A big round of applause as the curtain drops at the end of the second open enrollment period for the health insurance marketplaces with more than 11 million people signing up at the box office. OE2, as it’s affectionately called, was part sequel, part new production. Throughout its run, which was just over half the length of the premiere showing, Healthcare.gov and most of the state marketplaces held up under critical review. Back stage, the cast and crew breathed a sigh of relief. A laudable performance was key to overcoming a 2013 debut that was fodder for political critics and left the audience shaking their heads. A quick review of the media clips in the days following the reopening of enrollment finds it quickly faded from the headlines, giving credence to the adage that no news is good news!
For the reopening of enrollment, Healthcare.gov producers upstaged the old clunky application process with a sleek new streamlined version that immensely improved the experience for those who could use it. And a new window-shopping function got top billing by allowing prospective ticket buyers to preview the show without standing in line. Discounted tickets drove box office sales with 8 in 10 people paying $100 or less in monthly premiums.
The new production part – first time renewals – partially satisfied the reviewers. While most 2014 enrollees could keep their current coverage without taking action, updating their account could mean lower ticket prices and better seats. To what extent consumers considered their options and updated their information to assure they got the most financial help available to them is unclear without additional data from the marketplaces.
Overall, OE2 was a significantly improved performance. But all artists are focused on how to improve their craft, so Say Ahhh! can’t help but ask what’s keeping the marketplaces from getting a standing ovation?
Fixing enrollment barriers for families with immigrants. Legal immigrants and citizens living in immigrant families, who represent a large chunk of the remaining eligible but uninsured in the U.S., keep getting bumped to the back of the line. People in immigrant families continued to face significant barriers to enrollment during OE2, despite the fact that these barriers were well documented following the initial open enrollment period. The marketplaces must develop an alternative mechanism for verifying identity for people with no credit history (which also affects many low-income citizens) and find better, faster ways to verify immigration status.
Updating APTC eligibility at renewal. Enrollees who kept their same seats – that is, allowed their coverage to auto-renew – may have missed out on better coverage at a lower cost. At a minimum, the auto-renewal process should recalculate premium tax credits based on updated income, the most recent federal poverty guidelines, cost of the benchmark plan, and changes in age rating.
Improving notices. The lack of easy to understand notices is a fixable problem, although perhaps not as straightforward as it seems. Confusing notices create unnecessary demand on call centers and consumer assisters and lead consumers to misunderstand actions that they should or must take.
Educating consumers on how premium tax credits work. Many consumers will be surprised when they file their taxes to learn that the amount of premium tax credit (PTC) they took in advance doesn’t match the final PTC they qualify for based on their actual taxable income. Figuring out ways to communicate how PTCs work, what it means for tax reconciliation, and how best to project and report income will help ensure that consumers don’t end up panning the show.
Re-scripting the “old” application. The new application 2.0 is much shorter (16 vs. 76 screens) and much improved. But applicants must fit a specific profile in order to use it while individuals with less straightforward family circumstances are directed to the old application. There have been some improvements to the original application but it could be enhanced even further by tweaking tricky questions such as those that ask about access to employer-based coverage and tax filing status, as well as household members in order to accommodate differences in how Medicaid and the marketplaces determine household size.
Boosting the performance of the call center. Consumer assisters report that the performance of the call center was not much improved during OE2. Of course, assisters and the national experts who provide them with technical assistance deal with more complex cases that challenge us as well. That said structuring the call center with units dedicated to serving specific types of consumers would help build the expertise needed to deal with complicated situations. Additionally, involving stakeholders in reviewing call center scripts would go a long way to pinpointing better ways to communicate with consumers.
Supporting the supporting cast. Consumer assisters, including navigators, enrollment counselors in community health centers, and certified application counselors, are our unsung heroes. Financial support for the critical work they do should be increased not decreased. Additionally, the FFM and other state marketplaces should create a dedicated web portal for assisters to facilitate the application process and communicate with consumers, as does Kynect, Kentucky’s high-performing marketplace.
Making the appeals process work. A mail-in only appeals process is inefficient and results in delays when prompt decisions can make the difference for people with urgent health care needs. Options to file an appeal online or over the phone, which are the preferred methods of applying for coverage, should be added.
OE2 wasn’t totally flawless but the performance far exceeded the prior year. And ultimately, one clear measure points to its box office success. Just midway through OE2, one national poll showed that the country’s uninsured rate had dropped nearly 5 percentage points in one year under the Affordable Care Act, falling to a new low of 12.9%. Maybe we have yet to reach blockbuster status, but compared to the first open enrollment period, I’m giving OE2 two thumbs up!
A special thanks to the Robert Wood Johnson Foundation for its support of our work on providing feedback to HHS and highlighting how ACA implementation is impacting consumers.