Feds debut sluggish ACA health insurance exchange in WyomingBy Ron Feemster — October 11, 2013
More than a week after enrollment opened, it is unclear how many Wyoming residents are shopping for insurance in the new federal marketplace created by the Affordable Care Act.
During the first week the new insurance marketplace was open, which corresponded to the first week of an ongoing partial shutdown of the federal government, www.healthcare.gov received 8.6 million unique visitors, according the Centers for Medicare and Medicaid Services. The call center took 406,000 calls and 225,000 people requested online chats. HealthCare.gov provides links to the insurance plans available in Wyoming and 33 other states.
Unfortunately, no Wyoming-specific figures were available from CMS, despite repeated requests to sort the database for Wyoming zip codes or IP addresses. Since the shutdown, no one has answered calls at the regional office of CMS in Denver, which oversees Wyoming, Montana, the Dakotas, Utah and Colorado. Not even the Wyoming Department of Insurance had access to information about Wyoming-specific traffic.
“We don’t have any portal or any secret way to get in there and look at what is going on,” said Tom Hirsig, Wyoming’s insurance commissioner, on Oct 4. “We hope that by next week the federal government may begin sharing information.”
Hirsig, who spoke by telephone from a conference in Lake Tahoe on Friday and from a statewide speaking tour on Wednesday, said that most state exchanges, at least in Western states, did not appear to be doing better than the federal website.
“Most of them are up for viewing, but you can’t buy anything yet,” Hirsig said after conversing with other Western insurance officials who were at the same conference. “It takes a little bit of time for everyone to get the glitches worked out.” Consumers must purchase a plan by December 15 in order to be covered on January 1, the first day that the new insurance plans can take effect.
Hirsig said his own experience trying to log onto the federal site was as frustrating as what he has read about in the press. He started to create an account, but the site crashed before he was able to complete the process.
“I got everything entered and was up to (choosing) the security questions,” Hirsig said. “Then it kicked me off. I tried twice. You get all the way up to the security questions and then you lose all the information.”
WyoFile’s experience getting on the site was no better. During the first week, we were stuck on a screenshot that informed visitors of the high traffic volume and urged patience. On Thursday of this week, WyoFile’s attempt stalled at the security questions that stymied Hirsig.
In a Wall Street Journal report Monday, independent analysts hired by the Journal said, “The site appeared to be built on a sloppy software foundation. Such a hastily constructed website may not have been able to withstand the online demand last week.”
In addition to some design features that caused the federal site to load and respond slowly, flaws in its identity verification program slowed sites run by the other 16 states and the District of Columbia. The state and D.C. sites must interact with the 34-state federal site in order to check the identity of applicants, according to the Journal’s consultants.
After shutting down the site for maintenance last weekend, CMS says it has taken steps to make the site more responsive under high traffic, including adding server capacity and making software changes.
Politics and reality
The new system is getting off the ground slowly, which has fueled the political fires in Washington. Republicans, who shut down the federal government in an attempt to force defunding, delays or changes to Obamacare, crowed that initial software glitches exposed the new healthcare system as a failure. President Obama and the Department of Health and Human Services urged patience. Meanwhile, thousands of Wyoming consumers, like hundreds of thousands around the country, still have the obligation to purchase insurance.
Under the “individual mandate” provision of the ACA, most Americans under the age of 65 must buy insurance if they do not receive it from an employer. At the end of the year, they must pay a fine — a tax, according to the Supreme Court — if they do not have insurance and earn more than the federal poverty limit. In some states, those very poor people would qualify for health coverage under Medicaid. But not in Wyoming, which so far has elected not to expand Medicaid. In this state approximately 18,000 very poor people will be too poor to qualify for a subsidy. They will almost certainly be uninsured but will pay no fine.
About two in three uninsured Americans plan to buy insurance on the new health insurance exchanges, while one in four plan to pay the fine instead, according to a Gallup poll released the day before the exchanges opened. In 2014, Americans who do not have health insurance will be subject to a $95 fine. The fine rises by $47.50 for up to four uninsured children, up to 1 percent of the family income or $285, whichever is higher, according to healthcare.gov. By 2016 the base fine rises to 2.5 percent of income or $695 per person, whichever is higher.
Navigating the ACA
Many people who are shopping for insurance on the exchanges — or who simply want to become informed enough to make a decision about whether to buy insurance — will be looking for help. The new healthcare law is confusing and often overwhelming for many of the uninsured, who may be shopping for insurance for the first time in their lives.
A persistent, national right-wing media campaign to brand Obamacare as a government takeover of healthcare has contributed misunderstandings about the law.
“Most people think it is a government run insurance plan, which it is not,” said Danielle Allred, a certified application counselor with the Wyoming Health Council, who is based in Powell, Wyo. “A lot of people are just confused about what the marketplace is.”
Allred, 24, is one of about 18 people in the state who have received or are now receiving training from CMS to help people understand the law. About five counselors like Allred were hired by Community Health Centers on grants from HHS. Another 13 people will be hired by Wyoming Seniors, Inc., and the Cheyenne Medical Center. This group, called “navigators,” will receive slightly more training than the CACs like Allred, according to Jan Cartwright, director of health policy at the Wyoming Primary Care Association.
