Analysis: Successes and failures of the Affordable Care Act in Vermont
MONTPELIER -- Margot Page was worried about a gap in her health coverage. It was March and her pharmacy claims were being rejected.
Earlier in the year, Page, 61, of Sunderland purchased health insurance through Vermont Health Connect, the state's online insurance marketplace.
Her old coverage expired in March, but despite months of back-and-forth with Vermont Health Connect customer service representatives, she was unable to change the start date of her coverage, which was mistakenly entered as April.
In a panic the first week of March, Page reached out to her friend, Rep. Patti Komline, R-Dorset, for help.
Komline put Page in touch with Lindsey Tucker, a deputy commissioner for the Department of Vermont Health Access, and the woman who happens to be in charge of the day-to-day operations for Vermont Health Connect.
In an email dated March 6, Tucker wrote, "Unfortunately, it is not yet a simple process for us to change effective dates" for a policy. Tucker was able to elevate Page's case to a manager. By the next week, Page's immediate problem was fixed, and she was able to pick up her prescriptions.
"I can't imagine what it's like for the elderly or disadvantaged in our state or people who don't know someone that can help," she said.
Page continues to have problems with her account, most recently in July when she went to the dentist for an annual cleaning. The dental coverage she was paying for didn't show up in the system.
Her experience is common among commercial customers and Medicaid beneficiaries with Vermont Health Connect, according to providers and navigators, who help enroll people in coverage.
Page's story illustrates that when patients have trouble with their coverage through the exchange, it helps to have an advocate.
Robert McBride, 63, found an advocate through the free clinic in Bellows Falls where he lives. Linda Raymond-Empey, executive director of the Vermont Coalition of Clinics for the Uninsured, volunteers there and is a certified navigator. She helped McBride enroll in coverage that he said is making a difference in his life.
McBride lives on a fixed income from a few properties he manages and Social Security. In two years he'll qualify for Medicare, the government insurance program for the elderly and disabled, but in the meantime, it has become difficult for him to keep up with premiums in the individual market.
"There really weren't other options for me," said McBride, who needs health insurance to manage his diabetes. "If this didn't exist, I'd be having to make some really hard choices."
The premium for his insurance -- $792 per month last year -- was becoming unaffordable. His subsidized premium on the exchange this year is $112.
Gov. Peter Shumlin recently described Vermont's implementation of the Affordable Care Act as a "tale of two worlds," divided by those who are happy with more affordable coverage and those who have been thwarted by the system.
For people who are having difficulty accessing insurance coverage through Vermont Health Connect, "it's occupying people's whole days," according to Lawrence Miller, the state's chief of health care reform.
"It's invading their sleep," Miller said. "It's keeping people up at night. It's causing a tremendous amount of stress for a lot of folks."
The governor and Miller describe the situation as "unacceptable" and say the state will put in place contingencies to ensure a smooth renewal and open enrollment period in the fall.
One reason it may appear that there are fewer success stories is what Raymond-Empey calls the 10-to-1 rule. Someone having a bad experience with the system tells 10 people, whereas someone that the system worked for only tells one person about it.
"I think that's even more true today with social media," she said.
Users of Vermont Health Connect were generally reluctant to share publicly their experiences, in part because they didn't want to discuss medical conditions or financial support from government subsidies.
Early signs of expanded coverage in Vermont
The Affordable Care Act is expected to expand health coverage in two ways: by subsidizing commercial insurance to make it more affordable and by expanding the income eligibility for Medicaid in states like Vermont that elected to do so.
Advocates have raised concerns that some people who signed up for commercial insurance won't be able cover the costs throughout the year, but for McBride and many others the subsidies have made a real difference.
Close to 130,000 individuals used the exchange to get covered - another 34,000 small business employees were enrolled directly by insurers. Virtually the entire population covered by the phased-out Catamount and VHAP state health programs have transitioned to Vermont Health Connect.
It has not been cheap. The state has spent more than $72 million in federal money on Vermont Health Connect, and it's expected to cost close to $100 million more to complete.
The system was rushed online as the result of a federal deadline, and still isn't finished.
Vermont already had one of the lowest uninsured rates in the country - due in part to the VHAP and Catamount programs - at 6.8 percent or 42,760 people, according to Household Health Insurance Survey conducted in 2012.
The survey will be conducted again in August, and the results will be the best window into how the Affordable Care Act is performing in the state.
But there are early signs that it's expanding coverage in Vermont, though providers caution that the numbers they're seeing are preliminary.
