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Two of the nation’s largest health insurance companies announced proposed mergers last year that would drastically change the health insurance market in Georgia.

In this report, Georgians for a Healthy Future summarizes current insurance market concentration in Georgia, outlines the impact of mergers on premiums and access to health care providers, explains the role of regulators in approving mergers and Georgia’s review process, and provides policy recommendations to protect consumers.

Next week, public hearings will be held on the proposed Aetna-Humana insurance merger. GHF’s health policy analyst Meredith Gonsahn will provide testimony. If you are interested in attending,more details are available and if you have any questions about GHF’s public comments, please reach out to Meredith.

GO TO REPORT

Georgia’s many summer festivals provide a unique opportunity for Georgians for a Healthy Future and our partners to get out in the community and talk with people about how health policy impacts their lives and how they can be advocates. On June 11^th and 12^th, we continued our summer festival outreach with an information & education booth at the Peachtree Corners Festival in Peachtree Corners. Our primary focus out in the community has been coverage gap education, but we also talked to attendees about our other priorities, including  health insurance enrollment and youth substance use prevention. We also asked attendees who stopped by the table to sign postcards to show their legislators that they support closing the gap.

In addition to outreach, we collected stories of several Georgians who fall into the gap. One grandmother in her early 60s told us that she is taking care of her grandkids full-time and crossing her fingers that she doesn’t get sick before she becomes eligible for Medicare. All of the people that we spoke to that fell into the gap knew they were in the gap and why it exists, but were hopeful that Georgia’s lawmakers would do something soon to fix the problem.

The Cover Georgia coalition was well represented at the festival as well, and we want to give a special thanks to Feminist Women’s Health Center, Georgia Watch, and Hemophilia of Georgia for volunteering with us. If you’re interested in volunteering with us at upcoming festivals, please reach out to Whitney or Laura.

It’s been an exciting few weeks for Close the Gap advocates. We are pleased to see that several of Georgia’s leaders  have expressed to the press that they are willing to take a second look at closing Georgia’s coverage gap. By closing the gap, they would help not only hard-working Georgians but also struggling rural hospitals and the communities that rely on them. We hope to work with our state leaders in the coming months to build further support and to find a solution that works for all Georgians. Below you’ll find links to articles covering the conversation happening at the Gold Dome.

Op-Ed: The irrefutable logic of Medicaid expansion for Ga.
AJC | June 22

Louisiana’s expanding Medicaid, and Georgia should too
Flagpole | June 22

Task force aims to reshape Georgia stance on health coverage
Georgia Health News | June 21

Will Louisiana’s Medicaid expansion provide a model for other states?
Georgia Health News | June 20

Why A Ga. GOP chair wants to ‘re-examine’ Medicaid expansion
WABE | June 15

Medicaid expansion remains divisive for Georgia Republicans
Associated Press | June 11

HOW YOU CAN GET INVOLVED

Email your legislator and tell them you support closing the coverage gap!

Did you know that you can find and email your legislators right from the GHF website? Just enter your address and we’ll find your state representative and senator! Send them a brief email telling them that the time has come for our legislature to come together to close Georgia’s coverage gap! Send your email here.

Need more resources on the coverage gap?

These resources will help you understand what the coverage gap is and what it means for you and the state.

Medicaid Chart Book

Georgia Left Me Out

Does your organization support closing the coverage gap?

Your organization can show its support by joining the Cover Georgia coalition. Email our Director of Outreach & Partnerships Laura Colbert for more information.

Georgians for a Healthy Future was excited to meet and engage colleagues in rich discussions around policy, grassroots organizing and coalition-building to make prevention counseling more widely available for young people. This June, we joined advocates from other states in Philadelphia for the Community Catalyst Substance Use Disorders Advocacy Convening. The three-day conference gave us valuable insight for the next phase of our advocacy and policy efforts to expand the use of Screening, Brief Intervention and Referral to Treatment (SBIRT) through the activation of Medicaid codes for youth. Activating Medicaid codes would allow providers to be reimbursed for the time they spend conducting SBIRT and would encourage greater use of the tool.

Over the past three years, in partnership with the Georgia Council on Substance Abuse, GHF has advocated for turning on SBIRT codes and raised up youth substance use disorders as a critical public health issue that can no longer be overlooked in Georgia. We will publish a white paper on the potential benefits for turning on the Medicaid codes for youth SBIRT services in Georgia in the coming months. Check out our website to find out more about our Somebody Finally Asked Me campaign, additional resources on youth substance use prevention, and how you can get involved.

