BEYOND THE WEBSITE A STUDY OF THE EARLY IMPLEMENTATION OF THE AFFORDABLE CARE ACT IN PENNSYLVANIA FEBRUARY 2014 A STUDY OF THE EARLY IMPLEMENTATION OF BEYOND THE WEBSITE THE AFFORDABLE CARE ACT IN PENNSYLVANIA ACKNOWLEDGEMENTS In December 2013, all twenty-nine members of the Fels Institute of Government Master of Public Administration (MPA) Class of 2015 worked together to produce the first version of this report. Focusing on their university’s home state of Pennsylvania, they studied the early implementation of “health exchanges” and other key provisions of the Patient Protection and Affordable Care Act of 2010, better known as “the ACA” or “Obamacare.” They did so as the capstone research and writing exercise for their MPA core curriculum’s first-year, first-semester Public Management (GAFL 732) course. Under the supervision of the course co-instructors, Professor John J. DiIulio, Jr., Mr. Joseph P. Tierney, and Mr. Marc Siegel, they divided into six “task groups,” each of which probed a particular ACA implementation challenge. And a seventh “task group,” composed of representatives from each of the other six, led the class in drafting the report. Even though the course had ended (and all grades were final!), during January 2014, MPA candidates Morgan Jones, Kathryn McCarthy, and Chase Staub, working with Mr. Tierney and Ms. Lauren Cristella, Director of Fels Marketing and Strategic Initiatives, revised the report in consultation with other Fels MPA candidates. The Fels faculty, staff, and students are grateful to Dr. Richard P. Nathan of the Rockefeller Institute, and Prof. Michael Rich of Emory University, for their advice and counsel on the research. At the end of January 2014, the entire class met to discuss the present version of the report and to plan further revisions for later in the spring semester. A third and final version of the report, updated to reflect certain post-January 2014 facts and findings, will be released in May 2014. The release will coincide with a national conference at Penn sponsored by Fels, “Making the ACA Work: The View from the States.” That conference will bring i BEYOND THE WEBSITE together Dr. Nathan, Professor Rich, and other ACA implementation researchers, health care policy experts, and other leaders from more than two dozen states all across the country. The co-authors of the present report are as follows: Chapter 1, Quality and Affordability of Insurance Plans Available in Pennsylvania • Enrique Aguilar, Yakup Akkaya, Dan Bernick, Dylan Hewitt, Morgan Jones, Khun Laphai, Kathryn McCarthy, Mary Kate Miller, Lucas Stellar, and Ruoyun Wang. Chapter 2, Navigational Assistance • Akeem Anderson, Ethan Conner- Ross, Sabrina Maynard, and Vasantha Pratha. Chapter 3, Education and Consumer Research • Lucas Da Silva, Liam Dougherty, Zahava Stadler, Amy Verbofsky, and Dylan Wulderk. Chapter 4, The On-Line Enrollment Process • Grace Chung, Han Jung, Ike Onyeador, Vera Partem, and Maria Wahlstrom. Chapter 5, SHOP Exchanges • Ben Block, Phyl Khalil, Sara Marie, Chase Staub, and Mikecia Witherspoon. ii A STUDY OF THE EARLY IMPLEMENTATION OF BEYOND THE WEBSITE THE AFFORDABLE CARE ACT IN PENNSYLVANIA CONTENTS Acknowledgements ........................................................ i Foreword . ix Chapter 1: Quality and Affordability of Insurance Plans Available in Pennsylvania ...................................................1 I. Demographics and Geography ...........................................1 A. Demographic Foci ..................................................1 B. Income Specifications ...............................................2 C. Geographic Foci ....................................................3 II. General Overview of Spotlight Counties ...................................4 III. Affordability ...........................................................9 A. Methodology .......................................................9 B. Taxonomy ........................................................10 C. Navigating Affordability .............................................11 D. Shopping and Comparing Plans Using Premiums ......................12 E. How do I Know What my Premium Subsidy and Out-of-Pocket Subsidy Will Be? ......................................13 F. Making Sense of Metals and Metals ..................................14 G. Medicaid .........................................................21 IV. Quality ...............................................................23 A. Methodology ......................................................23 B. Challenges and Limitations .........................................25 C. Observations and Findings ..........................................25 iii BEYOND THE WEBSITE Chapter 2: Navigational Assistance in Pennsylvania ..........................27 I. What Types of Assistance Are Available in Pennsylvania? ..................27 A. Navigators ........................................................29 B. Certified Assistance Counselors (CAC) ...............................32 C. Agents and Brokers ................................................33 D. Federal Oversight ..................................................34 II. Who is Offering In-Person Navigational Assistance in Pennsylvania?. 