Picture of health

Despite an uncertain future for the Patient Protection and Affordable Care Act—a.k.a. the ACA or Obamacare—more than 91,000 Nevadans enrolled in health insurance complaint with its provisions for 2018.

The ACA has been under threat since long before Donald Trump became president on Jan. 20, 2017.

Since it was enacted nearly eight years ago, there have been many dozens of attempts made in Congress to repeal, amend, delay and defund the ACA—all unsuccessful. Yet, when Trump came to power with the benefit of a Republican-controlled Congress, many thought it would only be a matter of time before the ACA was dismantled.

And concerted attempts to do so were made during 2017, beginning with a Jan. 12 vote in the Senate to pass a budget resolution containing language allowing repeal to happen through the budget reconciliation process—which, importantly, prohibits a filibuster in the Senate and allows for passage of legislation with only a simple majority, rather than the three-fifths majority otherwise needed.

Less than two months later, House Republicans revealed their replacement for the ACA—called the American Health Care Act. But it was withdrawn a few weeks later, on March 24, because it had not garnered enough support to pass. More than a month of Republican Party infighting followed before the bill was put to a vote and narrowly passed the House by a margin of 217 to 213. From there, it was sent to the Senate for deliberation.

The Senate quickly rejected the House’s measure, choosing instead to write its own bill—the Better Care Reconciliation Act of 2017—which was unveiled on June 22. After another month and several delays in voting, the bill failed in a vote of 43 to 57, with nine Republican senators voting against it. And, just two days later, on July 27, the Health Care Freedom Act, a.k.a. the “skinny repeal” bill, was introduced and quickly defeated in a 49 to 51 vote, when Republicans Susan Collins of Maine, Lisa Murkowski of Alaska, and John McCain of Arizona voted against it, alongside Democrats.

A final repeal attempt—an amendment to the House’s American Health Care Act, named the Graham-Cassidy bill after its sponsors, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana—was introduced in September but never brought to a vote.

The repeal attempts, while ultimately unsuccessful, were not without effect. The months-long debates surrounding them created massive uncertainty in insurance markets across the country—an issue that was exacerbated by very real blows dealt to the ACA by the executive branch.

Despite having criticized Obama for the frequency of his executive orders—which, in February 2016, Trump called “a basic disaster”—the new commander-in-chief signed his first one on the day he was sworn into office. It was an order designed, according to then Press Secretary Sean Spicer, to “ease the burden of Obamacare as we transition from repeal and replace.”

The order gave the heads of all executive departments with “authorities and responsibilities” related to the ACA the power to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision” of the ACA that they deemed to place a burden on states, individuals, insurers or health care providers. And it was only the first of many.

During 2017, the Trump administration also made decisions to stop paying cost-sharing subsidies (CSRs) that reimburse insurers for the discounts they’re required to give some ACA enrollees; gave states more control over Medicaid implementation, including allowing them to impose work requirements; encouraged states to submit waivers to the Centers for Medicare & Medicaid Services (CMS) to make additional changes to their Medicaid programs, like charging recipients premiums, testing them for drugs and cutting them off from benefits if they fall behind on payments or paperwork; cut the open enrollment period for insurance sign-ups in half, from 90 to 45 days; and slashed federal funding for enrollment advertising and in-person enrollment support by 90 percent and 40 percent, respectively.

As a result of all of this, some insurance carriers, like Humana, stopped offering ACA plans, counties in many states faced months of uncertainty about whether their residents would have any ACA plans available to them at all, and about a half a million fewer people signed up coverage in 2018 than did in 2017.

In Nevada, however, despite facing these challenges, 2018 enrollment numbers exceeded the previous year’s.

Silver lining

Nevada Health Link, the state’s public health insurance marketplace, is one of five that are state-operated but rely on the federal government’s platform—healthcare.gov—to enroll people in ACA plans. These states—which also include Oregon, New Mexico, Kentucky and Arkansas—pay a fee to CMS for use of the platform. And, unlike states with fully federally operated marketplaces, they pay for and manage their own marketing and in-person enrollment assistance programs.

Heather Korbulic—the executive director of the Silver State Health Insurance Exchange, the agency that operates Nevada Health Link—figured this arrangement might warrant greater flexibility for the state. So, when the Trump administration announced the truncated 2018 enrollment period, she asked for it.

