Monday, August 02, 2021

ACA enrollment under ARPA: The view from near 100% FPL (and San Antonio)

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The ACA's tragic coverage gap confronts poor people in the 12 states that have refused to date to enact the ACA Medicaid expansion with a cruel logical absurdity: they may earn too little to qualify for government-supported health coverage.  Adults in households with incomes below the Federal Poverty Level (100% FPL) do not qualify for subsidized coverage in the ACA marketplace.

A few weeks ago, I noted that on May 5 CMS put a modest patch on the coverage gap by rescinding a Trump era policy of demanding income verification from marketplace applicants in nonexpansion states if "trusted data sources" indicated that the applicant's income was likely below 100% FPL -- i.e., ineligible for subsidies -- and the applicant had estimated an income above that threshold. (Since HHS's computer systems can't be retooled instantly, CMS explained, the exchanges will continue to request documentation in these circumstances for some time -- but in followup communication, they will "notify those consumers that they need not provide the requested information.")

In effect, a low-income applicant can make a good faith estimate of a household income in the coming year above 100% FPL and qualify for subsidized coverage (now free through 2022, if income is below 150% FPL, thanks to the subsidy boosts in the American Rescue Plan enacted on March 11). Documentation will not be required (though awkwardly, it will be requested for some time).  If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant's income estimate is made with "intentional or reckless disregard for the facts."* 

The opportunity for low-income applicants to estimate their way into free coverage is the sort of regulatory forbearance that inspires high moral dudgeon from conservative adversaries of the ACA. In fact, though, poor or near-poor people in nonexpansion states who get as far as applying for health coverage - many don't, as ignorance of ACA programs is pervasive -- are likelier to underestimate their income than overestimate it. 

Estimating annual income: the view from 100% FPL, plus or minus

That was one key upshot of a conversation I had last week with Ana Maria Garza Cortez, VP & Chief Development Officer at Centro Med, a Federally Qualified Health Center with 23 locations in San Antonio, Texas, serving over 111,000 patients. 

Texas has the nation's highest uninsured rate (24.5% for adults aged 19-64 in 2019), lowest eligibility threshold for Medicaid (about 14% FPL for parents), and largest number of people in the coverage gap (an estimated 771,000 in 2019). The state also has seen enormous enrollment growth in the ACA marketplace since the pandemic struck. In June 2021, enrollment was 54.5% higher than in June 2019 by my estimate, up by almost 500,000.

Enrollment is boosted right now, Cortez told me, by the provision in the American Rescue Plan that deems anyone who receives any unemployment income in 2021 to have an income of 138% FPL, making them eligible for a free silver plan with strong Cost Sharing Reduction. That new path to coverage just went live on on July 1.**

"What's great right now is that families that wouldn't have qualified previously are now qualifying because one of them received an unemployment check," Cortez said. "I don't think they realize that unemployment will qualify them -- they are pleasantly surprised."

The key word here is "surprise." Ignorance of ACA offerings is pervasive, all the more so among low income people and people for whom English is not a first language. Those who find their way to an application usually have no idea that there is a minimum eligibility threshold for the marketplace. They have no idea that their state refused to expand Medicaid, creating a coverage gap. 

When prospective applicants at Centro Med do fall in the coverage gap -- fail to qualify for marketplace coverage because their income is below 100% FPL -- they are often incredulous.

"Sometimes they want to speak to someone else because they think we don't know what we're talking about," Cortez said. "It just doesn't make sense to them that they have to earn more money [to qualify for subsidies].  So we let them talk to another person. They have to hear it two or three times from other people."

Estimating annual income can be particularly difficult for low-income workers. I  asked whether Centro Med assisters, who are aware of the eligibility threshold, help with the estimate. Cortez said that they most emphatically do.

"We review all of their income to make sure that they've calculated properly. Take a situation where the husband does contract work, and then the wife may have steady employment but may not be working  a full 40 hours. We compare and review their income for the last three months...We give them an understanding of how to project their income."

"We also review their annual income," Cortez added. "We might say, 'Look at your income tax from last year -- how did you fare? -- was it the same employer? --  were you working the same hours? Did anybody get a raise?' You get to review the whole family situation."

