Friday, October 06, 2017

How well will healthcare.gov function for 2018?

Everyone who follows the fate of the ACA is by now familiar with the Trump administration's multi-pronged sabotage of the individual market: the constant threat to stop CSR reimbursements to insurers, which in itself has likely driven up 2018 premiums by upwards of 20%; the threats not to enforce the individual mandate, which will likely depress enrollment; the radical cutbacks in enrollment outreach and assistance; the propaganda denigrating marketplace offerings; the shortened enrollment period and gratuitous Sunday shutdown; and now, Trump's looming threat to undermine the risk pool, state authority and ACA consumer protections by giving carte blanche to association health plans.

This multi-pronged assault led me to wonder whether healthcare.gov, the federal exchange, will function adequately. I took a look at the website yesterday, and again today. And I must say, what's there is somewhat reassuring. In fact, today new prompts went up to start preparing people for open enrollment. The array of options on the home page is clear and well designed:


It is easy to get to the initial tasks that people in different situations will want to undertake:


1) For people seeking coverage for the rest of 2017, there are prompts to a) determine whether they qualify for a Special Enrollment Period, and if the answer is likely to be yes, b) preview currently available  plans and prices.

2) For people preparing to re-enroll in 2018, there are clear urgings to update one's status and to shop actively rather than auto-enroll, as well as information about what communication to expect from one's current insurer.

3) For prospective new enrollees, there is well organized basic info and a quick screener to indicate what kind of financial help (if any) is likely to be available. Here's what appears if you say you're seeking coverage for two adults in a Medicaid expansion state:


Note that this screener includes links not only to the "see plans and prices" preview tool, but (in an expansion state, in this case New Jersey) to a Medicaid application for those whose incomes seem to qualify them.   You can also go straight to a Medicaid screener after choosing the "get ready to apply" option on the home page. If you indicate a Medicaid-eligible income, you can go straight to a Medicaid application.

There is also a clear path from multiple entry points to the "see plans and prices" preview feature. Since early 2014, this tool  has enabled users to answer a handful of questions (e.g., zip code, number of people seeking coverage, their ages, and family income) and get quotes for all the plans available to them, with good clear summaries of policy terms. At different times this very valuable tool has been more or less easy to find, often shifting position throughout open enrollment. As of now, a link appears immediately after the user has determined likely eligibility for a Special Enrollment Period -- logically enough, as coverage for 2017 can only be obtained with such eligibility.

The preview tool's design has changed several times in three years. Last year, a feature was added enabling the user to screen for a plan or plans in which a given healthcare provider was in-network or given drugs were covered. That feature has been moved so that it appears after the menu of choices has been listed. The same is true for a feature that estimates yearly costs based on whether you designate yourself a likely "low use," "medium use" or "high use" patient. The back-loading of these screens makes good sense to me: a user should be able to quickly see the financial terms at which coverage is likely to be available, then drill down into which plan works best.

The "see plans and prices" tool has one important glitch at present. In design, it does a good job alerting users whose incomes qualify them for Cost Sharing Reduction (CSR) subsidies to the fact that these subsidies are available only with silver plans. This alert appears on two screens in succession before the menu of available plans appears. Here is the latter:


The glitch, however, is that when you click on "See all silver" plans, the filter doesn't work, and you see bronze plans first. That is, plans are ranked by premium, lowest to highest, as they are if you click on "see all plans." This is disorienting. While a silver plan for an individual with an income of $20,000 might have a deductible of $250, the bronze plans that appear first will likely have deductibles north of $6,000. If you think you're seeing silver plans, it can be hard to process the fact that you're seeing bronze -- especially if you're a first-time viewer and don't know what to expect at each metal level.

This needs to be fixed. But overall, it seems that whoever is at the controls of the healthcare.gov interface is working to help users find appropriate coverage. healthcare.gov is much more than a user interface, of course, and it takes constant effort to make the site function properly -- interacting with insurers, the IRS, state health departments, navigators, third party online exchanges authorized to process applications, and others. Whether those relationships and functions are maintained remains to be seen. But the updating and basic functioning of the user interface is a pleasant counter-trend surprise at the present moment.

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