Health Policy – Imran Cronk

Transportation Shouldn’t Be a Barrier to Health Care

This op-ed was originally published for Stat News, a healthcare-focused outlet started by the Boston Globe.

Transportation issues shouldn’t prevent anyone from getting to or from a doctor’s appointment. But they do just that for an estimated 3.6 million Americans. Some of these individuals don’t have cars or access to public transportation. Others can’t afford taxis or Ubers.

Take the case of Greg, who lives in Fairfax, Va. (His name has been changed to protect his identity; this story is used with his permission.) Three years ago, at age 64, he found himself without a job and living in a friend’s basement. Diagnosed with diabetes, Greg struggled to keep up with his medications. Without a car or access to good public transportation, he couldn’t see his doctor often enough for the exams, test, and self-management education he needed.

He eventually needed to be admitted to the emergency room, where doctors found that he had developed peripheral neuropathy, a complication of diabetes that can occur when the disease is not properly managed. Two of Greg’s toes had to be amputated. That hospitalization and its awful consequences might have been avoided with a few low-cost rides to the doctor before his problems worsened.

This simple issue — not being able to find or afford a ride — turns into an enormous hidden costs for patients, caregivers, providers, insurers, and taxpayers alike. Missed appointments and the resulting delays in care cost our health system an extra $150 billion each year.

In theory, help is available. Medicaid programs spend $3 billion nationwide a year on something called non-emergency medical transportation (NEMT). It is intended to help low-income and disabled individuals get to and from their appointments. Medicaid contracts with different brokers from state to state, sometimes county to county, and these brokers subcontract rides to hundreds of local transportation companies.

But the NEMT system is broken. Some of the local van fleets and cab services aren’t equipped with modern technology such as GPS tracking or automated dispatch. Others provide shoddy service that has been described as“nightmarish.” What’s more, $3 billion a year isn’t nearly enough to provide rides to all of the Medicaid beneficiaries who need them.

As the cofounder of an organization that aims to address these transportation barriers to care, I see or hear about how these problems affect real people each and every day. In Detroit, a contractor routinely shut off its phone lines at 5 p.m., leaving sick and elderly people — including a 79-year-old cancer patient — stranded at appointments without rides back home. In Connecticut, a contractor was hit with civil rights violation complaints for transporting immune-compromised children with cancer in the same van with other sick passengers.

A company in Milwaukee received thousands of complaints about late or no-show rides for cancer, dialysis, and other medical appointments. In a New Jersey surveyof NEMT users, more than half of the respondents said they had “missed appointments, feared for their safety during transit, or suffered harassment, disrespect, or other indignities at the hands of the drivers.”

Even though the system is broken at many levels and there are no easy fixes, we can’t turn our backs on the problem. Earlier this summer, the National Patient Advocate Foundation organized a policy consortium entitled “Transportation: The Road to Nowhere for Too Many Patients.” It convened patient navigators, policy makers, and innovators from across the nation to take a hard look at the issue and brainstorm solutions.

One key take-home message was that improving and expanding NEMT programs, possibly with public-private partnerships between state Medicaid agencies and emerging technology platforms, such as Uber and Lyft, would be good for the nation’s health and our health care spending.

Investing in a streamlined, modernized NEMT program makes sense. Anevaluation of Florida’s NEMT program found that the state would save $11.08 for every dollar invested if just 1 of every 100 subsidized rides prevented an individual from being hospitalized due to missed or delayed doctors’ appointments. If those savings can be achieved in a fragmented program, imagine what would happen if the program actually worked well.

My organization, Ride Health, isn’t waiting to find out. Instead, we are focused on using widely available on-demand ride technology to help connect the dots between patients, providers, insurers, and drivers. We aren’t alone — health systems, transportation companies and insurers across the country are developing innovative new models and partnerships to address the challenge.

It will take a village to help millions of patients, some of them in hard-to-reach locations, overcome the transportation barriers they face today. We hope that these efforts will make it easier for vulnerable and chronically ill patients to reach care; enable providers who are paid based on their patients’ outcomes to address this social determinant of health; lower the cost of care for insurers; and benefit drivers who tend to see fewer requests for rides during the day.

All Americans should have access to timely care. Lack of transportation shouldn’t be a barrier, especially for those who need it most.

Imran Cronk is a cofounder of Ride Health, an organization that helps health care providers coordinate solutions for patients who face transportation barriers.

Will price transparency affect hospital provision of less profitable services?

This post was originally published for the Health Policy$ense blog of the Leonard Davis Institute of Health Economics.

The question of whether and how much hospitals cross-subsidize unprofitable services with more profitable ones is an important one, especially as wide variation in hospital pricing within and across markets is documented. If prices become more transparent, and a hospital’s revenues from high-margin services drops, will hospitals reduce the amount of less profitable services they provide?

For a hospital’s bottom line, not all service lines are alike. Some are quite profitable (such as cardiology or neurosurgery) while others are low- or no-margin (such as psychiatry, substance abuse treatment, and trauma), partly because they attract uninsured and underinsured patients and partly because operating margins for these services are slim and in some cases even negative. Cross-subsidies are often considered the principal mechanism through which hospitals provide unprofitable care, thereby fulfilling their social missions. But they’re hard to detect in hospital accounting systems.

In the first study to quantify this effect, LDI Senior Fellows Guy David and Lawton R. Burns and colleagues Richard C. Lindrooth and Lorens A. Helmchen, estimated the magnitude of cross-subsidies within hospital systems. They studied how market entry by specialty cardiac hospitals (high-margin services) affects the provision of psychiatric, trauma, and substance abuse care (low-margin services) by general hospitals. They found that general hospitals facing new specialty competition decreased their admissions for unprofitable services and increased their admissions for a profitable service (neurosurgery).

Consistent with cross-subsidization, reductions in the volume of psychiatric, substance abuse, and to a lesser extent trauma care were greatest among the hospital systems most exposed to a potential loss in volume of their cardiac services. Their model estimated reductions of 15% for inpatient psychiatric admissions, 18% for substance abuse admissions, and 5% for trauma admissions.

Their findings indicate that intensified price competition for profitable service lines due to price transparency may have the unintended consequence of reducing the volume of less profitable, though important, services a hospital provides. But perhaps that would not be a bad thing. As pointed out in the study, research from industries such as telecommunications and transportation finds that regulated cross-subsidies are a highly inefficient way to supply unprofitable services (especially considering the alternative of direct subsidies coupled with competition).