“When we were told that there’d be a 45-day open enrollment period—it’d be cut from 90 days to 45 days—I sent a letter in response to those proposals and said, ’That doesn’t give us enough time. We’ve already started planning and strategizing our marketing and our outreach for the next year,’” she explained during a recent interview. “I asked specifically because we do pay them so much of our revenue to lease their system, and because we’re kind of—partners is what we call each other in this endeavor—if we could extend our open enrollment period for our state, because we believed that would be the right thing to do. And I was told that there was not going to be any flexibility for that.”

Around the same time, Korbulic was notified that not only would the enrollment period be shortened, but the healthcare.gov platform would be taken offline every Sunday night for maintenance—a different schedule than in years past and, she said, a dramatic one, “when you only have 45 days, and you live in a state that is 24-hours.”

“So I sent a letter to the CMS and asked them if we could extend our open enrollment to allow for additional time as a result of those extreme maintenance schedules,” she said. “And I also pointed out that we’re paying the same amount, and [they] just totally changed the rules of the game. We agreed in a federal platform agreement that we were going to have a 90-day period. We were going to pay x-y-z monies for that. … I said, ’Where is our discount?’ I don’t think I even got a response to the part where I asked about the changes to our agreement and where our discount would be. But that continues to be something I talk about.”

With no extension or discount and the open enrollment period looming, Korbulic’s agency turned its attention, in the spring, to developing new plans and rates for the state—a job that was complicated by the threat of ACA repeal.

“We have a congressional body dominated by a party that has kind of trotted out the ’repeal and replace’ language for eight years, and finally we start to see what kind of legislative action they’re going to take,” Korbulic said.

In the end, of course, no legislation was passed, and the specter of an ACA repeal in 2017 faded when Congress turned its attention to tax reform. However, the months of uncertainty took a toll. In Nevada, two insurers—Prominence and Anthem—had announced their decisions to exit the state’s public insurance exchange in 2018, leaving 14 of Nevada’s 17 counties without on-exchange insurance options as a result. Nevada Health Plan, the only remaining insurer, said it would only cover residents in Nye, Washoe and Clark counties. The problem remained unresolved until mid-August, when insurer SilverSummit announced it would enter Nevada’s market and offer coverage in all 17 counties.

According to research by the Kaiser Family Foundation, there were, at different points during the year, a total of 82 counties facing a similar predicament in states across the country. But, by late August, the last of these so-called “bare counties” had secured insurance options for their residents. However, it came at a cost—literally.

Premiums in states across the country jumped dramatically. According to a report from NPR’s Marketplace, some Florida premiums jumped by as much as 45 percent. In Georgia, it was 57 percent. And in Nevada, the average rate increase was 36.8 percent.

Korbulic explained that this was not entirely due to the instability created by repeal rhetoric. Some of it was the result of executive action—and inaction.

“While we’re trying to develop rates and we’re trying to develop plans, we’re hearing ambiguity around whether or not cost-sharing reductions would be paid,” she said. “And it’s still a part of the ACA statute that insurers have to provide those, but whether or not they’d be paid was up in the air. This is in the middle of trying to develop rates.”

In October, the Trump administration moved forward with canceling cost-sharing reductions. But, according to Korbulic, it was a blow for which the Silver State had prepared, thanks to Division of Insurance Commissioner Barbara Richardson.

“She worked closely with commissioners across the country, and a lot of them made the same decision she did—which is, ’We’re so unclear on what’s going to happen about this that we need to be proactive and make sure that companies and our consumers are protected from any potential wavering on CSRs.’ So we’d already loaded our rates. There was a special window for states that had not, but let’s just say I did not envy them in those last couple of weeks right before open enrollment started, trying to scramble and make that happen.”

And, thankfully, for the more than 87 percent of Nevada ACA enrollees who qualified for premium subsidies, the costs were offset, leaving little impact on consumers.

Another area in which Nevada was prepared was marketing for open enrollment. At the end of August, the Trump administration announced plans to slash the ACA enrollment advertising budget from $100 million to $10 million. According to Korbulic, despite Nevada having “always benefited from the fortification of [federal] ad campaigns in generating awareness,” the state’s own marketing efforts were robust enough to make up for it.

In addition to running its own ad campaign through television, social media and billboards, the exchange attended more than 200 community events during 2017.

