How Colorado's Health Exchange Is Weathering a Changing Policy Environment
The individual mandate is gone. The "public charge" might be changing. The cost of insurance continues to be high. CHI's Jackie Zubrzycki talks with Kevin Patterson, CEO of Connect for Health Colorado, Colorado's health insurance exchange, about how the exchange is weathering a changing policy landscape and working to help people navigate the complex insurance enrollment process.
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This transcript is taken from an automated transcription of the recording. It contains typos. Please reach out to firstname.lastname@example.org for clarifications.
Welcome to the check up the Colorado Health institute's podcast on health and health policy in Colorado. I'm your host Jackie super key. It's December and open enrollment is in full swing. People are buying health insurance for 2019. Maybe you get your insurance through work in which case you probably had to fill out some forms and pick between a few options.
Maybe you have public insurance and have gone through the process of signing up for Medicaid or Medicare or maybe you're one of the tens of thousands of people who will purchase health insurance through connect for health, Colorado Colorado's Health Insurance Exchange. That was me in 2016. What insurance you have matters a lot for your health care options?
It's a big decision. And in the last year there have been a lot of policy changes and proposals especially at the federal level that could really affect people who are buying insurance on the exchange. We decided to take some time to talk with Kevin Patterson the CEO of connect for health, Colorado about some of these changes and just about the exchange and what they do.
We covered a lot of ground in this conversation including how connect for health Colorado is reaching out to rural communities and those who might not have access to the internet why they're concerned that some immigrant families might not be getting the care or insurance. They need and how Colorado compares to other states.
So Kevin, you're the director of connect for health, Colorado. Can you tell us a little bit more about what connect for Colorado is its history and kind of where it stands in 2018?
Kevin: Sure. So connect for health Colorado is Colorado's health health Marketplace. And so what we do is we administer the tax credits that people typically take advantage of out of the Affordable Care Act interestingly enough, you know the idea of Connect Four. Colorado actually came out of the 208 commission they called it this came out under the Republican former Governor Bill Owens who was just trying to find ways to have a conversation around the state about how do you address high cost for health insurance, especially on outside the metro area?
So the commission was created there was a blue ribbon report that came out towards the end of his. Administration and right before Governor former Governor Ritter took over there were 32 recommendations that came out of that report one was creating this connector so that people could shop and see what they could purchase online for health insurance and so fast forward Governor Ritter came in he had a health agenda.
There was this Affordable Care Act thing that came out and everybody said well, why don't we use this idea of a connector to build our state-based Marketplace and we can have our own state-based exchange and do this in a Colorado way. It really was an idea that they wanted to have local control over these kinds of decisions and how it was I would be implemented so then governor.
Almost former Governor Hickenlooper came into power and next thing, you know, we were talking as I was part of his administration about the health exchange and creating it in the legislation. Came came. And here we are today with a state-based Marketplace that we've been operating since that first open enrollment and every year making more improvements for customers.
And you know, since I've been here the last three and a half almost four years really being focused around improvements that make the customer experience better while we try to make ourselves more compliant with Federal rules. Audits and all that other fun stuff nobody likes to talk about but we are very much in charge of dealing with.
Jackie: Yeah. And so this is where in 2018 this is the fourth or fifth.
Kevin: This is open enrollment number six open enrollment.
Jackie: Number six, great. So in those six years a lot of policy changes have been coming up that have affected the market in different ways and really just the last couple weeks have seen a lot of changes that affect the marketplace.
Yeah. Yeah, and so the first one that I wanted to ask you about is this change to the individual mandate, so that's this idea that if you don't have health insurance you need to pay a tax penalty, and so 2019 is going to be the first year that we've had these exchanges and we don't have a penalty.
So can you tell me a little bit about how? What you're thinking about that change, are you seeing any changes in enrollment that about that penalty?
Kevin: So, you know when the Kaiser Family Foundation was looking at this earlier, you know, they were making an assumption that somewhere around eight percent Marketplace enrollment might be impacted because of the impact of the penalty and.
You know, I think you know what we were thinking before open enrollment started is you know, we weren't expecting a huge hit because of the penalty we were figuring two one two issues one the penalty wasn't really large and so. I don't know that was driving a whole lot of change and that I think some people were seeking insurance and saying okay, I'd rather not pay the 695 or whatever the percentage worked out for them.
But they also we were seeing just people knew that they needed insurance and so they were making the decision to shop because they figured they needed to make sure they had health insurer. So. You know what? We've seen this year, you know, there's nothing empirical I can point to that says exactly.