As David and colleagues note, their results should make us question whether to continue to rely on hospitals’ assumed ability to cross-subsidize unprofitable, yet social desirable services. It may be that internal cross-subsidization is not an efficient way of reaching social goals, and that setting Medicare and Medicaid reimbursement at a level high enough to preserve access to such services is a better option. The movement toward price transparency may hasten that day of reckoning.

Physician Pay-for-Performance – Learning From the British

This post was originally published for the Health Policy$ense blog of the Leonard Davis Institute of Health Economics.

“How do we close the gap between the care we actually provide and what ought to be provided?” This was the question posed by Dr. Martin Roland to open a recent seminar at Penn. Roland’s research focuses on the implementation of pay-for-performance schemes in the United Kingdom’s National Health System (NHS). He has found that the evidence of impact on quality of care is modest and mixed.

Roland, who is the RAND Professor of Health Services Research and Director of the Cambridge Center for Health Services Research at the University of Cambridge, has studied the United Kingdom’s experience with the Quality Outcomes Framework (QOF). This pay-for-performance scheme, established in 2004, provides financial incentives to general practitioners (GPs) for improvements in clinical care, practice organization and patient experience.

Providing a behind the scenes view of the QOF’s development, Roland explained how the British Medical Association (BMA), representing the physicians, and the British Department of Health (DoH), representing the government and its contracts with individual GPs, negotiated the program for about 15 months. The BMA had demanded that doctors should be paid more, while the DoH asked for something in return for that extra payment. According to Roland, “quality was what the BMA offered to convince the Treasury that doctors weren’t getting something for nothing.”

Did they get the ‘quality’ that was promised? Sort of. In 2014, Roland and colleagues published findings in the British Medical Journal showing that the QOF reduced emergency hospital admission rates by 2.7% in its first year (2004) and 8% by 2010. The study looked only at conditions that were deemed to be “ambulatory care sensitive conditions” meaning those for which improved quality of care by GPs would make a difference. The authors commented that the decrease is “…larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay-for-performance scheme may have had impacts on quality of care beyond the directly incentivised activities.”

The evidence based on clinical quality indicators, however, is harder to find. In a New England Journal of Medicine policy report, Roland commented that: “Clinical care probably improved after the introduction of the QOF, though the effects were not compelling and were difficult to disentangle from other ongoing quality improvement initiatives.” These other initiatives include changes to national guidelines and the introduction of public reporting of quality of care.

In the NEJM report, Roland noted that the QOF has had some unintended consequences, including some evidence that the program has had adverse effects on the quality of care for conditions that were not included in the program. He also discussed the potential for physicians to game the system in order to maximize income by cherry picking healthier or less complex patients, although he notes that these practices have “not been as widespread as administrators feared.”

The unintended consequences were not all negative, though. At the Penn lecture, Roland explained how clinical data, extracted from the electronic records that the QOF required, has been used to create nationwide public reports on quality of care. The program brought electronic health record adoption from 40% to 100%, and as a result, he said, the United Kingdom has an electronic medical system that is “built for recording quality, rather than billing.”

The QOF also resulted in a significant shift in the role of nurses and other staffing structures for GP practices. In the NEJM report, Roland writes: “First, there was an increase in nursing staff, with the management of major chronic diseases such as diabetes increasingly moved out of regular responsemode consultations into nurserun, protocoldriven clinics. Second, there was an increase in administrative staff so that family practitioners could have rapid access to data on their performance.”

The evidence regarding the QOF pay-for-performance program’s ultimate impact on quality of care is mixed, according to Roland. “There is evidence that outcomes improved, but I wouldn’t want to oversell it.” He maintains that there is no magic bullet for quality improvement. “Efforts to improve quality of care with single, short-lived things rarely work. Major improvements are possible if you use multiple and sustained quality improvement strategies.”

For more on physician incentives, and how to make performance measures meaningful, see this Q&A with LDI Senior Fellow Amol Navathe.

The Transportation Barrier: When You Don’t Have a Ride to the Doctor’s Office

This article is cross-posted from my article originally published in The Atlantic in August 2015.

Around midnight on a rainy Saturday two summers ago, a 60-year-old man wandered into the waiting area of the North Carolina hospital where I worked as an emergency-room volunteer. He had just been discharged, he told me, adding that his vision was messed up from medication. He had arrived in an ambulance several hours ago, but didn’t have money for a bus ride home. He lived with his disabled mother, who was unable to drive, and had no family close by.

I pointed him towards the admissions-and-discharge station to see if someone there could help him. He went over to explain his situation to the nurse in charge—but the hospital, she told him, could not pay for his bus or cab fare: “The system just cannot handle that expense for everyone,” she said.

The man grew visibly frustrated. After getting the same answer from a few more members of the hospital staff, he seemed to give up. He paced the waiting room, looking out the windows at the rainy night outside. It wasn’t obvious what condition had brought him to the hospital, but now he was off-balance and staggering. I watched him from my station across the waiting room, concerned that the hospital could do nothing to help him get home.

When my shift ended a few minutes later, the man was still standing near the window, seemingly without a plan. I approached him and asked whether the hospital had figured something out for him. He said they had not.

“Where do you live?” I asked.

He described an area that was about eight miles away, on the other side of town from the hospital but not far from my home.

“I might try to walk,” he said.

A vision-impaired, older man trying to walk eight miles, at night, in the rain—no part of it seemed like a good idea. “Do you want me to give you a ride home?” I asked. “My shift just ended.”

Around 20 minutes later, I pulled up in front of his home, and we shook hands and parted ways. It was lucky, I thought as I drove away, that I was in the right place at the right time. But how often do patients stranded at the hospital experience the same good fortune?

Past research on health care access has examined the ways in which distance can present a problem for people in rural areas, but poorer people in suburban and urban settings, even though they may live closer to a doctor or hospital, can still have trouble with transportation. Some households don’t have a vehicle, or share one among multiple family members. As Gillian White noted in The Atlantic in May, low-income neighborhoods are hit particularly hard by shoddy transportation infrastructure—subways may not service areas on the fringes of a city, buses may be unreliable, and both are vulnerable to strikes or service suspensions. And for those who are disabled, obese, or chronically ill, riding the bus or the subway can be a difficult undertaking.

