A vision for healthcare reform in PA

Sometimes it feels as if we are spinning our wheels with all the disagreement about solutions to our broken healthcare system. Recently I attended a conference in Harrisburg that gave me hope for the future in our home state. It was the annual conference of the Pa Health Access Network (PHAN), Pennsylvania’s only statewide, consumer-driven organization working to expand and protect access to high-quality, equitable, and affordable healthcare for all Pennsylvanians.

Titled “A New Path Forward: Moving Toward Fairer, More Equitable Healthcare in Pennsylvania,” the conference featured state leaders in the healthcare reform effort. In addition to policy people from PHAN, among the presenters were legislators Bryan Cutler and Dan Frankel; Pa Insurance Commissioner Jessica Altman; Zachary Sherman, the newly appointed Executive Director for Pennsylvania’s own new ACA (Affordable Care Act) marketplace exchange; and the heads of Community Legal Services and Community Health Centers. The work these people are doing and their vision for shoring up healthcare in our state are inspiring. I am excited to share some of their plans and ideas with readers of this paper, focusing on the state exchange that is under development.

When the ACA was signed into law in 2010, it provided that states could establish their own healthcare exchanges, subject to ACA regulations, to go live in 2013-14. The expectation was that most would decide to do that. In fact, over time, only a dozen or so states chose that option, with others relying on the federal exchange on healthcare.gov.

Since Trump came into office, the federal marketplace exchange has experienced shorter enrollment periods, much less information on the web site, major cuts in the navigator program, and competition from cheap, short-duration plans that are practically worthless. Minimal reporting and data from the federal government have also been problematic.

Pennsylvania is among a handful of other states that are now developing their own exchanges partly in response to these sabotage efforts at the Federal level, but also in response to promising new information technologies. In addition to reducing operating costs through the efficiencies made possible by these new technologies, state-run exchanges can target local needs better and create solutions based on their own demographics. Pa’s own exchange will benefit from the best practices gained from other states’ experiences. The leaders in this effort are projecting a 5-10 percent savings in health insurance costs in the first few years of the new marketplace.

The bill creating the Pa exchange passed with unanimous bipartisan support and was signed by Governor Wolf in July 2019. The exchange is expected to be up and running in January 2021, with the enrollment period beginning in November 2020.

Currently, fewer than 400,000 Pennsylvanians are enrolled in the federal ACA marketplace exchange, and about 700,000 have Medicaid coverage due to the state’s expansion of that program. In both 2018 and 2019, the uninsured rate was 5.5 percent of the state population, down from over 10 percent in 2010. Largely due to confusion about the Federal marketplace, Pennsylvania enrollments in the federal exchange have declined from 426,059 in 2017 to 365,868 in 2019. People hit hardest by higher costs have been those who were not eligible for subsidies.

As a keynote speaker at the conference, Insurance Commissioner Altman explained how the state exchange would save money for enrollees and insurance companies, leading to many more Pennsylvanians who do not have employee-based insurance getting coverage.

The key to reducing costs overall, stabilizing the insurance market, and bringing premiums down is a state reinsurance fund. This fund will directly pay some of the healthcare costs for high-cost individuals, lowering premiums for other insured Pennsylvanians on the individual market as well as reducing the approximately $2 billion cost for healthcare premium subsidies to assist low-income individuals. Savings from the decreased operational costs of the new exchange and federal savings will be used to create the reinsurance fund. The combined savings and anticipated federal government reinsurance contribution will save Pennsylvanian consumers up to $250 million in annual health insurance premiums.

Zachary Sherman, Executive Director for the state exchange, was also a keynote speaker. Pennsylvania is fortunate to have recruited him to lead this effort. A member of Rhode Island’s original implementation team for its state exchange,

“HealthSourceRI,” Sherman has held several positions there since its establishment in 2011, including Chief Financial Officer, Chief of Staff, and, since 2015, Director. Under his leadership, enrollment increased 11 percent in 2017-2019, a period during which enrollment through the Federal marketplace fell by 9 percent.

Sherman’s vision for Pa’s exchange, shared by other healthcare leaders at the conference, includes transparency, coordinated healthcare programs (from the ACA exchange to Medicaid to CHIP for children), more enrollment navigators and much more comprehensive training for them, and expansive outreach to community healthcare organizations and similar entities.

The goal for healthcare enrollment is “NO WRONG DOOR.” That is, navigators will be knowledgeable about the eligibility rules for all government healthcare programs and will have access to an individual’s or family’s existing application for another program, including “Proof of Income” on record with the Pa Department of Human Services. Navigators will be able to help connect applicants to the right program(s) without their having to apply or reapply for each one. Although the federal enrollment period was shortened by the Trump Administration, our state exchange will be able to extend it for other reasons, as it expands what is covered under existing “Special Enrollment” periods.

State healthcare leaders at the conference recognize that even if healthcare becomes more affordable, access to actual care can still be a problem for many people due to lack of transportation or a lack of providers close by. Already PA has become a nation-wide leader in using Medicaid to address the “social determinants of health” such as age, poverty (and food insecurity), and rural locations. The state has been working with community-based organizations to address these special issues as part of the access problem of healthcare. Pa has a vibrant and growing number of community health centers and is working on more trauma centers in rural communities. More is being done to expand public transportation options for seniors as well as for other carless people in rural communities.

The ultimate fate of the ACA, of course, could destroy this vision for healthcare in Pa. If the current Texas lawsuit to end the entire ACA on “Constitutional” grounds succeeds, however, there will be many lawsuits to follow. In the meantime, Republicans would have to answer to their constituents when they do not have good plan to replace the ACA. Returning to our past broken and costly “free market” system, with its denials of coverage for people with pre-existing conditions and other dreadful practices, is not an option people will welcome. The future depends on voters using the ballot box to ensure this does not happen.

Jeanne Duffy, Ph.D., has served as a college professor, an analyst and project manager for several large companies, and a college administrator in charge of foundation and government support. She is an active member of Gettysburg Democracy for America’s healthcare taskforce.