Ebenezer Baptist Church is a cornerstone of advocacy and social justice in Atlanta. On June 20^th, Laura Colbert, Director of Outreach & Partnerships, was invited to join their Women’s Season celebrations to talk about the importance of closing Georgia’s coverage gap. She spoke to a crowd of about 60 women on a day when the theme was health and self-care.

In keeping with the theme, Laura discussed how the women and parents in Georgia’s coverage gap are often unable to access health care so that they can better care for themselves and their families. She also highlighted the connection between health care coverage and better financial health—an important consideration for the low-income Georgians stuck in the coverage gap. Finally, she highlighted that parents who have health care coverage are more likely to keep their kids covered too.

At the end of Laura’s time, Ebeneezer women signed coverage gap postcards to let their legislators know that they support closing the coverage gap. If you haven’t done the same yet, click here to raise your voice and let your legislators know that this is an important issue that you want addressed.

Georgians for a Healthy Future’s Executive Director Cindy Zeldin sat down with A Spirit of Charity author Mike King to discuss his new book on the role of public hospitals in America. Below is a Q&A that delves into some of the book’s major themes. On July 19th, Georgians for a Healthy Future will hold a book event in Atlanta with Mike King, providing a unique opportunity for the advocacy community to discuss the history and role of public hospitals in America and the direction of health policy in Georgia with the author.

Why did you decide to write this book?

I have been writing and editing stories about medicine and natural medicine like thai kratom powder and health care policy for about 30 years where they use different kind of medicines, you could for example this reach out to one!. When the newspaper business collapsed and I chose to leave it in 2009, I thought I’d just retire and take it easy. But when the Affordable Care Act passed in 2010 I realized I had the time, without daily deadline pressures, to tell a story about the most important effort at reform over the last 50 years and how it might play out right here in Atlanta and at Grady in particular,.

How do public hospitals serve as a window into America’s health system?

As the book hopefully makes clear, the people who show up in the emergency rooms and clinics of America’s public hospitals are the result of all gaping holes, political compromises and unintended consequences of decades of attempts to reform our health care system. Even in our noblest of efforts, we always seem to leave whole segments of our society behind. Donald Trump, in a candid moment earlier in the campaign when the media pushed him for more details about what his alternative to Obamacare would look like, frustratingly blurted, “Look, we won’t let people die in the streets, OK?” In some ways that’s been our baseline as a health care system from the start, which is why public hospitals were created. We don’t let our citizens die in the streets. They get sick in the street but, if they are lucky, we get them to a public hospital that hopefully will rescue them from dying before they return to the streets. That’s a harsh assessment, I know, and we do much better than that in many places thanks to the commitment of engaged local and state leaders, but there are too many places where the local public hospital seems expected to shoulder this burden on its own.

Four of the five hospitals profiled in your book are located in the South, and the role of Southern politicians in crafting U.S. health policy is explored throughout the book. Why a focus on the South?

Because the South is where the most problems are. Texas, Florida and Georgia lead the nation in the dubious distinction of having the most uninsured residents among all 50 states – mostly because all three have refused to expand Medicaid the way the ACA called for. Louisiana is high on the list too, but the new governor there is moving to try to expand Medicaid. Parkland Memorial Hospital in Dallas, Jackson Memorial in Miami, the University Medical Center in New Orleans (the replacement hospital for Charity) and, of course, Grady, all have to contend with a huge percentage of patients who are poor and uninsured and could be, should be, covered by Medicaid. That’s why I chose them.

Some public hospitals like Grady were established during segregation. The 1946 Hill-Burton Act, which catalyzed hospital construction, contained a provision permitting segregation in hospitals receiving federal funds. How does this legacy of segregation impact public hospitals today?

Hill-Burton was the first time federal law actually codified a separate-but-equal funding mechanism and it was inserted into the law specifically to get members of Congress from the South to go along. Rural hospitals around the South and more than a few in the suburbs were built in the 1950s and 60s with Hill-Burton money. Grady was rebuilt as a segregated hospital in 1958. After the enactment the Civil Rights Act in 1964 and Medicare in 1965 that changed. Segregated hospitals – public and private – stood to lose too much money that they would be getting for the care of previously uninsured elderly patients if they stayed segregated. But there is still a legacy to overcome. There’s a reason elderly Atlantans still refer to Grady as the Gradies, going back not that long ago to when there was a Black Grady and a White Grady, with black nurses taking care of black patients and white nurses taking care of white patients. It still complicates the public discussion about how best to finance and administer this particular public hospital. I suspect that goes on in a lot of communities around the South that share a similar legacy.

You write that public hospitals serve as a “pressure release valve” for our nation’s health system. What do you mean by this?