As a result, some people may find themselves without a way home after an emergency trip to the hospital, or miss a doctor’s appointment simply because they don’t have a way to get there. In a 2001 survey of 413 adults living at or below 125 percent of the federal poverty level in Cleveland, Ohio, published in the journal Health & Social Care in the Community, researchers found that almost one-third of respondents reported that it was “hard” or “very hard” to find transportation to their health care providers—a problem that can mean more than a few missed checkups. A survey of 593 cancer patients in Texas, published in the journal Cancer Practice in 1997, found that in some cases, trouble with transportation led patients to forgo their cancer treatments. The problem was especially prevalent among minority survey respondents; 55 percent of African American and 60 percent of Hispanic survey respondents reported that transportation was a major barrier to treatment, compared to 38 percent of white respondents.

More recently, a 2012 survey of 698 low-income patients in a New York City suburb reported that patients who rode the bus to the doctor’s office were twice as likely to miss appointments as patients who drove cars. And in 2013, a review published in the Journal of Community Health found that around 25 percent of lower-income patients have missed or rescheduled their appointments due to lack of transportation. The patients who reported issues with transportation also missed filling prescriptions more than twice as often as patients without that same problem. “These consequences may lead to poorer management of chronic illness and thus poorer health outcomes,” the study authors wrote.

In some situations, patients without transportation access may wait for a medical emergency just to be able to see a doctor, explained Shreya Kangovi, a professor of medicine at the University of Pennsylvania. “Mr. Jones might have a disability that makes it difficult for him to use public transportation, so he has been waiting until he’s really sick, short of breath, and then calling an ambulance because there is no other good way to get care,” she said.

“If a patient can’t get to see their health-care team, then it’s a domino effect,” said Samina Syed, the lead author of the 2013 study and an endocrinologist in Madison, Wisconsin. “Missed appointments mean that they can’t address their questions and concerns, or update physicians on changes in their health history or life circumstances,” a situation that can be particularly worrisome for patients with diabetes and other chronic diseases that require ongoing active care.

Some health-care providers are trying to lessen the problem by employing community health workers (CHWs), people who help patients navigate the health care system. CHWs, who typically don’t have health-care backgrounds, will coordinate transportation for patients to and from appointments, motivate them to take their medications, and help them implement positive lifestyle habits. In 2014, there were an estimated 50,000 CHWs in the U.S.

A 2003 report on health disparities from the Institute of Medicine praised the CHW model, declaring that it “offer[s] promise … to increase racial and ethnic minorities’ access to health care” and improve their quality of care. Some research has supported this idea: One 2007 study found, for example, that CHWs can help patients better manage their hypertension, and a 2014 study found that patients who worked with CHWs scheduled more primary-care follow-up appointments than those who didn’t.

Some hospitals and physicians also use care coordinators: people who, unlike CHWs, are trained in a health-related field, most often social workers or nurses. These coordinators support groups of low-income or chronically ill patients, helping them to understand their care plans and schedule primary-care visits instead of making trips to the E.R.

Although a significant number of patients, especially those with few resources, struggle to find consistent and reliable transportation, there are some options for those who know how to find them. Each state has a “non-emergency medical transport” benefit for people with Medicaid, covering a certain number of rides per month, and some Medicare Advantage plans also cover a limited number of trips each year (eligibility for this benefit varies by state). Some states contract with local companies to provide rides; others enlist volunteers, or hire taxis. Some private insurers have followed suit, taking similar steps to make transportation more accessible for their clients, though this may involve co-pays or put policyholders through a lengthy bureaucratic process to prove their need for the benefit. In many cases, non-emergency rides must also be requested several days in advance.

In some cases, the restrictions surrounding these transportation programs can prevent patients from taking advantage of them. The patient I encountered in the ER at midnight, for example, did not have the luxury of planning his ride home in advance. No one who undergoes emergency hospitalization has the benefit of foresight for planning how they might leave. And patients who are receiving planned care at the doctor’s office or in an outpatient setting might not be aware of the resources available to them through their public or private insurance plan. Low-income patients—the same group most affected by transportation barriers—are also likelier to lack health literacy, making it harder for them to navigate the web of regulations required to get a ride.

“If you have health-literacy issues and if you don’t have good access to care to begin with, you’re not going to be able to fill out the application and get your provider to fill out their side of it,” Kangovi said. “Barriers like that, which seem small and detailed, end up being insurmountable barriers for patients.”

Often, doctors may not even realize that their patients have problems with transportation, Syed said, since patients can be embarrassed or otherwise hesitant to raise the issue. “There are things patients might not tell you, or that you don’t ask them, and so they just hear from the doctor that you shouldn’t miss your appointments, and they say, ‘Okay,’” she said. “But there is more to it that is beyond their control.”

“You can provide the best care in the world,” she added, “but it doesn’t matter if the patient has no way to get to it.”

King v. Burwell: A Victory for the Affordable Care Act

This blog post was co-authored with Anina Oliver and Alyssa Kennedy for the “Wonk Tank” blog of the Wharton Public Policy Initiative (PPI) at the Wharton School of the University of Pennsylvania.

In late June, the Supreme Court made a 6-3 decision in the King v. Burwell case, which upheld health insurance subsidies provided to low- and middle-income people in the 34 states where the federal government operates the insurance exchanges under the Affordable Care Act (ACA). As previously mentioned in The Health, Education, and Welfare branch’s review of the case in March, the case centered on whether the federal government had the authority to provide subsidies to help low-income Americans buy health insurance. The plaintiffs argued that the law as written did not allow for subsidized insurance in the 34 states – representing 8 million enrollees – where the federal government had set up insurance exchanges. Thus, they contended that the insurance subsidies were only allowed in states that have set up their own insurance exchange by pointing to the clause: “established by the state.”

WHAT WOULD HAPPEN IF THE GOVERNMENT STOPPED OFFERING SUBSIDIES?

RAND researchers found that eliminating tax credits in the 34 states would severely disrupt the overall individual health insurance market. Specifically, eliminating tax credits in all of those states would cause:

“Premiums in the individual market to rise 43%”
“Enrollment in the individual market to fall by 68%; 70% among adults ages 18–34”
“More than 11 million Americans to become uninsured”

[RAND’s findings]

They also found that by eliminating subsidies in federally facilitated insurance exchanges (FFM):

“Premiums in the individual market in FFM states would rise 47%”
“Enrollment in the individual market in FFM states would fall by 70%”
“About 8 million Americans would become uninsured”

[RAND’s findings]

Ultimately these subsidies, in the form of tax credits, allow many Americans to be able to afford health insurance so that the overall individual insurance market is secured from falling into a “death spiral.” Therefore, if these subsidies were eliminated not only would millions of people not be able to afford health insurance, but also the insurance market would have begun to fall into severe financial jeopardy. President Obama and Congress would then have had to scramble to find a quick solution to prevent such a catastrophe.