This is the percentage that moves but we're saying about. Six to eight percent increase in enrollment as a result of what we've seen this year is over last year in plant selections now, some of it could be because we silver loaded and and that has actually made the silver plans even more affordable in some of the bronze plans, you know, you can get them from zero to fifty dollars for two-thirds of the folks that are shopping.
So I think it's really about the price point. Yeah, folks that are needing insurance.
Jackie: And just so I think a lot of our audience will know what silver looting is and I know it's a bit complex, but if you had to explain it to someone who was like, what's that?
Kevin: I think the easiest way to understand it is a lot of the since our second lowest cost silver is where we index what the tax credit is if we load the rate on Silver that means there's more tax credit available.
For folks as a result of how we do that indexing. And so that just means there's more financial assistance available. And so for folks that come in if you're looking at a bronze silver gold plan, you know for bronze. That's the the metal tear that has a lower premium. Probably more out-of-pocket.
But for a lot of folks if that's what you can afford that's a great option and for a number of folks, they're getting zero dollar premiums because the tax credit allows them to shop and get a screaming deal as we like to say.
Jackie: Yeah, I will be curious to ask maybe early in the year how many people do wind up paying zero dollars for their health insurance? That seems pretty magical.
Kevin: Yeah, we're seeing $0 bronze and even in a few instances just depending on you know, family size and what you what your income is. We've seen a few $0 Silver's coming through the door as well. And so it's a great opportunity. I think for people to make sure that they just look and Shop because we know that that's what's going to be the most important for folks.
Jackie: Yeah, so I'm going to ask a little bit more about that enrollment later. But first I wanted to going back to these federal policy changes affecting the exchange. So this is the first week of December and last week. There were a couple different things that came out from the federal government that might affect health insurance exchanges.
So I was interested in this guidance that said the people might be able to use that tax premium to pay for plants that aren't qualified or aren't compliant with the Affordable Care Act, which would be a big change.
Kevin: Yeah. I. You think that that is something we do have some concern about you know, what we want to make sure people have our plans that have this essential health benefits.
And so what we don't want to see is people coming in and thinking that they are covered for certain things and then they find out later. Oh I got this great deal, but maybe I didn't get all that. I thought I bought sure and so we just want to make sure that folks understand exactly what they're buying and so for us, it's about having that Essential Health Benefit making sure they buy the right. Plan for them and we think because of silver loading. It gives folks a lot more affordability this year than they didn't have last year. And so for us that seems to be the best policy that we can approach that with right now. And so I don't think that's something that we necessarily are advocating or looking to take advantage of but we certainly understand that.
For folks, you know affordability is an issue, especially for folks that are outside of metro Denver where you don't have the same kind of competition in Access.
Jackie: Yeah. So yeah, the cost of health insurance is it outside of Denver is something that we've heard a lot about in the last couple years. I know that the price of Health Plans has gone down for for some people but.
Health insurance is still expensive for a lot of folks. And yeah, so I wonder if you can talk a little bit about what you think. We're going to be seeing in 2019 with costs any efforts to address that that you think our listeners should know about.
Kevin: Yeah for our perspective, you know, we're just the window in which you see that cost when you buy the health insurance and so.
What we what we do doesn't necessarily impact price. We're just trying to be transparent. So people understand what those costs are and why they're paying them and what the impact is for their own pocketbooks and households. I do believe that I would expect to see legislation in this next session coming up to really address some cost issues coming from other stakeholders and interested parties out there.
I think those things will be what we will be watching as well. And I think you know, you have to just figure out what's driving the cost and and try to make sure that the policies and perhaps new legislation will really address what's pushing those levers to make that cost higher and you know that we've had now another cost commission and I think they're going to be leaned on to really.
Help advise policymakers on what things they need to do to try to drive those costs down and we just will reflect those in what carriers charge in terms of rates.
Jackie: So something that's on the mind of a lot of people in the world of Health, but beyond that is this potential change to something called the public charge.
And so that's this idea of how people use public programs and services like Medicaid. And how that might affect their immigration status. So I wonder if you can tell us a little bit about what can I for health Colorado seeing or any of your thoughts on this potential change to the public charge rule
Kevin: sure. So, you know, we're finalizing our comments. We've had a couple of conversations internally and with our board who wanted to make a pretty strong statement. In opposition of this rule. I think it has. Serve to mute folks seeking assistance where they probably should especially around Health disparities and people not not wanting to even go into emergency rooms.