We often refer to these places as safety net hospitals. But I contend they are more than that. The existence of a single hospital in a community that is chartered or required to take in all patients regardless of ability to pay fundamentally alters the medical marketplace in that community. It allows those hospitals that compete with it to measure their anticipated level of charity care against their expected revenue from insured patients and come up with a formula that helps them stay healthy and able to grow. It is not that most of these competing hospitals don’t provide a responsible level of charity care. Most of them do. But it is always at a level they can afford to provide. Public hospitals operate on a totally different business model. They have to take all comers and the only way they can stay open is to get some level of funding from state and local taxes to offset their losses. Here’s another way of looking at it: If Grady had gone belly up in 2007 and 2008, all the uninsured and indigent patients it served would have swamped the emergency rooms of Piedmont, the Atlanta Medical Center, Northside, St. Joseph’s, Emory and DeKalb Medical as well as other hospitals, jeopardizing their ability to provide the level of services their business model calls for. The safety valve would have blown.

Information about Medicaid, the health care program intended to help finance care for low-income Americans, is interwoven throughout your book. How are the histories and fates of Medicaid and public hospitals intertwined?

They are the key to understanding each other because Medicaid patients make up a large portion of the patients who go to these hospitals. When Medicaid was enacted in 1965 the theory was that with a health insurance program now in place for the poor and with Medicare available to the elderly, our nation’s public hospitals would finally start getting paid for many of the services they had been providing on a charity basis. But unlike Medicare, Medicaid was hampered – I would argue fundamentally flawed – by a series of compromises to get it through Congress. States were given a much bigger role in determining how poor you had to be to qualify for Medicaid, how much they wanted to pay doctors and hospitals to provide services for Medicaid patients and indeed whether they wanted to participate in the program at all. (Arizona didn’t join Medicaid until the 1980s.) The result was a checkerboard of health care programs for the poor around the country, based largely on what the states decide. And in the South, Medicaid has been chronically underfunded at the state level and treated more like a welfare program. This is how Southern politicians get away with calling it a failure. They starve it for funds, make it difficult for low-income people to get covered by it, grossly underpay doctors and hospitals that take patients covered by it and then decry the program for not working and being inefficient.

America’s health system is characterized by fragmentation. Why do you think this is and what is the role of public hospitals in a fragmented system?

We’ve all heard it before. America has a sick care system, not a health care system. And that system is based on who pays for sick care, not necessarily how we can more effectively pay for care to help keep people healthy. The good news is that the ACA is moving in the direction of breaking down some of the silos that have developed over the decades in how we deliver and pay for health care, with an emphasis on moving away from paying a fee for specific services and toward paying for overall wellness. That’s good. But it will take years to see results. Public hospitals will need to move in this direction as well – and some of them are. Cook County’s Medicaid Program (County Care) is coordinating care with its community hospital and clinic network and the federally funded community health centers in Chicago. The initial results look encouraging. If it works it will not only save lives but help control the rise in costs. But public hospitals must adapt to these new models and remain, in most large cities, the sole providers of costly essential services like trauma, HIV/AIDS and behavioral health for those who are still uninsured.

You write that, if public hospitals didn’t exist, “We would have to invent them.” What would an America without public hospitals look like?

It would be fascinating to see, wouldn’t it? Public hospitals were created one hundred to one hundred and fifty years ago when it became obvious that the charitable institutions in large American cities could not meet the demand for care caused by yellow fever, cholera, pestilence and other public health threats, not to mention the population growth in cities after the Civil War. The almshouses and infirmaries, often staffed by religious women and funded by churches and community groups, just could not keep up. I suspect the same would happen today if we came to rely exclusively on the nonprofit sector to take over the responsibility for caring for the poor and uninsured. Even if we became enlightened and created a system of true universal insurance for all Americans, there would still be a need for expensive specialty areas. Trauma care, infectious disease programs, severe, chronic mental health services – these essential services now almost exclusively provided by public hospitals – I would suspect they would require some level of local and state financing at a public facility that would go beyond what they can expect in the way of revenue from a public insurance plan.

Grady is featured prominently throughout the book. What did you learn about Grady by writing this book that you didn’t know before?

