Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:

• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

CO-OP'portunity Brings Competition, Lower Costs for Small Businesses

Consumer Operated and Oriented Plans, or CO-OPs

for short, are a new health insurance option for small business owners. Created by the Affordable Care Act, CO-OPs are consumer-directed and required to engage members in plan oversight. Only insured members can vote for and run for a seat on the CO-OP’s Board of Directors.

What is a CO-OP?

The federal CO-OP program offers low-interest loans to eligible nonprofit groups to help set up and maintain these issuers. CO-OP loans are only made to private, nonprofit entities that demonstrate a high probability of financial viability. All CO-OPs receiving loans were selected by the Centers for Medicare & Medicaid Services on a competitive basis based on external independent review by a multi-disciplinary team. As CO-OPs meet or exceed developmental milestones, funds are allowed to be incrementally drawn down.

Taking Advantage of a CO-OP'portunity

The Illinois small business community capitalized on the CO-OP option. Small businesses in Illinois had been confronting high health insurance costs that threatened their ability to offer employee coverage. Illinois was previously dominated by one major health insurance carrier, who in 2014 wrote over 90% of the public health insurance marketplace policies in state. This market dominance gave small business owners few options in terms of obtaining and providing their employees with affordable health insurance. With CO-OPs offering the promise of increasing competition and lower rates, small businesses and individuals formed a CO-OP owned by its members and operated by its advocates.

Small Business Have More Choice

CO-OPs are following through on that promise. The Illinois CO-OP has enrolled over 35,000 members for 2015. During the second open enrollment period, one of every four new enrollees to the 2015 public marketplace is choosing a CO-OP. This additional competition is fantastic news for small business owners and their employees.

And High-Quality Plans

The Illinois CO-OP has been able to roll out innovative and transparent plans that connect consumers with provider choices they know and trust, because of the CO-OP's close relationship with the medical community. A consumer’s commitment, as an individual or employee, to choose the provider on the front end and at the time of selecting insurance coverage motivates the provider to build a strong relationship with that consumer. As a consumer-focused company, The CO-OP's small business insurance offerings are also designed by individuals who are attuned to the unique needs of this community.

The Bottom Line

The majority of small business owners value and care about their employees. Moreover, healthy employees with access to quality medical care are happier, more motivated and productive. Stabilizing health insurance premiums for small businesses while at the same time enabling them to procure quality coverage for their employees is a true game-changer. Small businesses drive our economy. Providing them access to affordable health insurance will benefit not only the small business community, but the entire Illinois economy.


Elliot Richardson
Founder and CEO
Small Business Advocacy Council

From Getting Insurance to Actually Using It

After the 2015 Open Enrollment Period 347,300 Illinoisans purchased plans through the marketplace, and 541,000 people have enrolled in Medicaid since its expansion in 2014. While connecting individuals to coverage is good news, the newly insured are often overwhelmed by having to navigate the overly complex healthcare system and understand the related insurance and medical jargon.  This confusion and lack of experience counteracts one of the healthcare reform law’s major goals: to reduce medical costs by increasing access to primary care. Obtaining coverage will not offset a lifetime of avoiding the doctor’s office and visiting the emergency room for primary care. The newly insured must learn how to find a doctor, fill a prescription and read a prescription label. Without that, they are subject to poor health outcomes and high costs. The newly insured must gain health literacy which can only happen through the combined efforts of consumers, communities, providers and governing bodies.

What is Health Literacy? 

The Centers for Disease Control and Prevention define health literacy as the degree to which an individual can obtain, process, communicate and understand health information and services. People with low health literacy are more likely to be uninsured. Similarly, uninsured individuals show lower health literacy scores compared to those receiving employer-based coverage.

So Why Does Low Health Literacy Matter? 

It is not altogether surprising that the uninsured and those with low health literacy are less likely to seek preventative care; more likely to experience poor health outcomes; and more likely to encounter higher medical costs. According to the Kaiser Family Foundation, only 1 in 3 uninsured adults said they had a preventive visit with their physician in the previous year, and uninsured adults experienced higher mortality rates than the insured. An Institute of Medicine report found a similar pattern of healthcare use for those with low health literacy, stating this group was less likely to seek preventive care. Research also found that lower health literacy in Medicaid managed care settings is connected with higher mortality. This shows that the uninsured and people lacking health literacy interact with the healthcare system in similar ways: poorly. Using the healthcare system is something people must learn. Giving someone a computer does not mean they know how to type. In the same way, connecting a person with healthcare will not alter their level of health literacy.

Old Habits Die Hard. The newly insured will continue receiving care in ways most familiar to them, which can translate to using the emergency room for non-emergencies. According to the Oregon Health Insurance Experiment, individuals who received Medicaid coverage increased their emergency room use by 40%. Asked to comment on the results, the state director of policy and programs for the National Association of Medicaid Directors alluded to the importance of promoting health literacy in the newly insured. She said, “this is not something that is unexpected” and “the key to getting inappropriate costs down for all patients is educating people about where they should go when it’s not an emergency.”

How to Address Health Literacy

Government Efforts
State initiatives, including an Illinois Emergency Room Diversion Grant are acknowledging the importance of patient education and using outreach to reduce ER use. In Illinois, hospital staff led outreach explaining the proper use of the ER and offered a 24-hour nurse triage line as an alternative. Meanwhile, Maine is targeting ER super-utilizers through community care teams that offer intensive case management including home visits and health coaching. Recognizing state efforts like that of Illinois and Maine, CMS listed patient education as a recommended component of programs targeting ER super-utilizers.

Health Professional Efforts
Beyond education on how to use their health insurance, health professionals can improve the usability of health services by reducing medical speak in patient interactions. Healthcare systems can also create plain-language pamphlets for patients to reference after leaving the doctor’s office. By speaking with patients in a relatable manner and sharing usable information, doctors better position healthcare consumers to adhere to medical recommendations.

