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Blog & News
Minnesota should keep our State-Based Marketplace. Here's why.
January 28, 2016:Earlier this month, the Minnesota Health Care Financing Task Force, of which I am a member, recommended that Minnesota continue operating MNsure as a State-Based Marketplace (SBM) rather than switch to a Federally-Facilitated Marketplace (FFM). I agreed with the recommendation. Here's why:
- Minnesota knows how to run successful healthcare programs for our residents, and we do it well.
The federal government issued new guidelines stating that an FFM will not accommodate state-specific programs or eligibility criteria. Moving to an FFM would therefore require that we dismantle MinnesotaCare, a program that is unique to Minnesota and offers generous benefits at a reduced premium to folks whose income is too high to qualify for Medicaid but too low for Marketplace coverage to be affordable, even with financial assistance. We would have to move the 76,000 individuals enrolled in MinnesotaCare to HealthCare.gov, where they would have to pay more for less generous coverage—ultimately making coverage less accessible for them. Minnesota has a long history and expertise in administering health insurance coverage programs, and we should continue to support our state-based initiatives. -
With an SBM, we keep premium assessments in Minnesota and control their growth.
The new FFM guidelines also require states to pay a fee for using the HealthCare.gov platform. This fee would go directly to the federal government, and the fee could increase over time at federal discretion. Currently, the premium assessment levied through MNsure stays in Minnesota to support Minnesota-specific programs, and we control any changes in the percentage of premiums assessed. -
An SBM promotes integration of eligibility and enrollment systems at both the state and county levels, and this integration helps Minnesotans efficiently enroll in coverage and maintain benefits.
Minnesota has been working on an integrated eligibility and enrollment system that links MNsure, MinnesotaCare, and Medicaid while also providing a platform for the integration of other public programs (e.g., the Supplemental Nutrition Assistance Program, or SNAP) to help the state and counties more efficiently administer Minnesota programs and services across the board. This level of integration will boost operational efficiency, help the nearly 900,000 individuals enrolled in Minnesota’s healthcare programs maintain their coverage consistently, and ensure that folks are benefitting from all the programs and services for which they are eligible.
Integration progress has been slow, but it is happening, and integration is worth working on and supporting. States that rely on HealthCare.gov have faced challenges in the transfer of information in a timely and efficient way. This is because, in most states, HealthCare.gov only assesses Medicaid eligibility, leaving it up to the state to make the final eligibility determination. This process adds an extra administrative layer that costs the states money and can lead to unnecessary delays in coverage enrollment. Moreover, states using HealthCare.gov must still electronically transfer information between Medicaid and HealthCare.gov after eligibility has been determined, and 20 states report that these transfers are delayed or problematic. Given these FFM-related operational concerns, it makes more sense to continue to develop a system where these processes are interconnected and functioning in a way that ensures the efficient eligibility determination and enrollment of Minnesotans. -
Moving to an FFM would cost Minnesota $5 million and distract from improving the interconnectedness of Minnesota’s IT eligibility and enrollment system.
The estimated cost for Minnesota to move to the FFM platform is $5 million. Not only would this move take additional state resources, but it would divert attention away from the slow but steady improvements in Minnesota’s IT infrastructure that are needed to integrate state and county programs. The time and money that could have been spent on the build-out of Minnesota’s IT system would be tied up with making Minnesota’s systems interface with a new federal system that is still a work in progress. - An SBM gives Minnesota control of the funding and function of our health insurance Navigators, who have played a critical role in local enrollment efforts.
Navigators and enrollment assisters have been critical in enrolling people in MNsure, MinnesotaCare, and Medicaid. Without an SBM, the navigator function becomes a component of the FFM and is thereby removed from state and local control. The Task Force recognizes and acknowledges the importance of community-level enrollment assistance functions, going so far as to recommend additional improvements to consumer assistance resources. Minnesota has a strong history of efficiently-run and successful enrollment programs, and our Navigator program under the ACA is no exception.
