Affordable confusion. Inaugurating insurance exchanges, a major component of the Affordable Care Act, raising questions and frustration. We're getting expert insight from Iowa's Insurance Commissioner, Nick Gerhart, Meridian CEO Dr. Andy McGuire and Genesis Health Administrator Ken Croken on this edition of Iowa Press.
Borg: The Affordable Care Act, most call it Obamacare, is making major changes in how Americans pay for their healthcare. Despite controversy, various components are now taking effect, a major one just this past week as the new health insurance exchanges began offering options to individuals and families who qualify. And that's a question in itself, who qualifies? And there are a lot of other questions too, including how is it affecting doctors and hospitals? We're seeking insight from Iowa's Insurance Commissioner Nick Gerhart, Dr. Andy McGuire who heads the physician owned Meridian Health Plan and from the Quad Cities Genesis Hospital's Communication Director Ken Croken. Welcome back to Iowa Press, all of you.
Thanks for having us.
Nice to be here.
Borg: And across the table Political Writer James Lynch of the Gazette published in Cedar Rapids and Radio Iowa News Director Kay Henderson.
Henderson: As the state's insurance commissioner you are the point person in sort of arranging the state level exchange. How did it go on the first day? There were some glitches.
Gerhart: There were definitely some glitches and there continue to be glitches. In fact, I am unaware of someone who has successfully enrolled through the marketplace to any of these carriers. It may have happened this morning but as of yesterday it had not happened.
Gerhart: Well, there's been some technical glitches and Washington D.C. is the federal exchange. Apparently what we have been told from our federal partners is that the volume and the amount of interest has caused the system to come down. We have been telling Iowans it's probably best to wait a week or so. If you want coverage beginning January 1st you don't have to enroll until December 15th and the open enrollment period goes all the way to March 31st of next year.
Henderson: Can you tell what the volume has been on the state specific exchange?
Gerhart: I don't have any data for Iowa specifically. We've been told in the first two days over 5 million unique visits, we know that much in the first two days, but that's all I know.
Borg: Let me clarify. Are you saying you don't know if anyone has successfully enrolled yet?
Gerhart: Not through the marketplace. We know that some folks have enrolled with different carriers going direct but I am unaware of anyone who has enrolled through the marketplace yet successfully.
Henderson: Can -- at Genesis you are one of the so-called navigators, if you will. First of all, what is a navigator? And what have you been helping people do?
Croken: Well, the navigator is a federal designation. We sought a grant from the federal government and received that. We then went out and hired three people who are in the process of being certified right now. I believe one of the three is fully certified. We, of course, have the complication of being certified in Illinois as well as Iowa and for the federal programs so there's three levels of certification required. We are in the process of scheduling 300 education and enrollment events to be held at churches and schools and grocery stores and wherever people come to be.
Henderson: Is Illinois having the same problem that Iowa is?
Croken: Well, I think that, you know, if the bad news is the computers have ground to a halt, the good news is there's so much demand on these systems for this service that I believe people will be back. But yes, it's a system wide problem and the federal shutdown that keeps the IT people from addressing some of these issues in a timely way isn't helping either.
Lynch: Ken, what is the number one question you're hearing from people about signing up, enrolling?
Croken: Well, I think that, again, who is eligible. As was said earlier, the financial eligibility is a complication, particularly on the Iowa side of the Mississippi because of the Iowa Health and Wellness Act, which splits the federal poverty guideline, eligibility at 100% sending the lower half of that to Medicaid, to expanded Medicaid and the upper elements of that into the exchange program and people aren't sure where they belong.
Lynch: Nick, is that the same thing, questions you're hearing?
Gerhart: Yeah, we're hearing a lot of questions. We're getting some frustrated Iowans who are talking to us about I've been online now for three hours and was bumped out, I've called the federal call in number and no one is answering the calls. We've called the federal call number quite successfully a number of times so I'm not really sure where that disconnect is. I've had staff members get through within five to ten minutes on average. But we've had some frustrations there and people are just asking where can I go to get help. Well we have three navigators in the state of Iowa, we're going to have some certified application counselors throughout the state of Iowa and obviously agents and brokers are still out there and they can still sell product --
Borg: This is kind of out of your hands, isn't it? There's nothing you can do as Insurance Commissioner of Iowa?
