Georgia consumers relieved of threat to health coverage by U.S. Supreme Court’s third affirmation that Affordable Care Act is lawful

With the ACA firmly in place as the law of the land, federal and state law makers should turn their attention to improving affordability and closing remaining coverage gaps

Statement by Whitney Griggs, Health Policy Analyst at Georgians for a Healthy Future regarding today’s ruling on the California v. Texas lawsuit by the Supreme Court of the United States. The lawsuit sought to invalidate the Patient Protection and Affordable Care Act; Georgia was a plaintiff in the case.

Yesterday, the Centers for Medicare & Medicaid Services announced the approval of Georgia’s 1332 State Innovation waiver, title “Georgia Access”. Laura Colbert, Executive Director of Georgians for a Healthy Future has issued the following statement:

“Despite repeated attempts, Governor Kemp’s Georgia Access proposal still fails to explain how a shutdown of the most popular and streamlined health insurance enrollment platform in order to move to a decentralized, privatized enrollment system will address the challenges faced by Georgia consumers, especially those who remain uninsured.

On November 4, 2019, Governor Brian Kemp released a draft plan that, if approved, would drastically undermine comprehensive coverage for the 417,000 consumers who now have comprehensive coverage through the marketplace. Federal law allows states to make changes to the Affordable Care Act (ACA) so long as a comparable number of Georgians have coverage that is at least as comprehensive and affordable as they would have under the ACA, and the changes do not increase the federal deficit. Even under the most forgiving interpretation of these guardrails, Governor Kemp’s proposal fails to meet the test.

Fortunately, there’s still time to fight back! The state is required to seek public comments on this plan and will be accepting comments until December 3, 2019. Comments can be submitted online at CoverGA.org, at in-person comment hearings. This is an opportunity for Georgians to tell state leaders how this plan will impact their health and finances, and the health and finances of their loved ones.

Instead of undermining the coverage that so many Georgians rely on, state leaders should focus on preserving critical consumer protections, strengthening comprehensive coverage, investing in outreach and enrollment to Georgia communities, and working to address the rising health care costs for low-and middle-income Georgians. 

Disrupts coverage for more than 400,000 Georgians with a privatized marketplace 

Governor Kemp’s proposal seeks to expand coverage to approximately 30,000 out of more than one million uninsured Georgians at the peril of those consumers currently enrolled in comprehensive coverage using a risky new program. 

At the center of his plan, Governor Kemp aims to decentralize how consumers currently enroll in individual market coverage in favor of private web brokers and insurers. This means that consumers would no longer have an unbiased place to compare plan options and instead would be forced to rely on private entities who would have the incentive to enroll consumers in plans that offered the highest commission and not necessarily the plan that best fits their health needs.

Likely result: Georgia consumers will struggle to navigate numerous websites, translate the sales lingo of insurers, and disentangle conflicting information. For many, it may be harder to find in a plan that they feel good about.

Limits financial assistance, increasing out-of-pocket costs

Along with dismantling healthcare.gov, Governor Kemp plans to restructure financial assistance in a way that would raise premium costs for comprehensive coverage and likely cause many Georgians to lose coverage altogether. Under his plan, consumers could use financial assistance to purchase skimpier coverage, like short-term plans, that don’t have to meet the ACA’s minimum standards. Additionally, his plan doesn’t address whether or not cost-sharing reductions would be required, which currently help to lower deductibles and other out-of-pocket costs for certain low-income consumers. As a result, Georgia consumers should expect to pay more out-of-pocket to get the care they need.

To make matters worse, because financial help is based on premiums for comprehensive coverage that will likely become more expensive under this plan, providing financial help to all eligible Georgians will cost more than what is currently budgeted. This means that some consumers who currently receive (or are eligible for) financial help would lose this valuable benefit.

Likely result: Premiums for comprehensive coverage will rise. At the same time, fewer Georgians will receive financial help to purchase coverage. Georgians will pay more out-of-pocket when they need health care.