REVIEW OF THE COURT’S DECISION

In the Opinion of the Court, Chief Justice Roberts first discusses three core reforms of the ACA (insurance regulation in the form of guaranteed issue and community rating requirements, an individual mandate, and tax credits to individuals) and the critical importance that all three are being upheld to maintain the integrity of the Act. King et al. argue that the Act states that an individual may be eligible for a tax credit if he is enrolled in an insurance plan through “an Exchange established by the State”, meaning that subsidies should not be available to individuals who gain insurance through federally run exchanges. The Government rebuts that this phrase should be read to include federal exchanges.

Roberts continues that when judging an agency’s interpretation of a law, the Justices applied the two-step framework utilized in Chevron U.S.A., Inc. v. NRDC. First, they examine whether the statute is ambiguous; then, they determine if the agency’s interpretation of the statute is reasonable. But, Roberts quotes from FDA v. Brown & Williamson Tobacco Corp, “In extraordinary cases, however, there may be reason to hesitate before concluding that Congress has intended such an implicit delegation.”And Roberts states that King v. Burwell is such a case. Tax credits are a core reform of the ACA, involve billions of dollars, and affect the price of health insurance for millions of people. He states that had Congress intended to delegate the role of determining whether or not users of federal exchanges can qualify for tax credit to an agency, they would have expressly named one. Thus, it follows that the Supreme Court must determine the true intent of the law.

Section 36B of the Internal Revenue Code concerns refundable credit for coverage under a qualified health plan. It allows an individual to receive tax credits to buy an insurance plan exclusively if the individuals enrolls in a plan through “an Exchange established by the State under [42 U.S.C. Section 18031].” Thus, he outlines that three things must be true: first, that the individual must enroll in an insurance plan through an exchange; second, that the exchange must be established by the State; and third, that exchange must be established under [42 U.S.C. Section 18031]. The controversy is surrounding the second requirement, which Roberts posits is not clear when read in the context of the overall Act. Roberts points out two examples in which the Act, if it indeed meant to refer only to an exchange established by the state as a state exchange and not including federal exchanges, would not make sense. Section 18032 defines those who are eligible for health plans through the exchange as “qualified individuals” who “reside in the State that established the Exchange.” If the wording were taken at face value, there would be no qualified individuals on the Federal Exchanges, though, Roberts states, “the Act clearly contemplates that there will be qualified individuals on every Exchange.” Additionally, the Act states that the health plans the exchanges offer should consider “the interests of qualified individuals … in the State or States in which such Exchange operates,” which would be similarly exclusionary of individuals using the federal exchange; Thus, Roberts concludes, “[t]hese provisions suggest that the Act may not always use the phrase ‘established by that State’ in its most natural sense. Thus, the meaning of that phrase may not be as clear as it appears when read out of context.”

Roberts also states that in Section 18041, which that allows the Secretary of Health and Human Services to create “such [an] Exchange” in a state if the state does not create one. This, he says, indicates that state and federal exchangers should be the same. But if only state exchanges benefitted from tax credits, they would be fundamentally different Roberts concludes the Opinion of the Court by asserting that Section 36B is not only ambiguous, and that when considered correctly in the context of the laws, intends that tax credits be able on federal exchanges as well.

Justice Scalia wrote the dissent; in a summary both of this case and the strong tone he uses throughout the dissent, he writes, “the Court’s interpretation clashes with a statutory definition, renders words inoperative in at least seven separate provisions of the Act, overlooks the contrast between provisions that say ‘Exchange’ and those that say ‘Exchange established by the State,’ gives the same phrase one meaning for purposes of tax credits but an entirely different meaning for other purposes, and (let us not forget) contradicts the ordinary meaning of the words Congress used.” Specifically, he disagrees with a number of key points of Roberts’ opinion.

Scalia asserts that federal exchanges established in states that do not form their own can operate without tax credits; unlike Roberts, who states that all three of the main reforms of the ACA must all be upheld in order to increase the number of insured individuals, Scalia posits that guaranteed issue and community rating requirements, and the individual mandate are sufficient. Continuing his spirited criticism of the Opinion of the Court, he states that the phrase “Exchange established by the State” appears seven times of the Act that mentions tax credits, and that it is unlikely that Congress would have mistakenly left out any reference to federal exchange each of the those many times. He states that the Court should have only interpreted the law as written by Congress as opposed to “interpreting” it, and memorably asserts that the Court has effectively rewritten the law to “uphold and assist its favorite” to the extent that it should instead be called “SCOTUScare”.

THE FUTURE OF HEALTHCARE REFORM

The King decision affirmed that the ACA is and will continue to be key legislation responsible for advancing and improving the U.S. healthcare system. It even solidified the notion that, as President Obama said, “The Affordable Care Act is here to stay.” Yet, as the U.S. continues forward with the ACA, it is important to realize that the Act is not infallible and there are still important areas of the law and its implementation that need to be changed and revised.

Observers noted that several of the 14 states that established their own exchanges might decide to switch over to the federal exchange. These pioneer states that embraced the law, and its core concept of the transparent insurance exchange, will soon face difficulties in maintaining their exchange websites due to technological complexity and dried up federal and state funding. Now that the potential risk of losing tax credit subsidies for purchasing coverage through the Healthcare.gov exchange has been averted, it might not be as difficult for states like Vermont and Hawaii to make the change from a state-based exchange to a federal one – in essence, outsourcing. Margot Sanger-Katz wrote in the New York Times last month that, “If the court had ruled for the health law’s challengers, we would have seen more states adopting the state-based model to preserve subsidies for their residents. Now that the government has won, movement is likely to be in the other direction.” However, it remains an open question whether switching from a specialized state exchange to a more generic federal one will be so simple.

The ruling has also brought to the fore another decision facing some states: whether or not to expand Medicaid eligibility using federal funding. 19 states, most of which are under Republican leadership, have not moved forwardwith expansion. However, the tide is starting to turn as the ACA gains strength in measurements of both judicial and public opinion. Last month President Obama traveled to Tennessee, a state where, like in many others, hospitals and insurers want Medicaid expansion while the conservative-leaning state legislature and governor are against expansion. The reasons for opposition are a combination of blanket political resistance to the ACA, concerns over long-term budget sustainability, and concerns of diminished state-based autonomy regarding how to provide healthcare for low-income populations.