Northwestern University’s Division of General Medicine and Geriatrics focuses on improving engagement between providers and patients and has developed plain-language materials that communicate complex health topics. For example, researchers created written information and videos available in Spanish and English that teach patients diabetes self-management. The modules use simple language and rely on pictures to communicate aspects of diabetes care, such as how the disease can impact a person’s eyes. By using these materials when interacting with diabetes patients, health professionals communicate vital aspects of care in an accessible manner, increasing the likelihood that patients adopt the healthy behaviors.

Community Health Literacy Efforts
The Be Covered Illinois campaign is promoting health literacy by generating easy-to-read written and online materials, creating short videos explaining critical concepts and utilizing community partnerships to expand the reach of their communications.  By producing written fact sheets on finding the right doctor and developing web content on using your coverage Be Covered empowers the newly insured with the knowledge to navigate health insurance and health care systems more effectively. Be Covered’s Dr. Lopez video series, presented in both English and Spanish, addresses health insurance topics, chronic disease, prevention and more. Be Covered broadens the reach of their education efforts by partnering with 82 organizations in Illinois, including Illinois Health Matters, that share information and materials with their own constituencies.  As part of that effort, Be Covered provides regular content for social media and shares copies of consumer friendly resources free of charge to partners.

Illinois Health Matters recognizes the importance of not only getting insurance but using insurance. The website features resources such as a Medical Cost Look Up, that allows consumers to estimate out-of-pocket costs for medical services and a resource on Immunizations and the ACA, outlining the vaccines children and adults can access for free because of healthcare reform. The website also has a tip sheet titled What to Know About Provider Networks, explaining steps consumers can take to avoid high medical costs associated with out-of-network care. These are just a few examples.

Illinois Health Matters is taking on the challenge of supporting a more health literate population, but we can’t do it alone. Join us. One great way to start: subscribe to our newsletter to stay informed and share the knowledge with your clients and coworkers. The healthcare community can achieve the vision of the Affordable Care Act, but only through the joint efforts of providers, policymakers and organizations supporting health literacy.

Bryce Marable MSW

Health Policy Analyst 

Health & Disability Advocates

Employer-Sponsored Health Insurance Staying Steady

Rates of employer-sponsored healthcare have not declined since the implementation of the ACA, according to Fredric Blavin, a Senior Research Associate at the Urban Institute’s Health Policy Center. These findings, published in the January 2015 issue of Health Affairs, are based on his analysis of the Health Reform Monitoring Survey. Researchers at the Urban Institute administered this survey to workers between June 2013 and September 2014, asking if they are/were employed and if they are/were offered employer-sponsored health coverage. Analysis of these national data, displayed in figure 1, suggests that rates have remained statistically constant. The pre-existing and new ACA economic incentives for workers to obtain coverage from employers remains strong; the feared erosion has not yet materialized.

Massachusetts An Early Example

Earlier studies on Massachusetts’ employer-sponsored insurance market support Blavin’s findings. Between fall 2006 and fall 2009, a period of time which included adoption of the state’s health reforms, the rate of employer-sponsored insurance increased by 3%.

ACA Provisions Prevented Downward Direction

Incentives in the healthcare law have restrained the predicted drop-off in employer coverage. Provisions, such as ongoing preferential tax treatment of premiums through payroll deductions and the mandate to provide coverage for businesses with 50 or more workers, have persuaded employers to continue offering plans.

But Small Firms Are Left Out

One notable result from this survey is the nagging imbalance between large firms and small firms offering coverage.  Although mechanisms like the small employer tax credit and the SHOP Marketplace are meant to close this gap, small businesses have not taken advantage. Outreach and education with small businesses represents a large opportunity for insurance coverage expansion.   Small employers need information to understand provisions of the ACA in order to provide health insurance options to this growing workforce.

Michele Thornton, MBA
Insurance and Benefits Consultant

Illinois Small Businesses Should SHOP for 2015 Health Coverage

Small business owners: are you considering all available options to find a health insurance plan that works best for your business and employees?

One resource for Illinois small business owners is the Small Business Health Insurance Options Program, or SHOP, where employers can compare group health insurance options. The SHOP is open year-round for small employers to browse, compare plans, and fill out applications online.

The Benefits of SHOPping Around

Buying health insurance through the SHOP can help small businesses save money. According to the Robert Wood Johnson Foundation, total spending on healthcare by small businesses will decrease by 8.7% because of provisions in the healthcare law. Small employers that offer coverage through the marketplace may be eligible for a tax credit that can cover up to 50% of their employees’ premiums. The Small Business Majority’s tax credit calculator shows if small businesses are eligible for the credit and how much money they could receive.

There are even more benefits to buying a SHOP plan, because small businesses will no longer be charged more for female workers, who had been paying up to 50% more for their premiums before the healthcare reform law. In addition, employers will no longer pay more for workers with pre-existing conditions and will benefit from new limits regulating health insurance costs for older workers.

Health & Disability Advocates, a non-profit with 16 full-time employees, is an example of a small organization that used the SHOP and found a better deal. Both HDA and its employees gained – the non-profit is now spending approximately $20,000 less on healthcare, while its workers have lower premiums and have access to a wider network.

The Downside of Sticking With Your Current Plan

As many as 80% of companies with up to 50 employees opted to renew their non-compliant plans for 2014, and a similar percentage will likely try to do so this year. Small business owners who decide to renew their old plan may not save money and may instead see a price increase for 2015. This is why investigating all health insurance options, including those offered through the SHOP, could benefit small businesses. Many could save money by purchasing a plan through the health insurance marketplace, or through selecting a plan with better coverage for about the same cost.

How to Start

In order to begin the enrollment process and explore options, Illinois small businesses can visit the SHOP online, or contact a certified health insurance broker to assist with the enrollment process. The more small business owners know, the easier it will be for them to get their employees more-affordable insurance coverage. Once owners have found a reasonable option for their small business, they can stop worrying about health insurance and do what they do best – run the companies that make up the backbone of our state and our nation.

