Insurance exchanges at heart of new law

BOSTON >> Even a dataset self-described nerd like Peter Kim was almost undone by his hunt for health insurance.
Kim left the corporate world in 2005 to become an independent consultant, losing employer-sponsored insurance for his family of four. But the search for individual health plans proved incredibly complicated, he said. And most were too expensive, to boot.
"It was impossible to compare plans," said Kim, 42, who lives in Cambridge. "I finally gave up trying."
He and his wife use catastrophic coverage, pay out of pocket for routine medical care - until they discover the exchange of health insurance that Massachusetts established in 2006. A linchpin of the state law passed under Mitt Romney as governor, requiring most residents to have health coverage, the exchange is essentially an online marketplace designed to simplify the purchase insurance and thus help people to find a plan they can afford.
If the Supreme Court confirmed President Barack Obama federal law health care in a decision expected this month, proponents say the trade will be a crucial tool for extending insurance. The debate over the law focused on the individual mandate, the provision of lightning rod that requires most Americans to have health insurance by 2014.
But once the court decides if the law is constitutional, the focus could shift to exchanges.
The law requires each state to establish an exchange, but many are reluctant, complaining about everything from spending to perceived federal intrusions. Some, such as Louisiana and Maine, refused. Others are postponing crucial decisions until the court rules and the election in November plays.
So far, only about 15 states and the District of Columbia have established exchanges, with California and Maryland between the furthest in their planning.
Kim's experience in Massachusetts, which, along with Utah is one of only two states with an exchange and running, illustrates how the exchanges are ideally supposed to work. After only one hour of research on the site of the exchange, he said, he found a better deal. He enrolled in Harvard Pilgrim plan for which he pays $ 1086 per month for his family.
The exchange, called the connector of Health, has been operating since Massachusetts passed its own individual mandate in 2006. For all the criticism that has been launched in health state during this year's Republican presidential primary, surprisingly little attention has been paid to this part of the law.
Even if the Supreme Court strikes the federal mandate, many people believe that some form of trade could still be crucial to extend coverage in a number of states.
In Massachusetts, insurers bid to participate in the connector - which include plans offering some level of hospitalization, prescription drugs, maternity care and other services deemed essential by the state - and the connector use its market leverage and guidelines to promote innovation and competition between them.
"He can - and has - helped people to find more affordable options than they otherwise knew existed," said Glen Shor, Executive Director of the connector.
But for the satisfaction of all Kim, connector officials acknowledge that they need more customers like him, full-paying customers who do not qualify for a government grant to offset their premiums. So far the program has attracted only about half of this population in the individual market of the state, officials said connector.
Instead, about 82 percent of the estimated 224,000 people insured through the connector have incomes low enough to qualify for state and federal grants. They pay a modest premium or not.
This is precisely what many opponents fear trade: instead of a free market, they will become something like a program of expanded public welfare.
The connector has fought fiercely to attract another important component of national efforts for health care overhaul - small businesses, who have long complained of being kicked out of health insurance market.
While Massachusetts law requires that many small businesses offer coverage to their employees or pay a penalty, many saw no incentive to purchase insurance through the connector, said Joshua Archambault, Director of Policy health care to the Pioneer Institute, a conservative research organization here. Approximately 1,700 small businesses currently provide a total of 4,320 people across the connector - only a tiny fraction of this market.
"This means that any group that has been promised a reform has not seen," said Archambault.
Shor said that the connector has been taking steps to attract smaller companies, this year by adding more "popular brand" insurance companies with options for small businesses, including Blue Cross Blue Shield of Massachusetts. also added a wellness program that allows discounts of 15 percent off the employer's premium costs if certain conditions are met.
Amy Whitcomb Slemmer, executive director of Health Care for All, an advocacy group in Boston, said she was concerned about the large number of clients in unsubsidized program - 52 percent of them - so choosing Plans called bronze, which have the lowest monthly premiums. These plans tend to have high deductibles (up to $ 4,000 for a family) and maximum out-of-pocket costs, which means that people who become ill often end up paying a lot.
"We are increasingly concerned about high-deductible plans that resemble a short term solution to people," Whitcomb Slemmer said. "We spend so much time helping people understand what their risk take. "
Andrea Cunningham, of Watertown, a plan for the bronze was the most realistic option. She quickly found an insurance for his family of three through the connector after her husband lost his job in February. Sitting at her dining room table with a laptop, Cunningham, 30, entered his age and that of her husband, their zip code and the number of people in their family. Within seconds, his options - plans of tens in total - emerged.
The best part, she said, was how simple it is to compare standardized plans - how each load in co-pays for prescriptions, doctor visits and hospital stays, for example.
"It was very easy to take a look and determine what price range we wanted," she said, "and then dive deep into one or two of them."
She chose a bronze plan for which she and her husband, who is still out of work, pay about $ 900 per month.
The vast majority of people who got insurance through the connector since the downturn began have not had to worry about deductibles because they are eligible for subsidized coverage. In this program, the big challenge was to keep costs down as the numbers have steadily increased.
If the Supreme Court upheld the right of national health, the connector will face significant changes in its customer base. Many customers will be transferred to Medicaid funded under the law of expansion of this program. So attracting more customers for non-subsidized program will be crucial, said Nancy Turnbull, an associate dean at the Harvard School of Public Health, who is on board connector.
"For the exchange to continue to be a major purchaser and the influence on the market," she said, "we will need to be able to add more small employers and people potentially other . "
For the first church in Cambridge, attended by his seven employees in the choice of the Commonwealth this year after facing a rate increase of 10 percent on the previous plan, the switch was worth it.
The church is still paying 3 percent more than last year for its new policy, through Tufts Health Plan, and employees pay more for non-generic drugs only in their old regime. But the Rev. Karen McArthur, Minister Affiliate stewardship, said the church hopes to save 15 percent by joining the program wellness news.
"Even if there were a lot of things we can do to make our internal work policies for what they offered," McArthur said, "there was little energy to do so. We really wanted to participate this, because we truly believe in him. "


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