Even patients who have private insurance will begin to feel the pinch: most insurance companies are requesting double-digit increases in 2016 for individual plans, including those purchased through exchanges, due to higher-than-estimated claims from enrollees under the Affordable Care Act. While supporters of the law applaud the fact that people are making use of their new access to long-needed care, insurance companies will have to make upward premium adjustments that affect all beneficiaries. These premium increases will not help the President’s case as he strives to secure the healthcare cost-reduction legacy of the Affordable Care Act.

These issues with the ACA are important to address as the U.S. continues implementing provisions of the Act and working on reforming our healthcare system for the future. And despite the ACA’s success and future changes, it will continue to face legal challenges and calls for repeal by many of its challengers; it will also continue to be a much discussed and debated piece of legislation in the upcoming 2016 presidential race.

Major Reforms Proposed for Medicaid Program: How Are Patients Impacted?

This blog post was co-authored with Taja Towne for the “Wonk Tank” blog of the Wharton Public Policy Initiative (PPI) at the Wharton School of the University of Pennsylvania.

Last month, the Centers for Medicare and Medicaid Services (CMS) issued long-awaited proposed rules for Medicaid managed care organizations – private insurance companies that receive a set amount to money from state agencies to care for entire Medicaid populations. The proposed rules, which govern a program that has expanded significantly over the past decade to include about 46 million beneficiaries and 73 percent of the total Medicaid population, have not been updated since 2003. The 39 states that contract with managed care plans for their Medicaid populations are expected to resist the new rules, which some observers say will reduce autonomy on the part of states to determine how to run their Medicaid programs.

The more than 600-page document, currently open for public comment on the federal register, proposes the following rules, among others:

Sets a required medical loss ratio (MLR) for plans at 85 percent. MLR is the percentage of a health plan’s revenue that is spent on actual medical care instead of administrative expenses and profits;
Requires plans to be transparent about which health providers and services are covered, ensuring that consumers understand their “network adequacy” and have options within a certain distance from their zip code before enrolling;
Requires states to provide more accurate figures regarding payments to health plans to ensure that plans are not being overpaid or underpaid in capitated (per-patient budget instead of traditional fee-for-service) arrangements;
Allows Medicaid beneficiaries in managed long-term care to switch to fee-for-service plans without extra expense if their long-term care provider is out-of-network.

The motivation for these changes, according to CMS administrator Andy Slavitt, is to bring Medicaid managed care plans in line with reforms that have been implemented, and proven tenable, across other parts of the health insurance industry. CMS found that while medical loss ratios of Medicaid managed care plans are on average higher than the 85 percent minimum, one in four were below 83 percent and one in 10 were below 79 percent.

Medicaid managed care, which primarily includes seniors and persons with disabilities who tend to require more long-term treatment and care, is a costly system. Enrollment in managed care has increased dramatically over the last few years and the non-partisan Congressional Budget Office (CBO) estimates that Medicaid’s yearly spending which is currently at $60 billion,will exceed $100 billion a year by 2023.

While seniors and those with disabilities are the populations that will be most impacted by these proposed rules, other patients with Medicaid will benefit as well. Currently, Medicaid programs have time/distance rules where primary care providers must be available to those enrolled within a certain time or distance. The proposed Medicaid rules would seek to expand this requirement to OB/GYN, behavioral health and dental care. This would mean that Medicaid members would have greater access to services that might have been out of reach before.

These proposed rules seek to provide more uniformity in regulations across states and increase accountability. Nationwide it was found that nearly 40% of Medicaid/Medicare certified nursing homes only receive a 1 or 2 star rating out of 5 on the CMS scale. Advocates of these changes believe that best practices should not vary from state to state. CMS’ Slavitt said in a statement, “this proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”

Not surprisingly, the proposed regulations are being met with strong resistance from Medicaid managed care organizations. Jeff Myers, President and CEO of the Medicaid Health Plans of America (MHPA), says that the rules diminish state decision-making and autonomy. “States, because of the nature of providing care for their individual citizens, may choose to have some things included in the MLR and some things not included. The way in which you manage case management or other ancillary services varies state to state.”

Those different methods, as Myers and his counterpart at America’s Health Insurance Plans (AHIP) have stated, include administrative expenses that provide personal care management services to keep patients healthy and avoid expensive hospital visits. If plans are compelled to keep non-medical expenses under 15 percent of revenue, it could compromise these services in addition to the targeted overhead expenses and profit.

“An arbitrary cap on health plans’ administrative costs could undermine many of the critical services – beyond medical care – that make a difference in improving health outcomes for beneficiaries, such as transportation to and from appointments, social services, and more,” said Dan Durham, the interim CEO of AHIP.

Recent analysis from commentators has indicated that the new rules should not be a significant challenge for insurers. Joseph Marinucci, a credit analyst at Standard & Poor’s, told Modern Healthcare that “it’s not much of a stretch” because most plans already reach an 85% MLR. From Josh Raskin, a senior analyst at Barclays Capital: “With respect to these regulations, we believe that the passage and lack of any material negative surprises should serve as a clearing event for the space.”

With these proposed rules, CMS is attempting to bring the Medicaid managed care industry into line with existing rules across the industry. While the impacted stakeholders are pushing back, observers do not think the rules will dramatically alter the Medicaid managed care landscape from a business standpoint.

It will be critical, however, to watch how the proposed rules evolve into a final rule based on comments submitted in the next two months. Josh Gorman, founder of a health consulting firm, told Bloomberg that “this is literally the biggest healthcare regulation in a dozen years.”

And while the battle over details is fought mostly between federal regulators and the industry, the growing number of Medicaid beneficiaries who rely on managed care coverage ought to be represented in the process as well.

Improving Diabetes Care in the United States (My Senior Thesis)

In 2009 it was reported that the United States led all OECD countries with its high rates of lower-limb amputations and acute hospitalizations related to diabetes. 2011 data show that we exceed the OECD average, age-standardized diabetes prevalence by nearly 40 percent and have the sixth highest prevalence in the 31-member group. The CDC reports that one in every three U.S. adults might have Type 1 or Type 2 diabetes by 2050. Although there are signs of encouraging progress, more should be done to improve financial and material access to care — and the process, quality and outcomes of that care — for patients who have diabetes or are at risk of developing the condition in the future.

Last summer, supported by a generous grant from Penn’s Center for Undergraduate Research and Fellowships (CURF), I toured Australia for three weeks to learn about its approach to diabetes care. Through in-depth conversations — with general practitioners, endocrinologists, nurses, diabetes educators, public health officials, hospital administrators, and policy researchers — I learned about programs and structures that might be adapted and implemented into the United States’ healthcare system, despite the surface concerns of demographic and cultural differences.