Jesse Greenberg
Director, West and Midwest
Small Business Majority

Don't Chip Away CHIP

Leaders, from Illinois and across the country, are calling on Congress to continue funding the Children’s Health Insurance Program by highlighting its success in reducing the number of uninsured children and warning that these children may lose coverage or receive less age-appropriate care.  The Children’s Health Insurance Program, or CHIP for short, offers developmentally appropriate healthcare for low-and-moderate-income children from families earning wages above the Medicaid threshold.  In Illinois, the program covers 219,000 children and pregnant women as of June 30, 2014.

The healthcare reform law funded CHIP until October 2015, but states need quick federal action as they plan their budgets for the coming year. Unfortunately, Congress may forgo CHIP funding, because children could potentially obtain health insurance through the health insurance marketplace. However, the health benefits in a marketplace plan may not equal those offered through CHIP, and families may not be able to afford the premiums and co-payments.

CHIP’s Benefits are Better

The essential health benefits in the marketplace’s qualified health plans can differ from CHIP’s; marketplace plans can either enact more stringent benefit limits or not cover important pediatric services. For example, a Government Accountability Office study of CHIP programs in five states including Illinois found that marketplace plans were more likely to limit pediatric services and that CHIP offered more generous ceilings for certain services.

Of special significance for children, marketplace plans are not required to cover pediatric dental services if a stand-alone dental plan is available. This means families might be forced to purchase a dental plan in addition to a general health plan for their children—increasing monthly premiums. Since the individual mandate would not apply to dental coverage, families may forgo pediatric dental coverage altogether.

Children in the Illinois CHIP program, All Kids, benefit from Early and Periodic Screening, Diagnosis, and Treatment services. EPSDT can identify medical conditions at an earlier and more treatable point in time and link children with necessary care. The benchmark plan for the state does not offer a comparable set of services. 

Higher Costs and Family Glitches

CHIP health plans, including Illinois’ All Kids, have better cost sharing arrangements than marketplace plans. Monthly premiums in All Kids range from $0-40, while the marketplace’s lowest cost bronze plan in Chicago had a heftier premium of $76 per month.

A report by the nonpartisan Medicaid and CHIP Access Payment Commission found similar patterns across the nation. According to the report, the actuarial value, or the costs covered by a health insurance plan, is generally lower in marketplace plans.

Parents and children forced out of CHIP plans would also encounter higher healthcare prices due to the ACA’s family glitch. The healthcare law bases affordable workplace insurance—and a family’s eligibility for marketplace financial assistance—on the cost of insuring individuals, not families. Parents are placed in the bind of being unable to afford their employer’s family plan, because that option involves much higher costs, but cannot qualify for tax credits or subsidies.

Stick with CHIP

Advocacy groups and leaders from both political parties have called CHIP a success. Since its creation in 1997, the program has increased the number of children with health insurance: 8 million children were enrolled in 2012 alone. The program has contributed to the marked decrease in the percentage of uninsured children, which has fallen from 13.9% to 7.1% over the past 17 years. Because of CHIP’s proven track record and uncertainty surrounding healthcare options in a post-CHIP era, Congress needs to continue funding this important program.

Bryce Marable, MSW
Policy Analyst
Health & Disability Advocates

Employers: Dropping Group Health Insurance Could Cost You

Looking ahead to 2015, many employers are deciding how to respond to the rising cost of employee group health insurance premiums. A study of employers by the large consulting group Mercer suggests that “the per-employee health benefit cost will rise by an average of 3.9% in 2015.” Although this is moderate compared to past premium-increase trends, “two-thirds of respondents say they will make changes to their health plans next year to rein in cost growth.”

Using Cash Pay-Outs Instead

To control costs, some small employers are considering dropping group coverage altogether. In a recent article by the Wall Street Journal, WellPoint, Inc. reported that “its small-business-plan membership is shrinking faster than expected and it has lost about 300,000 people.”

Many small employers are instead planning to offer a cash payout – a lump-sum of cash – for employees to purchase coverage on their own or through the new ACA marketplaces. While this may appear an attractive way to rein in health insurance costs, employers must consider the tax implications for employees and their organization. Taken together, cash pay-outs will actually increase costs overall for both employers and employees.

Employees Will Pay More...

Group insurance is a better deal for employees. With group health insurance, the amount that an employer pays towards an employee’s health insurance is not counted as taxable income. In addition, employee premium contributions can be withdrawn pre-tax directly from their paycheck. This substantially reduces the employee’s overall taxable income and the income tax they will pay. The example below shows the monthly take-home pay for a person making $6,250 per month who participates in an employer-sponsored group health plan.

As the example indicates, the employee’s net pay is $3,955. In comparison, if the same employee instead received a cash pay-out to purchase health insurance individually, they would make $3,595 per month. Example 2 shows how employees will end up paying more in taxes and more for their insurance when a cash pay-out is used.

As you can see, cash pay-outs will reduce overall employee compensation. When employees give workers cash to pay for their own health insurance, the money increases their gross income and in effect the monthly taxes they must pay. Additionally, the money directed toward employee premiums cannot be withdrawn pre-tax from their paycheck.

The real numbers will change depending on premium costs, tax brackets, and income level, but the message is consistent: employees will lose money. Employee Benefits Corporation has a great calculator tool that helps individuals understand the personal impact of pre-tax benefits.

... And So Will Employers

Because cash pay-outs increase employee gross income, the amount that the employer must pay in state and federal taxes will also increase. In our example above, when the employer offered group health insurance, the employee earned a base monthly salary of $5,650. In the second scenario, the employee’s monthly salary increased to $6,850. Employers pay on average 7.65% of their monthly payroll for Social Security and Medicare. For the employer providing group health insurance, the cost for Social Security and Medicare is $432; the employer offering cash instead of benefits would pay $524. This results in a difference to the employer of $92 per month – just for this one employee.

Higher salaries created by cash pay-outs also mean higher workers compensation costs, and short-term and long-term disability insurance. Since workers’ compensation replaces a portion of the employee’s salary, the higher the salary, the higher the costs. The same is true for short- and long-term disability insurance, which replaces all or part of employee salaries.