Weakens consumer protections

In order to allow private companies to run enrollment, the Governor’s plan seeks to eliminate crucial consumer protections. The protections that may be suspended include the requirement that insurance plans include enough doctors and hospitals so people can get care (called “network adequacy”); requirements about what information insurers must provide to consumers and how that information is presented; and mental health parity, which requires insurers to cover mental health services in a similar way as other health care. The Governor’s plan assumes these new skimpy plans will provide 90% of the benefits that comprehensive coverage under the ACA provides. There is no explanation or evidence to support this assumption.

Removing the requirement to cover the ten essential health benefits and mental health parity threatens access to critical services for many consumers with pre-existing conditions. For example, treatment and recovery services for people with substance use disorders would be threatened at a time when the state continues to struggle with opioid-related deaths and substance use disorders in general. These consumer protections enable people with mental illness and substance use disorders to obtain insurance that covers their conditions without bankrupting them. Without them, consumers will have to pay out-of-pocket for life-saving care, opening them up to thousands of dollars of medical debt.

Likely impact: Skimpy plans that do not offer basic health services like prescription drugs, maternity care, or mental health services will become commonplace. As a result, Georgians will have a harder time accessing needed care and will pay more out-of-pocket.

The bottom line is Governor Kemp’s plan is terrible for Georgians. Any rational analysis will find it doesn’t meet even the laxest requirements of federal law. Georgians should weigh in today to reject this plan!   

In March 2019, Georgia lawmakers approved SB 106, the Patients First Act. The new law allows Georgia to use two kinds of health care waivers to make changes to health coverage in the state. These waiver plans could affect you, your friends, family, neighbors, and Georgians all across the state and the way you access and pay for health care.

(Waivers allow a state to set aside or “waive” certain requirements imposed by the federal government and try new models of providing health coverage and care.)

The state has hired Deloitte as a consultant to work with state leaders to develop the waiver plans. Georgia’s decision-makers have proposed an aggressive timeline and aim to finalize the waiver plans by the end of 2019.

Two types of waiver plans

Two types of plans are being developed by state leaders: an 1115 waiver and a 1332 waiver. An 1115 waiver allows Georgia to make changes to the state’s Medicaid program. Medicaid is the state’s health insurance program that covers kids, some low-income parents, seniors, and people with disabilities, and pregnant women. SB 106 limits the 1115 waiver to cover people making up to the poverty line (about $12,000 a year for an individual or $26,000 for a family of four). Medicaid expansion, which GHF has advocated for, would extend public coverage to people with incomes just above the poverty line (138% of the federal poverty line.) A successful way to use an 1115 waiver would be to cover everyone under the poverty line and exclude barriers to coverage such as burdensome paperwork requirements, confusing cost-sharing, or counterproductive lock-out periods.

A 1332 waiver allows the state to make changes to private insurance and the health insurance marketplace. About 450,000 Georgians buy their health coverage through the marketplace. Most of these Georgians receive federal tax credits to cover some or all of their premium costs. (Another 827,600 of Georgians are eligible for private coverage and financial help to buy it but have not yet enrolled.) A successful way to use a 1332 waiver is to establish a “reinsurance program” to reduce premium costs. This waiver should also ensure all plans continue to cover the essential health benefits (like prescription drugs) and maintain protections for people with preexisting conditions.

You can weigh in!

Now is the time to ensure that Georgia gets a plan that will provide comprehensive coverage to as many people as possible. Thousands of Georgians across the state could gain health care coverage through the Patients First proposals. While positive intentions have been expressed by Georgia’s elected officials about the forthcoming waivers, none has yet committed to ensuring all Georgians have a pathway to comprehensive, affordable coverage.

For every 1115 and 1332 waiver that the state wants to pursue, Georgia’s policymakers must seek input from the public. Because there are required state and federal public comment periods for each waiver proposal, there will be at least four public comment periods (a state and federal period for an 1115 waiver and a state and federal period for a 1332 waiver). These are your chances to help shape and influence health care in Georgia!