Here is a rundown of the major programs that support Australians with diabetes: the National Diabetes Services Scheme (NDSS) provides informational support and subsidized equipment for self-managed glucose testing and insulin therapy; the Pharmaceutical Benefits Scheme (PBS) provides subsidized diabetes medications with low co-payments; the Medicare Benefits Schedule (MBS), which covers Australians of all ages, provides five visits each year to allied healthcare professionals such as dieticians and diabetes educators; the Practice Incentives Program (PIP) provides general practitioners with bonuses for completing annual cycles of diabetes care for their patients.

I believe that this suite of services, to which all Australians with diabetes have access, can be provided at a subsidized or free price to all Americans with diabetes. Access to high-quality information and support groups, self-management equipment, medications, the advice of diabetes educators and podiatrists, and physician incentives to complete evidence-based care processes: these aligned systems, working for all patients with diabetes, might have a significant impact on patient health and reduce the nation’s healthcare cost burden.

This program would at least be an improvement on our current state: low-income and under-insured patients unable to afford medications and self-management equipment; complex rules that discourage access to useful allied health support services; and patients who are unable to manage their conditions until devastating complications land them in the hospital.

Over the next seven months I will research and write a senior thesis that examines the costs, obstacles and implementation strategies for this potential program. Although I am primarily looking at the potential program’s economic and health impact, I will incorporate knowledge about the role of behavior and environment on chronic disease, as well as the different experiences of patients with diabetes across cultural groups.

Even if the proposed program turns out to be too expensive and the potential health impact unclear, I think that this inquiry will be a useful learning experience and look forward to starting the journey. Feel free to reach out with comments and suggestions!

What Now? Replacing Medicare’s Failed Sustainable Growth Rate

This blog post was co-authored with Anina Oliver for the “Wonk Tank” blog of the Wharton Public Policy Initiative (PPI) at the Wharton School of the University of Pennsylvania.

The worlds of Washington and health policy were abuzz last month as House leaders from both parties announced a permanent solution to Medicare’s “sustainable growth rate” formula that has been a legislative thorn for almost two decades.

The formula, introduced in 1997, limits increases in the amount that Medicare pays physicians. Each year, when healthcare cost growth has exceeded this growth target, Congress has passed a short-term measure called a “doc fix” to avoid making the stipulated cuts. While these temporary fixes have been funded by cuts elsewhere and by anticipated healthcare savings down the road, saving about $165 billion over time, many observers have called for a permanent repeal and substantive solution.

Last month, the House passed the legislation – “SGR Repeal and Medicare Provider Payment Modernization Act of 2015” which includes repeal in addition to cost-saving strategies. It was introduced by Rep. Michael Burgess, MD (R-Texas) and has 20 co-sponsorships, including 14 Republicans and six Democrats, and the public support of Speaker Boehner and Minority Leader Pelosi. The bill is an attempt to replace the faulty SGR formula and shift Medicare spending from a volume-based to value-based system by rewarding high quality care and not the sheer number of procedures performed. The bill is part of a larger package that includes two years of extended Children’s Health Insurance Program (CHIP) funding.

As always, paying for the bill was an issue. Senate Republicans in particular had reservations about the bill’s costs: its ten year cost is estimated at $200 billion. However, these numbers may be largely offset by not having to pay for future SGR patches—on which Congress spent $170 billion over the last twelve years—potentially bringing the cost down to $60-70 billion. [1]

The Senate reconvened this week and passed the bill within 48 hours; without the repeal of the SGR, physicians with patients, who are program beneficiaries, would have sustained pay cuts of 21%. Nominally, these cuts already went into effect on April 1st, but the Centers for Medicare and Medicaid Services (CMS) stated that they would not process payments until April 15th.

Many Republicans did not want to add more to the deficit with a bill that is not fully financed, while several Democrats, including all twelve on the Senate Finance Committee, had expressed discontent that CHIP funding is only guaranteed extension through fiscal year 2017 and would prefer extension through 2019. The impending deadline and the overwhelming desire to repeal the SGR pushed Senators displeased with several of the bill’s stipulations toward supporting it.

The payment-focused strategies have received the most media attention, as they are the direct successors to the SGR formula. These cost-saving measures include the following: rates paid to physicians will grow by 0.5 percent through 2019, freeze between 2020-2025, and grow by 0.5 percent or 1 percent (depending on whether a provider is in Advanced Payment Model programs) beyond. Other savings will come from higher premium payments from wealthier Medicare beneficiaries, higher out-of-pocket payment from Medigap beneficiaries (people who get supplemental coverage for services not include in their Medicare plans), and more limited payment increases to nursing homes and hospice and home care agencies.

There are also several delivery system-focused strategies that also have important cost-saving implications. These measures provide funding for chronic care management, more transparency on physician cost and service data, expanded availability of claims data, and measures to reduce administrative burdens faced by providers.

The chronic care management provision, effective from January 1st of this year, allows payment of $40.39 per member per month to physicians, physician assistants, nurse practitioners and midwives who provide at least 20 minutes of non-face-to-face care management activities for a patient with multiple chronic diseases. An analysis showed that a family practitioner can earn more than $200,000 in annual gross revenue from this program alone.[2] There is an unanswered question, though: will the value of these several minutes of chronic care management make a significant impact on downstream costs per patient and drive lower Medicare spending?

The provider transparency provision, beginning this year, makes available information about payments made to physicians in the Medicare program, as well as the kind and frequency of services each unique physician offers. TheMedicare Physician Compare website is currently limited to basic information about each provider, but there is a plan to add service, cost and quality information “as soon as technically feasible.” This information is intended to make it easier for beneficiaries to select providers appropriate for their needs.

The expanded data availability provision, beginning in July 2016, allows qualified entities to analyze combined (both claims and non-claims) Medicare datasets to help private healthcare providers and physicians improve their quality of care, better understand their populations, and develop new models of care. The data must be provided free of charge and will be subject to privacy protections, but the provision represents a relaxation of previous constraints.

The provision to reduce administrative burden emphasizes EHR interoperability and telehealth. The bill sets a goal to achieve “widespread exchange of health information through interoperable certified EHR technology nationwide” by the end of 2018 and proposes creating a website that helps providers choose the best systems for their practice. The bill also encourages research on telehealth and remote patient monitoring services, where devices are used to gather information and ask questions, the data from which can be interpreted by a healthcare professional.

In the context of the long history of failed sustainable growth rate fixes, as well as the future trillions of dollars in unfunded liabilities for the Medicare program, there is uncertainty for the future. The issue now facing legislators and policymakers is this: how do we make up for the savings that the SGR was supposed to create now that it might be repealed?

