On September 13, 2016, the Census Bureau released its report on Health Insurance Coverage in the United States for 2015. The number and percentage of Americans who were uninsured dropped again in 2015 after a precipitous drop in 2014. The uninsured rate dropped from 10.4 to 9.1 percent, while the number of uninsured dropped from 33 to 29 million. Both the rate of those uninsured at the time of the interview or for the entire calendar year dropped. Nearly 91 percent of Americans had insurance coverage in 2015.
Employer-based coverage continued to be the most prevalent form of coverage (at 55.7 percent covered at some point in the calendar year), followed by Medicaid (19.6 percent), Medicare and direct-purchase insurance (both at 16.3 percent), and military coverage (4.7 percent). The greatest change in coverage was in direct-purchase insurance, which increased from 14.6 to 16.3 percent. While the numbers of people covered by every other form of insurance increased, the only other form of coverage where there was a statistically meaningful increase in percentage of population covered was Medicare, which increased by 0.3 percent.
As in the past, the highest rates of coverage were among Americans over age 65 (98.9 percent) and under 19 (94.7 percent). Coverage increased at every age and within every age group, with the greatest increase at 1.7 percentage points among working age adults, resulting in 87.4 percent of that group being covered. There continues to be significant variation among age groups, however, with sharp drops in coverage at age 19 and again at age 26, and a significant increase at age 65. Not surprisingly, children and adults over age 65 had higher rates of public coverage (42.6 and 93.8 percent respectively) while working age adults had the highest rate of private coverage (72.7 percent).
The uninsured rate dropped among nearly every demographic category measured by the Census Bureau including:
- the disabled;
- full-time and part-time workers and the unemployed;
- people at all education levels;
- people at all income levels (with those with the lowest incomes experiencing a greater increase than those with higher incomes);
- people at all poverty levels (with individuals with incomes below the poverty level continuing to experience much lower levels of coverage-82.6 percent-than those above 400 percent - 95.5 percent);
- urban and rural residents; and,
- members of all ethnic groups (although the increase among Blacks was not statistically significant).
All states had statistically significant increases in coverage except three (South Dakota, North Dakota, and Wyoming), but decreases in the uninsured rate were greater in Medicaid expansion states (2.4 percentage points) than in non-expansion states (2.1 percentage points).
GAO Reports
On September 12, the Government Accountability Office (GAO) released three Affordable Care Act reports. Two were the 2015 and 2016 installments of the GAO's “secret shopper” program, under which it attempts to enroll fictitious applicants in qualified health plans (QHPs) and advance premium tax credits (APTC) through state and federal marketplaces. The third report examined evidence of enrollee satisfaction with marketplace plans and complaints to federal and state regulators.
Disheartening News On Undercover Enrollment
The undercover enrollment testing results were again disappointing. The GAO once again, as it had earlier, submitted applications for fictitious applicants to the federally facilitated marketplace and to two state marketplaces: California and Kentucky. Most of the applications were for health plan enrollment and premium tax credits, but some were for Medicaid or for both programs.
For 2015, the GAO submitted 10 fake exchange applications and eight fake Medicaid applications. Eight of the 10 exchange applications were submitted online, and all were blocked by the identity proofing software and could not be cleared by the identify proofing contractor. In each case, however-and in the two cases where applications were initially submitted by phone-the applications were cleared by phone.
Four applications contained Social Security numbers with digits that are not used by the Social Security Administration, four claimed employer coverage that did not meet minimum essential coverage (MEC) requirements, and two were duplicate enrollments. All were approved subject to submission of documentation, which in some cases was provided and in others not. The marketplace did not check with the fictitious employer to verify the lack of MEC.
All applications remained active at the time the report was drafted. Of the eight claims for Medicaid, three were approved by the marketplace; four were denied Medicaid but approved for marketplace coverage, and one was denied.
In 2016, the GAO submitted 15 fictitious applications, 14 for qualified health plan (QHP) enrollment and advanced premium tax credits (APTC), and one for Medicaid. Fourteen were blocked at the identity proofing stage, but all were tentatively approved subsequently by phone or through a written application. In four cases, the GAO used identities it had used in 2014 and for which premium tax credits had never been reconciled. The applications were approved based on an attestation that taxes had been filed.
