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Opinion: The Next Challenge for Obamacare -- Finding and Enrolling the Uninsured

An extraordinary outreach effort will have to be mounted to bring the benefits of ACA to many who need insurance the most.

The road to national health reform has been rough, to say the least. The Patient Protection and Affordable Care Act (ACA) passed Congress three years ago in a cliffhanger vote following the death of Sen. Edward Kennedy and subsequent loss of the Democrats’ filibuster-proof majority. Then the law survived its historic Supreme Court challenge mostly unscathed.

Today, the national health overhaul appears to be withstanding ongoing partisan bickering, with the important exception of a few states in which the Medicaid expansion will apparently not be implemented. The main provisions of the law will go into effect in a few short months. Closer to home, recent decisions from the Christie Administration make the reform path clear in New Jersey -- the federal government will run our health insurance exchange and Medicaid eligibility will be expanded to thousands of uninsured low-income individuals and families.

In spite of surviving the gauntlet thus far, the successful implementation of the health law is far from assured. Potential pitfalls are numerous. One of the most challenging is the construction of the exchange marketplace, which will consist of a federally run website (to be found, ultimately, at healthcare.gov) and call center. Other important steps include the certification of plans to be offered in the subsidized exchange, procurement of “navigators” to find and help enroll eligible uninsured persons, and education of the public about the requirement to purchase coverage and options for doing so. Recent national polls show broad confusion about the reforms (and even that the ACA is the law of the land).

All of the foregoing steps need to be taken well before the annual open enrollment period for subsidized coverage on October 1 this year.

A challenge equal to building a well-functioning exchange is finding the uninsured and informing them about how to get coverage. According to a 2009 survey by the Center for State Health Policy, six of every 10 working-age adults who were without coverage at any time in the prior year had been uninsured for full year or more. This group of longer-term uninsured is on average younger and poorer and more likely to be noncitizens than their counterparts with shorter spells without coverage. Those demographics suggest that many in this group may lack a basic understanding of the American system of public and private health-coverage options.

Enrolling a high proportion of the uninsured is important for several reasons. First, one of the biggest determinants of premiums is the health of enrollees, and people with health problems are the most likely to sign up for coverage. Healthier groups will be less motivated seek out coverage, especially if doing so is unclear or complex. If the healthy fail to enroll in large numbers, premiums will be higher.

Second, the ACA is designed to encourage market competition, but competition is unlikely to grow without a robust pool of enrollees. Currently, New Jersey’s nonemployer health insurance market is highly concentrated. The largest insurer in the nongroup market covers nearly three-fourths of enrollees, and the top two insurers hold a combined market share of over 90 percent. With high take-up among the uninsured this market could grow substantially, potentially spurring competition.

Finally, of course, having health coverage is important to the health and financial well being of those who enroll. It is also important for the financial stability of our hospitals and other healthcare providers.

Given the inexperience with coverage of many of the uninsured and the changes in the way coverage will become available, broad education of the public is critically important. The federal government will contract with organizations to hire “navigators” who will work with individuals to find coverage, obtain subsidies to which they are entitled, and find their way through the system.

But the feds are making less than $2 million available for New Jersey navigators, plus some funds for community health centers to facilitate enrollment. Indications are that federal resources for wider marketing and public education will be paltry. Massachusetts launched its 2006 health reforms with an all-hands-on-deck marketing campaign, ensuring a strong response to the requirement to obtain insurance and offer of subsidized coverage options.

A recent expert panel on preparing the New Jersey public for the ACA drew lessons from the Massachusetts experience and from successful strategies here in New Jersey to maximize enrollment in NJ FamilyCare. A bill being debated in the New Jersey Legislature would have the state agencies help with public education, but even if enacted it is not likely to bring new resources to the table. Beyond finding new state resources, New Jersey certainly can leverage the deep consumer support expertise it already has available through the Department of Banking and Insurance and the NJ FamilyCare program.

Regardless of what additional wherewithal can be mustered, resources for public education and outreach ahead of the October open enrollment will be scarce, making it critically important to target them carefully. There are uninsured in every community, but there are also certain areas with large concentrations of people lacking coverage.

Of the nearly one million uninsured New Jersey residents whose family incomes fall in the range where free or subsidized coverage will be available, more than one in 10 live in Essex county and over half live in one of five counties (Essex, Hudson, Middlesex, Passaic, and Bergen). Looking at it from another perspective, some of these counties have huge proportions of their low- to moderate-income populations without coverage. Essex, Hudson, and Passaic counties, for instance, each have an uninsured rate of 40 percent among adults without dependent children below the ACA subsidy income threshold. Not only should outreach and education be targeted to these areas, but health plans should be working toward enhancing their provider networks in these areas to handle the influx of newly covered lives. The eleventh hour for health reform implementation has arrived, and healthcare leaders in New Jersey have their work cut out for them.

Joel C. Cantor is the director of the Center for State Health Policy and professor of public policy at Rutgers University. He has authored numerous studies of health insurance regulatory policy, healthcare delivery system performance, and access to care for low-income and minority populations. He serves frequently as an advisor on health policy matters to New Jersey state government. The views expressed in this essay are solely those of the author and are not endorsed by funders of the Center for State Health Policy.

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