CITATIONS:

1. Joyce Frieden, “Negotiations Heat Up on Permanent SGR Fix,” MedPage Today, March 17, 2015. http://www.medpagetoday.com/PublicHealthPolicy/Medicare/50515.

2. Jon Reid, “Political Pressure Could Stifle Amendments to SGR Repeal,”Morning Consult, April 3, 2015.http://morningconsult.com/2015/04/political-pressure-could-stifle-amendments-to-sgr-repeal/.

Do Integrated Delivery Systems Deliver on Cost and Quality?

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

A new study by LDI Senior Fellow Lawton Burns and colleagues challenges the conventional wisdom about the societal benefits and comparative advantages of integrated delivery networks (IDNs). A literature review and detailed analysis of financial and quality indicators found “scant evidence” of improved quality, lower cost per case, or greater societal benefit.

Last month, Burns, James Joo-Jin Kim Professor of Health Care Management at Wharton, presented these findings at a joint Federal Trade Commission (FTC) and Department of Justice (DOJ) workshop on health care competition. From the study’s abstract:

Looking at the benefits to society, the authors found that there is evidence that IDNs have raised physician costs, hospital prices and per capita medical care spending; looking at the benefits to the providers, the evidence also showed that greater investments in IDN development are associated with lower operating margins and return on capital. As part of this report, the authors conducted a new analysis of 15 of the largest IDNs in the country. While data on hospital performance at the IDN level are scant, the authors found no relationship between the degree of hospital market concentration and IDN operating profits, between the size of the IDN’s bed complement or its net collected revenues and operating profits, no difference in clinical quality or safety scores between the IDN’s flagship hospital and its major in-market competitor, higher costs of care in the IDN’s flagship hospital versus its in-market competitor, and higher costs of care when more of the flagship hospital’s revenues were at risk.

The study, commissioned by the National Academy of Social Insurance, defined IDNs as vertically integrated health services networks that include physicians, hospitals, post-acute services and/or health plans, or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums). Prominent examples include Geisinger and Henry Ford Health Systems.

Why have IDNs enjoyed a “halo effect” of perceived higher quality and efficiency from their IDN status? One reason is their “revenue at risk” payment mechanisms through capitated arrangements, health plan revenue or two-sided ACO models. Conventional wisdom suggests that these risk arrangements create incentives to deliver higher value care. However, Burns and colleagues found no relationship between revenue at risk and the costs of care.

Comparing an IDN flagship hospital and its main in-market competitor on Medicare spending in last 2 years of life, the study found:

The IDN flagship hospital with no revenue at risk was 6.8% less expensive than its in-market competitor
The IDN flagship hospital with some revenue at risk was 20% more expensive than its in-market competitor
No apparent cost of care advantage conferred on IDN hospitals that operate their own health plan
No meaningful differences in readmissions, infection rates, complication rates between the IDN flagship hospital and its in-market competitor
No meaningful differences in patient satisfaction scores or Leapfrog Group hospital safety ratings between IDN flagship hospital and its in-market competitor

The authors note the difficulty in obtaining transparent information about IDN financing and resource allocation, and recommend more detailed and routine disclosure of financial and structural practices, as well as a comprehensive, national all-payer claims database to compare rates paid to different kinds of providers for the same services.

Other authors of the report include Jeff Goldsmith, Wharton doctoral candidate Aditi Sen, and Trevor Goldmith. See the authors’ commentary in Modern Healthcare here.

The Role of “Agent-Navigators” in ACA Marketplaces

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

As the February 15 deadline for open enrollment on the ACA marketplaces approaches, surveys tells us that many uninsured people remain unaware or misinformed about whether they qualify for subsidies to help purchase health insurance. Prior to the ACA, many people looked to agents and brokers to understand their options and to help them find an individual plan.

But agents and brokers face obstacles in fully engaging in the marketplaces, as an RWJF/Urban Institute Issue Brief concluded from interviews with insurance professionals after the first open enrollment period. They reported obstacles such as IT issues, poor training, inadequate customer support, and difficulty being paid from state marketplaces. Further, the authors noted, agents and brokers tend to have minimal experience working with a low-income population, and may lack relationships with communities with historically low levels of insurance.

Lafayette Jones and Sandra Miller Jones don’t fit that bill. Using their experience marketing products to African American communities, they have embraced their role in connecting people to insurance through the federal marketplace. In partnership with other licensed agent-navigators, their organization has helped more than 3,000 people and families across North Carolina find health insurance. The following is an edited transcript of our conversation with them.

LDI: How did you decide to become involved in health insurance enrollment and what skills do you bring to the table?

We were already, over the last decade, working with a number of insurance companies and AARP. As a result of our relationship with AARP (and collaborating partners Aetna and Magic Johnson Enterprises), we were doing health fairs in Washington, D.C., New York, Atlanta and other markets targeting African Americans. We designed programs around Medicare enrollment and developed a specialized toolkit that was distributed through churches, barber shops, community centers by “feet on the streets” ambassadors.

When the ACA came along, we began to look at it and wonder how we could be of value. We decided to get familiar with it and we went to [a large insurance company]. Their president asked us to develop a multicultural marketing program, in particular targeting African Americans in North Carolina. Now we provide access to products sold by multiple insurance carriers.

How do your clients find you and access your services?

We fish where the big fish are. We know that we can target certain zip codes, we know that we can find our target audience at churches, at beauty salons, at barber shops and community centers. We understand the culture and how to navigate the culture. We have flyers, posters, print and digital ads, we use gospel radio and all kinds of other tools to reach the target group of people.

There are about 28,000 zip codes in the U.S. You can find 80 percent of African Americans in 2,000 or 3,000 of those zip codes, so a small number of zip codes allow you to be in touch with a high number of African Americans and Latinos.

What is the demographic breakdown of your clients in terms of age, race and gender?

I would estimate that 90% of our clientele is African American. We also work with about 10% Hispanics and Whites. The age groups range from 21 to 64 years old and they are skewed toward that middle range of 35 to 55.

Because we are in the south and there is a significant minority population in rural counties, we have been involved with rural African Americans just as much as urban. There is a significant number of underserved Whites and Latinos on the fringe of African American communities – in continuous neighborhoods nearby – and they often walk into our enrollment centers.

What sort of training process was involved with becoming an insurance agent?

When we became licensed insurance agents in the state of North Carolina, there were lots of product-specific training programs about each of the carriers – Blue Cross Blue Shield, Aetna, Coventry, United Health and others. It was a lot of studying individual company programs, state licensing, and federal government programs.

