In fourth year, Obamacare exchange eyes broader role

Arielle Levin Becker :: CTMirror.org

Jim Wadleigh

The head of Connecticut’s health insurance exchange, Jim Wadleigh, has been talking about his organization’s taking on a larger role in addressing coverage affordability, health care delivery and health disparities. And that tends to elicit this response:

“Wait, you’re not just an enrollment organization?”

This fall, the exchange, Access Health CT, will begin its fourth year of selling private insurance plans to Connecticut residents, as well as enrolling people in Medicaid. But its leaders are eyeing a broader role, focused on not just getting people covered, but improving health.

“The Affordable Care Act was created to help these areas: Health disparities, affordability, cost transparency,” Wadleigh said. “We will continue to improve our enrollment process. It will become a small piece of how we feel our role in the ACA implementation will play.”

The broader mission, as Wadleigh views it, will include efforts to ensure that people are using their coverage to get preventive care, to push for changes in how care is delivered, to give people tools to determine the cost of care, and to make health care and insurance more affordable.

Others who have been involved in trying to get people covered under the health law have also been focused on the next steps – how to ensure that the newly insured can find providers to treat them and that they get the right type of care, how to shift from a system that largely focuses on treating sickness to one more focused on keeping people well, and how to address growing health care costs that most view as unsustainable.

The exchange’s mission, adopted in 2012, calls for decreasing the number of uninsured residents, improving health care quality, lowering costs and reducing disparities through a competitive marketplace. Wadleigh told the exchange’s board Thursday that the idea now was to “move forward down that continuum.”

But Benjamin Barnes, secretary of the state Office of Policy and Management and a member of the board, said that, while the exchange has “built something of enormous significance,” it also needs to maintain its focus on further reducing the number of uninsured state residents and work more closely with other groups involved in health reform efforts.

“We have tens of thousands, maybe 100,000, uninsured Connecticut residents today. We are not currently on a trajectory to cover them through the exchange in the foreseeable future,” he said during the board meeting. “That should remain the focus, or at least one of our focuses, in addition to keeping everybody and everything we’ve built working properly.”

And Barnes said satisfying the exchange’s mission requires “increasingly strong partnerships” with other organizations, including health care providers, nonprofit organizations focused on coverage and care quality issues, and the state Department of Social Services, which runs the Medicaid program. Close to 200,000 people are now covered by the portion of the Medicaid program that was created under the federal health law, nearly twice as many people as purchased private insurance through Access Health. The relationship between Access Health and DSS has at times been strained.

“I don’t think that that partnership is as strong as it should be,” Barnes said. “That’s unfinished business of significant magnitude.”

Wadleigh said many of the remaining uninsured are not in the country legally, making them ineligible for Medicaid or exchange coverage. Many people nationally are watching a California proposal to allow undocumented immigrants access to that state’s exchange, he said.

Wadleigh acknowledged the need to figure out how to work better with DSS, and said he and Social Services Commissioner Roderick L. Bremby are working on it. He also said the exchange hasn’t been as attentive as it could be to health care providers.

“We as an organization are not simply an enrollment organization. We have to be a facilitator across all of these functions in order to protect everyone in the value chain,” he said.

There are already multiple state-level efforts underway to address changes in health care, and some observers have questioned how well they coordinate with each other. They include a state-level health reform effort, the state innovation model, that aims to create new standards for primary care practices, to better link medical care to a wide range of factors that influence people’s health, and to create standards for new payment models that focus on care quality and efficiency.

The state’s health care cabinet is in the midst of a process aimed at identifying ways to address health care cost growth and price variation. A task force is examining the way the state regulates health care providers and facilities. And many health care provider groups and insurance companies are pursuing their own strategies to change how care is delivered and paid for.

Why should Access Health take those things on too?

Wadleigh told the board that the exchange is “one of the few organizations in the state implementing the Affordable Care Act,”  and uniquely positioned to expand its work.

“It is a long road,” he said. “It will take us years to be able to get through this process.”

So what would that look like?

One focus, Wadleigh said, will be to shift the customer service from what he described as a reactive model to more of a “concierge-type” service that reaches out to customers. That could include year-round outreach to help people use their insurance, deal with tax issues related to the health law, and select plans. As an example, he noted that more than 12 percent of customers whose income qualified them for plans with discounted cost-sharing instead picked lower-premium plans that required them to pay more out of pocket when getting care.

Other goals involve the use of data. The exchange oversees the state’s developing all-payer claims database, which is intended to include troves of health care claims data that could provide a glimpse into health care costs and usage – and potentially be used to identify gaps or areas where certain types of care appear to be heavily used. Wadleigh described it as a tool that could be used to target health disparities, give customers a better sense of health care costs when shopping for insurance plans, and provide more ways for people to understand the cost of care.

As of Monday, 105,437 people in the state had private insurance plans purchased through the exchange – the figure was higher at the end of the recent open enrollment period, but some have dropped out since then – and Wadleigh hopes having that many customers could give the exchange a voice in pushing for health care delivery system changes and efforts to make health care and coverage more affordable.

One possibility, he said in an interview, could be actively negotiating with insurance companies that seek to sell plans through the exchange. Currently, the exchange allows any carrier that meets its standards to sell plans through its market, although insurers’ rates must go through an approval process by the Connecticut Insurance Department. Before the exchange’s first open enrollment period, some advocates pushed for Access Health to be selective about which plans the marketplace would sell, and to have the ability to negotiate rates. But Access Health leaders at the time opposed the concept, warning that being too selective or setting too many restrictions could leave fewer choices for customers.

Wadleigh indicated he’d like to consider trying to negotiate with insurers or making arrangements with hospitals that could influence the cost of care.

“What can we do to disrupt the market?” he said. “One-hundred thousand customers is a big number.”