Stick With Group Health Insurance

Before quickly migrating to cash payouts employers should quantify cost implications for themselves and their employees. This calculation can complicate and lengthen the decision making process – but it is time well spent in the long run. If the goal is to reduce financial burden, using cash pay-outs ultimately creates the opposite effect and the promised reduction in costs is an illusion.



Michele Thornton, MBA
Insurance and Benefits Consultant

Why Narrow Networks are a Big Deal: A Discussion of Network Adequacy

A network is defined as the healthcare facilities, professionals, and suppliers that an insurance carrier has contracted with to include in a given health plan. Network adequacy is the extent to which a health plan has a satisfactory number of primary and specialty healthcare professionals that consumers can access in a timely manner.

The terms network and network adequacy are pretty technical words, so the average consumer may not know their definition, but a percentage of the population is even unaware of how to apply these terms to the process of purchasing a health insurance plan. According to a Commonwealth Fund survey of marketplace shoppers, 25% said they did not know the quality of the network for their health insurance plan. The survey results indicate that consumers may lack an awareness of how network adequacy impacts them on a personal level.

Consumer Problems with Network Adequacy

Consumer awareness is important, because network adequacy can have a tremendous influence on a patient's quality of care. For example, plans can include a hospital in their network, yet exclude doctors or specialists working at that hospital. As a result, patients may unknowingly receive care from an out-of-network doctor and be left with an exorbitant bill. This practice, in which consumers must pay the costs beyond the allowable amount determined by the health insurance company, is called balance billing. Sometimes the lists of healthcare professionals in a network are not even accurate, which may lead consumers to enroll in a plan that does not have their desired provider. Also, hospitals serving special populations, such as children, have reported difficulty being included in networks – preventing families from getting needed care at a reasonable cost.

Network Reforms Proposed

These issues may soon change. The National Association of Insurance Commissioners (NAIC) recently released a new draft model law for states, which has proposed some significant reforms. To begin with, hospitals would need to develop a process for alerting patients in cases where they may be seeking treatment from an out-of-network provider who happened to be working at an in-network hospital. In addition, insurance carriers would be required to update changes to their provider networks on a monthly basis and must make this information available online and in print form.

NAIC's draft model law also created the general recommendation for states to create sufficiency standards accounting for elements such as the amount of specialty services available, geographic accessibility, the number of providers, the wait time for receiving care, and the hours of operation for participating providers. NAIC gives states latitude in how they apply their sufficiency standards. However, NAIC does note that some states have chosen to adopt quantitative standards that set minimum numbers for providers for maximum travel times and maximum waiting times, among other metrics.

Changing Consumer Experiences for the Better

The reforms requiring insurance companies and healthcare providers to communicate accurate and timely information on healthcare networks are a much needed help for consumers who lack basic knowledge of their options (which may be due to the fact that they hate shopping for health insurance). Mandating more open lines of communication would simplify the process of finding and using health insurance. With readily available information, consumers would know what providers and hospitals are a part of their plan. Importantly, state actors are recognizing the significance of empowering consumers with knowledge, as the Illinois Department of Insurance recently released fact sheets on networks and out-of-network benefits.

Beyond improving communication with consumers, NAIC’s draft language on sufficiency standards would support consumers who have purchased a plan in having the ability to access the healthcare providers they need to stay healthy – without traveling great distances or waiting long periods of time. Advocacy needs to be done at the state level to guarantee that the sufficiency standards in place are in line with the intentions of NAIC’s draft model law and create quantitative metrics to determine a network’s strength.


Bryce Marable, MSW
Policy Analyst
Health & Disability Advocates

People with Disabilities and the ACA

The Affordable Care Act (ACA) is making health insurance coverage more affordable and accessible for millions of Americans. With the passage of this law, individuals and families have more control over their care – especially individuals with disabilities. The ACA provides people with disabilities a basic protection – they can no longer be denied access to health insurance simply because of their health history.

Under the ACA, individuals like myself can no longer be denied health care because of a pre-existing condition. This is significant for the up to 129 million non-elderly Americans living with some type of pre-existing health condition such as asthma or diabetes, including 17.6 million children.

We have come a long way over the past year. All combined, in just one year, we’ve reduced the number of uninsured adults by 26%. Additionally, 76 million Americans with private health insurance are getting preventive services such as vaccines, cancer screenings, and yearly wellness visits for free. Finally, more than 7 million Americans are enrolled in the Marketplace and more than 8 million additional individuals are enrolled in Medicaid and CHIP, compared to last fall.

We have much to celebrate but there is work to be done. November 15 marks the beginning of the second enrollment period, which will run until February 15. The Administration is committed to ensuring that all Americans have access to coverage. The open enrollment period is a time for Americans already enrolled to re-enroll. It is also a chance for those without coverage to enroll for the first time.

Take a few minutes to watch Joey talk about what the ACA has meant for him and millions of others:

To learn more about getting covered, please visit HealthCare.gov.

By Taryn Williams
Associate Director of the White House Office of Public Engagement.

Posted with permission from The White House Blog 

Small Businesses in Illinois Lack Knowledge of What the ACA Has to Offer Them

With Illinois granted early access to the Small Business Health Options Program exchange, or SHOP, small businesses in the state already have the opportunity to familiarize themselves with a new online resource for purchasing health insurance for their employees.

For those that qualify, purchasing health insurance through the SHOP exchange can represent a smart business decision. They can receive tax credits covering up to 50% of their contribution to employee premiums, plus the SHOP allows small businesses to combine their purchasing with other small businesses to keep costs low.

The healthcare law does not require small businesses with fewer than 50 full-time equivalent employees to provide health insurance. Because 94% of businesses in Illinois employ fewer than 50 people, a large majority are exempt from offering health insurance.

The SHOP was meant to minimize the number of people left out of health reform by helping small businesses provide health insurance anyway, with tax credits and collaborative purchasing power incentivizing this option by keeping costs lower.