I've heard stories it just yesterday when I was out in the roar doing another event hearing from an assistance Network Health Coverage guide who was saying, you know, people are saying they're not going to go home for. The holidays because they're afraid they're going to get stopped coming back and you know it we think that it's it's it doesn't apply to the tax credit and we want make sure that that's clear but I do believe that the fear that it strikes in people so that they don't get help.
Services could cause other kinds of issues within our communities that we really don't want to deal with and so I think it's something that we are speaking out against because it is just an issue that you got to be able to provide that health care for folks and and to have them in fear of that is just something that we don't feel comfortable.
Jackie: Yeah, and I actually hadn't even realized I had thought about this in terms of Medicaid, but I hadn't really realized that people also were thinking that just taking advantage of the tax credit could potentially take away their ability to get
Kevin: when you're dealing with fear. People won't want to take a risk.Yeah, and so even though you will tell them that they're like, well I'm hearing this and and so the misinformation gets out there and went. Fearful information it spreads like wildfire and it's really hard to contain it. And and so this is what I mean. I literally just heard this yesterday and it just stopped me in my tracks because I'm like, oh my goodness.
This is what's going on. And so we think that it's something that we would just want to make sure people. Call us. Make sure we'll get you the right information, but we understand why people would be concerned and they may not want to take that that risk, but we're just trying to make sure they have the right information
Jackie: and just one more clarifying question on that. So is the way that rule changes written are the tax credits something that could affect someone's immigration
Kevin: the way that the way that we read it the answer is no but I think what happens is people, you know, the the tax. It is a part of the Continuum of Eligibility. So you can move from Medicaid you get a job you go to Medicaid expansion, you take extra hours or you get a promotion. You can move to the tax credit. Well, that's great if you stay on the tax credit, but if you are ours drop down or you just happen to take a job for the holidays you go back to Medicaid folks are nervous about moving back and forth depending on where they fall on the eligibility Continuum. And so that's why I think people get really nervous about it.
Jackie Yeah, the. A lot of sense and so just switching a little bit back a couple of years and thinking about the creation of the exchange. So we know that Colorado's uninsured rate has really been going down in recent years in 2017. I think we saw like, well, we've got the lowest uninsured rate we've had and Some of that was maybe on the marketplace but a lot of that actually wound up being because of Medicaid expansion when I looked at those numbers. I was kind of struck by the fact that while we've got this new Marketplace that we haven't really seen a huge huge growth in individual insurance. So maybe that was just me who was surprised but I wonder could you talk a little bit about what we saw after the introduction of the marketplace in some of these ACA changes sure.
Kevin: I think there's a number of factors that that fall into that but I think there are. Two maybe three most important one Medicaid expansion. Let us know that our citizens maybe were a little poorer than we thought because it's all based on federal poverty level. And so there were a number of people that fell into the Medicaid expansion number and that number was a lot larger than I think a lot of people anticipated when we when we saw some of the initial estimates, so that's one piece, too.
You know, we see a number of people that are above the Medicaid expansion, but they can't quite you know, you have to project your income. And so if you're projecting your income and your at 350. Percent of poverty or above you might not sign up for the advance tax credit because if you if you are a lot of your Revenue comes in and that last quarter of the year, you don't want to take the chance of making too much and then having to pay the tax credits back so you don't want to you know, go out seeking health insurance and get a tax bill.
So I think we have a number of people that do that and they're and they're probably really small, you know some or a company of one maybe two they're doing something that they left a job somewhere else. They come to Colorado because they love the quality of life and they're working kind of independently.
So I hear a number of folks that do that. I think the third one is we have a number of small companies and I mean 10 or fewer who can't afford to actually pay for. Employer-sponsored care because they can't kick in the percentage that we were required for a group plan. And so you've got folks that are working but don't think that they actually qualify for anything.
They might think that whether hear about this Medicaid thing, but they don't hear about us as much because you know, we're just a smaller subsection of the health market. And so I mean I've talked to people whether there be a breweries restaurants. Small independent shops that just don't understand that, you know, they might move up for Medicaid expansion, but they don't know that they need to come to us for the for what we do on the marketplace.
And so, I think those three reasons is probably why we see a little bit muted in terms of the number of people on The Exchange, but I think we know we're going to work a lot more closely with smaller businesses to see if we can get them to kind of come in and at least get their focus on the individual market so that they at least have access to coverage.
Jackie: Great, that makes sense. Yeah, so. Thinking about enrollment for this year. I did by my insurance on the exchange a couple years ago and it was a very useful thing to have. I was freelancing at the time and didn't have insurance through work. I did find that there are a lot of steps to go through and just it was a new system for me of what it like what is connect for Colorado.
