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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000438861.43121.63
AJN Reports

The New Health Insurance Marketplace

Jacobson, Joy

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Abstract

Many uninsured aren't aware of what the ACA can offer.

After the October 1 launch of the state and federal health insurance marketplaces, a focal point of the Affordable Care Act (ACA), users trying to enroll reported a wide range of success and failure. Washington State's Healthplanfinder set one of the best examples: 25,000 uninsured residents enrolled in the first two weeks, and 37,000 completed applications. In Oregon, though, there were no online enrollments in the same period; troubles with the Cover Oregon Web site allowed browsers to view plans but not apply for coverage, according to the Oregonian online.

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And by week three at HealthCare.gov, the $300 million federal site responsible for enrolling residents in the more than 30 states that have federally run or federal–state marketplaces (also called exchanges), the glitches were still so severe that some predicted the site would need a complete software overhaul to work at full capacity (read more about those assessments in the October 17 USA Today). In a Rose Garden speech on October 22, President Obama said there was “no excuse” for the problems but didn't identify them, promising that, “We've got people working overtime, 24/7, to boost capacity.” He urged people to apply “the old-fashioned way,” by phone, at (800) 318-2596, or in person (local navigators can be found at http://localhelp.healthcare.gov). “If one thing is worth the wait,” the president emphasized, “it's the safety and security of health care that you can afford.”

The Centers for Medicare and Medicaid Services granted $67 million to train navigators, or “in-person assisters,” to help enrollees with what could be a daunting process. Still, with coverage set to begin on January 1 and enrollment for small businesses and individuals open until March 31, a potentially more significant problem is becoming apparent. A Gallup poll found in mid-October that in the states relying on the federal marketplace, 71% of uninsured Americans were still somewhat or very unfamiliar with it—a barely perceptible improvement over September.

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CAPITALIZING ON ‘DEEP COMMUNITY CONNECTIONS’

In several states, nurses and others are taking on the task of reaching the people who need information the most.

In Arizona, which did not set up its own state marketplace, an estimated 1.2 million residents are uninsured—one in five, according to the Arizona Hospital and Healthcare Association, one of the highest rates in the country. The Phoenix chapter of the National Association of Hispanic Nurses (NAHN) has partnered with AARP to inform as many eligible Arizonans as possible about the federal marketplace. Adriana Perez, an assistant professor at Arizona State University and the chairperson of the education committee at the NAHN's Phoenix chapter, has worked with an AARP partner to train 15 nurses to provide bilingual education to individuals and small businesses. The nurses have found, Perez said, that not only are people pleased to learn that preexisting conditions and “essential health benefits”—basic services and medications in 10 categories such as maternity and mental health care—must be covered by any new plan, they're surprised that these weren't covered all along.

The outreach sessions are taking place in churches, clinics, senior centers, a Chinese cultural center, a lesbian-and-gay community center, and businesses (such as beauty shops in Maricopa County); the goal is to reach 1,000 people by year's end. The nurses begin with the basics, defining words like copayment and deductible that might be unfamiliar to people who've never had insurance. In describing the range of plans the marketplace provides, from bronze through platinum, and the tax credits available to low-income residents to offset the costs of the premiums, the nurses want to make sure that people understand the consequences of each option.

“In the community the biggest fear is ‘Can I afford it?’” Perez said. “We inform them of the tax credits and cost-sharing subsidies and say, ‘Don't just look for the cheapest plan, because if you need a lot of health care, you'll have more out-of-pocket costs over the long term.’ They have to understand affordability.”

In Illinois, whose state–federal marketplace is called Get Covered Illinois, VNA Health Care in Aurora has received several grants to help uninsured residents enroll in Medicaid or buy insurance, whichever they qualify for. Linnea Windel, the president and chief executive officer, said that 50 assisters (most of whom aren't nurses) are helping people in community health centers and elsewhere in several suburban counties west of Chicago. And they're also visiting the homes of those unlikely to seek the help themselves, many of them isolated because of disabling conditions and identified by a family member. “[Local chapters of the Visiting Nurse Association] have these deep community connections and understand how to get information to people,” Windel said. “We're a part of the fabric of the community. We see it as aligning with our mission of serving everyone.”

In Washington, one of 16 states (plus the District of Columbia) to have set up its own marketplace, Libby Weisdepp manages the in-person assister program at Choice Regional Health Network in Olympia, covering seven mostly rural counties. Weisdepp said that although she and her team were met with overwhelming enthusiasm by those enrolling, the major task for the 140 trained assisters (most of them not health care providers) will continue to be “getting the word out.”

“What we've heard over and over is that physicians and nurses have a huge impact on how their patients behave,” Weisdepp said. “Saying to a parent, ‘Your kid is covered and now you can be too,’ goes a long way when it comes from a health care provider. Also, these new plans have lots more benefits, and their patients will have access to more coverage. That message goes a long way, too.” Weisdepp's experience is borne out by an August Kaiser Health Tracking Poll, in which 44% of those surveyed said a personal physician or nurse was the most trusted source of information about the ACA, but only 22% said they'd heard anything about the new law from a physician or nurse.

Perez sees the health insurance marketplace as an important opportunity for nurses. She emphasized that this moment is historic and implored nurses to get engaged. “Be involved,” she said, “no matter where you work, whether it's a senior center, a hospital, an academic setting. Let's stay tuned to the real challenges as people enter the marketplace so we can be better advocates for patients.”—Joy Jacobson

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RESOURCES FOR NURSES ON THE HEALTH CARE MARKETPLACE

If you've found yourself scrambling to understand the new insurance marketplace, you're not alone. In Adriana Perez's experience, many of her nurse colleagues in Arizona have said, “I know that the ACA is coming, but I have no idea what that means. We don't have any training, and I wonder what we're supposed to know.” Here's a list of resources that might help.

The Henry J. Kaiser Family Foundation maintains updated profiles of each state's progress in implementing its marketplace: http://bit.ly/1gqap2H. For a graphic showing who's exempt from mandatory enrollment and what the penalties are for failing to enroll, go to http://bit.ly/18zFmf4. And for an online calculator to determine eligibility for Medicaid or for tax credits when buying insurance in the marketplace, go to http://bit.ly/15VagNV.

The Health Resources and Services Administration offers a tool kit with sample webinars and handouts for educating patients and clinicians: http://1.usa.gov/1bXaRn5.

The American Nurses Association explains the basics of the marketplace and advocates a central place for advanced practice nurses in the plans: http://bit.ly/19QMV1j.

The Commonwealth Fund discusses what tax credits are available for enrollees, how Medicaid expansion covers those who can't afford to buy insurance, and what will happen to the uninsured in states that haven't expanded Medicaid: http://bit.ly/H1WLmW.

The Robert Wood Johnson Foundation offers videos, infographics, and research reports geared toward helping the public understand, in straightforward terms, the many aspects of health care reform: http://bit.ly/17SA3Tw.

The Centers for Medicare and Medicaid Services Web site features an interactive map showing its distribution of $3.6 billion to states to establish marketplaces: http://go.cms.gov/177evZV.

Families USA provides resources for those wanting to find or become a state assister: http://bit.ly/1d6nT1j.

Cuidado de Salud, the Spanish-language version of HealthCare.gov, is online: www.cuidadodesalud.gov.

HealthCare.gov offers a glossary of terms related to the ACA: http://1.usa.gov/17SXY5n. And there's a primer on the five categories of marketplace plans: http://1.usa.gov/19Rwb83.

© 2013 Lippincott Williams & Wilkins. All rights reserved.

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