- With an SBM, Minnesota maintains access to state-level data that support health system planning and evaluation.
Minnesota currently has ready access to eligibility and enrollment data, a benefit that is not available to states using the HealthCare.gov platform. Access to granular data enhances Minnesota’s ability to understand its health insurance markets, evaluate and project the movement of people between coverage types, and design and target effective outreach strategies. Without easily accessible eligibility and enrollment data, we cannot refine and improve broad access to coverage.
The bottom line is that there is no silver bullet for marketplace implementation. State-Based Marketplaces and Federally-Facilitated Marketplaces each have their own challenges with the accommodation of complex eligibility rules and enrollment processes that are part of the ACA. However, Minnesota has a history of successful health coverage expansion, enrollment expertise, and operational efficiency that warrants keeping the marketplace within our sphere of control. We are a unique state that may not be appropriately represented at the federal level through an FFM, and we can more effectively assert our own interests by taking charge of them ourselves.
Blog & News
November 2015 SHADAC Newsletter Now Available
November 20, 2015:The November 2015 SHADAC Newsletter is now available.
Access the newsletter to learn about SHADAC publications and activities, news from the states, new resources for state health policy research, announcements from SHADAC staff, and a list of recommended reading.
Publication
SHADAC Newsletter, November 2015
The SHADAC newsletter contains updates on SHADAC activities, news from the states, resource updates, and blog highlights.
Click on the image below to download a PDF version of this newsletter. Subscribe to our newsletter here.
Blog & News
Brett Fried: Expanding access to health care coverage critical to reducing a state's uninsurance rate (Cross-Post)
November 19, 2015:The following content is cross-posted from Health Talk, the blog of the University of Minnestoa's Academic Health Center. It was first published November 10, 2015, and posted by Matt DePoint:
Photo: New York Times http://www.nytimes.com/interactive/2015/10/31/upshot/who-still-doesnt-have-health-insurance-obamacare.html?emc=edit_th_20151101&nl=todaysheadlines&nlid=20932956&_r=2
According to a recent New York Times article, the majority of people who remain uninsured after the Affordable Care Act (ACA) was implemented in the United States live in the South and Southwest and they tend to be poor.
But why is this the case?
Health Talk spoke with Brett Fried, a senior research fellow at the State Health Access Data Assistance Center (SHADAC), to learn more about why there are such glaring differences in uninsurance rates across the United States.
Health Talk (HT): There is a distinct difference geographically in the NYT map. Why do you think this is?
Brett Fried (BF): As mentioned in the New York Times article, whether a given state chose to expand Medicaid seems to be the major driver of how many people remain uninsured the state. This association is consistent with recently released data from the National Center for Health Statistics (NCHS): These data show that, compared with non-expansion states, the percentage of uninsured non-elderly adults in Medicaid expansion states was generally lower and declined more dramatically between 2013 and the first quarter of 2015 (with an average drop of 7.8 percentage points in the expansion states and an average drop of 5.9 percentage points in non-expansion states).
HT: What is Minnesota doing well compared to other states?
BF: Minnesota has a long history of reform, including pre-ACA coverage expansions, which contributed to relatively low rates of uninsurance even before federal reform. Minnesota continued this tradition by implementing the early Medicaid expansion option under the ACA in 2010 (along with only six other states and the District of Columbia) and expanding Medicaid fully in 2014. In addition, Minnesota’s state-based marketplace, MNsure, conducted an intensive outreach and enrollment campaign and funded widespread in-person enrollment assistance. The impacts of these efforts can be seen in the New York Times map, which shows Minnesota already low uninsurance rate declining significantly between 2013 and 2014. This is consistent with U.S. Census Bureau data, which show the Minnesota uninsured rate dropped from 8.2 percent in 2013 to 5.9 percent in 2014.
HT: What can those predominantly southern states learn from Minnesota?