“Those are just the people who are funded under grants,” said Cartwright, who expects employees of many local institutions, including senior centers, libraries and community centers, to take the CMS training. “We think that in most communities there will be a place to get help. People who have never used a computer or who have never had insurance will need some extra care.” Cartwright is also signed up to take the training herself.
All of the CMS-trained helpers aim to explain the law, but not to influence shoppers’ decisions.
“I’m supposed to be completely unbiased,” Allred said. “I can’t steer people to one plan or one company. I inform people that they do not have to buy coverage, but that they pay a fine if they don’t.”
Allred has an office at the Migrant Health Program, a health clinic in Powell. But much of her time is spent traveling. She covers patient needs in Park, Big Horn, Washakie and Fremont counties.
“I can’t go to people in their homes,” she said. “But I can meet them in any public place that has WiFi, like a coffee shop or a library.” She is just beginning the job, which is her first full-time job after graduating from the University of Wyoming with a degree in Spanish in May. “We want to get to all of the people who are uninsured and who need help understanding the law. It’s going to take a while. It can be challenging because of the distance.”
Much of the expertise that Allred and her colleagues provide is also offered on HealthCare.gov through the live chat system. In the conference call with CMS, Cartwright learned that 500 new live chat operators have been hired to help people while they are logged onto the site. In fact, live chat was working Thursday even when WyoFile found it impossible to log onto the site.
“The live chat operators get the same training that the navigators get,” Cartwright said. “I feel very strongly that it will be a great resource for people.”
One thing that is clear about the new healthcare marketplace is that insurance will be expensive in Wyoming — at least for anyone who does not receive a subsidy. Plans are available in Platinum, Gold, Silver and Bronze levels, which correspond roughly to policies that pay 90, 80, 70 and 60 percent of the cost of treatment, leaving the rest of the costs to the patient. Subsidies are calculated on the basis of the Silver plan.
Without a subsidy, a single person 50 years old who lives in Laramie would pay $596 per month for a Silver plan by WINhealth Partners or $683 per month for a Silver plan from Blue Cross Blue Shield of Wyoming. The Blue Cross Blue Shield network of providers appears to be a bit larger, according to the websites of the two companies, but the 10 essential benefits offered under the plans must be nearly identical under the new law.
If these prices seem high, they are. Under the ACA, prices for health insurance are higher in Wyoming than in any other state in the nation, including Alaska, an even larger and more sparsely populated state.
“Wyoming has always had high health insurance costs,” Hirsig said. “The cost of health care is higher in Wyoming than in other states. That drives the cost of insurance.”
Buyers are eligible for a federal subsidy to help pay their premiums if they earn less than 400 percent of the federal poverty level — just under $46,000 for an individual or about $94,000 for a family of four.
“If you get a subsidy,” Hirsig notes, “a Silver plan in Wyoming will cost the same as a Silver plan anywhere else.”
Detailed information about the costs and benefits of coverage plans can be found in the datasets on the national ACA enrollment site. Prices vary somewhat between the three coverage areas within the state: Cheyenne and Casper (the only two metropolitan statistical areas in the state) and the rest of Wyoming.
The two main insurance companies in the state had few new customers during the first week the ACA was available. And those came form direct calls or insurance agents. But shoppers have several months left before they must commit to a plan, even if they want coverage to start on the first day of January.
In earlier rollouts of new insurance programs, such as the Medicare Part D pharmacy coverage and the state health insurance program signed into law under Gov. Mitt Romney in Massachusetts, people shopped for a while before they signed up, according to CMS. Most signed up for those plans closer to the date when coverage went into effect.
Many medical providers, such as Dr. Dean Bartholomew, the physician-owner of a clinic in Saratoga, Wyo., welcome the new coverage with some serious reservations. Like every doctor, Bartholomew wants to increase access to care. He accepts all insurance and treats all patients, regardless of their financial situation. But that often leaves him with accounts receivable that are hard to collect.
“I usually have $15,000 to $25,000 in unpaid balances that people are chipping away at, $15 or $20 a month,” he said. “I worry that people are just going to take the policy with the lowest premium and not think about the deductible. It’s doctors with small clinics like mine who have to collect that deductible.”
For people whose incomes are low enough, the Affordable Care Act provides additional subsidies to cover some of the copays and deductibles. Bartholomew, like many other people, has heard about this but does not know all the details.
Like many of his patients, Bartholomew is also a customer looking for insurance on the exchange. He provides health coverage for the people who work at his clinic. He went on the SHOP exchange, the part of HealthCare.gov for small business owners to research coverage options for his staff.
“They said it was unavailable,” he said. “I’m going to have to wait.” For people like Bartholomew, who need to make health insurance part of a larger business budget, that wait may be more painful than for individuals, who often have fewer people depending on them. “It would be nice if we could start thinking about this now,” he said.
Almost everyone in Wyoming will have to wait. Even the insurance commissioner: “I don’t know of anyone who’s gotten through on the exchange,” Hirsig said. “I’m not surprised. It’s predictable with a rollout of a program this large. Hopefully they will get it up by November.”
— Ron Feemster covers the Wind River Indian Reservation for WyoFile in addition to his duties as a general reporter. Feemster was a Visiting Professor of Journalism at the Indian Institute of Journalism & New Media in Bangalore, India, and previously taught journalism at Northwest College in Powell. He has reported for The New York Times, Associated Press, Newsday, NPR and others. Contact Ron at firstname.lastname@example.org.
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