Gerhart: There's nothing we can do other than be in contact with our federal partners at CMS which is the Center for Medicare and Medicaid Services so we are talking to them regularly as we identify other issues that come up and we're just really trying to help them to the best of our ability. But you're right, it's out of our hands.
Croken: But I would like to just add though that while there is frustration with the enrollment process there is a great deal of consumer satisfaction with the availability of these programs. So if the process is troublesome people are glad for the opportunity.
Gerhart: I think that's a good point, if I could just interject for one second, because I think at the end of the day there are new options available to many Iowans, there's tax credit assistance available to Iowans for a family of four all the way up to $94,200 and these are avenues that were not available before. So while there is frustration we keep telling people there's plenty of time to enroll.
Henderson: Andy, first question to you is, what is Meridian?
McGuire: Meridian is a managed care plan for Medicaid and now for the health and wellness plan and what we do, we're a very high touch health plan and it's really interesting what you're all talking about is exactly what we're doing is there are a lot of people who need access to health care and have not had it. I saw a survey the other day that 93% of people who are uninsured have put off any kind of health care because of financial concerns. So those people are now going to get access either through the exchange or through the health and wellness or through Medicaid. And the wonderful part about that is when you have access you can start to do the preventive care that really is so important.
Henderson: And the health and wellness plan you just referenced is the state's decision to expand to maybe 170,000 more Iowans the ability to enroll in Medicaid. I just want to make sure --
McGuire: Yes, as Ken said, it is up to 100% is in this, poverty level, federal poverty level they have a wellness plan that will come into some parts we do. And we will be helping those members to figure out who their PCP is and how they get their preventive care. And that really is something.
Henderson: Why didn't your company participate in the exchange?
McGuire: We're not in the commercial population at this point.
Henderson: But aren't some of the Medicaid patients encouraged to go to the exchange to enroll?
McGuire: They are and by the time that decision was made, June 15th, it was really right on top of each other. So since we typically are not in commercial but we do do that segment there was no way to sort of --
Henderson: So maybe next year?
McGuire: Absolutely. I think next year we will -- we are in the exchange in other states but next year we may be in the exchange.
Lynch: What would you have to see to make, to jump into the exchange?
McGuire: You know, honestly right now I'm so focused on getting the health and wellness people in and the Medicaid people in I'd have to, you know, make sure we could just do it personnel wise. But it is a good idea I think because what people don't understand I think sometimes is this population sometimes needs some help with barriers to getting their health care, transportation issues, two jobs so hard to get in at the time they need to and so that high touch model really does work. And we're so about quality that that is what this group needs too to get their preventive care.
Borg: And just to reemphasize and reiterate, you serve mostly low income, those who are on Medicaid.
Borg: Alright. Mr. Gerhart, Iowa's largest insurance server, 85% of the market, Wellmark Blue Cross and Blue Shield, isn't participating. What is the effect of that?
Gerhart: Well, I think we're going to determine what that is as this plays out to be honest. But yeah, our largest insurer and our second largest insurer, United Healthcare, neither are going to be in the marketplace. What I would say is we had 10 carriers either file medical plans or dental plans. Two of those carriers are medical plans that are statewide, offered in all 99 counties. And so they're out there, there are new options available. They filed I think 120 plans total.
Borg: I know it's yet to be seen how it plays out, but would you expect that Wellmark and others who aren't participating, some of their customers would be migrating to the health insurance exchanges for something less expensive?
Gerhart: They might and the exchange is the only place where an Iowan can get a tax credit so some people may go check this out. We asked, who is going to look at this? Anybody can go look at the marketplace to see what is available and, again, I think we're going to have more carriers in year two. Wellmark has said they're going to be there in year two so I think we'll have more carriers.
McGuire: Well and I think one of the big things that people know about this is pre-existing conditions. And there are a lot of people who have been on, say, Wellmark or United and have a pre-existing condition that has happened, breast cancer, diabetes, they may be really doing well but they have not been able to change their insurance because they are basically uninsurable up until we had the Affordable Care Act. And now that we have this I think there will be people going because I know their premiums have been going up. I talked to a person last night, her premium is $1500 a month and these premiums are going to be half to a third of that. And they won't have the pre-existing condition problem. So I think that is really going to be a big part of it.
Croken: It is also probably worth noting that we have a new entry into the marketplace here, co-opportunity, which, again, is truly, that is their name and that is also their model. They are a co-op and their rates are going to be, I think they're going to drive the market pretty aggressively and I suspect people will change, particularly once they understand that their pre-existing condition is no longer a barrier to making a change.
