Going into her fourth open enrollment period helping people find insurance plans on the exchange set up under the Affordable Care Act, Holly McCamant noticed something different.
“The number of appointments going into November is way lower,” said McCamant, a certified application counselor at Southwest Montana Community Health Center in Butte.
Last year at this point, McCamant already had the whole month of November scheduled with people coming in to get help picking an insurance plan. This year, she has only the first 10 days booked.
McCamant first saw a change at the start of the year, after Republican President Donald Trump took office alongside a Republican-dominated Congress. Both had long promised to repeal and replace the Affordable Care Act, also known as Obamacare, the landmark health care legislation from the former president that significantly revised the country's health care system.
“I already had a big change in enrollments during January compared to the other years because of everyone talking about how they want to get rid of (the Affordable Care Act),” McCamant said last Thursday. “And a lot of people get confused about exactly what they are doing, and they don’t follow it closely and they think it’s going away.”
But the Affordable Care Act is still there, still the law of the land, and before this year’s open enrollment period starts Nov. 1, those who help Montanans navigate the exchange are working to make sure everyone knows it’s business as usual.
Since Trump took office after a campaign based in part on a promise to repeal and replace the Affordable Care Act, Congress has had multiple failed attempts to either revise or do away with the law. After those false starts, Trump began an effort to dismantle the law on his own, ending subsidy payments to insurance companies, slashing the budget used to advertise the open enrollment period, reducing grants that help people get assistance signing up for coverage and cutting the enrollment period.
In Montana, though people who have been involved in open enrollment for years say the state has a strong network to connect people to help, there are still concerns and confusion.
“I think over the last year the Affordable Care Act and health insurance marketplace have been in the news a lot,” said Olivia Riutta, with the Montana Primary Care Association. “I think a lot of what people hear is uncertainty about the future of the Affordable Care Act. There were many iterations of repeal and replace. I think it’s easy to be confused about where we’re at, did anything pass and if it did pass what did it do and what does it mean for my family here in Montana and my ability to afford an insurance plan?"
Given that lack of clarity, Riutta said the work of health insurance navigators and certified application counselors like McCamant are more important than ever.
Navigators and counselors can help anyone who needs help signing up for insurance. They do the work at no cost to consumers and don't get money from insurance companies. Montanans can go to covermt.org to find a navigator or counselor in their area and those without internet access can visit their local clinic, community health center or hospital to get connected to help.
Assistance can range from explaining health insurance terms and figuring out if doctors are in-network, to what specific drugs are covered under prescription plans and completing the application process from start to finish.
A study done by Enroll America in 2014 found that having in-person assistance while trying to enroll meant a consumer was twice as likely to be successful. In Montana, about 63,800 purchase plans on the exchange from three companies.
At the end of August, the federal Centers for Medicare and Medicaid Services announced it would cut navigator grants by about 40 percent, going from $62.6 million to $36.8 million. Jill Baker, project director of the navigator program for Planned Parenthood of Montana said even with less money this year, outreach efforts statewide will still be substantial.
“It’s is a little less money to work with this year, but we are still able to run a robust program,” Baker said last week.
Planned Parenthood is the only organization in the state that receives navigator funds, money that is used to help people sign up for insurance on the exchange and advertise the open enrollment period, which runs from Nov. 1 to Dec. 15 this year instead of through January. Last year, Planned Parenthood helped more than 15,000 consumers with information about health insurance and had 7,423 one-on-one interactions with consumers, which also includes enrollments in Medicaid.
Earlier this summer, Montana Health Network, which also had a federal grant, decided to pull out of the program.
“We just kind of felt we had probably done what we needed to in terms of exposure and making sure people knew about the Affordable Care Act,” said Chris Hopkins of Montana Health Network. “We voluntarily withdrew based on that we felt there was saturation.”
The organization worked primarily though hospitals, some of which have continued with their own certified application counselors. Navigators also marketed the enrollment period in addition to signing up people.
“We just didn’t feel the need for the marketing piece to continue,” Hopkins said. Before Montana Health Network withdrew from the navigation grant, it asked if Planned Parenthood could apply for and receive its funding, which it did.
Hopkins said he doesn’t think Montana Health Network still providing navigators in the communities it previously served would make much of a difference today.