Far from being eager to inflate their income over the eligibility threshold, Cortez said, applicants tend to be wary of  unknown consequences. "They're afraid that if something happens and they don't qualify they're going to have to pay back all this money. That fear that keeps people from applying and enrolling." As noted above, this was never the case, and Centro Med will inform clients of that fact. "We explain everything," Cortez said. "But in the end, some can't convince them." 

The lingering shadow of Trump's public charge rule

I asked whether that skittishness might have been exacerbated by the chill cast on pursuit of public benefits by the Trump administration's notorious expansion of the public charge rule, which, as expanded, threatened to penalize the immigration status of legally present noncitizens who accessed public benefits such as Medicaid and food stamps (but not including marketplace subsidies). Though invalidated by the Biden administration, the imprint of the Trump-era expansion of the rule lives on.

"There's a lot of public charge fears here," Cortez said. "The stories we hear are amazing -- of family members receiving letters because of public charge, or even of people deported because of public charge...people bring up these stories, and we don't what the facts are."

Affordable Care...where?

Beyond the complexities of income projection, ignorance of the what the ACA is and how it works is rife in Texas, and exacerbated by Republicans' longstanding vilification of the law. "We still see people who won't sign up for 'Obamacare' but will sign up for 'marketplace,' Cortez noted.

While ambiguity may be fruitful in that case, political polarization is not conducive to public understanding.  "Nobody knows what to call this insurance," Cortez said.  "We [Centro Med staff]  know it as 'marketplace.' Some people call it Obamacare, some people call it Trumpcare, some people don't know what to call it. They just call it the ACA. That itself is confusing, and then they have to choose the plan.  It's overwhelming for the general public. I was explaining this process to my neighbor, who responded 'Oh, is the affordable care still here? I thought it was canceled.'" (I have heard the same  tale from other veteran navigators in red states.)

As for Medicaid, according to Cortez, people don't realize how severely limited access to it is for adults in Texas, where children account for more than three quarters of total enrollment. Barely 1 million adults in Texas are enrolled in Medicaid, a state where 4.2 million people aged 19-64 (24.5%)  are uninsured. Nonetheless, when Medicaid comes up, Cortez said, a common response in Texas is, "Oh, that's for lazy people." 

Getting word out

As a FQHC, Centro Med has a dedicated funding stream for enrollment assistance, and is in fact required to provide it and report results. Nationally, the Health Resources and Services Administration (HRSA) provides over 1,200 health centers nationwide about $200 million annually in federal funding to support outreach and enrollment. These HRSA funds were initially supplemental awards under the Affordable Care Act and  became a permanent part of health center base grant awards. In 2019, health centers conducted almost 5 million "assists" to prospective enrollees, according to Ted Henson of the National Association of Community Health Centers. 

While the annual HRSA funding exceeds the most ever allocated to CMS’s ACA’s “Navigator" program for enrollment assistance, the navigator organizations were charged more specifically with outreach and education. The Trump administration gutted funding for the navigator program, reducing funding by 84% from a peak of $63 million in 2016 to $10 million in 2018 and years following. While the Biden administration has allocated $80 million for navigator groups for the next Open Enrollment period, beginning November 1, the program has operated on a shoestring for years.

The cuts hurt, according to Cortez. Advertising and marketing is especially needed now, as awareness of the subsidy boosts enacted in the American Rescue Plan and the emergency Special Enrollment Period opened by the Biden administration is limited. Centro Med does a high volume of enrollment assistance, and, to get word out, partners with local government, schools and universities, hospitals, faith-based organizations, and nonprofits, helped by grant funding from Methodist Healthcare Ministries.  Nonetheless, Cortez said,  lacking a federal navigator grant, "We still need a lot more marketing dollars to get the word out. We're doing a disservice to the community when they don't know this is available. There's only so much money we can spend on marketing without it coming from the federal government."

Photo by Marcus Aurelius from Pexels.


* See 26 CFR § 1.36B-2 (6), "Special rule for taxpayers with household income below 100 percent of the Federal poverty line for the taxable year."

** Marketplace enrollees who enrolled prior to July 1 who received (or will receive) any UI income this year will have the benefit credited retroactively, when they file taxes for 2021.

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