Total Missourians enrolled in the health insurance marketplace for 2018 increased by 1 percent from last year to about 245,000, according to the federal Centers for Medicare & Medicaid Services.
It’s not a lot, but considering the circumstances, local enrollment organization representatives said they’re pleased with the numbers – the first increase since a large drop three years ago. Enrollment has held steady at around 244,000 patients each year back to 2016. But the year prior was 15 percent higher, with about 290,000 enrolled in 2015, according to CMS data.
As conversation circulated about possible health care reforms following the election of President Donald Trump, Nancy Kelley, the Missouri Foundation for Health’s program director for expanding coverage, suspects media reports contributed to seeing the slight increase in 2018.
“There may have been an unintended benefit of having so many things in the news so that it raised people’s awareness that maybe they should be paying attention,” Kelley said.
Alongside it came confusion about the future of what the new administration would and wouldn’t do regarding Affordable Care Act coverage, said Kate Conn, manager of Cover Missouri’s Springfield-based southwest hub and a certified application counselor manager at CoxHealth.
“There were so many mixed messages, and I think people wanted to come in and receive help to get clear answers,” she said of individuals who visited Cover Missouri, a Missouri Foundation for Health subsidiary that assists in health care coverage enrollment.
Conn also speculated enrollment increased by individuals seeking to advocate for ACA in the face of its potential repeal.
“We have seen a huge advocacy movement with people really speaking up and sharing their stories and just actively talking about the benefits that they’ve received from the Affordable Care Act,” she said.
Although the Trump administration cut federal funding for ACA advertising in 2017 to $10 million from $100 million and grants for grass-roots enrollment assistance groups were slashed by 40 percent, Conn said the Cover Missouri southwest hub was largely precluded from the impact as it utilizes grants for its advertising – totaling about $10,000.
“We were still able to advertise as heavily as we had in the past year, so that was really helpful,” she said. “We were able to partner with a lot of other organizations to get the word out.”
Queen City care
In Springfield, there is only one option for a marketplace insurer and, as of now, only one hospital with an insurance agreement for ACA patients.
A month after the Dec. 15, 2017, enrollment deadline, CoxHealth does not have an ACA insurer secured. Cox HealthPlans officials say they are still negotiating an agreement with Ambetter Health, a health insurance marketplace owned by Centene Corp.
“While discussions are going well, nothing has been finalized yet,” CoxHealth Media Relations Coordinator Kaitlyn McConnell said via email. “There is no particular reason other than they just need time to work through the aspects of this.”
CoxHealth was forced to make a change after the hospital’s sole ACA insurer, Anthem Blue Cross and Blue Shield, decided in September to discontinue local marketplace coverage for 2018. Ambetter, of St. Louis, is the only insurance coverage option under the ACA in Springfield, through Mercy Hospital Springfield.
Conn said out of 375 individuals enrolled through Cover Missouri’s Springfield office, 150 switched to Mercy/Ambetter from CoxHealth.
“We had quite a few consumers who were or are currently patients with CoxHealth and are set with CoxHealth,” Conn said. “There was a lot of uneasiness around the fact that they might have to switch or didn’t know if they would have to switch.”
Mercy Certified Application Counselor Rebecca Brannon said her office had 149 counseling sessions regarding 2018 coverage, about the same as last year. However, enrollment decreased in the Mercy office to 147 in 2018 from 173 in 2017.
Since 2014, the number of insurance companies nationwide participating in HealthCare.gov’s marketplace has fluctuated – and current participation is lower than ever. Kaiser Family Foundation research shows the number of insurance companies in the marketplace peeked in 2015, with an average of six per state, and it has dropped since then to average 3.5 carriers per state for 2018, according to Springfield Business Journal reporting.
In February 2017, Humana Inc. announced it would end marketplace coverage, followed by Anthem pulling 2018 coverage from several Missouri counties, including Greene. Had Ambetter not thrown its hat in the ring, Greene County residents would have been left without any federally subsidized health coverage this year.
Although the proposed GOP health care reform bill did not pass, ACA isn’t out of the woods of change. The rule mandating penalties for uninsured individuals was repealed when Congress passed its tax reform bill Dec. 20, 2017. According to the Congressional Budget Office, the move could result in as many as 13 million fewer Americans having health insurance. It estimates about 5 million of those individuals will be those who previously were enrolled in health insurance – either with ACA or not.
“A big piece of our education has been about the law and letting people know about the penalty. I think that is a motivator for some people to enroll in health care,” Conn said. “But our main method has always been to help people understand the value of having health insurance.”
At Mercy, Brannon said the educational approach is much the same.
“It’s not necessarily about not having to pay the money at the end of the year. It’s about your health. And that was the whole idea of ACA,” she said. “We try to make them see that, yes, the penalty will be taking effect in 2019, but look at all the positives of having health insurance and why.”
The CBO’s assessment of the rule’s repeal also estimated that premiums would increase as a result of younger, healthier patients opting out of health insurance coverage. The perhaps elderly and sicker patient pool left behind, federal officials estimate, could experience increased premiums by 20-25 percent.
“I think it’s kind of a formula on both sides, because that is the math that we understand to be true,” Kelley said. “If it’s all of them that drop out, then insurance will become more expensive for the people who are remaining in the market who are often maybe sicker and use their care more.”
However, Conn said premium tax credits often help to even out insurance expenses.
“In the past when we’ve seen a premium increase, the premium tax credit always increased to compensate for that increase in price,” she said.
Part of combating this potential collateral damage, Kelley said, goes back to educating the public on the benefits of having health insurance – even if they are no longer being penalized. She also pointed out the repeal won’t take effect until 2019, which means those uninsured in 2018 can still be penalized.
“Again, it’s going back to trying to get as many healthier folks to understand and to appreciate the value of health insurance and perhaps make a different choice than just dropping it,” Kelley said.
Rhonda Lewsader now leads the city of Springfield’s law department as city attorney after two decades of service.
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