an outreach effort under the banner Get Covered Tennessee. "Enrolling more than half a million individuals and families in a state as large as Tennessee will take a combined effort of Navigators, health care providers, and community volunteers, and will take a high level of collaboration across a diverse range of public and private stakeholders," a Seedco bulletin states.
In the Knoxville area, enrollment efforts are being bolstered by at least two provider groups. Cherokee Health Systems, which operates as a Federally Qualified Health Center serving 63,000 low-income patients in 14 East Tennessee counties, has gotten a $240,000 FQHC grant to build a full-time enrollment and outreach staff of five, according to Cherokee vice president Joel Hornberger. At the same time, Knoxville Area Project Access, an arm of the Knoxville Academy of Medicare, which arranges treatment for the indigent with 1,200 participating doctors, will be devoting its staff of 12 to the effort, according to its director, Mark Burns.
An arm of the federal Centers for Medicare and Medicaid Services has recently rolled out a website—Healthcare.gov—that those involved in the enrollment effort deem helpful. It promises that, "The Marketplace simplifies your search for health coverage by gathering the options available in your area in one place. With one application you can compare plans based on price, benefits, quality, and other features important to you before you make a choice. You can also get help online, by phone, by chat, or in person."
While all plans must offer the same set of federally defined "essential health benefits," choosing among the four tiers of allowed coverage (Platinum, Gold, Silver, and Bronze) is anything but simple. And determining how much a plan will cost after taking into account the premium subsidies available to enrollees with incomes up to 400 percent of FPL and cost-sharing offsets for those below 250 percent of FPL gets vastly more complex. Both Hornberger and Burns believe that personalized assistance will be needed in most cases, and that's what they are gearing up to provide their patients. A widespread fear is that older people or people with conditions that have heretofore excluded them from getting coverage will be much more likely to enroll than younger, healthier people. Resultant adverse selection, as it's known, could drive up premiums on the Exchange to the point where they'd become prohibitively expensive.
Given space constraints, all of these complications will have to be the subject of a separate column.