GHF and our Cover Georgia partners will let you know when the public comment periods begin and end and we will provide an easy way for you to have your say. Make a plan to submit comments during every public comment period so that state leaders know how their ideas will impact you and your family! Your story can help make a difference for thousands of Georgians and can support positive changes in health care coverage.

To learn more, visit coverga.org and download our new Happening Now fact sheet! Follow #CoverGA on FaceBook and Twitter for the most current updates!

Sean “Saifa” Wall is an Atlanta-based intersex justice activist. He is currently enrolled in a health plan with Ambetter through the Affordable Care Act’s health insurance marketplace (also called healthcare.gov).

As an activist, Saifa’s income is generated exclusively through contractual work, which means that his employers do not provide health benefits. He talks to people about issues that affect the intersex community. He also serves as a public health researcher that consults with racial justice and domestic violence organizations.

Saifa enrolled in coverage in 2016 with the help of a GHF health insurance navigator after being uninsured for over two years. (He was also able to purchase dental coverage.) Saifa pays a premium of $63 per month after a $500 tax credit helped to lower his costs. His coverage allows him access to hormone therapy and behavioral health services, among other essential health benefits. He loves his medical provider and receives high quality treatment as an intersex person who is hormone dependent.

Saifa was recently diagnosed with osteopenia, which means his bones aren’t as dense as they need to be to prevent breaks and other injuries. Saifa will need comprehensive medical care as he works to build bone mass; much or all of that care will be covered by the comprehensive insurance plan he purchased through the ACA.

Like Saifa, 450,000 Georgians rely on the ACA marketplace to access comprehensive, affordable health coverage. Many more Georgians are eligible for marketplace coverage but remain uninsured for a variety of reasons.

Georgia’s new law, called the Patients First Act or SB 106, may bring changes to private health insurance in the state but Georgia leaders have not yet spelled out what changes they plan to seek. An effective way to use their new flexibility would be to maintain the protections and financial help that Georgia consumers enjoy while building a “reinsurance program” to bring down premiums for everyone. (This approach has been successfully tried in seven other states.) If premiums fall or remain steady, this could attract more Georgians to the marketplace and get more people covered.

When Saifa was asked what he would tell legislators about having health coverage, he replied: “As an intersex activist, I believe health care is a human right.” While this belief isn’t yet reflected in Georgia’s state health laws, the ACA allows consumers like Saifa to take advantage of comprehensive, affordable coverage options and protections from discrimination in the health system, among many other advances.

For the first time in Georgia, there is widespread and bipartisan agreement among Georgia’s Governor and legislative leaders about the pressing need to provide health insurance to more Georgians. To address the state’s rising uninsured rate, Governor Brian Kemp has put forth a bill, SB 106 (also called the Patients First Act), that would allow the state to submit two kinds of health care waivers:

• A Medicaid 1115 waiver that could be used to extend coverage to more low-income Georgians, among other reforms; and
• 1332 State Innovation waivers that would make changes to Georgia’s private health insurance marketplace.

(Waivers allow a state to set aside or “waive” certain requirements imposed by the federal government and try new models of providing health coverage and care.)

While the legislation’s goal to extend affordable, quality coverage to more Georgians is one with which GHF wholeheartedly agrees, the bill currently falls short by limiting the number of people who would benefit, increasing the likely costs to the state, and leaving to door open to an erosion of critical consumer protections.

SB 106 limits a future 1115 Medicaid waiver to cover only adults making up to 100% of the federal poverty line (FPL) ($12,490 for an individual and $21,330 for a family of three per year). While this would cover 240,000 more Georgians than are currently eligible for Medicaid, the cut-off leaves out an estimated 200,000 uninsured Georgia adults making just more than poverty-level wages (up to 138% FPL). These Georgians make up to $17,296 for an individual and $29,435 for a family of three.

The Affordable Care Act envisioned that all adults making up to 138% FPL would be covered by Medicaid and provides states with an incentive to do so. States that extend coverage to these newly-eligible adults pay only 10% of the costs and the federal government picks up the rest (90%) in perpetuity.