That it is even bigger and more complicated and harder to manage than I ever dreamed. I think the current administration there is doing a really good job at getting the hospital positioned to be everything it can be. The quality of the specialty services there – trauma, neuroscience, neonatology, burn care, sickle cell, infectious disease – has probably never been better, and they get well informed visiting Litchfield Neurofeedback to learn about the benefits of Neurofeedback Therapy. The cancer program there, in addition to being first rate at the acute care level, is making great strides in the community in the much-needed area of early detection and treatment. That will go a long way toward reducing the disparities that exist in morbidity and mortality between white and black, affluent and poor residents of our community. But the hospital is still heavily reliant on the business and philanthropic community to grow, especially when it comes to capital improvements and equipment. That’s all been private money since the comeback started. State and county officials have yet to step up to the plate to help. If they are willing to help the Braves and the Falcons build new venues, they must be willing to step up to help Georgia’s most important hospital build and grow and provide essential services.

What role does Grady serve in health care policy in the state of Georgia?

The state needs to recognize Grady is a statewide institution, if for no other reason than it is the training ground for about one in every four doctors practicing in Georgia. I’ve often wondered whether the state’s relationship with Grady would be different if it had been affiliated with a state medical school instead of Emory and Morehouse – two private medical schools. Perhaps then it would have paid more attention to it. Even though Grady gets patients from almost every one of Georgia 159 counties, it isn’t realistic to think the state must subsidize indigent patient care there, but it could do much better and providing funding for the specialty services that Grady provides to all Georgians – trauma care, burn care, infectious diseases, etc. And, of course, it should expand Medicaid coverage so that Grady and all other hospitals in the state that have a heavy load of uninsured patients will at least have an opportunity to recoup some of their costs.

Where do you think Georgia is headed on health care policy? 

I think we’ll expand Medicaid. Eventually. After President Obama is in the rear view mirror. We’ll call it something else so it doesn’t sound like it is part of Obamacare. But we will have squandered $3 to 5 billion and 100 percent federal funding to make this impetuous political statement, and no telling how many Georgians – one study puts it at 1,200 lives a year – who died because they lived in a state where they should have, but were kept from, enrolling in Medicaid. With a little political vision – and the help of advocates and experts – my hope is that we could create a Medicaid program that isn’t so fragmented; that fully integrates primary care and acute, hospital care; that reorganizes local hospitals and health departments into a true public health system that helps people stay healthy and when they get sick have no barriers to the care that they need. That shouldn’t be a pipe dream in a country as wealthy and smart as ours. That should be a working reality. On the other hand, try to visit what is a medium.

Does a strong consumer voice make a difference in health policy outcomes? According to a Mathematica Policy Research evaluation of state-level consumer health advocacy projects supported by the Robert Wood Johnson Foundation (RWJF), yes!

At Georgians for a Healthy Future, consumer engagement is woven into each of our initiatives to bring the needs – and voices – of Georgia health care consumers into the public policy process. Over the past two years, one of our top priorities has been maximizing health insurance enrollment and ensuring that, once enrolled, consumers can access the care they need. Our work in this area, along with that of similar efforts in seventeen other states, was recently evaluated by Mathematica. The evaluation focused on the activities and outcomes of the eighteen Consumer Voices for Coverage (CVC) projects funded by RWJF.

Georgians for a Healthy Future was a CVC grantee in 2014-2016. Through this program, we focused on outreach, education, and enrollment in coverage and used this work to inform and strengthen our policy work. The CVC evaluation found that coalitions, such as the one led by GHF in Georgia, played a central role in successful outreach, allowed consumer advocates to work together to help maximize enrollment and retention, and helped identify policy issues needing attention.

These coalitions worked to increase enrollment in health coverage programs by building alliances with diverse stakeholders, mobilizing and engaging consumers, identifying achievable policy options to address issues arising from consumer experiences, designing and implementing communication strategies, and securing resources to sustain these efforts.

While the CVC program is winding down, Georgians for a Healthy Future’s work in this area will continue through our Georgia Enrollment Assistance Resource (GEAR) network and through our ongoing policy work around coverage, access to care, and health care value. As we continue this health policy and advocacy work, we will leverage the advocacy infrastructure and ability to translate consumer voices strengthened through CVC into concrete policy actions.

To read the complete Mathematica evaluation, click here.

The weather is heating up and the official start of summer is just around the corner, but here at Georgians for a Healthy Future we’re already looking ahead to one of the hallmarks of fall: open enrollment! The fourth health insurance open enrollment period, known as OE4, will run from November 1, 2016 through January 31, 2017. Stay tuned for an announcement soon about our enrollment summit – an opportunity for Georgia assisters, advocates, and other enrollment stakeholders to reflect on OE3 and plan for OE4 – scheduled for this coming August.

