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You’re invited to a panel discussion about the state of health care in Augusta and across Georgia. Local stakeholders and community leaders will discuss the current state of health insurance coverage and access to care, present regional and state data on Medicaid and the uninsured, and discuss opportunities to work together to improve coverage and access to care through direct collaboration and through policy change. We will place a special focus on Georgia’s coverage gap and lessons learned from other states that have reduced their uninsured rates by expanding Medicaid or through alternative approaches, such as a waiver.     The event will take place at the Augusta Richmond County Public Library on Thursday, Sept. 24th, 9 to 11 am. Coffee and a light breakfast will be served. This event is free, but we ask that you please register so we can get an accurate head count.   Panelists include: Dr. Jacqueline Fincher, MD, MACP Board of Regents | American College of Physicians | Managing Partner,  McDuffie Medical Associates   A representative from Christ Community Health Services   Tim Sweeney, Deputy Director of Policy Georgia Budget and Policy Institute   Dr. Bill Custer, Director of Center for Health Services Research   Click here to register for the event.

This column was authored by Cindy Zeldin, Georgians for a Healthy Future’s Executive Director, and originally appeared in the Atlanta Journal-Constitution on September 28th, 2015.

 

Earlier this month, the Georgia Department of Community Health announced that it had abandoned plans — at least for now — to seek flexibility in Georgia’s Medicaid program to allow for expanded coverage and an innovative delivery-of-care model for the patient populations served by Grady Health System in Atlanta and Memorial Health in Savannah.

 

 

While this pilot program would have been fairly limited, it was designed with the changing health care landscape in mind and in the spirit of making the health system work better for patients. The proposal relied on an integrated care model with primary care medical homes, care coordination, data sharing and a focus on prevention. The costs to the state would have been nominal — negligible, even — as Grady offered to foot the bill. That this effort is not moving forward is a disappointment, but it should not be a conversation-ender.

 

 

For years, the nation’s uninsured rate appeared stuck at a stubbornly high level. This had implications for individuals and families who couldn’t access the care they needed, for communities and health systems that experienced spillover effects, and for overall health and productivity. Over the past year and a half, the tide has turned. The uninsured rate has steadily declined, and in some states it has plummeted to less than 5 percent.

 

 

It is a time of tremendous change in health care, yet this change is being felt unevenly. According to a recent Gallup-Healthways survey, states that both established their own health exchange (or a partnership exchange) and expanded Medicaid saw greater declines in their uninsured rates than states that did neither. States that viewed the changing health care landscape as an opportunity, and the Affordable Care Act as a toolbox, to improve coverage saw far better results than those who did not.

 

 

Many states taking this “opportunity and toolbox” approach are now building on the foundation of high coverage rates to invest in prevention, improve access to care and enhance value for consumers, often in collaboration with local health care stakeholders.

 

 

Kentucky, for example, has reduced its uninsured rate from over 20 percent to 9 percent since 2013. Combined with an intentional focus on prevention, this has translated to a more-than doubling of the number of screenings for breast, cervical and colon cancer and of dental and physical exams. Other states like Oregon are developing initiatives to contain costs, improve quality and achieve better price transparency for consumers.

 

 

Of course, not every promising initiative will be a smashing success, but the pace of innovation and advancement is historic for American health policy. Here in Georgia, approximately 500,000 people enrolled in coverage through the Health Insurance Marketplace, an exciting development that has helped bring our state’s uninsured rate down to just above 15 percent. In normal times, with all else being equal, this would be extraordinary.

 

 

And while this achievement is transformative for the people and communities impacted, these are not normal times for the health system. Georgia’s uninsured rate remains among the nation’s highest, and our health outcomes, among the nation’s poorest. Without a more deliberate focus on coverage, access, value and outcomes, Georgia risks falling further behind other parts of the country. We cannot continue to do less with less.

 

 

The demise of the Grady experiment, while a disappointment, should be a conversation starter about moving Georgia towards an “opportunity and toolbox” mindset. To date, our state has stayed on the sidelines while others have moved forward, but we don’t have to remain there.

 

 

The evidence is beginning to pour in from around the country, and we can take the most promising initiatives out there and use them to inform a uniquely Georgia approach. The clearest evidence we have shows us the decision by the majority of states (30 and counting) to expand Medicaid is foundational in transforming the health system. The Grady initiative, while not Medicaid expansion, was at its heart a delivery system reform that was predicated on moving its target population into coverage as a first and necessary step.

 

 

We cannot make progress as a state if 15 percent of our population is uninsured. Too many Georgians fall into a coverage gap our leaders can fix. Medicaid expansion should be on the table, not as a perfect solution, but as a necessary first step.