Vermont's network of 10 free clinics had 7.5 percent fewer health visits in the first half of 2014 than in the same period in 2013, down from 2,724 to 2,037.
Health visits are trending down, Raymond-Empey said, but she would want to see results for a longer period before drawing conclusions.
"It's hard to specifically attribute that to any one thing," she said.
Part of the trend is a shift in the role of Vermont's free clinics, which even pre-ACA began focusing more on their referral services. The overhead for providing health services compared to how many people they could serve was too low.
The free clinics now focus more on assessing people's health needs, getting them coverage and connecting them with primary care, she said.
Often they refer the uninsured or underinsured to Vermont's community health centers. Community health centers receive federal money to offer discounted services to people who would otherwise struggle to afford them. There are eight federally qualified health centers (FQHCs) in Vermont, with 48 locations throughout the state.
More than one-sixth of the state's population gets health services at an FQHC, and many of them are low- or middle-income.
Jack Donnelly, the CEO of the Community Health Centers of Burlington, the largest FQHC in the state, told the Green Mountain Care Board in late May that he had seen a dip in the number of patients relying on the income-based sliding scale for discounted services.
If the trend holds, he told the board, it would signal that more low-income Vermonters have coverage. Virtually all of the FQHCs have seen expanded coverage for patients, though they are cautious about reading too much into the results of such a small sample.
Donnelly would not provide VTDigger with payer-mix numbers for the first half of 2014, but most of the other FQHCs did.
In the first six months of 2014 the health centers showed a modest decrease in self-pay patients, with an average of about 2 percent when compared to the same period in 2013.
The extended open enrollment period this year, which was expected to end in December but because of ongoing problems with Vermont Health Connect that continued into May, makes it difficult to draw conclusions from that data.
"The jury is still out when you look at our overall payer-mix," said Andy Majka, CFO of Springfield Medical Care Systems, which operates seven community health locations in southern Vermont. But when he drills down to just the dental program, there's a more appreciable dip in self-pay patients.
There the number of self-pay dental patients dropped 20 percent in the first-half of 2014. The number of Medicaid patients jumped 15 percent and commercially insured patients rose 5 percent.
Isolating just the three months since open enrollment ended, Tom Pitts, CFO with Northern Tier Center for Health, said his FQHC has seen self-pay patients drop 45 percent. The vast majority of that drop has been in their dental business as well, he said.
The more precipitous drop reported by Pitts is likely because after open enrollment more Vermonters were newly covered and more people who were qualified for or purchased coverage earlier had their plans confirmed.
Unlike previous state health plans for low-income residents, Medicaid offers an adult dental benefit. The new benefit appears to be giving more low-income adults access to dental care. Dr. Dynasaur, Vermont's Medicaid program for children, has long covered dental, though a recent study shows it's underutilized.
"It could also be timing," Pitts said.
Medicaid patients have a $510 cap on their dental benefit. Depending on their need, those patients could be relying on the sliding scale again in a few months, he said.
If Medicaid patients are using more dental services, it could have major implications for the state, where most dentists are unwilling to take new Medicaid patients, because of low reimbursement rates.
Majka and other FQHC financial managers who were able to split out their payer-mix by type of service also saw a small increase in commercial coverage for behavioral and mental health services. That could be the result of an Affordable Care Act requirement that private insurance cover mental health services, but it's too early to tell, according to Majka and others.
More people covered, but by a messy system
Despite the early signs of expanded coverage, Vermont Health Connect is still a confusing tool for the public.
"There's no doubt the website was a mess," Raymond-Empey said. "It has improved immensely since October, but we still have miles to go before we sleep."
In the early days of Vermont Health Connect, the state was excruciatingly slow in transmitting enrollment information to the carriers. As a temporary fix, the insurance companies extended coverage for people they previously covered, and for new members they created "shell plans" that gave users "the illusion of coverage," according Dawn Schneiderman with Blue Cross Blue Shield of Vermont.
When members persist in that limbo state, "that begins to create an access to care issue," Schneiderman said.
The use of shell plans was widespread in the first half of the year, but has begun to taper off. Schneiderman said recently that Blue Cross, which covers the majority of commercial users, has shell plans for only 500 members currently. However, the state is only working through eight to 10 policies per day.
A much larger problem emerged this month when the state revealed that 22,000 Medicaid beneficiaries had not yet been reviewed for renewed coverage. The rate of Medicaid recipients renewing coverage is about 45 percent this year; typically the rate is 90 percent, according to state officials.
