NJ Spotlight

Consumer Advocates Pledge To Bring More People Under ACA Umbrella

What will it take to extend healthcare coverage to 1 million or more New Jerseyans?

NJ Spotlight — September 12, 2016

By Lilo H. Stainton

Leaders of the NJ for Health Care Coalition, a statewide advocacy group of nonprofits, labor unions, advocacy groups, and provider organizations, are recommitting to a new round of battles to improve the ACA. They hope to close gaps in the federal law, reduce consumer costs, and create a sustainable system more focused on keeping people in good health. Getting there will require greater public investment, additional government oversight, and better collaboration among stakeholders, they said.

The group, which was founded nearly a decade ago to expand access to healthcare, notes that the Affordable Care Act has been good news for scores of New Jersey residents. But far more people remain beyond its reach or are still unable to afford the quality healthcare the federal law sought to provide struggling Americans.

Since the ACA's implementation in 2014, more than 700,000 Garden State residents have been added to the healthcare insurance rolls through the state's expansion of Medicaid or with lower-cost private plans individuals have purchased with the help of federal subsidies. But experts believe more than 1 million people still lack coverage and more than 500,000 undocumented residents are barred from coverage under the law.

At a conference on Friday hosted by the Health Care Coalition, which involves nearly three dozen groups, discussed a variety of strategies to expand insurance coverage; limit out-of-pocket costs; increase accountability, quality, and care coordination for consumers; and build healthy communities outside hospital walls.

"We've been thinking a lot big picture these days," said Dena Mottola-Jaborska, associate director of New Jersey Citizen Action, which hosted the event, noting the five-year anniversary of the ACA's official passage and New Jersey's upcoming governor's race.

Addressing these goals will require public officials to combat longstanding weaknesses that are widely acknowledged, but tricky to resolve, like ensuring that there are enough doctors to treat Medicaid patients, but also more controversial changes, such as expanding insurance coverage for immigrant children or strengthening the rules against out-of-network "surprise" billing, speakers said. Rectifying many of these concerns will require additional pubic funding and is likely to spark opposition from powerful interest groups, like hospitals, doctors and insurance companies.

"Healthcare should not be a place for profiteering. Healthcare should be a human right guaranteed to all," cheered William McNary, a national healthcare organizer from Citizen Action in Illinois, who roused conference-goers with his near-religious fervor.

Late last month Gov. Chris Christie heralded the success of New Jersey's Medicaid expansion, a provision of the ACA that allowed the state to raise the program's income ceiling and enroll more than 500,000 new residents since 2014. Operating as NJ FamilyCare, the program covers a total of 1.7 million beneficiaries.

Christie said that, among other benefits, the expansion enabled more than 9,000 individuals to newly qualify for substance-abuse disorder programs and that demand for these services has shot up nearly 500 percent since 2013, before the ACA took effect. The change also resulted in fiscal savings for state residents, he said, with New Jersey's share of the Medicaid bill dropping from 45 percent to 39 percent as a result of a better federal match on program dollars.

But Christie has been less enthusiastic about other parts of the ACA, which remains highly controversial politically. His administration declined an option to create its own online marketplace for lower-cost private policies, so the federal government built it by default. Nearly 300,000 residents who don't qualify for Medicaid but can't afford full-price policies have since purchased policies on this market, with the help of federal subsidies.

Several at Friday's conference said that while the Medicaid expansion has been effective, the marketplace has had some problems. Consumers are particularly concerned about the costs involved; despite federal subsidies that bring premiums down to less than $100 for the majority of policyholders, copays and cost sharing means many can still not afford the treatment they need.

"Medicaid has been such a great success and the marketplace has been somewhat disappointing," said Josh Spielberg, who works on Medicaid issues for Legal Services NJ. "Even if you can afford the premium you get stuck with the cost sharing."

Ray Castro, a healthcare analyst with New Jersey Policy Perspective, suggested the state could do more to ensure marketplace insurance plans are designed to keep out-of-pocket costs low. The coalition would also like to see the state have greater regulatory control over insurance rates, as some other states do. Insurance companies point out that this is already one of the most heavily regulated states and that rates reflect the cost of care here, which is among the highest nationwide.

"In New Jersey we're in pretty good shape in that all the essential services are excluded from the deductible" under marketplace plans, Castro said, "but you still have cost sharing and if the cost sharing is too high, that's going to be a problem."

Surprise billing is another priority for the coalition. Members support a highly controversial measure (A-1952/S-1285) that requires greater disclosure from insurance companies, places caps on certain charges, establishes a dispute-resolution system, and provides other consumer protections. An assembly version was approved in June by a committee governing insurance issues and coalition members are pushing for more action this fall.

Johanna Calle, a program coordinator with the NJ Alliance for Immigrant Justice, said that even with an insurance card it can be hard to find a provider that will take a specific plan is accessible by public transportation and, in many cases, speaks a patient's language. And if one family is turned away, that news travels fast through the community, she said. "We always just send them to the FQHC (Federally Qualified Health Centers), which treat patients regardless of insurance or citizenship status," she said.

Castro said the coalition is looking at options to help consumers who currently earn too much to qualify for Medicaid, but are struggling to make the marketplace plans work financially. Ideas include a state-administered health plan similar to Medicaid to cover these patients, or a public health insurance plan, operated by a government agency, to compete with private plans on the marketplace. Another goal is to expand Family Care to include all children under a certain economic threshold, regardless of immigration status. Castro said such an effort would generate significant savings over time, but the upfront costs make these options politically challenging.

Even Medicaid has its problems, speakers noted. Access to care for those with government insurance is also blocked by a chronic lack of providers who will accept Medicaid, which reimburses them at far lower rates than private insurance plans. Spielberg, with Legal Services, described "phantom networks" in which a website might list 30 primary-care providers that claim to take the government plan, when in fact only a handful actually do — and several who these doctors have poor patient ratings.

Most important is keeping people healthy, explained Kwaku Gyekye, director of population health for RWJ Barnabas and Jersey City Medical Center. Instead of investing in hospital systems alone, he said more needs to be spent on ensuring people with chronic diseases get well and keeping communities healthy, with options for fresh food, exercise, and safe, nontoxic surroundings.

"We've more or less flipped it over," Gyekye said, so the hospital is no longer the central focus. Helping patients pay for transportation to a checkup, or rewarding them with a gift card for monitoring their blood pressure can help empower patients and provide better outcomes, he said. "It still is possible to increase quality and decrease cost," he said. "It can be done. It's just having the commitment and doing it."

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