Helming The ACA’s Biggest Success
The story of the Affordable Care Act has been limned with woe: Balky websites, people supposedly losing their insurance coverage, declarations by many prominent voices that it is a “trainwreck,” among other less-than-charitable descriptions.
But there have also been successes, and the Golden State can lay claim to many of them. The biggest one of all may be the Covered California insurance exchange. Forecasters with the University of California projected that a maximum of 830,000 residents would obtain coverage through the state's exchange. It topped the 1 million mark earlier this month, with open enrollment continuing through Monday.
Peter V. Lee is the executive director of Covered California, having taken the job after serving as the longtime chief executive officer of the Pacific Group on Health. Lee, who spoke at the annual Keenan Summit in Burbank on Tuesday, sat down with Payers & Providers publisher Ron Shinkman to provide his thoughts on how Covered California has performed to date, and what may lie ahead.
Q: Final enrollment numbers could be 40% higher or more than the highest projections. Given all the challenges both the federal and state exchanges have had (your counterparts in Minnesota and Oregon have resigned due to poor performance) why does California stand out so distinctly? What did you do right?
A: In the end, I think we did pieces right on every one of the three main foundations of success. We had a good mix of plans in every one of our markets, and our decision on standard benefit designs was consequential. That makes it easier to communicate (what's offered), and easier to enroll. Number two, our marketing and outreach was effective. It was based on from day one, having a multi-faceted marketing approach, starting with community-based outreach, rolling into electronic and social media. And third, our enrollment processes. We did a lot of focus on getting our basics basically working. We wanted to make sure things worked 90% of the time for 90% of the people. It was not to say we did it all right. We tried not to have too many bells and whistles, but when we did is when we stumbled. An example of that was when we aspired to have a provider directory. It was a really, really hard thing to do. Some of the most sophisticated purchasers in the country have wrestled with it for years and failed, and we tried to have it almost on day one. It was overambitious. It was for all the right reasons, but generally we focused on the core functionalities.
Q: Aside from the core functionalities, there have been few technical glitches in the exchange platform. What did your team do in terms of details to avoid the issues hit by virtually every other exchange? Was there lots of testing involved?
A: It didn't work as we wanted it. We dropped the ball on getting (benefit, subsidy qualification and payment) notices out, when effectively we were being barraged by huge enrollment. That led to consumer confusion, and long wait times on the phone. We are really careful in not claiming we had a perfect consumer experience. And on Dec. 23, our deadline for coverage (becoming effective) on Jan. 1, our system slowed down a lot. But you can't build infinite capacity. If you do, you pay a lot for it. That's one of those tradeoffs. I think on some levels, we had many of the problems faced by many other exchanges, but on the whole, we focused on functionality. Our business process is also shared by the (Department of Health Care Services, which runs the Medi-cal program). We had very clear lines of authority, and clear decisionmaking processes. That discipline to focus led to our relative success.
Q: There's still quite a bit of resistance to the ACA in other parts of the country, but what has been going on here suggests that California continues to lead on healthcare policy implementation. Do you think other states more resistant to the law will begin following Covered California and the state's example? Have you been asked for advice from other states?
A: I actually have multiple calls a month with the other exchange directors and with the federal marketplace. I've learned a lot from my colleagues in other states, and I think they have learned a lot from us. It is absolutely one of my hopes that other citizens in other states say “why don't we have insurance like they do?” Because it means there are 5 million Americans who would have had health insurance but for their states not implementing (the ACA) as effectively as we have.
Q: I would say that's a low number.
A: It is a low number, because we're only counting the exchanges, and not Medicaid expansion (which has been rejected or is still under review in half the states). It could be 15 million, easily. And I very much look forward to a time when we all, with Medicare, embrace it. Medicare was a very controversial law. We had the (American Medical Association) say it was the “fall of Western civilization,” that it was a “Commie takeover.”
Q: Yes, but there's a lot of vitriol still surrounding the ACA, and most of it in Medicare's case went away after the program went into effect.
A: I do think it is absolutely the case, and that is unfortunate, that it may take another presidential election to get beyond it. The opposition is mostly political, not (policy-oriented). And I mean is this is about opposition to this administration and to the president and not wanting to give it a win, as opposed to rolling up your sleeves and looking at the policies undergirding it. These are very moderate policies that have been embraced by Republicans and even those on the conservative right. It's not a single-payer system. It involves private health plans. This is as about free market as you can get.
Q: You're a policy person but from the business world. Do you think your experience and perspective has played into the success of the exchange so far?
A: Personally, my background in California, I know many of the players. I mean the people who represent the health plans, the physician groups, the health plans, the consumer advocates, the employers. I didn't just work at the PBGH, but the Center for Healthcare Rights. We as a state have been struggling to make healthcare reform work for a long time, many of the players know one another, and I think they were ready to lean in and make this work. And having a few years in Washington has definitely been helpful to me. It gave me the perspective of how to work with people with (the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services. I could pick up the phone and talk to them, and they could call me and see how things were going on the ground.
Q: There has been some concern about timely payment of premiums by exchange enrollees. What has been the trend for Covered California? Do you think there's going to be a significant shed of lives in the coming months due to non-payment? The nationwide trend has been around 15%.
A: There will be a lot of churn in the exchanges. There's been a lot of churn in the individual market. People get jobs – hallejeullah. Some people I'm sure, and we don't have good data on this, signed up for two plans, trying to make their decision. We don't know what the right number is. It's interesting, the state of Washington, they require binder payments. When they give enrollment numbers, it's paid numbers, and we're going to be moving to that. My most conservative estimate is we might hit 15% for the churn, but that the numbers could only come in better than that. And back to the current enrollment numbers, that would take us down to 850,000, which is still better than the 830,000 number. The last thing I want to do is be on the deck of the aircraft carrier saying “Misson Accomplished.” We seek to underpromise and overdeliver.
Q: There has been some criticism about the way Covered California has marketed to some ethnic groups, particularly Latinos. What changes do you expect to make in that area in the coming months?
A: It is very easy to be a Monday morning quarterback, especially in the middle of the first quarter. Some of the criticisms of our marketing to the Latino community were absolutely conscious. One of them was that the ads were too dry. We made a decision not to use humor. Other states made other calls. We made a judgment call. I think we’ve done a decent job.
Q: What is some of the outreach to the Latino community?
A: I feel very good about partnering with Dolores Huerta to use the fact that we’re closing open enrollment on Cesar Chavez’s birthday, which is a state holiday, to use that as a focal point for organizing. And when you think about young people, the 18-to-34-year-olds, and Latinos, it’s the same. They’re in city colleges, they’re in Cal States, and that’s where we are. They’re in markets, so we’ve expanded to a range of markets that sell in Latino communities.
Q: Is this a long-term position for you?
A: Yes. This is a building process. I was at PBGH for 10 years, eight as CEO, and two where I negotiated a role to work on national health policy. I am generally not flighty.
Q: Do you see your success here as a potential entree into politics?
A: Absolutely not. Guffaw! Peter laughs out loud! No, this is not a steppingstone. It is an opportunity for hopefully helping to reshape healthcare for California and the nation.
( This was edited and condensed from the original interview)