BF: The predominant lesson from Minnesota (and other states) is that a commitment to expanding access to coverage—whether through traditional Medicaid, a Medicaid waiver, or other public coverage programs—is critical to significantly reducing a state’s uninsured rate. While Minnesota has historically been a leader in health reform, resulting in consistently low rates of uninsurance, southern states such as Kentucky and Arkansas that expanded Medicaid under the ACA (the first through an expansion of traditional Medicaid and the second through a Medicaid waiver initiative) also saw dramatic reductions in their rates of uninsured. In fact, Census data show that the uninsurance rate dropped from 14.3 percent to 8.5 percent in Kentucky and from 16.0 percent to 11.8 percent in Arkansas between 2013 and 2014.
HT: Can you explain the role Medicaid expansion and politics plays in the uninsured rates?
BF: Data clearly show the Medicaid expansion has been the driver of coverage gains under the ACA. The Centers for Medicaid and Medicare services reports an increase in 13.6 million additional enrollees between October 2013 and August 2015. While Medicaid enrollment growth occurred in all states, it was driven by states that expanded coverage: Among states that expanded coverage, Medicaid grew by 31 percent between a pre-ACA baseline period and August 2015, compared to 10 percent growth among non-expansion states.
Among the 19 states that have not expanded Medicaid, politics seems be driving the debate around whether to expand. The political debate varies in each state, but opponents of expansion commonly cite: opposition to expanding a “broken system,” a belief that Medicaid reduces the incentive for personal responsibility among enrollees, concerns over the impacts of expansion on state budgets, and a belief that expansion would constitute an infringement on “states’ rights”, among others. In order to gain political support, a handful of states have applied for and received a waiver to expand Medicaid in a non-traditional way. Non-traditional approaches have included implementing expansion through a premium assistance program, charging premiums/contributions, eliminating select required benefits and providing incentives for healthy behaviors.
HT: What can be done to encourage more people to become insured?
BF: It has been commonly reported that states have seen enrollment gains among the “low hanging fruit” and that those who remain uninsured are the “hard to reach.” This seems particularly true for states with very low rates of uninsurance, like Minnesota. A recent SHADAC analysis examined the characteristics of the uninsured in 2013 versus 2014 seems to bear that out: Our analysis shows that compared to the uninsured in 2013, those in 2014 were more concentrated in groups that have consistently been uninsured (e.g. men, Hispanic, non-citizens, those with less education). State data can play in important role in targeting outreach to the uninsured, and to that end, SHADAC provides data to states on the characteristics and location of the remaining eligible for Medicaid and the health insurance marketplaces.
Publication
SHARE Quarterly Update: July - September 2015
SHARE Panel at APPAM Will Consider Early Post-Expansion Utilization Data
Four researchers will present findings from their SHARE-funded studies on a panel at the 2015 Fall Research Conference hosted by the Association for Public Policy Analysis and Management (APPAM) in Miami, Florida. The panel, titled “Early Data on Health Care Utilization after Coverage Expansion,” will take place on Thursday, November 12th, and will feature presentations from Peter Cunningham (Virginia Commonwealth University), Marguerite Burns (University of Wisconsin – Madison), Angela Fertig (Medica Research Institute), and Michael Dworsky (RAND Corporation). Kathy Hempstead, Coverage Team Director at the Robert Wood Johnson Foundation, and Brett Fried, SHADAC Senior Research Fellow, will act as discussants. Learn more.
December 8th Webinar: Analysis of Provider Network Monitoring Practices
Karen Brodsky and Barbara Markham Smith of Health Management Associates (HMA), will discuss their SHARE-funded analysis of trends in provider network monitoring practices by states and health plans during a December 8th webinar hosted by HMA. They will highlight key findings from a survey of health plans and state regulators concerning provider network adequacy compliance and monitoring standards (detailed in an in-depth report here). Based on these findings, they will provide recommendations for states and health plans seeking more effective and efficient ways of ensuring adequate provider access for members. Register for the webinar.