The people affected were on Medicaid before the Affordable Care Act increased the program's income threshold and many are close to or below the federal poverty line. Many are children and families.
Medicaid beneficiaries are accustomed to a paper review at the same time each year. This year, they were sent notices starting in April requiring them to use Vermont Health Connect to complete their review. They could also call the call center or get help from a navigator.
The state took a hiatus from reviews from August of last year through April. Mark Larson, commissioner of the Department of Health Access, was not sure if beneficiaries received notices at the typical renewal time.
All claims filed by people whose Medicaid eligibility couldn't be confirmed during that period will be covered retroactively. But the state didn't make that clear to providers until last week.
Many beneficiaries may have chosen to delay or forgo care over that nearly four-month period because they were concerned they might have to cover the entire cost of care.
The situation is creating a headache for providers as well, many of whom continued to provide services to Medicaid patients without guidance from the state.
"If they tell us they are eligible and they come up as ineligible, we have to assume they have Medicaid," wrote Claudia Liebold, CFO of The Health Center in Plainfield, in an email, before the announcement of retroactive coverage from the state. Her staff has held "all billing until patient's status is upgraded," she said.
The state has asked providers to resubmit unverified Medicaid claims after Aug. 1.
At pharmacies, said Raymond-Empey, this was not a problem because they require payment upfront. If a patient ordered medication early enough in the day, and they sought her help, she was able to get them verified after a few hours on the phone, thanks to a recently implemented process for elevating calls that relate to medical necessity.
If a patient doesn't have a medical necessity that needs to be dealt with right away, providers and navigators said it takes days or sometimes weeks of back-and-forth with the Vermont Health Connect call center to verify someone's Medicaid eligibility.
The state is still investigating the low renewal rate, but an initial review shows they "don't think that anyone got the wrong notice," according to Emily Yahr, a spokeswoman for Vermont Health Connect.
Miller previously told lawmakers at a hearing that "it doesn't look like noticing was done correctly."
Part of the problem could be that there is a disconnect between the two separate departments that handle eligibility duties. The Economic Services Division of the Department for Children and Families sends out the notices for Medicaid. Meanwhile eligibility determinations are conducted through Vermont Health Connect, which is part of the Department of Vermont Health Access.
Some beneficiaries who did try to use the Vermont Health Connect website to renew may have ended up in the "change of circumstance bucket," if they made a mistake entering their information, Miller said.
A mistake could be something as small as using an abbreviation in an address, and must be fixed by calling the busy Vermont Health Connect call center.
Those people's changes are now in a queue with the thousands of other changes being requested. The most recent figures from the state show there are 14,000 people that need to fix a mistake or make a real change in their coverage.
Vermont Health Connect has processed roughly 7,000 changes since they began working to tamp down the backlog after open enrollment, but it's unclear if they're making progress as people continue trickle in with errors or other issues.
Many of the actual changes to coverage could impact people's Medicaid eligibility or the subsidy they're receiving, which could haunt the state at tax time, when the subsidies people received must reconciled with their actual income.
Vermont did a much better job of pulling people into the system than it did making sure the system works properly.
Navigators made contact with Vermonters an estimated 1.5 million times during the seven months of open enrollment. But the work doesn't stop after open enrollment, because many people needed as much or more assistance after signing up for coverage.
Navigators with the free clinics made 3,600 enrollments and went on to do 3,700 follow-ups, or calls to the VHC call center to fix coverage issues for people they were assisting. The 3,700 is not an unduplicated count, and many people needed several follow-ups, Raymond-Empey said.
Last year 18 organizations received $2 million in grants to help people enroll in coverage. This year 21 groups will split $1.85 million, in grants of between $21,000 and $200,000. Some will focus on helping small businesses use the exchange, while others will focus on exchange eligible populations.
Of the latter, many navigators are veterans from the first round of enrollment.
Larson said the state continues to value the work of navigators, who often do more than just help people sign up for coverage, but "we expect that in the future that level of assistance would not be necessary."
That's no guarantee though, as state officials have signaled that it's unlikely users will be able to fix errors or make changes through website during the upcoming open enrollment period.
State officials and advocates have all expressed concern about processing Medicaid coverage renewals through the website, which is not dissimilar from making changes because people are essentially just updating their information.
If the state is unable to integrate the necessary IT systems on the back end to allow changes and renewals, the state will continue to process them manually, according Miller, chief of health care reform.
Larson said he's pleased with the number of people who enrolled, and he believes Vermont Health Connect is expanding coverage.
But he says that accomplishment will "continue to be overshadowed by the problems we're experiencing."
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