Borg: Do you agree, Nick, that something like that, a low cost provider kind of like Southwest Airlines entering the Des Moines market, that will drive down other costs?
Gerhart: Well, I think what you're going to see is that as companies look to file their rates next year they're going to look at the market today and now that you have these apples to apples comparisons, anyone can go out and look, I think it's probably going to dictate pricing certainly for year two and I think it's going to be a market that is going to be very competitive. So you're going to have up to 250,000 Iowans could qualify for some level of tax credit assistance in this marketplace is what our research is telling us. So there's going to be a lot of people looking at that marketplace.
Lynch: Nick, if I am successful in logging on and getting on to the exchange, what do I find? Is it just -- do I have one choice? Do I have multiple choices? Can you briefly describe --
Gerhart: Great question. You have multiple choices and all the plans are based on metal tiers now starting at a platinum level plan and then it goes to a gold, goes to silver then bronze and if you're under 30 you get a catastrophic plan. And each one of those there's up to 10 plans. So the average Iowan when they go look they're going to have about 40 options to look at. The platinum is going to be the most expensive premium and the bronze is going to be the cheapest premium. But what we've been telling folks is look at your total financial out of pocket, the event that your preventative services, your chronic management services, those are going to be covered without deductibles and copays but once you go beyond that you're going to be on the hook for something whether it's a deductible, copay, coinsurance. So you might want to look, the bronze is the cheapest per month but it's going to have the highest out of pocket in the event you actually use the insurance.
Lynch: Okay, so it sounds like there's lots of options. If I have, for example, diabetes and my spouse has say a heart condition, is this going to get really complicated? Am I going to be able to figure this out?
Gerhart: You'll be able to figure it out but it is going to be complicated. That is why, you know, we're telling people to talk to a navigator, talk to an insurance agent, talk to a certified counselor, talk to someone who can help you get through this process. What we've been telling folks too is if you don't like your plan you can switch next year as well. So, in other words, some of these plans have been more narrow in network which is tailored to maybe one set of providers, some are very wide in network so that varies the cost as well. But if you're in a plan you don't really like there's no more underwriting for a medical conditions so there are no pre-existing conditions so you can always switch next year.
Henderson: You mentioned something earlier and I want to ask specifically about people who aren't part of this universe that we generally think of the uninsured going into this marketplace to get coverage. So let's say I work for a private employer and I have a huge deductible but my private employer is paying for my insurance. Would it be cheaper for me to go in there to find an insurance plan rather than be covered by my employer?
Gerhart: It may be. It gets complicated because your employer contribution and then your contribution would be pre-tax. But it could be for some folks. The issue would be whether or not you would qualify for a tax credit. If you have access to affordable coverage, which is determined as 9.5% of your income or less, and that plan that they have offered you is minimum value, which is 60% actuarial value, which is the bronze level if you're in the marketplace, if you have access to that then you would not qualify for a tax credit. But that doesn't mean you couldn't look, you could still shop and look.
McGuire: And, Kay, I think one of the misperceptions about the exchange is that it is for low income or it is for uninsured. And really there are a lot of self-employed people out there that are your neighbors that have been dealing with problems with getting individual health care for years.
Croken: And I also think that we're getting a lot of questions, being in a college town, the underemployed, younger workers, there is a real opportunity for them here to secure insurance, especially as Mr. Gerhart pointed out the catastrophic insurance. Some of our younger people don't consumer a lot of health care services but they are one injury, one accident, one illness away from a financial catastrophe.
Henderson: But one of the criticisms of this is that those 23 year olds, 24 year olds could go out now and buy a plan that is far cheaper than what they would find on the exchange. Is that true?
Croken: I should probably defer to Nick on that.
Gerhart: Depending on what they're looking for, yes, that could be true. But there are catastrophic plans available that are very reasonably priced. It's probably a little bit more than what is out there today. If you're under age 26 you can stay on your parents' plan, even if you're married. That is a new reform that a lot of younger people are taking advantage of as well. But if you're going to go compare a qualified health plan, which are the 120 some plans that we certified at the division, to these plans in existence I've heard the analogy it is apples to pork chops.
Henderson: Andy, how long have you been in the insurance industry? I know you came to Meridian from I believe it was American Republic?
McGuire: And then Wellmark. I've been in probably about 15 years.
