Health Disparities, Affordability Part of the Debate on Improving Health Insurance

WASHINGTON — The nation’s capital may be politically divided, but lawmakers are finding room to at least discuss several issues related to health insurance, including reducing ethnic disparities in coverage and making insurance plans easier to compare, several health policy experts said Friday.

One issue Congress will be facing involves the expanded subsidies included in the American Rescue Plan for people signing up for health insurance coverage through the Affordable Care Act’s insurance marketplaces, said Elizabeth Wroe, JD, principal at the Leavitt Partners consulting firm. “What happens when that sunsets at the end of this year? Does that create a moment for potentially Congress to step in and expand those subsidies, or enact other policies in addition, to try to address enrollment?”

Unfortunately, however, “sometimes there’s not a very good understanding at the congressional level that you can’t just flip a switch on a number of policies, and particularly, when we’re talking about insurance markets, the fact that states have deadlines, and that health plans have a process that they go through for setting rates, setting premiums, and setting plans,” she continued. “It’s really important for a number of these issues to not wait to the 11th hour to talk about them.”

Another issue gaining steam is health disparities — and on insurers collecting information about them, Wroe said. “You’re making sure that plans actually collect the information that’s going to be really helpful and measuring whether or not benefit design is actually helping address health disparities and move forward on health equity.”

Annette James, chairperson of the Health Equity Work Group at the American Academy of Actuaries, said her organization is also working on that issue in a four-phase project. “We just finished the first phase: identifying and monitoring actuarial data sources and methods that may contribute to health disparities,” she said. “We will now start in the second phase of doing an analysis to see what research exists and where there may be gaps.”

The organization is also exploring whether insurance benefit designs “can actually create or perpetuate barriers” to health insurance access for disadvantaged communities, and can result in underutilization, James said. For example, “are high-deductible plans so cost-prohibitive that they inadvertently discourage appropriate use by certain populations? Can the pre-authorization and pre-certification processes increase reluctance to seek needed services in some communities due to the invasive nature of this protocol? And can a tiered network design actually discourage appropriate use of medical services and result in further underutilization, especially if first-tier providers are not readily accessible to disadvantaged communities?”

Insurance agents and brokers are another area of interest, said Wroe. “There’s definite consensus that agents and brokers have a role to play in enrollment,” she said. “But I think there’s also an acknowledgement that any of the different players need to be working under certain standards. So, I think there’s a place where you can see an enhanced role for agents and brokers with oversight, and making sure that everything’s being done in a way to help enhance enrollment in Qualified Health Plans.”

Auto-enrollment is another big focus, according to Wroe. “Whether that’s a federal program or federal standards with state implementation, or completely state auto enrollment options — there are a number of policies there that are really worth thinking through.”

While these discussions are happening, marketplace enrollment continues. JoAnn Volk, MA, research professor at the Center on Health Insurance Reforms at Georgetown University, noted that to date for the current open enrollment, 14.2 million people have enrolled in marketplace coverage, including 10 million through the federal marketplace and 4.2 million through the 18 state-based marketplaces. Most of those are returning customers, not new enrollees, she added.

Some states, such as Maryland, are reaching out to residents during tax filing time, asking them if they want to share their insurance status, income, and other relevant information to determine whether they might be eligible for Medicaid or a marketplace insurance plan, Volk said. “In the first year of that program — 2020 — 60,000 people shared their data and most of those — 53,000 — were deemed eligible for marketplace subsidies or Medicaid.” Although only 4,000 of those people enrolled in coverage, the program started before the enhanced marketplace subsidies were available, which may have played a role in the low uptake. “But it may be a successful strategy for reaching those who have proven harder to reach,” she said.

Lawmakers are also looking at the issue of further standardizing health plans to make it easier for people to choose among them. Although the healthcare marketplaces have divided their plans up into “gold,” “silver,” and “bronze” plans distinguished by cost and benefit levels, “this takes it a step further to really lock in cost-sharing for particular services and in many cases makes more services available without having to pay the deductible,” including primary care and behavioral health, Volk said.

Standardized plans also offer set copays rather than “coinsurance,” because “it’s easier for consumers to understand what their out-of-pocket costs are when they’re looking at a dollar number instead of 20% of some unseen cost that may show up on their bill one day,” she said. The federal government’s Notice of Benefit and Payment Parameters released in December 2021 requires standardized plans to be available on the federal healthcare.gov insurance marketplace beginning in 2023. In addition, Volk noted, eight states plus the District of Columbia already have standardized plans, and Colorado will use them beginning in 2023.

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