Earlier this spring, new renewal policies and consumer shopping tools were announced (see a roundup of these changes from Georgetown University’s Center on Health Insurance Reforms) and health insurance plans released their initial rate filings (see Georgia Health News’s coverage here, including comments from GHF’s Executive Director Cindy Zeldin), giving us early insights into what we might expect in the upcoming open enrollment period. It’s important to keep in mind that initial rate filings provide important information to regulators, stakeholders, and consumer advocates but they aren’t a good predictor of what consumers will actually pay for health insurance this fall. That’s because proposed rates must first undergo scrutiny by regulators and don’t take into account consumer shopping behavior or the availability of premium tax credits.

While we’re busy preparing for OE4, we also know that health insurance enrollment does happen year-round (if you are engaged in enrollment activities this summer, please tweet about them using #enrollment365). Life changes like marriage, moving, or job loss can happen during any season, triggering special enrollment periods (SEPs). Awareness of SEPs is low, and assisters play an important role in helping consumers who qualify navigate the process. Despite low enrollment during SEPs, however, the Centers for Medicaid and Medicare Services (CMS) recently issued a new rule further tightening them. GHF is concerned these changes could dampen enrollment among qualified uninsured individuals. If you are an assister and are finding that qualified individuals are having difficulties enrolling in an SEP, please let us know.

Finally, if you or your organization helps consumers navigate the health coverage or health care landscape, please consider joining GEAR, the Georgia Enrollment Assistance Resource network. GHF formed GEAR last year to help members of Georgia’s enrollment community learn from each other, share consumer-facing educational materials, and stay apprised of best practices from around the country. Joining GEAR is free, and through it we provide networking and learning opportunities for individuals and organizations that assist health care consumers. And it helps GHF keep our finger on the pulse of what consumers and assisters are experiencing so we can be better advocates. Learn more here.

The Georgia Department of Insurance will be holding hearings this summer on two key mergers that could impact the cost, quality, and coverage of health insurance that Georgia consumers are able to obtain.

Three of the nation’s biggest insurance companies (Aetna, Anthem, and Centene) are seeking mergers that would drastically change the health insurance market in Georgia and other states. What’s at stake for consumers is competition. Consumers benefit from competition, it encourages companies to offer lower prices, increase quality, and spur innovation. Currently in Georgia, the top four insurers control at least 75 percent of the market for individual, small group, and Medicare plans sold in the state. If the proposed Aetna-Human and Anthem-Cigna mergers go through then millions of Georgians can expect to see affordability, choice, and access greatly impacted.  But Georgia has the opportunity this summer to assess the merits of these mergers and, if approved, to guarantee that negative outcomes for our state’s consumers are mitigated.

State regulators have  power to approve mergers

Before the proposed Aetna-Humana and Anthem-Cigna mergers can go into effect in Georgia, both must be approved by the Georgia Office of Insurance and Safety Fire Commissioner (DOI). The DOI began reviewing the two proposed mergers in the summer of 2015. See initial findings for Aetna and Anthem here. After the review process is completed, a public commenting period, which includes a public hearing, will begin. During the public comment period this summer, consumer advocates have the opportunity to provide input and testimony in the public hearings where insurers will be questioned.  Following the public hearing, the Commissioner will issue a final decision to approve the mergers as is, approve with conditions, or disapprove.

How consumer advocates can get involved and have their voices heard

• Submit public comments and/or questions on how you believe mergers would affect consumers. Email mergercomments@oci.ga.gov or send by U.S. mail to Administrative Procedure Division, 2 Martin Luther King Jr., Drive, West Tower, Suite 1016, Atlanta, GA 30334
• Attend the hearing on the pending Aetna-Humana and Anthem-Cigna mergers. To receive meeting notifications, subscribe here
• Georgians for a Healthy Future plans to submit public comments and provide testimony. If you would like to learn more about our comments and sign onto them as a partner organization, contact Meredith Gonsahn at mgonsahn@healthyfuturega.org.

How to ensure that bigger means better for consumers

Georgians for a Healthy Future looks forward to participating in the public commenting process. Over the next month, we will release a policy brief on insurance mergers to help inform our partner organizations and submit public comments to Georgia’s DOI. We will put forth recommendations of merger approval conditions for premium stability, network adequacy, value-based coverage, consumer protections, and regulatory oversight. We recommend that Georgia’s DOI carefully consider whether or not to approve each merger and which remedies best address the expected concerns of and effects on consumers.

Once the mergers are approved they cannot be reversed. Therefore, we urge extreme caution in reviewing whether the mergers should be approved at all. If, at the end of the comment and review period, the DOI has a high degree of certainty that the mergers can benefit consumers, the DOI should set conditions for approval by which insurers should be held accountable to ensure consumers realize these benefits.