Eight more applications were approved subject to supporting documentation being filed. In five cases, fake documentation was provided and the application was cleared. In three, more partial documentation was provided and coverage was continued. In yet three more, no documentation was provided but in only one was coverage terminated. Disconcertingly, in three cases where enrollment was approved the GAO was unable to successfully make premium payments and initiate coverage.
Obviously these results are disheartening. Premium tax credits and cost-sharing reduction payments through the marketplaces will cost about $39 billion this year and the Medicaid expansion $64 billion. It is important that these funds be properly spent.
On the other hand, the GAO reports offer no specific recommendations to the agencies. And CMS has been quite active in addressing questionable enrollments. In 2015, CMS terminated coverage for 500,000 enrollees who failed to document sufficiently citizenship or immigration status and reduced premium tax credits for 1.2 million enrollees. As of March 31, 2016, the marketplace had terminated coverage for 17,000 consumers who failed to document citizenship or immigration status and adjusted premium tax credits for 73,000 enrollees.
CMS has allowed individuals whom the Internal Revenue Service (IRS) has identified as not having reconciled their 2014 ATPC to continue coverage for 2016 based on an attestation that they had in fact filed their 2014 taxes; this stems from concern over the time lag between the time individuals file their taxes and the time the IRS identifies them as having filed. CMS is currently reviewing tax filing attestations to ensure that individuals who claim to have filed their taxes have in fact done so.
CMS and the state marketplaces must tread a careful line, making reasonable efforts to ensure that consumers are in fact eligible for coverage and financial assistance, but not imposing such substantial documentation requirements as to discourage legitimate applications or terminate enrollments inappropriately. CMS also has limited resources for making programming changes in HealthCare.gov and for following up on documentation issues and must focus these resources where they will go the farthest in making sure that individuals are enrolled, and enrolled properly.
It would make little sense, for example, for CMS to devote substantial resources to the forensic examination of documentations submitted to it to ensure that they are not fake, as long as documents are not facially invalid or altered. CMS did not choose to make requiring marketplaces to verify employer coverage a top priority but is now moving ahead with notifying employers when employees claim the employer does not offer adequate and affordable coverage.
There is in general little reason for an individual to submit a fake or duplicate application for health plan enrollment, as the GAO does. What is to be gained by an individual who does not exist enrolling in coverage that cannot be used, or to enroll in several states? Moreover, our entire tax system is largely an honor system. Billions of dollars are lost each year because businesses fail to report or underreport income or claim excessive expenses. But no one is proposing that businesses be required to document all of their income and expenses with the IRS. CMS should continue to take steps to ensure compliance, but must be reasonable and balanced in its efforts to do so.
Better News On Enrollee Satisfaction
The third GAO report, “Most Enrollees Reported Satisfaction with Their Health Plans, Although Some Concerns Exist,” offers a more positive message. The Report reviews six reports from three organizations of enrollee satisfaction with qualified health plans from 2014 to 2016. The GAO concludes that the vast majority of enrollees are satisfied. Most surveys found overall satisfaction rates to range from the mid-70 to mid-80 percent range, only a little below satisfaction rates for employee plans.
Satisfaction rates with choice or provider and doctors and services covered were also high, in the 70 to 80 percent range in most surveys. National surveys reported over half of enrollees using their plans and one found that over 60 percent of enrollees who needed care could access a specialist in two weeks or less. Satisfaction with premium costs and the costs of care was lower, but varied from the mid-40 percent to the mid-60 percent range. The GAO also reports concerns from stakeholders, and in the research, regarding the ability of enrollees to afford and access care and understand their coverage.
The report also describes the efforts of CMS and of the states to monitor the post-enrollment experience of enrollees and to review information reported by consumers and assisters. The GAO report offers detailed information on almost 2 million cases received and resolved by CMS during 2014 to 2015. The largest categories of cases involved enrollment, disenrollment, cancellation, and termination concerns; and requests for tax forms. CMS is also collecting enrollee satisfaction data from health plans and monitors information from assisters. Finally, state-based exchanges are monitoring health plan satisfaction information.
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