But to what extent are small businesses taking advantage of the SHOP? Health & Disability Advocates and Crain’s Chicago Business teamed up to find out and conducted a survey of small business owners. The results are documented in a recently released report from Health & Disability Advocates and an article in Crain's Chicago Business.

The survey found that small businesses are not using the SHOP to purchase health insurance and are largely uninformed about it:

• Fewer than 18% of small business owners said they had learned “a lot” or a “a great deal” about the SHOP.
• Only 11% took advantage of the small business healthcare tax credit.
• And finally, 31% of small businesses surveyed said they did not know whether they were receiving the small business healthcare tax credit.

These findings mirror national trends. In a national survey by the National Small Business Association, 8% of small business owners reported they would use the SHOP to buy health insurance. Similar figures from the Kaiser Family Foundation were cited in a recent blog post at The New York Times.

Small businesses would gain from outreach and education on benefits of the SHOP and how to use this resource. Informing the business owners about the SHOP would equip them with information that they could use to enroll their employees in health insurance, an important benefit that helps in retaining and attracting workers.

Since small businesses overwhelmingly rely on brokers when purchasing insurance, the broker community could be a resource in outreach and education efforts. Indeed, brokers are increasingly viewed as vital partners in healthcare outreach and enrollment efforts. For example, during the first enrollment period they played a key role in the famously successful effort in Kentucky. Partnering with brokers to conduct outreach can help increase the numbers of small businesses that offer health insurance – and the number of individuals enrolled in healthcare.

The bottom line is that small businesses in Illinois are not aware of the Small Business Health Options Program, the tax credits available to them, or other ACA provisions that could benefit them. For us to effectively reach these important job creators and help them take advantage of these provisions, we must engage the broker community to provide this new outreach and education to their existing clients.

Bryce Marable, MSW
Policy Analyst
Health & Disability Advocates

Illinois Entrepreneurs and Small Business Need SHOP Employee Choice

Illinois is one of 18 states recently granted a delay by the Department of Health and Human Services for the employee choice feature of the small business health options program marketplace, or SHOP.

But what exactly is employee choice, and why is this important to small business owners? Below are some frequently asked questions and answers to help small employers learn more about this crucial provision of the SHOP.

Q: Just what is employee choice?
A: Employee choice is a feature of SHOP that allows small business workers to choose from a number of plans from different insurance carriers. The employer chooses a healthcare plan tier level (bronze, silver, gold and platinum), and the employee then chooses among a variety of health insurance carriers within that tier.

The healthcare plan tier level is based upon what percentage of healthcare costs a plan will cover. For bronze plans, insurers pay 60%. For silver plans, insurers pay 70% of healthcare expenses. Gold plans pay 80% and platinum plans pay 90%. The employee choice option is important to employers and their workers because it allows employees to pick a plan and carrier that works best for their needs, instead of the business owner choosing for them.

Q: Why is the employee choice feature important to small businesses?
A: By including employee choice in the SHOP, the Affordable Care Act reverses a longstanding market trend that left small employers on unequal footing. These kinds of benefits have historically been reserved for large businesses and public employees, while small businesses often have to offer a “one-size fits all” plan with added cost and fewer benefits.

Based on Small Business Majority’s opinion polling, it is clear small business owners want to offer this to their employees. The Small Business Majority found two-thirds of small employers believe allowing employees to choose from multiple carriers is an important element of the SHOP. And for small businesses, this component is fundamental in distinguishing the new SHOP marketplace from the outside health insurance market.

Q: What impact does the delay of employee choice have on Illinois’ small businesses?
A: The HHS final rule allowing states to opt out of employee choice for yet another year harms small businesses because it puts them at a competitive disadvantage to large firms that are able to offer a choice of plans to their employees. In states like Illinois, where the SHOP marketplace is run by the federal government, allowing further delay of employee choice puts small businesses at a competitive disadvantage to small employers in other states where marketplaces have employee choice.

Q: When will Illinois small businesses have access to employee choice through SHOP?
A: Barring any further delays, Illinois will implement employee choice in 2016. Employers will then be able to offer the additional benefit of allowing their employees to choose which insurance carrier they’d prefer to use for their health insurance.

While the Administration’s decision to allow states to delay employee choice for an additional year was a letdown for small business owners, the SHOP still helps small employers compare and evaluate health insurance options and get the small business tax credit to help with employee premiums.

Learn more about the SHOP, employee choice and enrollment by reading the Small Business Majority’s Health Coverage Guide which contains a wealth of information for small business owners regarding enrollment, the Affordable Care Act, and the healthcare system.

Jesse Greenberg
Director, Midwest and West
Small Business Majority

Illinois Granted Early Access to SHOP Marketplace

Yes, the Affordable Care Act offers individuals and families quality health insurance, but did you know small employers with less than 50 full-time equivalent employees can take full advantage of the Health Insurance Marketplace? Online functionality for the SHOP, aka the Small Business Health Options Program, is available starting later this October as part of SHOP early access, which is only available to 5 states. Illinois is one of the lucky few. Brokers and Small Businesses, check it out at HealthCare.gov!

This incremental launch will help identify issues early and assist brokers and businesses in building confidence in utilizing the SHOP online system.

During SHOP early access, Illinoisians can do the following to initiate enrollment:

• Establish a Marketplace SHOP account
• Establish an agent or broker to their account if they wish
• Complete an employer application
• Obtain an eligibility determination
• Upload an employee roster when enrollment functionality is available
• Starting in November, browse health plans with coverage starting in 2015

The SHOP Call Center can be reached at 1-800-706-7893 (TTY: 711) Monday through Friday, 9 a.m. to 7 p.m. EST.

While small businesses have always had group plan options, many even available online, there were challenges that got in the way of providing group coverage to their employees. Premiums were expensive and small businesses lacked the purchasing power of larger organizations. The SHOP makes some pretty substantial changes to the ways in which small businesses can buy plans.

Why SHOP?