Henderson: What do you think the overall impact on the insurance market will be of the implementation of the Affordable Care Act?
McGuire: Well, I think that is a good question.
Henderson: That's why I asked it.
McGuire: I'm not sure anyone without a crystal ball knows. But I think, Nick said it earlier, I think there will be some disruption and I think we're all kind of waiting to see what kind of disruption that is. And in my particular part it's a little different but for a Wellmark or a United it really will be a disruption that will be interesting.
Croken: But what is terribly important that we have to constantly remind ourselves, this is not about the insurance industry, it is about wellness and preventative and primary health care, which 250,000 Iowans today are not getting on a regular basis.
Henderson: Well, that begs the question, are people going to be healthier?
Croken: Absolutely I believe that they will be.
McGuire: Because preventative care, so you're going to an ER because by the time you go to the ER you have a stomach ache that is so bad you can't stand it. That is a very inefficient way to provide health care. So what you can do, if we can get these people to a PCP, a primary care doctor, and we can get them to have their physical and their preventative care, what happens is you catch that very early and that's not such a big problem. So now you have a healthier Iowa, absolutely.
Borg: Go ahead.
Croken: I was just going to say it is the difference between a flu shot and a one week acute care stay in a hospital with pneumonia related to flu and everything else.
Borg: But I was going to ask you, Nick, about Ken's comment here just a moment ago. It's not about the insurance industry, it's about preventive health care. I think it's maybe about preventive health care, it's all about the insurance industry isn't it? You're the insurance commissioner.
Gerhart: I would say that this is a remarkable transformation of the insurance industry and there are a lot of insurance reforms. Again, no pre-existing conditions is a big one. When you look at the plans that are out there carriers are looking at four factors is all when they underwrite an Iowan. Where do you live? How old are you? Whether or not you smoke can be a big factor. And the size of your family. So there's four factors now that a carrier would use across the state of Iowa to underwrite.
Borg: Do you think that -- I'm going to ask you a direct question and you may not be able to answer it. Is Wellmark going to lose market share because of this?
Gerhart: You know, I really don't know the answer to that and I think we, time will tell. In six months we probably will know the answer to that. I think what I would tell you though is you have two statewide carriers that are going to be marketing throughout the state of Iowa, working with navigators, certified application counselors, brokers and agents and I think a lot of folks are going to be looking at where do I go for this and they're going to be looking at this as an opportunity for some different options.
Borg: Dr. McGuire, you shook your head yes and I want to have the chance -- will Iowa's largest insurer lose market share?
McGuire: You know, back to Kay's, I'm not sure you know in the commercial population. I think Nick is right, it's kind of one of those wait and see. I do know though in the Medicaid population and the health and wellness, that is a huge bunch of people who are going to come into and have access to health care. So that is a complete disruption, if you will, or change in what we're going to do. It's going to be a change --
Lynch: So the market is getting bigger?
McGuire: It's getting bigger and those people have -- people get health care in Iowa, we don't turn them away but it is inefficient and so it is really important that we get these people to have the real access to health care and the preventative care they need.
Croken: And if I could add, Dr. McGuire, not only is it inefficient, it is ineffective for the same reasons you mentioned earlier. People getting primary care in an emergency room setting is not good care and it is terribly expensive. So we're paying more for less. With this opportunity to get everyone insured, get everyone into a primary care provider relationship, we believe this will advance the Governor's objective of a healthier Iowa overall.
Lynch: Ken, I want to ask you about the impact on hospitals, what this will mean for them. And one of those factors is the cost shifting that goes on now when people go to the emergency room because they don't have health insurance, health care insurance and we all end up paying for that. Is this going to reduce the incidence and the impact of that cost shifting?
Croken: I believe that it will. Time will tell. Genesis Health System last year provided upwards of $60 million in uncompensated care. We don't have $60 million, we got that from the rest of you and your higher costs. So if everyone was enrolled in an insurance program, and sadly I'm afraid we won't enroll everybody, but if everyone was enrolled then the burden of that care would be spread evenly across the entire population and I think everyone wins when that happens.
Lynch: Do consumers understand that?
Croken: I suspect they do not because I hear those questions frequently, which is why it is so important and we've heard this debate in other corners now why it is so important that young people enroll in this program. Perhaps they won't consume very much health care services themselves but as a responsible body if we all come together, get the health insurance that is appropriate to our position, well that spreads the burden and doesn't put it unfairly on one group of people.