If Georgia’s leaders approve SB 106 in its current form and leave out the adults just above the poverty line, our state will miss out on the ACA’s “enhanced match rate”. Wisconsin is the only other state that has opted to take this route, and as a result, has paid $1.1 billion more to cover 80,000 fewer people.

A small change to the language in SB 106 would give the state the flexibility to increase coverage to people up to 138% FPL, allowing the state to cover an estimated 440,000 Georgians at a lower cost.

The second part of SB 106 allows Georgia to submit at least one 1332 State Innovation waiver. These innovation waivers were created by the ACA to allow states to test different approaches for providing primarily private health insurance to their residents. At the same time, the law established “guardrails” for 1332 waivers to ensure consumers were sufficiently protected. Unfortunately, these guardrails have been greatly weakened in recent months leaving consumers at risk.

So far, all eight states with approved 1332 waivers have carried out plans that benefit consumers—and Georgia could too. However, the broad language in SB 106 as currently written allows for proposals that could also create sizable and risky changes that harm consumers. For example, Georgia could allow the ACA’s financial help that is now available to consumers to buy coverage to be used instead for the purchase of junk insurance plans. This would likely draw healthy consumers out of the ACA Marketplace to cheaper, low-quality plans and send insurance premiums into an upward spiral for consumers with pre-existing conditions who need comprehensive coverage.

Georgia’s legislators could narrow the scope of allowable 1332 waivers by specifying that the waiver must be used for a specific beneficial reason, like establishing a reinsurance system to lower insurance premiums, or by laying out a set of principles that the waiver must meet to ensure Georgia consumers are fully protected. (GHF’s Executive Director proposed a set of consumer-friendly principles when she testified to the Senate Health & Human Services Committee in February.)

Georgia’s leaders have taken an encouraging step forward by proposing changes to state law that aim to increase access to care and address affordability concerns for Georgia families. A few small, meaningful changes to SB 106 would assure a path to affordable, quality health coverage exists for all Georgians.

Want to learn more? Here are a few resources that you may find helpful:

• Georgia Left Me Out fact sheet
• Understanding Medicaid in Georgia and the Opportunity to Improve It: A chart book
• What you need to know about waivers and Medicaid expansion by Georgia Watch
• What you need to know about 1332 waives and Georgia’s health insurance marketplace
• Getting Georgia Covered: What we can learn from consumer and assister experiences during the fifth open enrollment period

Follow changes and updates about SB 106 in GHF’s weekly legislative update emails.

With four open enrollment periods completed and a fifth one beginning in the coming weeks, the Health Insurance Marketplace has become established as the avenue for purchasing coverage for thousands of Georgians who do not have access to have insurance at work. The fourth open enrollment period differed from the first three in several important ways, and understanding these variations will be important in ensuring that the Marketplace continues to serve consumers who seek access to affordable comprehensive health insurance. This report examines the characteristics of the consumers enrolled in the Georgia Marketplace, compares open enrollment 4 to the previous three enrollment periods, and provides a preview for open enrollment 5.

Inside you’ll find:

– Key themes in consumer and assister experiences during the 2017 open enrollment period
– A look forward to open enrollment 5
– Policy opportunities to increase enrollment, ensure access to care, address affordability issues, and facilitate continued consumer education and supports

You can find the full report here. 

Your member of Congress needs to hear from you today! 

They are at it again. Leaders in the U.S. House of Representatives are getting closer to having the votes they need to pass the American Health Care Act, legislation that would dismantle Medicaid and threaten the coverage of millions of Americans. They may vote as early as tomorrow! Call your Member of Congress today at 866-426-2631 and tell him to vote “NO” on the bill.

The latest proposal keeps all of the bad features of AHCA such as the $4 billion cut to Georgia’s Medicaid program and plans to strip more than 560,000 Georgians of their health insurance. Added to that it would allow states to gut the main consumer protections of the ACA and return to a time when insurers could discriminate against those living with preexisting conditions – charging them higher premiums and selling them plans that don’t meet their health needs by limiting benefits and increasing out-of-pocket costs.