Sarah Gollust Discusses Geographic Variations in Media Messages about Reform
Dr. Sarah Gollust of the University of Minnesota discussed her SHARE-funded research in a presentation titled, “Media and the Politics of Implementation: Geographic Variation in ACA Coverage,”at the 2015 Annual Meeting of the American Political Science Association (APSA) on September 6th in San Francisco. The presentation focused on an analysis of the geographic variation in the volume and content of televised messages about the ACA from October 2013 through March 2014. The next stage of the project will link patterns of media messaging at the market level to individuals’ attitudes and behavior using national survey data (Kaiser Health Tracking Poll and the National Health Interview Survey).Angie Fertig Finds Evidence Consistent with Pent-Up Demand among New ACA Enrollees
A new brief from Dr. Angie Fertig at Medica Research Institute highlights initial findings from a SHARE-funded study examining pent-up demand after the ACA. In the brief, Dr. Fertig, with co-authors Dr. Caroline Carlin and Dr. Sharon Long, examines administrative and claims data from a Minnesota health insurer to identify early patterns in the first claim for new Medicaid and commercial non-group (including Marketplace) enrollees who signed up for coverage between January and March 2014. The researchers found patterns of utilization that are consistent with pent-up demand among new Medicaid enrollees. However, the evidence of pent-up demand among new enrollees with non-group coverage relative to the comparison group is mixed. Tal Gross Explains Why Medicaid Expansion Makes Economic Sense
In a recent video from Columbia University’s Mailman School of Public Health, Dr. Tal Gross summarizes the policy implications of his SHARE-funded analysis of the economic impact of state ACA Medicaid expansion decisions. Dr. Gross and his colleagues at Northwest University found that the amount of money that state governments save from not expanding Medicaid is roughly equal to the amount of money that the hospitals in those states have to spend to care for the uninsured (i.e., their uncompensated care costs). These findings are detailed in Dr. Gross’s recent NBER working paper.
V-BID in Connecticut: Early Results Show Beneficial Impact on Utilization
The research team led by Dr. Richard Hirth at the Center for Value-Based Insurance Design (V-BID Center) at the University of Michigan released a brief highlighting initial findings from their SHARE-funded analysis of Connecticut’s Health Enhancement Plan (HEP) for state employees, which reduces cost-sharing for high-value clinical services and targets patient incentives to eliminate barriers to evidence-based care. The authors found significant improvements among HEP enrollees during the first HEP plan year for a variety of standard preventive measures compared to a control group of state employee health plan enrollees in four different states without a comparable intervention. The findings from this brief are highlighted in the podcast of an August 4th webinar that was co-hosted by SHARE and the V-BID Center.
Sarah Gollust, PhD
Sarah Gollust is the principal investigator on a SHARE-funded project to measure geographic variation in ACA-related media messages and the subsequent relationship of media messages to insurance enrollment from 2013 to 2014. Her broad research interests are in the politics and ethics of health policy, and she is particularly interested in understanding the media’s role in influencing the public’s opinions and perceptions of health policy issues. Learn more.
Fertig, A. August 4, 2015. "The First Insurance Claim of New ACA Enrollees." Presentation. Minneapolis, MN: Medica Research Institute Seminar.
Gross, T. July 2015. "Why Medicaid Expansion Makes Economic Sense." Video. New York, NY: Mailman School of Public Health, Columbia University.
Gollust, S. September 6, 2015. “Media and the Politics of Implementation: Geographic Variation in ACA Coverage,” Presentation. San Francisco, CA: 2015 Annual Meeting of the American Political Science Association (APSA).
Hirth, R. August 4, 2015. "Innovative Benefit Design for Connecticut State Employees - Findings from a V-BID Evaluation." Webinar. SHARE and the Center for Value Based Insurance Design at the University of Michigan.
Hirth, R. March 2015. "Connecticut's Health Enhancement Program for State Employees UPDATE (2015)." Issue Brief. Ann Arbor, MI: Center for Value-Based Insurance Design at the University of Michigan.
