Fwd: qotd: Now the churning begins

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-------- Original Message --------
Subject: qotd: Now the churning begins
Date: Wed, 2 Apr 2014 12:08:51 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



UC Berkeley Labor Center
April 2014
The Ongoing Importance of Enrollment: Churn in Covered California and
Medi-Cal
By Miranda Dietz, Dave Graham-Squire, and Ken Jacobs

Projections for enrollment in the new insurance options created under
the Affordable Care Act (ACA) are often point-in-time estimates. But
just as people frequently move in and out of being uninsured, insurance
coverage through Covered California (California's health insurance
marketplace) or through Medi-Cal is dynamic and can change for an
individual over the course of a year.

Following each cohort across 12 months and observing changes in income,
take up of employer sponsored insurance (ESI), and loss of insurance
recorded in the SIPP, the analysis predicts the share of those
originally enrolled who will remain in the same type of coverage at the
end of the 12 months.

For individuals enrolled in Medi-Cal:

74.5% Stay in Medi-Cal
16.5% Income increases, eligible for Covered California
9.1% Leave for job-based coverage
0.0% Become uninsured (zero "unlikely to hold in reality")

For individuals enrolled in Covered California (range between stronger
and weaker retention scenarios):

57.5%-53.3% Stay in Covered California
21.3%-20.5% Take up Medi-Cal/public coverage
19.0%-18.3% Leave for job-based coverage
2.2%-7.9% Become uninsured

Enrollment in Medi-Cal and Covered California will be dynamic as
Californians move in and out of coverage and change coverage sources.
This policy brief predicts a significant level of churn out of Medi-Cal
and Covered California each year. Approximately one-fifth of the cohort
of Covered California enrollees are expected to transition to public
coverage such as Medi-Cal, and another fifth are expected to transition
to employer-sponsored coverage.

Understanding the extent and nature of churn can help in planning for
ongoing enrollment, ensuring smooth health coverage transitions and
continuity of care, and reducing uninsurance.

* Effective implementation of the changes aimed at streamlining the
redetermination processes is required for the stability of the Medi-Cal
population to actually increase.

* It will be vital for the enrollment infrastructure — from outreach,
to the website, to in-person and call-center assistance — to be
available and active even outside of open enrollment periods.

* Making sure that people successfully transition from one type of
insurance to another will depend not only on the ease of enrollment, but
also the extent to which Covered California and Medi-Cal take advantage
of existing institutional points of connection to people undergoing
these life transitions, e.g., COBRA notices or government services like
unemployment, CalFresh (food stamps), or the Department of Motor Vehicles.

* It will be important that outreach, enrollment assistance, and
effective sign up processes are available throughout the year for
Medi-Cal and for those who experience life transitions that qualify them
for mid- year enrollment in Covered California.

Bouts of uninsurance are known to have negative health consequences. The
uninsured have higher mortality overall, and are more likely to go
without care. Those who are not continuously insured underutilize
preventive care, and have been found to use more care when they do
become insured.

http://laborcenter.berkeley.edu/healthcare/churn_enrollment.pdf

****


Comment by Don McCanne

One of the fundamental policy flaws with a fragmented, multi-payer
system of financing health care is that the eligibility of each
individual for various sources of coverage is dynamic - ever changing -
requiring movement in and out of various forms of coverage or ending up
with no coverage at all. This study from the UC Berkeley Labor Center
shows that just the movement out of California's Medicaid (Medi-Cal) and
exchange plans (Covered California) is projected to be considerable
during a twelve month period.

About one-fourth of Medi-Cal enrollees will leave the program because of
income increases exceeding eligibility levels for the program, or
because of becoming qualified for job-based coverage. For the Covered
California exchange, almost half will leave because of a decline in
income to levels eligible for Medi-Cal, or because of a transfer into
job-based coverage, or simply because of falling into the ranks of the
uninsured.

When you look at their recommendations to ameliorate the instability of
coverage, it demonstrates once again that ACA is increasing the
administrative complexity of our system when what we need is the
administrative simplicity of a single payer system.

This study does not address the many other circumstances that can result
in a change or loss of coverage, especially with employer-sponsored
plans. Unstable coverage - churning - can have negative consequences
because of disruption of continuity of care such as through your source
of primary care, especially if you have or will have a chronic disorder
requiring ongoing medical management.

The following paragraph is from a 2008 Quote of the Day (before ACA)
that describes a few but by no means all of the reasons for churning.
Churning is not a new discovery. Unfortunately, the ACA improvements
have only a minimal impact in reducing churning. With the new mandates,
eligibility requirements and other ACA provisions, churning may actually
show a net increase. Reading this paragraph will once again remind you
why we need single payer reform - an improved Medicare that covers
absolutely everyone, forever. With single payer, churning is eliminated.


"You may have changed jobs, likely more than once, and lost the coverage
that your prior employer provided. Your employer may have changed plans
because of ever-increasing insurance premiums. Frequently your insurer
introduces plan innovations such as larger deductibles, a change from
fixed-dollar copayments to higher coinsurance percentages, tiering of
your cost sharing for services and products, reduction in the benefits
covered, dollar caps on payouts, and other innovations all designed to
keep premiums competitive in a market of rapidly rising health care
costs. You may have lost coverage when your age disqualified you from
participating in your parents' plan. You may have found that health
benefit programs have been declining as an incentive offered by new
employers. Your children may have lost coverage under the Children's
Health Insurance Program when your income, though modest, disqualified
your family from the program. Your union may not have been able to
negotiate the continuation of the high-quality coverage that you
previously held. Your employer may have reduced or eliminated the
retirement coverage that you were promised but not guaranteed. Your
employer may have filed for bankruptcy without setting aside the legacy
costs of their pensions and retiree health benefit programs. You may
have decided to start your own small business and found that you could
not qualify for coverage because of your medical history, even if
relatively benign, or maybe your small business margins are so narrow
that you can't afford the premiums. You may have been covered previously
by a small business owner whose entire group plan was cancelled at
renewal because one employee developed diabetes, or another became HIV
infected. Your COBRA coverage may have lapsed and you found that the
individual insurance market offered you no realistic options. You may
have retired before Medicare eligibility, only to find that premiums
were truly unaffordable or coverage was not even available because of
preexisting medical problems."

http://www.pnhp.org/news/2008/july/keeping-the-insurance-you-have-dont-believe-it