Now is the time for your member of Congress to hear from you. Demand that our lawmakers put the best interests of Georgians and our state ahead of partisan politics. Call your member of Congress today to tell him to vote “NO” on the AHCA. Call 866-426-2631 now!

Want to do more?

Tell your friends, family, and social media networks that you made a phone call to your members of Congress and they can too! Use this tweet and Facebook post to spread the word!

If you or a family member benefit from Georgia’s Medicaid program, join the #IamMedicaidGA campaign! Policymakers need to know that real Georgians will be impacted by their vote on the AHCA. Get started here!

This August, GHF invited both advocates and enrollment assisters to the second annual Getting Georgia Covered summit. Bringing these two groups together was the first step in fostering ongoing conversations and partnerships to ensure that health coverage translates into meaningful access to care for Georgians. Through the summit, GHF collected feedback and input for a report that highlights how assisters and advocates can team up for consumers. We invite you to read and share Collaborating for Consumers: How Assisters and Advocates Can Inform Policy, in which you will find opportunities and best practices for collaboration to achieve our shared goals.

Direct consumer support plays an important role in assisting consumers to enroll into and maintain their health coverage. Georgians for a Healthy Future, primarily a health advocacy organization, provided direct enrollment services to Georgians in the last two open enrollment periods through enrollment events, in-person appointments, phone assistance and referrals. GHF continues to engage with other enrollment entities through its Georgia Enrollment Assistance Resources (GEAR) network which is a central hub of Marketplace resources, and provides technical support to assisters through newsletters, e-blasts, trainings, webinars, and forums.

In OE3, GHF primarily focused on post enrollment work undertaking more complex consumer cases such as resolving coverage issues with the Marketplace and insurance providers, payment issues, tax filing and reconciliation issues, and issues with supplemental documents. In this role, GHF provided crucial support to consumers and enrollment assisters to resolve these types of issues and help consumers maintain their coverage, feel free to visit https://syntheticurinereview.com/whizzinator-kit/.

Here is what our consumers reported about their experiences

GHF conducted a post-enrollment consumer satisfaction survey with 25 consumers between April and July 2016. The survey participants reported that they sought a combination of services during their appointments. The table below provides the details for each type of post-enrollment assistance.

Twenty-four out of 25 (96%) participants reported that they were able to resolve the issues that they sought assistance for, as explained by these quotes…

“Paid my premium, sent supplemental documents, added two kids to the application, received delayed cards” – Res# 1, Female, 30.

 “My coverage had been suspended for over a month due to a technical issue. GHF helped me reinstate my suspended insurance by advocating on my behalf with both Marketplace and Ambetter. My benefits were reinstated within 3 business days”— Res# 16, Female, 62.

GHF Success Stories:

Tony Caldwell, a consumer with disability, was waiting to get his power wheelchair for over a year. With direct enrollment support from GHF, he was able to get his application completed during SEP and select a plan that covered his wheelchair. Tony quotes, “I finally ended up getting my power wheelchair that I had been waiting for over a year. It has helped me from passing out. Thanks to you all.”

 Clyde Mohammed and his wife Sharda (West Indian couple) came to renew their marketplace plan at Switzer Public Library in Marietta. They also wanted to change their current plan since the premium was going up in 2016. Assisted the consumers to complete their application. They were found eligible for subsidies. They enrolled into a health plan with $57 monthly premium and $600 family deductible. The family was able to save over $150 in monthly premium by switching their plan.

The majority of the participants reported the Marketplace application process to be very complicated and that they couldn’t have resolved their issues without the help of an enrollment assister. Those participants who found the process to be comfortable reported the assistance they received to be the key reason.  Participants also reported that this page talk about it, from the education to enrollment assisters that made it easier for them to understand and use their new health insurance.

Trends from our direct consumer support experiences and those we have heard from our partners suggested that direct enrollment assistance was crucial for consumers in making enrollment decisions as well as tackling post-enrollment issues. Direct assistance will continue to be crucial for consumers, both new enrollees and re-enrollees, in the days to come as there will be changes in participating insurance providers, premium price, and personal details such as household size and income all of which will require enrollment assisters’ expertise.