36 A. Searching HealthCare.gov ..........................................36 B. Distribution of Navigators/CACs .....................................38 C. Interviews with Navigators/CACs ....................................43 III. What Role Does Technology Play? .......................................47 A. Online Assistance .................................................47 B. Additional Enrollment Options ..................................... 49 IV. Recommendations ....................................................51 Chapter 3: ACA Education and Outreach in Pennsylvania. .55 I. Education and Outreach by Government Organizations ....................55 A. State Government .................................................55 B. Local Government .................................................57 II. Education and Outreach by Service Organizations ........................59 A. Case Study: Non-English Service Organizations ...................... 60 B. Case Study: LGBT Organizations ................................... 60 C. Case Study: General Healthcare Advocacy ............................61 D. Case Study: Central Pennsylvania/ Drug and Alcohol Abuse. 63 iv BEYOND THE WEBSITE E. Case Study: Labor Unions ......................................... 64 III. Education and Outreach by Healthcare-Related Companies and Institutions. 65 A. Community Health Centers ........................................ 65 B. Hospitals .........................................................67 C. Pharmacies .......................................................71 D. Health Insurance Companies ........................................74 IV. Local Media Coverage of ACA Implementation ............................77 A. Newspaper Coverage ..............................................77 B. Television News Coverage ..........................................81 C. Radio News Coverage ............................................. 84 Chapter 4: The On-Line Enrollment Process ................................ 85 I. Assessment of the Enrollment Experience ............................... 85 A. The On-Line Enrollment Process Data (October – November 2013) ...... 86 B. Federal Data, State Data and Analysis ............................... 98 II. The Ideal Website & Feasibility .........................................104 A. Appearance - What Should a User-Friendly, Fully-Functioning On-Line Enrollment Process Look Like? .............104 B. Functionality - What Functionality Should the Site Offer? ..............108 C. Confidentiality - How Would You Assure Confidentiality? .............. 114 IV. Recommendations – An Ideal Website .................................. 118 V. Conclusion .......................................................... 119 Chapter 5: Implementation of SHOP Marketplace in Pennsylvania .............120 v BEYOND THE WEBSITE I. SHOP Overview ......................................................120 A. What is SHOP? .................................................120 B. Who Is Eligible for the SHOP Marketplace in Pennsylvania? ............ 121 C. Who Is Eligible for Employer Healthcare Tax Subsidy?. 122 D. What Health Insurance Plans Are Included in the SHOP Marketplace?. 123 E. Small Business Profiles: National and Pennsylvania Comparisons. 123 II. The SHOP Marketplace: Organization and Requirements. .125 A. The Establishment and Organization of the Federal SHOP Marketplace ..125 B. Employer Requirements for Participation ............................128 C. Steps to Enroll a Small Business in the SHOP Marketplace. 129 D. Cost Comparisons of the Available Plans on the SHOP Marketplace ......131 E. Incentives for Small Businesses ....................................136 F. Employer Healthcare Tax Subsidy ..................................137 G. Businesses over 50 FTE Employees .................................142 III. SHOP Marketplace Marketing, Outreach, and Development. .143 A. Outreach, Education, and Navigational Assistance for Small Business Owners ..............................143 B. Assessment of Media Coverage and Outreach Efforts .................145 C. Recent Media Coverage of the SHOP Marketplace ....................147 D. The Role of Brokers ...............................................148 E. The Role of Business Associations ..................................150 F.