What is up with resolve this so I wonder if there are any steps you've been taking to kind of address that confusion that people can sometimes experience when they're trying to figure out how to get. Insurance. So I think a couple things are important to do to bring two folks attention here one is what we do it.
I think when you come from employer-sponsored care where you're used to getting your insurance at work and you come to the individual Market, you're typically going from maybe a handful of choices four to five perhaps. In terms of your options to you know this year, we've got a hundred and twenty four so that can be a little bit overwhelming for folks to say.
Okay. How do I even begin to figure out what I'm looking for? So unless you know, you know, you know, which carrier you're looking for, you know, you've got a particular doctor, you know, you've got a particular formula or something on the formulary that you need to have his prescription. It's really hard.
And so what we've done over the past few years is have a quick cost plan finder tool, which can help you identify if you're looking for a particular Dot. A particular prescription we can make sure that the plan you're looking at actually include those things. If you don't know where to start it also can help you say are you a low medium high user of healthcare?
We can perhaps give you some suggestions on where to start so you can kind of winnow down the number of choices. To those that make the most sense for your circumstance.
Jackie: This is like an online tool that you're describing is an online tool where you can just anonymously shop just to kind of ant ask just some real basic questions of how do I get started?
Kevin: Sure. So we've won a couple of awards by having this tool so we're really proud of that. So that's that's issue. Number one this year. The second thing that we've done is we've worked with our federal and state Partners to actually simplify the eligibility process for the tax. Now this was a process that was quite complicated.
I think for folks especially coming in as we did Medicaid expansion because you had to get a hard Medicaid denial before you can shop on the exchange and a lot of folks were like, well, I'm not applying for Medicaid. I don't understand what this is about. And so we tried to make this a little more customer focus and say hey, let's just ask you some questions up front.
Let's see which way you're supposed to go. If you're stay on our side for the tax credit. Okay, we can just get you to shopping by asking fewer questions. But if you have to go to the Medicaid route, there's just other questions that Medicaid is required to ask you and so we try to do is just ask a few questions as possible a front get people to able to shop that actually qualify for the tax credit so they can move on with their day and if you need to go through because you've got chip or Medicaid, that's fine.
We can still get you there and we can actually help you with some of our additional assistance for folks. For sometimes you've got the kids that qualify for chip and the adults that qualify for the tax credit, right and the rules are different and and we expect people to know all these things off the top of their heads and I think it's just kind of crazy.
So what we try to do is make sure we've got a team of folks that can actually walk people through that process and make sure they get the eligibility correct up front and then they can move on with their lives.
Jackie: Sure. Yeah, and so these are things that in those first couple years of open enrollment we were seeing people experience that and. over time you've identified where some of those problems. Yeah, it popped up.
Kevin: It was really clear when I got here where people were getting stuff sure and those mixed hassles as we call them where there's chip and aptc in the same household. It's completely confusing and you know how they Define households using the same word, but they're using them very differently and then there's the tax household which is another great way to think about it.
And so I these aren't words that people use in their normal conversations at the Holiday party, right? And so we just try to make sure that we put the kind of information out there. So people can actually understand what decisions that they're need to make how they need to look at those things and what impacts they have on them.
Yeah. Absolutely. That's great. So I want to ask one or two more Colorado questions and then kind of zoom out to put what you guys are doing here in context. So we have a new governor coming into office pretty soon here and there's been a lot of conversation about this idea of Medicaid for all or some kind of.
Like more universal healthcare that was a theme in the polis campaign, and I just wonder looking ahead to you. See a role for something like connect for Colorado in that kind of vision. How do you see that all kind of coming together?
Kevin: Yeah. I think there's a lot of heard the the governor-elect talk about I think you know, there's this question of the public option.
I you know, whatever. We're going to call it, right, you know, some states have done this with a state exchange as part of the delivery system. So I certainly would see an opportunity for us to kind of. Talk about what we've learned by working with with citizens and customers and carriers around the things that work really well and what things might be challenges.
But I also think that I've heard the governor talked about reinsurance, which is also an opportunity to really begin to talk about how do we begin to drive down the cost and get the right amount of money into the system because we you have to have enough. Premium to pay the claims and so it's just it's a balancing act that we have to do there and I do believe that there are opportunities that we can also participate in that conversation.
So I actually look forward to engaging with the new Administration about some things that we've seen in other states some things that we've talked about with other stakeholders that we've been engaged in our state. So I think there's a lot that we can add to that that conversation.
Jackie: Yeah and reinsurance is this idea of sort of ensuring insurance companies.