What is the different between a licensed agent-navigator and the navigators we usually hear about in connection to ACA enrollment?

The federal government has a significant number of navigators on the street. Navigators are valuable for one specific job in one specific period. Navigators are good at finding and helping people to get enrolled, but our experience is that enrollment is just part of the process. For us, enrollment has meant everything from finding the people, making them aware of the benefits and downsides, and also helping them through to finding the right doctor when they enroll.

We have adopted the term agent-navigator because an agent-navigator can do more for the beneficiary and insurer group. Agent-navigators can provide people with professional counseling about plans on a year-round basis instead of just during open enrollment.

Are there enough navigators and agents in the field to meet the new demand?

We know that there is a dearth of African American and Latino insurance agents. There need to be more people in the field like us. We have gone from a small group of five when we started to almost fifty of us now. It’s a conglomeration, a collaboration, an association. A good portion of them don’t actually work for us. We got them because we said, “there are so many people trying to sign up. We need help!”

We don’t have any state grants or federal grants, and it’s certainly a labor of love, but we are also businesspeople. We have to find corporations to support it. When you look at insurance carriers and providers like hospitals, they are just becoming awake to how to serve this population. They know how to serve this population from a professional, medical point of view, but they just don’t have the tools we do and there are very few organizations around like ours.

Could you go more in depth about how you help people post-enrollment?

Many people have been to the emergency room but not to the doctor, and they don’t know the process or expectations when they have their own primary care physicians. There are people who are enrolled who don’t know what step three and four is. Once you get enrolled, you have a doctor – go see your doctor! You can’t sit there and let them tell you what to do. You have to have some dialogue and tell them what needs you have. Many people have not had insurance before and are used to going directly to the emergency rooms.

One young man who we coached didn’t pay his premium one month because he wasn’t sick. What that meant to us was that he didn’t understand what insurance was. We coached him to understand that you need to pay insurance every month because you get benefits every month, whether or not you use them.

For people who miss the income cutoff and live in states that did not choose to expand Medicaid, those people are absolutely lost because there is nothing for them. Some of their children are in children’s health insurance programs and Medicaid, but there is no funding for the parents. If the parents don’t have any insurance, and they haven’t had any insurance before, they don’t expect to get insurance and use it.

What other perceptions or understandings health insurance are out there that you have discovered through your work?

There are many people who are confused about what’s going on. They’re trapped between the Republicans’ and the Democrats’ constant fighting: “You should have health insurance” and “No, you should not have health insurance.” These people don’t know what to think. Their decision is often driven by political forces that have nothing to do with their health care.

We have another group of what we call “absolute converts.” These are the people who have heard about insurance and the Affordable Care Act. They want to know about it, but it’s kind of like when the ATMs came out in the world. Everyone looked at it and wondered what it was. And we weren’t quite sure if we were going to put our money in it, but you would press a button and money would come out. Well, ATMs are commonplace now and everyone uses them. Such is the same with health insurance and enrolling for health insurance.

There is also a group of people who have been told through videos and radio that, “all you have to do is just go to your laptop or computer and sign up. It’s like booking a ticket.” Well, maybe it’s like booking a ticket for those who fly. But for those who have never been on a plane, or don’t have a laptop or access to a computer, it is very new to them. We have talked to a number of our clients, many of whom are sophisticated people, who have gone online and been absolutely thrown.

What is your perspective on the technical and administrative problems during the first period of open enrollment last year?

The system has gotten better – no doubt about it. What we had last year and this year is vastly improved. The process of purchasing affordable health insurance is continuing to improve… because the geeks are here now! We are finding ways to create shortcuts where we can knock out some of the barriers to sign-ups.

The insurance companies – Aetna, Coventry, United Healthcare, Blue Cross Blue Shield – are benefitting too because they have never had such a huge number of people sign up. Can you imagine six to seven million people signing up for health insurance in a ninety day period with 14,000 points of data on each person? There are just so many systems that actually melted down. Even the federal government system melted down where they couldn’t take phone calls – on top of the original problems with the original website. So you had slowdowns and breakdowns with sign-ups.

Another problem that they had is that a large portion of the population is unbankable, where they don’t have a credit card or debit card. All they know is cash or postal money orders. The big boys didn’t know that. These are not PayPal people – they don’t know what PayPal is. They are flying below the radar, unbanked.

Then you have a group of people who want to get in on the deal but they can’t because they haven’t filed their taxes. They have never filed their taxes. Some of them are now beginning to file their taxes because they see the benefit of it. For the first time there is a program where if you have an income between x and y, you can actually get a really great benefit.

There are people that we have signed up with five or six children and we’ll get them a $1500/month subsidy for the husband and wife (the children are usually all on Medicaid and CHIP) to take care of their family’s insurance needs. It’s a really good thing. Their out-of-pocket is $5, $25, $50. It’s very minimal – or what we call minimal. A $5 payment per month for many of our clients is still a hardship.

What has improved this year with the ACA rollout and what still needs work?

First of all, the website works. That’s a big deal. In the Healthcare.gov call centers, the people are actually really good. I’ve talked to hundreds of them. The quality varies, but nine out of ten times they’re good. They’re friendly, they’re courteous, they want to help people. What the administration has done on the front end has worked.

Their marketing is weak. There are millions of people who they aren’t touching because they are underutilizing tools – and I don’t mean just navigators. They are spending a ton of money with navigators, which is fine, but there are other things they can do to develop a comprehensive program. When you are in this battle to spread the word, you need seasoned marketers with experience in this category. There is a group of people like us who can be an enormous help to the federal and state governments.

What client stories can you share that are particularly memorable?

I spoke to a woman yesterday. We’d been trying to get the daughter, who is 19, on her mother’s policy for three months. We have been working on this since day one but could not get through the administrative hurdles until now. We helped her do that and she was so pleased that her daughter would have health insurance too.

Another story comes to mind. A husband and wife came to Goodwill and sat down. She said that she was there to get insurance. He had his mouth stuck out and said that he didn’t want any of that Obamacare. She said to him, “Tell you what, buddy. We’re not going to have any more children here because I’m just not going to go through that process unless we have insurance and get comfortable. So we can sit here and get enrolled, or… guess what!”

What keeps you going in this work?

I’m getting ready to turn 71 and I’m working on this because I love it. I love going out into the field, talking with folks and feeling the joy. We’ve recently moved our offices to a black church with a brand new family enrichment center. Health is where it is. It’s the future.