First, financial assistance is now available in the form of a tax credit. This can substantially help employers by covering up to 50% of employer contributions towards employee premiums. This assistance provides the opportunity for businesses to offer employee coverage where it would have previously been unaffordable. Second, the SHOP helps small businesses harness the purchasing power of other small businesses, thus letting them play in the big leagues along with larger organizations.

Small businesses do not have to offer health benefits under the Affordable Care Act, but it is in their best interest to check out options and see what is possible, particularly if they are concerned with employee retention. Whether or not they decide to provide group health insurance coverage, small businesses are nonetheless required to inform employees of the Health Insurance Marketplace, so that individual coverage options can be explored.

Brokers and Small Businesses take note. The time is now to explore options, prepare, and get ready for a new system opening up possibilities for small businesses in Illinois.

Emily Gelber MSW, LSW
Health Policy Analyst
Health & Disability Advocates

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TAKE OUR SURVEY HDA and Crain’s Chicago Business are teaming up to poll local small businesses about new health benefit options. Why participate? By taking this short survey about the changing healthcare landscape, you can inform policymakers, insurers and other small business owners. Results will run in a November 17 article in Crain’s. Take the survey now

Providers Will Make Medicaid Care Coordination a Success

If the opening of the health insurance marketplace taught people anything, it’s that choosing health insurance is tough. Suddenly, people had to make a thorough evaluation of their finances, the types of care they depended on, the medications they needed, and more.

Equally important, but receiving a lot less attention are the similar challenges facing people who are trying to pick a coordinated care plan under Medicaid. Generally, having choices is a good thing, but being unarmed to make the best decision is scary. So, how does one pick?

No doubt, case managers, doctors, social workers, and community organizations hear this question all the time. When the system of health care is changing so rapidly, how are front-line professionals prepared to handle the number of questions and the confusion when they may not have a grasp on what this new system is going to look like in the first place?

Almost everyone who has Medicaid in Illinois will be required to pick a coordinated care plan. These plans are offered by managed care organizations (such as Aetna and Blue Cross) and by provider groups (such as Be Well Partners in Health) that have chosen to start innovations projects, which try new ways of managing care. Collectively, they are referred to as managed care entities, but for the sake of discussion, we will refer to them here as Medicaid health plans.

Medicaid health plans must include all of the benefits traditionally offered by Medicaid, a plan can also choose to provide more benefits than Medicaid. In addition, all plans require that members choose a primary care physician. Members with more complex care needs will also be assigned a case manager, either a nurse or social worker.

Why the Change

This shift is happening because 50% of Medicaid recipients are required by law to enter into coordinated care by 2015. But aside from the legal requirement, the move into coordinated care has a number of additional drivers, including cost containment. Medicaid costs are high, often a result of inefficiencies, uncoordinated care, and a fee-for-service reimbursement structure. The hope is that the move to coordinated care will reduce costs.

As part of the move to coordinated care, the payment structure is changing. Many, but not all, Medicaid health plans will receive a capitated rate to coordinate and provide care for Medicaid members, meaning a per-member monthly reimbursement regardless of the services provided. Providers will then contract with Medicaid health plans and can negotiate their rates of reimbursement. So, Medicaid health plans receive a capitated rate, providers then negotiate reimbursement rates with the particular Medicaid health plan. Medicaid health plans are thus incentivized to control costs, because they are going to make money based upon members receiving quality care at a lower cost, rather than based upon the number of services provided.

What will all of this mean for Medicaid recipients? Each Medicaid member will receive a letter detailing health plan options available through Medicaid (many have already received them) from the Illinois Department of Healthcare and Family Services. Most will have to choose one of the plan options detailed in that letter. If they fail to choose a plan, a selection will be made for them based on their past providers, location, and previous health plan affiliation.

The choices in the letter will be based upon the Medicaid population group and where that particular member lives. For example, ACA adults have different options than Medicaid enrollees that qualified based upon disability or age; people who live in metro Chicago will choose from a different set of plans from those who live downstate. As members of these plans, there will be new rules to follow, such as using networks specific to their plan. But the plans are all Medicaid, so all of the services an individual previously had access to will remain available. And this is when the provider gets asked for help. How do they help someone choose?

The Client Enrollment Broker

Fortunately, the Illinois Department of Healthcare and Family Services has created something called the client enrollment broker. This is service that helps Medicaid members get connected to a Medicaid health plan. The client enrollment broker website (enrollhfs.illinois.gov) is where one can find information on all of the available plans, including any extra benefits that might be available, such as an allowance for over the counter products. The site has links to the website of each specific plan, where consumers can review the details of each plan.

Of course, not everyone is tech savvy, or even has internet access. So the client enrollment broker is also available to assist with enrollment by phone. The client enrollment broker can be reached at 877-912-8880 Monday to Friday from 8 am to 7 pm and on Saturdays 9 am to 3 pm. The call is free.

Before speaking with the client enrollment broker, Medicaid members will want to focus on the questions to ask. They may want to write them down – much like people are advised to write down what they want to ask the doctor during an office visit. Here are some things they will need to consider when choosing a Medicaid coordinated care plan, and to discuss with the client enrollment broker if they call:

• The letter received in the mail will have a primary care provider listed. That is the provider that will be assigned to them if they do not choose a primary care provider and plan themselves. If the person has a primary care physician at present, it will be important to ask about plans with this provider in network. Otherwise, they may want to choose one before calling the client enrollment broker.
• Anyone with special healthcare needs should ask if their specialists are in-network.
• Anyone who uses medical care centers like skilled nursing facilities or hospitals should ask whether those facilities are in-network.
• The person also should consider what medications they are taking. Although Medicaid-covered drugs should be included in the formulary for every plan, there could be variations in copays or in generics vs. brand-name availability.

The client enrollment broker will ask for a social security number and the Medicaid member should have that available for the call.

This is a lot to consider, and the Medicaid population was not prepared to make these decisions alone. For someone who has never enrolled in a health plan before, or has only ever had one choice, these changes may prove overwhelming.