 

 

 

During the 2015 Legislative Session, the State Senate established the Consumer and Provider Protection Act Study Committee. This committee will review and make recommendations around several health insurance practices, including network adequacy. GHF has identified network adequacy, or the sufficiency of the health care providers patients can access when they enroll in a health insurance plan, as an important emerging consumer health issue. Our Executive Director, Cindy Zeldin, is a member of the study committee and looks forward to bringing the consumer perspective to the committee’s work. Cindy also recently appeared on WABE and Top Docs Radio to talk about network adequacy and participated in a panel discussion along with several state legislators at the Medical Association of Georgia’s Summer Legislative Education Seminar to discuss this important issue. Stay tuned for study committee agendas, updates, and opportunities to weigh in!

 

Study Committee Schedule:

 

September 14, 9:00 – 12:00

State Capitol, Room 450

 

October 26, 2:00 – 5:00

Tift Regional Healthy System, Tifton

 

November 9, 9:00 – 12:00

State Capitol

 

 

Over the past 50 years, Medicaid has ensured that our family members, friends, and neighbors have the quality health care they need. Be it our seniors accessing long term care services, kids seeing a doctor, or people with disabilities living independently, millions of people are better off because of this critical program. Medicaid has also shown itself to be an effective and cost-efficient program. Administrative costs are substantially lower than private insurance and because people using Medicaid have access to preventive services, small issues can be addressed before they end up as big, costly illnesses. Children in particular benefit from Medicaid. Studies show that kids with coverage show up at school ready to learn, are more likely to graduate from college, and end up with more earning potential as adults. In fact, more than 1 million Georgia children (about 35% of kids in our state) currently get their health care coverage through Medicaid. As we reflect on what Medicaid has meant for children and families here in Georgia, it has been nothing short of transformative. And while about 1.9 million Georgians overall benefit from the essential health care access that Medicaid provides, approximately 300,000 Georgians are still stuck in a coverage gap: they don’t qualify for Medicaid under its existing stringent standards, aren’t offered coverage at work, and earn too little to qualify for tax credits through the Health Insurance Marketplace. The majority of states have accepted federal funding to close this gap, but Georgia hasn’t yet taken that step. Closing this gap and extending Medicaid coverage to all low-income Georgians would be a powerful tool for improving the health of individuals and families throughout our state. At Georgians for a Healthy Future we are proud to advocate for the Medicaid program that has been proven to improve health and saves lives. For the millions of Americans, and many Georgians, whose quality of life has been improved because of Medicaid, we’re so happy to celebrate the 50th anniversary of the life-changing program.   More about Medicaid in Georgia!

Cindy Zeldin has been appointed by Lt Governor Casey Cagle for a study committee for SR 561, the Consumer and Provider Protection Act.

Georgians for a Healthy Future is proud to announce the appointment of our Executive Director Cindy Zeldin to the Consumer and Provider Protection Act Senate Study Committee (SR 561).

This study committee will consider a number of issues pertaining to consumer protections for health care consumers. One of the issues that is top of mind for GHF is the question of whether the provider networks that health plans have assembled are adequate to ensure that consumers have meaningful and timely access to all covered benefits. Known as network adequacy, this issue has become a hot topic over the past year. We look forward to working with the other study committee appointees to identify constructive policy approaches to ensure that Georgia health care consumers have meaningful and timely access to care, and we will keep you updated as the work of the committee progresses.

What is network adequacy?

Other members of the study committee:

Senator Dean Burke
Senator Renee Unterman
Senator Charlie Bethel
Senator Burt Jones
Manoj Shah, M.D.
Richard Smith, DDS
Mr. John Crew
Ms. Angela Waller
Ms. Cindy Zeldin
Mr. Richard Novak

 

GHF conducted in-depth interviews with and survey of enrollment assisters across the state to identify best practices and lessons learned from open enrollment 2.  Here’s a summary of what worked, what didn’t, and what we can improve on next year.

 

What worked during OE 2: Successful strategies and best practices

 

 

Using a variety of local venues to conduct extensive outreach. Across the board, enrollment assisters identified the importance of conducting a broad range of outreach and enrollment activities at the local level. They identified a variety of venues where they successfully reached consumers including libraries, churches, college campuses, Volunteer Income Tax Assistance (VITA) sites, doctor’s offices, community health centers, cooperative extension offices, small businesses, AIDS service organizations, and local hospitals. For example, one navigator organization worked with a nurse navigator who met with uninsured consumers who presented at the emergency room at the local hospital. The nurse navigator connected these uninsured consumers to a navigator organization, allowing the organization to reach a much larger pool of consumers than if they had not had this partnership. Enroll America also provided significant support to assisters’ outreach and enrollment efforts. Assisters were limited in their ability to retain personal information about consumers, but because Enroll America only provided outreach and education, they could retain contact information and follow up with consumers seeking more information about the Marketplace.

