A rumble in the courts

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Guest post: Jessie Kavanagh, Health Policy Intern at Community Service Society of New York

Last week, a 3-judge panel of the U.S. Court of Appeals for the District of Columbia ruled 2-1 that states using the federally-facilitated marketplace (healthcare.gov) cannot offer government subsidies to their residents. The same day, a 4th U.S. Circuit Court of Appeals in Virginia unanimously came to the opposite conclusion– that the states using the federal marketplace should be able to offer subsidies.

What to make of this conflict? Regardless of the disagreement, the bottom line for New Yorkers is simple: the decisions have no immediate impact on New Yorkers’ eligibility for the ACA tax credits and subsidies.

The main issue in these cases concerns the language in the ACA regarding the subsidies. The language states that subsidies are only available “through an exchange [aka marketplace] established by the state.” The U.S. Court of Appeals for the DC Circuit argued that this language means subsidies should be available only to people who enroll through a state-based marketplace. However, the 4th Circuit Court said that the law was ambiguous, and that the IRS was entitled to its interpretation that the federal marketplace acts as a state’s marketplace, and therefore all states can offer subsidies to their residents.

Ultimately, the ACA was written with the intent to make insurance more affordable for all Americans. And, it seems to be working. In New York, 3 out of 4 enrollees in commercial Qualified Health Plans during open enrollment- or 274,247 New Yorkers – were eligible for tax credits that made insurance more affordable.

 

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Navigator Leon McIntosh helps New Yorker Anna enroll

We all know finding the right health insurance plan can be complicated and overwhelming – even with the launch of the insurance marketplaces offering one-stop shopping under the ACA. One of the most exciting features of the ACA is the establishment of assister programs to help people enroll (e.g. Navigators and Certified Application Counselors). A new survey from Kaiser Family Foundation shows just how effective these groups were during the first open enrollment period.

According to the survey, administered to directors of assister programs around the country:

28,000 assisters helped 10.6 million people apply for coverage and financial assistance.

States with State-based Marketplaces, like New York, had a much higher ratio of assisters to uninsured and helped two times as many people relative to the uninsured population when compared to states with a Federally-facilitated Marketplace. Our own NY State of Health‘s recent enrollment report shows that 643 Navigators and nearly 4,000 Certified Application Counselors helped over 413,000 New Yorkers enroll in coverage. That’s nearly half of enrollees.

Most consumers who sought help applying for coverage were uninsured and had limited health insurance literacy.

The vast majority of programs reported that consumers seeking help had a limited understanding of the ACA and struggled with basic health insurance terms, like “deductible.” As a result, assistance took time – between one to two hours in most cases.

Nearly all assister programs have been “re-contacted” by consumers with post-enrollment problems, including questions about how coverage works.

Questions from consumers don’t stop at enrollment. However, assister programs are not trained on post-enrollment issues, and in many cases don’t have funding that allows them to provide this type of assistance. Instead, the ACA established Consumer Assistance Programs (CAPs) to provide these services, but these programs haven’t received federal funding since 2012. Luckily, New York legislators recently approved $2.5 million in the 2014-2015 budget for the State’s CAP, Community Health Advocates (CHA). Thanks to the funding, CHA will be able to provide more robust hotline and in-person services through community-based organizations in the coming months.

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Guest post:
Bob Cohen, Policy Director, Citizen Action of New York/Public Policy and Education Fund;
Theo Oshiro, Deputy Director, Make the Road New York

New York took a big leap forward in enrolling nearly a million New Yorkers in health coverage during the first open enrollment period under the ACA that ended in March, but we still have a lot to do to ensure that all New Yorkers, including traditionally excluded communities, fully benefit from the federal law. This is the simple message of a new “white paper” released in June by two HCFANY partners, the Public Policy and Education Fund and Make the Road New York, in conjunction with the Alliance for a Just Society, a national network for research, policy and organizing.

The report, Addressing Health Disparities Through the Marketplace: An Action Agenda for New York State of Health,” applauds NY State of Health for a number of steps it has already taken, like easing enrollment in emergency Medicaid. The white paper establishes a broad agenda with 11 recommendations for further actions by NYSOH and the Legislature. For example, the report recommends a greater focus on outreach aimed at reaching diverse communities through steps like stronger targeting of ethnic media and reexamining current restrictions on navigators on contacting New Yorkers in their homes. It suggests that public numerical targets be set for enrollment of groups like immigrants and people of color, that NYSOH move forward aggressively with translating its website into languages other than English, stronger enforcement of requirements that health plans develop clear strategies to address health disparities, and the establishment of  a stakeholder task force focused on the reduction of disparities.

 

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We already knew that nearly a million New Yorkers had enrolled through NY State of Health during the first open enrollment period from October 1 to March 31. But now we know more than ever about who they were, where they live, and how they enrolled. That’s thanks to the new enrollment report released yesterday by NY State of Health, the official health plan marketplace, which includes eagerly awaited demographics data such as age, race and ethnicity of enrollees.

HCFANY issued a press release, highlighting key findings from the data, such as the importance of in-person assistors in helping New Yorkers obtain health insurance. Nearly 50% of insurance applications were completed with help of in-person assistors, including Navigators, Certified Application Counselors, and brokers. In-person assistance was particularly critical for low-income New Yorkers: more than half (59%) of the Medicaid enrollees used in-person assistance to complete their application.

For the first time, the report offers a glimpse into the race and ethnicity, as well as preferred language, of New York enrollees. Though the data is incomplete – about one in four enrollees chose not to respond to the application on race – it nonetheless will help direct future outreach and enrollment efforts across the state. About 37% of enrollees who answered the question reported their race as Black/African American, Asian/Pacific Islander, or “other” non-white race. About 20% of Medicaid enrollees chose a language other than English, but no enrollees reported their preferred language as Korean, Russian, or French Creole, pointing to potential gaps in these communities. As useful as this data is, it only provides a statewide picture – there is still a need for race, ethnicity and preferred language by county in order to target outreach to the communities that need it most.

Financial assistance was key to the high enrollment numbers in Qualified Health Plans (private health insurance). Nearly 3/4 of enrollees got private health plans with financial assistance in the form of Advanced Premium Tax Credits (APTC) or a combination of both APTC and cost-sharing reductions. An average New Yorker who was eligible for financial assistance saved $215 per month in premium.

And, while some enrollees (about 13%) clearly benefited from the Medicaid expansion that made them newly eligible for public insurance, a whopping 93% of Medicaid enrollees were newly insured overall. That means many of those who enrolled in Medicaid were previously eligible but, for whatever reason, had been unable to enroll. New York clearly did something right in building it’s health insurance marketplace – the single, streamlined web application our State officials built is working. And, boy, did New Yorkers come.