Provider Participation Is Essential

So it is not surprising that providers will be called upon to assist clients in making smart choices. Without provider participation, individuals may not be able to make appropriate and educated enrollment decisions that directly impact access to and continuity of care. And just as important, providers can do their best to simplify these decisions by joining networks and being knowledgeable about their own health plan network membership. Even after members are enrolled, providers can help them navigate the new and narrower networks to avoid the costs of going out of network for care.

If one thing is clear it's that providers need to be engaged in the evolution of Medicaid. Without their involvement, foreign language speakers will not find providers that can speak to them, people with complex illness will not connect with physicians and specialists who have experience with those conditions, and patients with long-established doctor-patient relationships will suddenly be unable to see their doctor. Provider participation and networking is the solution to all of these issues.

But ultimately, providers need to be participating in the coordinated care system for reasons that go above and beyond making health plan choices easier for people on Medicaid. Right now, the entire Medicaid system – both traditional and expanded Medicaid – is rapidly transforming into a coordinated care system. That means that many clients or patients will be in that system, and they will be restricted to those networks. To keep their Medicaid patients, providers need to be in that system as well.

Another benefit is that billing can be simplified with Medicaid health plans. Back office billing functions – which are notoriously complicated and slow with fee-for-service Medicaid – could start to become more straightforward. In fact, Medicaid health plans should actually reimburse efficiently since they are contractually obligated to pay in a timely manner. Wouldn’t that be nice?

Care coordination is here and it is happening now. It’s time to participate. Providers can either play a part, or patients will feel the consequences. And really, so will providers.


Emily Gelber, MSW, LSW
Health Policy Analyst
Health & Disability Advocates

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Learn more about Medicaid Care Coordination.

Did Obamacare Destroy Competition in the Private Insurance Market?

One of the biggest criticisms of the Affordable Care Act was that it would be the death of the private insurance marketplace. Opponents of healthcare reform cautioned that the law change would crowd out private innovation in the market and make insurance carriers less interested in competing.

If we take a closer look back at the progression of insurance company involvement in Illinois, I think we’ll find that not only was this not the case – but in reality, the reverse was true.

Prior to the 2014 open enrollment period, the small business market in Illinois was extremely limited. If you had fewer than 50 employees, the options for group coverage were four to five carrier choices (depending on your county). These companies continued to churn business, and employers would change carriers every two to three years as their premium rate increases continued to increase. There were significant barriers to entry - and every time we saw a new carrier attempt to provide competitive options, the larger more traditional players quickly chased them out of the state.

For sole proprietors and the self-employed, the outlook was even bleaker. There were two or three competitive options, and the underwriting guidelines were so rigid that even those plans were unrealistic for many individuals hoping to gain private insurance coverage.

Reviewing the change to the market, we see that sole proprietors and the self-employed saw the biggest gain in options. The opening of the ACA Marketplaces in 2014 offered up to seven carrier choices for individuals in some regions of Illinois. Although many of the players were familiar faces, one – Land of Lincoln - was brand-new to Illinois consumers. Land of Lincoln is a co-op (oonsumer oriented and operated), a new type of insurance organization made allowable by the ACA.

The federal government has now awarded nearly $2 billion in loans to help create 24 new CO-OPs in 24 states. The CO-OP sponsors - consumer-run groups, membership associations, and other nonprofit organizations - are now moving forward to offer health coverage in competition with established commercial and nonprofit insurance companies. (Health Affairs Policy Briefs)

What about small employers? While the SHOP Marketplace faced many more struggles in Illinois, there were some indications of future hope in improving competitive choices for our state. First, Land of Lincoln did offer and enroll small employer options. This added a new type of plan for employers to consider – and because it was offered on the SHOP, employers that qualified and enrolled in their SHOP plans could take advantage of the Small Business Tax Credit.

Second, we began to see the creation and evolution of private marketplaces and partially self-funded programs being marketed to small employers. In the past, third party administrators had reserved these innovative solutions for larger clients. The need for financial solutions and minimum essential coverage has spurred creative thinking and new progressive options for forward-thinking small employers to test out. Although these solutions are in their early stages of development, they do reflect a market expansion - not contraction.

Finally, and perhaps most importantly, the existing small business market remained intact. All of the same original carriers that offered plans historically continued to do so in 2014. We didn’t see one single insurance company leave the state of Illinois - instead many of them continued to market aggressively to small businesses and create new plan offerings that would be both compliant with ACA rules and competitive.

As we begin to look forward to the 2015 open enrollment cycle, the question remains of whether this trend will continue or reverse. Early indications point to a growing market. Last month, the Department of Insurance in Illinois released a statement noting that 10 carriers have submitted applications to offer plans in the second year of the Marketplace. This representing a significant growth in choices in the insurance carriers and the numbers of plans they will offer from Year 1. (Get Covered Illinois). Here are the exact numbers:

Illinois Healthcare Marketplace Plan Options – Year 1 and 2
	Year 1 Options	Year 2 Submitted Options
Individual Plans	120	306
Small Group Plans	45	198

The Illinois Department of Insurance is not expected to announce which plans it has approved until early August. However, given the significant increase in possible options, we can expect that both the individual market and small group market will see growth for 2015. Although this is positive movement, my hope is that the department will focus its expansion of plan approvals on the small group marketplace, which was significantly under-represented in choices in 2014.

In any case, the numbers show promising evidence of expanded insurance plan competition under Obamacare – something that small employers and the self-employed desperately needed prior to its enactment. We can and should consider this component of the legislation a true economic win for Illinois business.

Michele Thornton, MBA
Insurance and Benefits Consultant

Learn. Connect. Share. PTSD Treatment can help.

June was PTSD Awareness Month. And although spotlighting it throughout the month of June brings a lot of great information to the public, it is important to remember that PTSD is something that many individuals struggle with throughout the year.

