With future of Obamacare in doubt, Nevada exchange focused on reaching more people in need

March 06--First, a reassuring word from the woman in charge of the state's Affordable Care Act program to the 89,061 Nevadans who signed up for coverage this year: You're good.

"There isn't any concern about 2017," said Heather Korbulic, executive director of the Silver State Health Insurance Exchange.

That island of relative certainty amid the swirling sea of questions about the ACA's future under a hostile Congress and presidential administration stands as rare encouraging news for Nevadans accessing health insurance through the public marketplace. Republican pledges to repeal and replace the ACA hovered over the program's open enrollment period, tasking Korbulic and her team with considerable myth-busting.

"With the environment we're in now with the Trump administration, there was a lot of confusion," said Janel Davis, communications officer for the exchange. "(Consumers said), 'I heard Trump's getting rid of the tax penalty.' We told them, 'No, that's a myth; this is still a law and you're going to have to pay that penalty.' You also had the other side of people, who said, 'I want to get that subsidy before it goes away.'"

Enrollment via Nevada's hybrid marketplace -- in which the state certifies plans and determines eligibility while sign-ups process through the federal healthcare.gov system -- grew by roughly 900 people in 2017, according to data from the Centers for Medicare & Medicaid Services. Within the 89,061 enrollees are about 29,000 people new to the program this year, CMS said.

While some who signed up for insurance through the marketplace expressed concern about its future viability, Korbulic and Davis said many more people discussed simpler questions with enrollment counselors.

"When I talk directly to our consumers, the mindset is less insight into where the dollars come from and what the politics looks like, and (more) a bigger concern about what they need to do to get the insurance for their family," Korbulic said. "Insurance is incredibly complicated. Even understanding the difference between a copay and a deductible, and outlining what your responsibilities are as a consumer, is enough of an uphill climb in terms of educational literacy."

Davis spoke with call-center counselors after the Jan. 31 close of the three-month sign-up period to find out the most common requests received.

"I think a lot of the consumers need an 'Insurance 101' because it's confusing," Davis said. "There's a lot of tax questions, and 'What's my payment going to be?' A lot of consumers struggle with the idea of what a deductible is. They see a huge number. When they're going through the enrollment process, (counselors) have to explain what this means."

Some new enrollees became used to managing their health through visits to urgent care and emergency rooms, running up sizable bills, Davis said, prompting the most basic of questions: "'Now that I have health insurance, what do I do with it?' They were calling our call center and finding out what their benefits are."

Nevada's enrollment grew from about 32,000 in 2014 to nearly 75,000 in 2015. This year's modest gains still pleased Korbulic, who cited the loss of roughly 80 percent of the 500 brokers who sold ACA plans in 2015 over a payment dispute with carriers as a major challenge in growing the number of covered Nevadans.

Korbulic and her team also have little idea of their target market because of an ongoing battle with CMS over data. People enroll through the federal government after the shift to a hybrid marketplace, giving CMS control of their demographic information. The exchange cannot access that data in real time, despite repeated requests to CMS.

CMS does not release demographic information on any set timetable, spokesman Jack Cheevers said. The data include aggregate information on age, gender, identified race, stated income level and rural/urban designation.

"The release of more such data would be a violation of our standards regarding the protection of personally identifiable information," Cheevers said.

CMS became a vendor for the state exchange this year, charging Nevada 1.5 percent in per-member, per-month fees after two years of operating at no cost. That amount jumps to 2 percent in 2018 and 3 percent in 2019, increases being negotiated between state and federal officials.

Especially with CMS now being paid by the state, Davis said it is "absolutely ridiculous" that state officials do not have better access to data that could help Nevada more efficiently spend its $2 million marketing and outreach budget, and potentially cover more people.

"We've got the low-hanging fruit," Korbulic said. "We need to go deeper into these communities where we've got uninsured and underinsured folks."

Korbulic foresees relative stability in the availability of ACA plans until at least 2020, because legislation discussed in Congress likely would build in a two-year transition period. Even that assumes Republicans in the House and Senate can coalesce around a plan and send it to President Donald Trump sometime in 2017.

That possibility appears far from guaranteed: Trump recently said "nobody knew health care could be so complicated," while conservative House Republicans demanded a full repeal of the ACA that might not be plausible with 20 million Americans standing to lose coverage.

"It's really hard to predict where this will turn out," said Dr. Joe White, a professor of public policy at Case Western Reserve University. "You could make an argument that they will think it's easier for them to mess with Medicaid than to mess with the exchanges. I don't know what's going to happen -- I don't think they know."

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