New Georgetown Report: Assessing Consumers’ Experience with ACA Coverage through the Eyes of State Consumer Assistance Programs

The number of uninsured continues to drop dramatically, thanks to the sweeping reforms contained in the Affordable Care Act (ACA). An impressive 16.4 million people have gained coverage since the law’s enactment in 2010. Yet while we know that access to health insurance has improved, important questions remain about whether that insurance is adequately meeting people’s needs. Unfortunately, there’s little in the way of systematic data collection about plans’ cost-sharing, provider networks, and benefit design.

One source of information about consumers’ coverage experiences are the state-run Consumer Assistance Programs (CAPs). CAPs were created to assist consumers with health coverage questions and problems. CAP call centers receive calls from consumers on a wide range of issues, from those seeking coverage to those with coverage that is not meeting their needs. As a result, these programs provide a unique lens on consumer experiences with coverage both before and after the ACA went into full effect in 2014. They can help us understand how consumers have benefited from the insurance reforms embodied in the ACA—and where there may still be gaps or problems with their insurance coverage.

While ACA grant funding in 2010 originally gave rise to 35 state CAPs, a lack of continued financial support has caused the majority to close their doors. There are only 13 CAPs remaining. CHIR researchers contacted these CAPs and of the 13, 10 agreed to send us data on consumer complaints and resolutions, as well as participate in structured interviews about consumers’ coverage experiences in their state, both before and after enactment of the ACA.

Not surprisingly, CAPs report that, before 2014, they had considerable difficulty connecting uninsured callers with affordable health insurance coverage. Today, they note that they have a greater number of options for people without insurance or who are leaving employer-based insurance. And some CAPs noted that they are receiving significantly fewer complaints about the lack of affordability of health insurance premiums.

However, significant challenges remain for many consumers. Primary drivers of calls and complaints to state CAP programs today include:

  • People caught in the “Medicaid coverage gap” in states that haven’t expanded their Medicaid program.
  • Victims of the “family glitch” who cannot afford the dependent coverage offered by an employer but are ineligible for financial assistance on the health insurance marketplace.
  • Insured individuals who cannot afford the cost-sharing on prescription drugs or who find their deductible to be an insurmountable barrier to obtaining care.
  • Potential violations of federal and state mental health parity requirements.
  • Narrow provider networks and provider balance billing.

CAPs help resolve consumer coverage problems by working with insurers, the marketplaces and state regulators. They are often able to resolve issues informally before they rise to formal grievances or appeals. However, the CAPs also serve a critically important sentinel function. Through regular reports and phone calls with federal and state policymakers and regulators, CAPs help identify coverage problems that point to more systemic challenges or gaps within the policy and regulatory framework. Going forward, CAPs are likely to continue to be a rich source of information about consumers’ experiences with health insurance coverage and whether it is delivering its promised value.

You can read the full report here.

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