“There were so many individuals and groups who really wanted to make sure that we continued the benefits that Nevada has had from having insured individuals,” she said. “I mean, it benefits our communities. It benefits our economies. It benefits our job market. Most importantly, it benefits the health of our families and our friends and our neighbors, which can only be good in the long run. Public health is important. And we had a tremendous turnout. We had so many engagement events. One was called a prep rally, and that generated just an overwhelming outpouring of our communities’ support.”

In the end, the Nevada exchange enrolled just over 91,000 people in plans for 2018. But Korbulic thinks the state can do better by cutting its ties to the healthcare.gov platform. In fact, she said, it’s a necessary step to be taken if Nevada Health Link is to survive.

Breaking ranks

In 2017, the federal government began charging a fee to Nevada and the four other state-run exchanges that use the healthcare.gov platform.

In order to pay for this and operational costs, Nevada Health Link collects a percentage of the premiums charged by insurance carriers in the state. Right now, the rate is 3.15 percent, .35 percent lower than the fee charged directly to carriers in federally operated marketplaces. However, two percent—nearly two-thirds of the money Nevada’s exchange collects—is used to pay the leasing fee for the federal platform. And, in 2019, that fee will increase to three percent, a figure that represents nearly all of the revenue Nevada currently collects.

It’s a problem that’s been on the exchange’s radar for more than a year now and one Korbulic had hoped to address earlier.

“That was another casualty of uncertainty last year—because [the state legislature was] in session—and the governor’s recommended budget included transition fees, so the monies that we would need to have authorized in our budget to transition away from healthcare.gov,” she said. “But, because of the uncertainty we were experiencing in February and March, when these decisions were being made about whether or not the ACA would even exist, the legislature wisely decided that this is probably not the right time to be purchasing new technology to support something we’re not even sure will exist.”

So, for now, the exchange will remain on the federal platform. But plans are being made for the transition. Using $1 million from its reserves, the exchange is planning to begin the process of implementing a new, private platform. Korbulic said she expects it will be in place by November 2019, just in time for the 2020 enrollment period.

Korbulic has estimated the annual cost of maintaining a private platform at around $6 million—which would be built into the agency’s biannual budget. If Nevada continues using healthcare.gov for enrollment in 2020 plans, it will pay an estimated $12 million for use of the platform.

While that figure is only an estimate, Korbulic said she’s confident a private platform will cost “significantly less than healthcare.gov, half of it, likely, maybe even less, depending on what we negotiate. But I’m confident that there will be a cost savings for Nevadans, or at least for the exchange, and if we have cost savings, then we can theoretically bring down the fee that we charge carriers. Maybe more carriers would likely come in, but, mostly likely, that cut would benefit the consumer in terms of their premium cost—because the carriers build our fee into their rates.”

And there are other benefits Korbulic said the exchange expects—including greater access to real-time information about Nevada consumers during open enrollment periods, and the ability to provide them with customer assistance directly.

“Right now, because we don’t have access to the back end of healthcare.gov, if a consumer calls our call center, we can answer questions, but if they have something that needs to be changed in their application, what we have to do is make a three-way call to healthcare.gov’s assistance center,” she said. “We stay with that person on the phone until they get their complaint resolved, because sometimes that’s not the best customer service experience with healthcare.gov, so we really want Nevadans to get the answers that they need. And we’ll make sure that they get resolutions to their issues. I think having just a more simple way to manage that will be great.”

Need insurance?

You may still be able to enroll

The deadline to enroll in health insurance plans for 2018 closed on Dec. 15, but some Nevadans may qualify for a Special Enrollment Period (SEP) that enables them to get coverage outside the normal open enrollment window.

♥ Consumers who were on Anthem or Prominence health plans that terminated on Dec. 31, when those carriers left Nevada, have a 60-day special enrollment period (until March 1) to enroll in individual health coverage and shop for a new plan in the marketplace.

♥ If you’re Native American, you can change Qualified Health Plans (QHPs) once per month. You are not bound to the open enrollment dates.

♥ If you’ve lost employer-based coverage, you may qualify for a special enrollment period.

♥ Changes in income and changes in family size resulting from marriage, divorce or the birth of a child are also qualifiers for special enrollment.

♥ You may qualify for special enrollment if technical errors occurred during your enrollment or if your eligibility for Medicaid or Children’s Health Insurance Program (CHIP) was improperly determined.

♥ To see if you qualify for a special enrollment period, visit http://bit.ly/1DxJ7Q5.