Lynch: If you're spreading that cost more evenly, to use that phrase that policy makers like to use, does that bend the cost curve down for everybody?
Croken: Absolutely it will bend the cost curve down, for that reason and also for the reasons Dr. McGuire has been so articulate about. The costs will go down if people indeed get that flu shot instead of the flu. All that preventative care is dramatically less expensive.
Henderson: But what about the concerns that we hear in the news media whereby they say flooded with patients, not enough caregivers, doctors are going to leave the profession, there won't be enough doctors to take care of people. Is that going to be the case?
Croken: I believe those to be scare tactics. We are expanding our physician -- Genesis, again, is the largest provider of primary care in far eastern Iowa and we're bringing on new doctors now and we believe it will be okay.
Borg: Well, let's ask a physician.
McGuire: And I can tell you, I've been asking people and as we go out and contract with hospitals and doctors, I think it's a scare tactic too. We see them as having a lot of capacity and they want more patients and they really, there's nobody who believes that like a doctor or people in that office that they know if you see them and you develop a relationship that is how we keep people healthier.
Borg: Well by the same token, will it require, Dr. McGuire, more health providers, more nurses, more doctors, more physicians assistants?
McGuire: I don't think it will need a lot more. We have some parts like psychiatrists, we don't have enough psychiatrists in Iowa and we all know that. But as far as primary care I think we can always use more but I think we will be able to handle Iowans quite well.
Croken: Particularly if we get creative in our delivery models I think and try some more innovative approaches, using nurse practitioners, physician assistants and other physician extenders I think.
Lynch: Dr. McGuire, your company deals with that Medicaid market and the state has asked for the federal Health and Human Services Agency for a waiver, a Medicaid waiver. If that is granted, if it's not granted, what is the outcome there? How does it affect health care services in Iowa?
McGuire: Well, right now everyone including Director Vermeer and Deputy Director Lovelady, they're all working on the idea that this is going to go through and we have no real choice at this point because of the timing but to work on it as if it is going to go through. Arkansas went through which is a very similar waiver. If it doesn't go through I would leave that to people in the legislature and Nick. I think that's going to be a problem that is, I don't really know what happens.
Lynch: Doesn't it leave a lot of Iowans in the lurch though?
McGuire: It leaves 150,000 to 170,000 Iowans in the lurch and that is what is happening in some other states where they did not approve Medicaid expansion. And the way the Affordable Care Act is built, it is built on these blocks and when you take a block out of the middle it is really a problem and that is what would happen here because they wouldn't be subsidized so they wouldn't get Medicaid but they wouldn't be subsidized, they'd be caught in the middle.
Borg: What is plan B if the waiver doesn't go through?
Gerhart: We're proceeding as if it is going to go through to be honest with you. Iowa Care goes away at the end of the year so it will be --
Borg: In effect it has gone away already and not accepting new patients.
Gerhart: Not accepting new patients and it is a waiver program that ends at the end of the year. So this is what we're working on.
Henderson: Andy McGuire, you're on the show today and it occurs to me that I've had a number of democrats mention to me that they had hoped you might run for governor in 2014. Might you ever put your name on a future ballot in Iowa?
McGuire: Well, I certainly wouldn't rule it out. I have to tell you right now I am so focused on taking care of these members and getting these people good health care that that's really where my focus is. But I, I've got to tell you, I love Iowa and so if that came along and I could help Iowa I would always do that.
Henderson: 2014 or 2016?
McGuire: Oh there's candidates already in now for 2014.
Borg: I want to thank you, first of all, and then talk about our next program. Thank you very much for being with us today.
Borg: And a special Iowa Press program will air Tuesday night, that's what I wanted to tell you about, on Iowa Public Television immediately following Frontline: League of Denial. We'll be assembling a panel of football and medical experts with an Iowa focus. Dowling Catholic High School's Athletic Director and Head Football Coach Tom Wilson, former University of Iowa and NFL tight end Marv Cook who also coaches high school football in Iowa at Regina and Dr. Andy Peterson who directs the University of Iowa's Sports Concussion Program. That is Tuesday evening immediately following Frontline. And in our regular time slot next weekend on Iowa Press we're discussing water quality and the latest efforts by the Environmental Protection Agency and cattle producers throughout Iowa. I'm Dean Borg. Thanks for joining us today.