“I think we’re all confused, not necessarily about what’s there and what’s not there, but it seems to change every day,” Hopkins said. “In many ways it would be helpful, but we still think within the state they could get that information. Local community health centers should still have somebody involved with that. The hospitals still have financial counselors that work with people on their health coverage. People still need to apply and enroll and see what’s out there.”
Marguerite Jodry is a navigator with Planned Parenthood in Billings. One of her goals is to reassure consumers that “first and foremost the Affordable Care Act is still law and they can still benefit from it.”
“It’s important to sign back into their accounts and update their applications because new prices and plans are available every year,” she said.
Many consumers worry about the cost of coverage after Trump announced the federal government would no longer reimburse health insurance companies for cost-sharing reductions, which are subsidies that help consumers offset some out-of-pocket costs. But the Affordable Care Act still requires insurance companies provide them to customers who fall between 138 and 250 percent of the federal poverty level.
“And because the amount of financial assistance is tied to the cost of premiums, assistance goes up as premiums rise,” Jodry said. “Many won’t experience any increase or a very small one.”
Some people worry if their health insurance company will still be selling on the exchange. Earlier this month the Montana Health Co-Op, one of three companies on the exchange here, said it wouldn't be able to offer plans in 2018 if it was not able to raise rates to make up for the federal government ending its subsidy payments. PacificSource was in a similar position, while Blue Cross and Blue Shield of Montana had assumed the payments would end and already accounted for them in annual rate adjustments. While the Co-Op and PacificSource were eventually able to increase their rates and will remain in the 2018 market along with Blue Cross, many consumers were left confused by the upheaval.
The move by Trump to eliminate cost-sharing reduction payments for insurers also left consumers worried their out-of-pocket expenses would go up, but insurance companies are still required by law to provide the subsides to consumers and tax credits are still in place for those who qualify.
“People have said to me they think that means there’s no premium tax credits,” McCamant said. “We have radio ads and posters trying to get the word out, but it’s tough when you’re fighting that. As soon as they started talking about getting (Trump) in office, I think a lot of people just threw their hands in the air.”
For this enrollment period, Planned Parenthood will receive about $375,000 through the navigator grant, about 24 percent less than what was available in Montana last year. With the funds, Planned Parenthood will run radio advertisements as well as promote the program on social media sites in targeted communities such as Billings, Helena, Great Falls, Missoula and surrounding rural areas.
“We want to help our most vulnerable Montanans get assistance with getting into the marketplace and choosing a health plan that’s best for them,” Baker said.
Though it’s less to work with, Baker said Planned Parenthood has worked hard to build relationships with sister programs around the state, including community health centers like the one where McCamant works, plus hospitals and tribal health care programs.
“In our state, we have a really strong assister program, whether it’s Planned Parenthood with our five years of experience or other organizations who provide outreach and enrollment assistance,” Baker said.
RiverStone Health in Billings has gotten a lot of calls from people asking what will happen to the Affordable Care Act.
“I think especially with the whole repeal-and-replace bills, a lot of people are hesitant to participate in this program because they’re anticipating it’s going to disappear,” said J. “Scooter” Gates, a certified application counselor. “So there is a lot of confusion.”
It’s still in place, she said, and people need to think about what they want to do for 2018.
One of the biggest changes this year is the shortened enrollment period, Gates said. Unlike previous years, when sign ups went through Jan. 31, the end date this time is Dec. 15.
In the past, people often waited until they completed their tax returns in January and had accurate income information before they sought help to enroll.
“My concern is people won’t be aware of the new date and they’ll call in January and say their taxes are done and they’re ready to enroll,” she said.
People who participated in the ACA in 2017 should soon get letters telling them if they liked their insurance plan for 2017, they can automatically be enrolled for the same one in 2018.
“Others will want to look and see if this is still going to be the best option, as far as services offered and premiums,” Gates said. “We encourage them if they want to look at plans, to call us.”
McCamant said sometimes people will call after the enrollment period ends frustrated about their premiums increasing.
“They will get a letter from whomever their insurer is that they had this plan that is no longer available so we’re signing you up for a different one. That could be going from $78 a month to $400 so they just cancel it,” McCamant said.
Actual plans for 2018 won’t be online until Nov. 1, although people can use an estimator tool to get an idea of what costs are going to be. Gates warned those who plan to enroll not to wait until mid-December to go online. Also important to remember: there are still tax penalties for people who do not have coverage.
“Based on prior experience, on the last day of enrollment the website will be overloaded,” she said. “So the ability to complete the process is a challenge.”