So when they have high-cost patients, they they are sort of protected from some of those variations. But yeah, that's great. And is there anything else just like looking forward to like the healthcare seen in Colorado that you're really this really on your mind right now?
Kevin: Yeah. I mean, we're really trying to find ways that we provide additional service and leverage for.
Rural parts of the state as well in the end the Western Slope and whether that's opportunities to find if we can provide direct service for for The Exchange in Mountain communities so that they don't always have to come to Denver to get a question answered or provide the service. We've talked to division of insurance about perhaps looking at ways that we can.
What's the right word that we can have a good metric around reimbursement rates for providers it can we leverage inefficient or small markets? So there's with better buying power for these smaller communities because it's tough when you're in La Plata County and you've. An individual Market, you've got a small group Market.
You've got a little bit of a large group Market, but they're all fighting for the same services at the hospital. Can we ban those together and give them a little more buying power and maybe have the exchange participate in that testing. Can we help with? Providing public employees a shopping experience as we've done as other other states have done at so I think there's just other opportunities that we have to help provide some additional benefit that a shopping platform that we use can identify and help.
Jackie: Yeah, and actually I did what I did wonder thinking about rural coloradans or I'm going to be about people who might not have access to like the internet that you need to kind of get started on some of this shopping are there particular like groups of people or particular areas where it's been a little bit harder to help them access the Insurance Exchange, you know.
Kevin: That's a great question. I do believe that we have digital divides for a number of our Mountain communities. What we think makes sense is is the way that the state has looked at it as well as a hub and spoke. And so while we may not be able to get to Rangeley as easily or dinosaur is easily as we can get to Steamboat if we can get to Steamboat and provide a service there as people kind of come in.
From the county into town we want to be just one of those stops that they're making as they're kind of coming into town for everything else that they're doing when they're doing their business in and then they can go back to their more rural community. And and we think that we can make that more convenient for folks.
Jackie: Yeah. That's great. Yeah, and so just thinking about how Colorado's Marketplace, you know, not every state even has something like connect for health, Colorado other. Have it but it might look a little bit different and I know that enrollment is looking different in States across the country right now at the end of 2018.
So yeah anything that we should know about sort of how Colorado enrollment is comparing to across the country how other other things about that make connect for health, Colorado unique.
Kevin: Yeah. I think we have been really lucky to have. Growth in enrollment that this early we've seen some of our highest enrollment days this year and I know other states are below some some are like double digit below last year some that our state marketplaces in some that are.
Federal Marketplace States and so, you know, I think that the fact that we're able to work so closely with our communities on an ongoing basis. We talked to Brokers we talked to assistance Network sites were talking to health coverage guys. We're talking to business owners that allows us to make sure that we can craft something that actually works for them and meets their needs and I think that makes a huge difference in this.
Jackie: Yeah, that's great. So I wanted to ask you something about your just personal perspective. I know that you were kind of in the world of Education before you were in health. I wonder if there are sort of things that you notice that are common or different between those two worlds of public policy and worlds of just
Kevin: It's a good question.
I think what similar is everybody has a little experience with both and so. And people have opinions in both worlds the education education and the health policy world that they hold very dearly and it's hard to have an abstract conversation because it impacts them personally, you know an education it's their kids.
It's their memories of when they went to school is there is their neighborhoods in the health world. It's literally life and death. It's their family members. It's some very personal story about what's going on with them. And so I get that it's hard to kind. Completely Divorce Yourself and say well, let's just have this very easy, you know philosophical conversation about it.
It's hard not to have it be. Quite a bit personal but I also think that there's the ability to make it where it's personal in a way that it actually makes great gains for people and I think that's where we hope this conversation will continue to move because I think we can make things better for people a lot of work has to happen.
We just want to make sure that we continue to be a critical part of that.
Jackie: Yeah, so Kevin. Thanks so much for sharing all this a lot of complexity in these systems, but sounds like we're on track for some high enrollment numbers in 2019. So will be curious to see what you wind up seeing.
Kevin Thank you so much.
It is a pleasure talking to you. Thanks.
Jackie: Thanks to Kevin Patterson for joining us. He's the CEO at connect for health, Colorado. You can find more episodes of the checkup at Colorado Health Institute dot org slash podcast coming soon will feature some conversations from hot issues and health our annual conference, which is happening in the first week of December this year in the meantime, make sure to follow us on Twitter and Instagram @ CoHealthinst and follow us on Facebook.
You can also subscribe to our newsletter sum it up. Thanks for listening. I'm Jackie Zubrzycki at CHI