Take the Fourth of July as an example: This great American holiday is only four days past the end of PTSD Awareness Month, but many people are not aware of the impact this holiday has on combat veterans with PTSD. For many of them, these exuberant displays of sound and light trigger combat flashbacks that last long after the last sparkler has fizzed out for the night.

This year, there has been more publicity around the effect that fireworks can have on returned vets. And there has been a growing campaign to increase PTSD awareness by placing signs in front lawns that read: "Combat Veteran Lives Here, Please Be Courteous with Your Fireworks." The experience of combat veterans on the Fourth of July is a prime example of the type of awareness that needs to continue beyond the month of June, and that is an awareness that centers on respect for those who suffered trauma in the past, and who continue to feel the effects to this day.

That being said, it’s hard to know how to be courteous of those with PSTD when you don’t have a very firm grasp on what PTSD is. Although it is most commonly associated with combat veterans – and vets as a population experience PTSD at a much higher rate – it also occurs in those who have lived through other violent experiences. The National Center for PTSD defines it as "a mental health problem that can occur after someone goes through a traumatic event like war, assault, an accident or disaster."

Understanding that PTSD is not limited only to combat veterans is an important step in learning how to be mindful of things that may trigger flashbacks or any other cognitive or bodily symptoms. Things that might seem part of the norm – like fireworks on the Fourth of July – can actually cause a painful reliving of a traumatic moment.

The way each person experiences their PTSD is different, and the only way to be able to really get a grasp on what these individuals experience is through talking with them. However, it is understandably difficult for many to recount their stories, so it is important to be patient and supportive. Reach out if you see that your friend or family member with PTSD wants to talk and be sure to listen to their story.

If you or a loved one struggles with PTSD, or if you just want to learn more about how you can help support someone with PTSD, the Department of Veterans Affairs' websie has a comprehensive section devoted to the condition, the National Center for PTSD (ptsd.va.gov). The section has resources for everything from treatment options like exposure therapy to a section specifically geared toward friends and family members.

Also, let people know that treatment is covered! The Affordable Care Act requires qualified health plans to include mental health services as an essential health benefit. The ACA also outlaws discrimination based on pre-existing conditions, so individuals with PTSD or other mental health symptoms need not be worried that they will be denied coverage or that their coverage will be cancelled.

This year’s PTSD Awareness Month motto was aptly put and is something to keep in mind throughout the year: "Learn. Connect. Share. PTSD treatment can help." Connect by reaching out to someone around you. And finally, share your experiences and knowledge with others.


Julia Ortner
Intern
Health & Disability Advocates

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To learn more:

• Explosion of Kindness – yard sign campaign
• For Vets With PTSD, Fireworks Can Trigger Painful Memories – at CBS Minnesota
• National Center for PTSD – at the VA

Supporting Chicago's Entrepreneurs: Marketplace Brings New Health Coverage Options

Finding the right healthcare plan can be stressful, and with all the noise surrounding the new healthcare law, it may seem downright overwhelming. But there’s good news coming out of Illinois. The state’s new health insurance marketplace is open for business, and it’s already providing small business owners and their employees with improved options for affordable coverage.

The new marketplace, Get Covered Illinois, is a partnership marketplace, which means the state and federal government run the marketplace together while Illinois prepares to run the marketplace on its own beginning in 2015. Get Covered Illinois has two branches – one for individuals, the other for small businesses. The individual marketplace is available to any self-employed individual or small business employee whose employer doesn’t offer insurance. Open enrollment for 2015 begins on November 15. In the meantime, employees and self-employed folks can use an online calculator to determine if they’re eligible for a subsidy to help cover the cost of insurance for coverage in 2015.

Many self-employed Chicagoans have already discovered the benefits of enrolling through the state’s marketplace, including Jade Phillips, a local children’s book author. After a brief stint with a precipitously high monthly premium and deductible from a private insurance company, Phillips says she spent the majority of her 20s uncovered. But this year, the self-employed entrepreneur was able to sign up for coverage through the individual market. For the first time in years, she’s enrolled in an affordable plan that allows her to continue doing what she loves while enjoying the peace of mind her new insurance brings.

There’s even more good news for small employers. The small business marketplace has year-round enrollment, so small business owners with fewer than 50 employees looking for a plan have plenty of time to determine if the new marketplace is the right choice. There are more than 230,000 small businesses in the Chicago metropolitan area, but in order for them to take advantage of this new option, entrepreneurs need to know what Get Covered Illinois’ small business marketplace can do for their businesses.

Here are some key facts about the marketplace to help get small employers up to speed.

• The new health insurance marketplace is one of the most important components of the Affordable Care Act for Chicago small employers. The small business marketplace allows small businesses with fewer than 50 employees to band together when buying coverage – giving them the kind of purchasing clout large businesses enjoy.
• The marketplace offers businesses more competitive choices, which can help lower premium costs, thus improving their bottom lines.
• Small employers that do offer coverage through the marketplace may also be eligible for a tax credit of up to 50 percent of your premiums. Check out our tax credit calculator to see if you’re eligible and to receive a tax credit estimate. 
• Illinois’ small business marketplace will offer employee choice in the future, which means small business workers will be able to choose from a number of plans from different carriers.

In order to begin the enrollment process, Chicago entrepreneurs can visit Get Covered Illinois’ site or Healthcare.gov and begin filling out a paper application, or visit contact a certified health insurance broker who can assist with the enrollment process.

What’s more, Small Business Majority’s certified educators can help answer questions regarding the enrollment process. Check out our state outreach calendar or the Small Business Health Care Consortium’s events page to find an event in your area.

To learn more about the small business marketplace, enrollment dates and coverage plans, visit our Health Coverage Guide (healthcoverageguide.org), which contains a wealth of information for small business owners regarding enrollment, the Affordable Care Act and the healthcare system in general.

The more small business owners know about the new marketplace, the easier it will be for them to get their employees and businesses more affordable insurance coverage. And then, instead of worrying about health insurance, they can do what they do best: run the companies that make up the backbone of our state and our nation. 

Mary Timmel
Midwest Outreach Manager
Small Business Majority