Leveraging the support of existing partnerships for outreach. All of the assisters interviewed acknowledged that one of their best methods for reaching consumers was building upon existing relationships with community organizations. One group wrote letters to community partners letting them know of their navigator services, which created more awareness in their communities. Another enrollment assister organization had deep ties with Family Connection Partnership organizations in their area, which allowed them to have a well-known partner in each of the counties that they covered.

These partnerships allowed the enrollment assister organizations to use existing frameworks of community organizations to educate and provide enrollment assistance to the populations served by these groups. Because of the strong presence and history these partner organizations have in the communities they serve, consumers also viewed them as credible.

Developing trust with consumers. One of the most critical aspects of providing enrollment assistance was for assisters, and their organizations, to be recognized as a trusted resource within their communities. This was especially true for assisters working with immigrant and non-English speaking populations. One Spanish-speaking enrollment assister noted that it put consumers at ease to have a native speaker, rather than someone speaking Spanish as a second language, helping them to enroll. Additionally, due to the strong anti-ACA sentiment in the state, enrollment assisters reported that it was critical to be considered a trusted resource in order to overcome ideological barriers.

Reaching large numbers of people through events and local media. Enrollment events served as valuable opportunities for assisters to efficiently reach large numbers of people. For example, one of the navigator grantee organizations organized large events in rural communities to provide centralized assistance to a larger pool of consumers. These events were marketed in the local media using radio spots, newspaper ads, and movie theater ads. Additionally, some assister organizations used local media outlets to reach a large number of consumers. One organization in South Georgia held a phone bank with a local television station. The organization reported that following this event, their call volume of consumers looking for enrollment assistance picked up substantially.

 

 

What challenges and barriers remain for consumers?

 

Enrollment assisters identified several challenges in enrolling uninsured consumers and noted some barriers that some uninsured Georgians still face.

Many consumers had limited health insurance literacy. More than two-thirds of our survey respondents identified low health insurance literacy as a barrier to enrollment. Many of the consumers that assisters worked with had never been insured before, so they did not know how to choose a primary care physician or pay their monthly premium. One of the assisters interviewed acknowledged they needed to educate consumers on how to use their health insurance, but that it was a challenge when scheduled with a large number of enrollment appointments. Additionally, some assisters reported that consumers chose the lowest premium plan because they did not understand the concept of a high deductible. Sometimes consumers would return to the assister wanting to change plans once they had tried to use their coverage.

Many consumers fell into the coverage gap. Assisters encountered a large number of individuals and families that fell into the coverage gap, meaning that they did not qualify for Medicaid or subsidies to help them pay for Marketplace coverage and were left without an affordable pathway to coverage. Some assister organizations estimated that over half of the consumers they worked with fell into the gap. Enrollment assisters were able to provide these consumers with a list of resources where they could go to get free or low cost care, but indicated frustration at not being able to do more to help. One navigator described it as emotionally taxing to repeatedly tell consumers that came to them looking for assistance that they were too poor to qualify for health insurance.

Immigrants faced verification and language barriers. Immigrants faced many challenges enrolling in coverage. Assisters reported that, when the consumer did not speak English and the assister did not speak the consumer’s native language, using interpreter services was difficult and often ineffective. Language barriers also created difficulty because key terms and concepts associated with health insurance do not translate well. The biggest barrier for immigrants, though, was identity verification. Enrollment assisters had little or no training on how to properly verify IDs or immigration forms. Additionally, technological problems sometimes prevented them from uploading these documents to healthcare.gov. When they were unable to upload these documents electronically, consumers had to verify their immigration status through the mail, which was a long and cumbersome process. There was also a common concern from families of mixed immigration status that sharing information about their families would lead to legal repercussions. Even though none of the immigration or family information shared with the Health Insurance Marketplace is used to identify immigrants that are not here legally, this is a misconception held by many

Confusion and political opposition to Affordable Care Act hindered partnerships. Stakeholders reported that confusion and political hostility created significant barriers to outreach and enrollment. In addition, the passage of the “Health Care Freedom Act” as part of HB 943 in 2014, which included language prohibiting state and local governmental entities from operating a navigator program, among other provisions, led to confusion among local health departments and other governmental entities regarding their participation in helping consumers enroll in health insurance. An earlier version of this legislation that was not enacted, HB 707, was even more restrictive than the final language that passed and the media coverage over that bill added to the confusion. Most of these entities opted for caution, which meant that potentially powerful partnerships for enrollment were missed. This legislation also ended the University of Georgia’s navigator program (The University of Georgia operated a navigator program through its cooperative extension service during OE1).

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In a 6-3 ruling the Supreme Court upheld tax credits in the Affordable Care Act. This is a big victory for Georgia health care consumers!

As an organization committed to making sure all Georgians have access to the health care they need, Georgians for a Healthy Future is celebrating today’s Supreme Court decision! This ruling is a big win and a big relief for the more than 400,000 newly enrolled Georgians who can keep their coverage and the access to care and financial peace of mind that comes with it.

