Thursday, April 02, 2020

The newly unemployed also need an emergency Special Enrollment Period

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After a week or two of rumors that the Trump administration would open an emergency Special Enrollment Period (SEP) on HealthCare.gov, the federal ACA exchange used by 38 states, the administration announced on Tuesday that it would not do so. Twelve of the thirteen state-based exchanges have announced emergency SEPs since March 10, with only Republican-ruled Idaho demurring.

As Jeff Young put it, team Trump could not choke down "an admission that the law and its benefits help people." Their spite will likely cost some people their lives and others all their worldly wealth. As the Kaiser Family Foundation's Larry Levitt noted, some 9.2 million of the nation's uninsured were eligible for ACA marketplace subsidies at last count (i.e., as of 2018).

Normally, enrollment in ACA-compliant private plans is only possible during Open Enrollment, which runs Nov. 1 - Dec. 15 in HealthCare.gov states. A SEP is available at other times only to those who undergo a "life change," such as loss of employer coverage, marriage, divorce, death of a family member, etc.

Whether fear of COVID-19 and the huge costs of hospitalization (ranging from about $9,000-90,000 by Kaiser's estimate) would induce many of the uninsured to seek coverage is an open question.*  Poor takeup among the subsidy-eligible has persisted since the ACA marketplace launched. The 9 million subsidy-eligible uninsured estimated by Kaiser roughly match total on-exchange enrollment. Takeup is better among those rendered eligible for Medicaid by the ACA expansion, but Kaiser also estimates that about 7 million uninsured are eligible for Medicaid and CHIP. An emergency SEP, plus a concerted public information campaign, might shrink those ranks.

The main benefit of an emergency SEP opened unconditionally to all may lie elsewhere, however. ACA enrollment can be complicated at the best of times. An ordinary SEP, including one triggered by job loss and attendant insurance loss, adds friction.  An applicant has to attest to and verify the loss of insurance; the marketplace has to confirm it, grant the SEP, and then open the gate. In some states, accepting evidence of loss of coverage is up to the insurance company with which the applicant seeks to enroll.

The pandemic has already triggered 3 million new jobless claims and will likely trigger many millions more -- as many as a staggering 20 million, Treasury Secretary Mnuchin warned Republican senators. The White House told reporter Amy Lotven that an emergency SEP is not needed because "there's already special enrollment for job loss."

That's true -- leaving aside the callousness with respect to 16 million or so Americans who were already uninsured and eligible for federal help.** But under the flood of newly unemployed and uninsured the existing SEP machinery is, um, creaky at best. Take the testimony of brokers working in HealthCare.gov states:

Unemployment offices are overwhelmed, and will be more so. Early signs are that the federal marketplace is overwhelmed, and will be more so.  An emergency SEP, truly designed for an emergency, would simply mimic open enrollment, and accept simple attestation of current income, with verification required later. The marketplace does routinely allow enrollment conditional on later verification of various required information, such as immigration status or current income. The idea now should be to get people insured -- and to reduce the normal friction of marketplace enrollment, not increase it.

As I've noted previously, some state exchange SEPs are designed to reduce friction, and some aren't.  In Washington, Connecticut and Nevada, an emergency SEP must start with a phone call; Nevada is particularly concerned to ensure that people who have already dropped coverage in 2020 can't start elsewhere without squaring up with their original insurer. In California and several other states, enrollment now is like enrollment during Open Enrollment -- relatively simple.  In Colorado, where SEP eligibility is normally determined by the insurer, you check a box if you've lost coverage or become uninsured during the pandemic, and insurers as of now are not requiring verification, according to Colorado broker and author Louise Norris.

It's true that in coming weeks new enrollment from the newly unemployed/uninsured may outstrip new enrollment from those who were uninsured when the year began. It's also true that Medicaid enrollment is available year-round and will likely outstrip marketplace enrollment.  But we need a simple, unified message that the exchanges are open for business and dedicated to providing all comers with whatever aid their financial situation entitles them to. Programs are in place that have the capacity to insure most of those currently lacking coverage or soon to lose it. What's not in place is an administration committed to getting that job done.

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* Data about the effects of emergency SEPs should soon flow in from the SBEs. Maryland announced yesterday that 10,000 state residents have so far taken advantage of the SEP to enroll in Medicaid or the marketplace. Maryland has about 250,000 enrollees in ACA-compliant plans, including off-exchange. As of 2017, the state had about 300,000 Medicaid enrollees rendered eligible by the ACA expansion, and 1.2 million total Medicaid enrollees.

** The SEP is not for job loss, it's for loss of insurance that goes with the job. No insurance, no SEP.  Timothy Jost points out to me via email: " many people who are losing their jobs are people who did not get covered during open enrollment because their income was too high for PTCs, or because they  had some kind of excepted benefit coverage through their job or simply weren’t worried enough about being uncovered.  I think Trump’s people really don’t understand the rules, and really do think that job loss is enough.  This is inexcusable ignorance." 
   Charles Gaba was hammering this point home all day yesterday. My focus here was on the friction in the SEP, not on those it leaves out, but I wish I hadn't glided over the White House error.

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