“Today we celebrate an important victory for health care consumers, and we are relieved that hundreds of thousands of Georgians can keep their coverage,” said Cindy Zeldin, Georgians for a Healthy Future’s Executive Director. “But there is still work to do. Georgia has the second highest rate of uninsured in the country, and three-hundred thousand Georgians fall into a coverage gap that was created by Georgia’s decision not to expand Medicaid.”

Now that the outcome of King v. Burwell is clear, we must not forget these workers, parents, and veterans in our state who still lack access to quality, affordable health insurance. It’s time to close the coverage gap.

Tell your legislator that it’s time to close the coverage gap!

 

Sometime this month, the Supreme Court will rule on King v. Burwell, a case that could have major implications for Georgia health care consumers. The Court will rule on whether the ACA allows consumers to receive tax credits to help pay for health insurance in the 34 states including Georgia that use healthcare.gov, the federally facilitated marketplace.  Here in Georgia, nearly 9 in 10 Georgians who enrolled in coverage this year accessed tax credits that made that coverage affordable.  A ruling for the challenger in King v. Burwell would place coverage at risk for more than 400,000 Georgians. GHF is working to keep you informed and updated with all the latest on this case. Here’s what you need to know.

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#Donttakemycare

 

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Local News Highlight

GHF surveyed and interviewed enrollment assisters across the state to understand not only the “what,” but also the “why” behind the second open enrollment period.  The results of that research have led us to several policy recommendations to maximize health insurance enrollment and retention and to ensure that coverage translates to meaningful access to timely and appropriate medical services for Georgia health care consumers.

1. Close the coverage gap in Georgia. Approximately 300,000 Georgians fall into the coverage gap, meaning they do not qualify for Medicaid under existing income eligibility guidelines in Georgia but their income is still too low to qualify for financial assistance (tax credits) to purchase health insurance on the Marketplace. Eligibility for tax credits begins at 100 percent of the Federal Poverty Level, or $11,770 for an individual or $20,090 for a family of three in 2015, while Medicaid eligibility for most adults in Georgia cuts off at income much lower. Thirty states including DC have closed their coverage gaps thus far with promising results. We encourage Georgia policymakers to take this important step as well to ensure all Georgians have a pathway to coverage.
2. Set and enforce network adequacy and transparency standards. Many of the plans sold through the Health Insurance Marketplace are Health Maintenance Organization (HMO) plans that feature narrow provider networks. While these narrow networks can help keep premiums down, a trade-off many consumers may be willing to make, consumers do not currently have sufficient information to make this choice. There is no information available to consumers at the point of sale about whether a provider network is ultra narrow, narrow, or broad, and provider directories are routinely inaccurate. More transparency and oversight are needed to ensure that consumers have accurate and useful information to make these choices. It is also important that all provider networks allow for meaningful access to all covered benefits. To ensure this, we support putting in place and enforcing network adequacy standards.
3. Encourage public-private partnerships and remove unnecessary restrictions on consumer education and assistance. Many of the enrollment assisters we surveyed indicated that reducing barriers to partnering with state government organizations such as public colleges, universities, and health departments would lead to stronger and more effective partnerships. Specifically, many respondents indicated that improved coordination between enrollment assisters, the Marketplace, and the Georgia Department of Community Health (DCH) to better facilitate PeachCare for Kids and Medicaid enrollment would be helpful. The “Health Care Freedom Act,” passed in 2014 as part of HB 943, prohibits state and local governmental entities from operating a health insurance navigator program and places other limitations on governmental entities. This provision has been counterproductive, creating confusion around what educational and consumer assistance activities local entities can engage in as they work to serve their community members. We recommend lifting these restrictions.

 

From choosing a plan to using your plan, health insurance can be complicated and many Georgians lack the information they need to make informed decisions.  In GHF’s recent report Getting Georgia Covered: Best Practices Lessons Learned and Policy Recommendations from the Second Enrollment Period, we interviewed enrollment assisters across the state and found that more than two-thirds of our survey respondents identified low health insurance literacy as a barrier to enrollment. Many of the consumers that assisters worked with had never been insured before, so they did not know how to choose a primary care physician or pay their monthly premium. One of the assisters interviewed acknowledged they needed to educate consumers on how to use their health insurance, but that it was a challenge when scheduled with a large number of enrollment appointments, although there are lawyers and Massachusetts firms that are specialized in insurances policies so they can help you understand better how it works. Additionally, some assisters reported that consumers chose the lowest premium plan because they did not understand the concept of a high deductible. Sometimes consumers would return to the assister wanting to change plans once they had tried to use their coverage. As we move forward, Georgians for a Healthy Future will be focusing efforts on improving the health literacy of Georgians and ensuring they have the knowledge, information, and confidence they need to make informed decisions.