As the snow continues to fall, the CHIR team has cozied up indoors with new health policy research. This month we read studies on rates of enrollment in Marketplace coverage for 2021, Navigator experiences enrolling consumers during the 2021 Open Enrollment period, and outcomes from balance billing arbitration in New Jersey.

Haley, J. & Wengle, E. Many Uninsured Adults Have Not Tried to Enroll in Medicaid or Marketplace Coverage. Urban Institute, January 2021

In this brief, researchers assess awareness of and experiences with public coverage options among consumers who were uninsured in September 2020 by analyzing data drawn from the Urban Institute’s Coronavirus Tracking Survey.

What it Finds

• Forty-seven percent of all uninsured adults neither looked for information about Marketplace coverage options nor attempted to enroll in Medicaid or CHIP coverage.
• Just 29.3 percent of uninsured adults attempted to enroll in Medicaid or CHIP coverage. Most of those adults who did not enroll did not do so because they did not think they would be eligible for coverage.
• Over 55 percent of uninsured adults who were familiar with Marketplace coverage reported that they looked for information about their coverage options, while almost 45 percent did not.
  • Over 42 percent of those adults who did look for more information on Marketplace coverage did not enroll due to costs.
• Just over 21 percent of uninsured adults reported having heard “a lot” about Marketplace coverage options, while 32.7 percent reported having heard “some.” Forty-six percent of uninsured adults had heard either “a little” or “nothing at all” about the Marketplaces.
• Regarding financial assistance for Marketplace coverage, only 11.4 percent of uninsured adults reported having heard “a lot” about subsidies, while 23.7 percent reported having heard just “some.” Almost 65 percent of all uninsured adults had heard “a little” or “nothing at all.”

Why it Matters

This report indicates that there are significant knowledge gaps among uninsured adults, particularly those who recently lost their employer-sponsored insurance due to the COVID-19 pandemic, and therefore may be unfamiliar with public coverage options. These findings suggest a need for renewed investments in outreach and enrollment efforts in order to increase health insurance coverage literacy and improve enrollment rates among vulnerable populations, particularly as the COVID-19 pandemic continues. 

Pollitz, K. & Tolbert, J. Opportunities and Resources to Expand Enrollment During the Pandemic and Beyond. KFF, January 25, 2021

In this brief, KFF researchers report on observations about the 2021 Open Enrollment period from Navigators and other consumer assisters from both federal and SBM states. Participants discuss challenges consumers have faced in enrolling for coverage, and offer suggestions to improve enrollment outcomes. 

What it Finds

• Unused funds, largely from marketplace user fee revenue, have accumulated to over $1 billion over fiscal years 2018-2020.
  • Spending cuts on consumer assistance resources and outreach and advertising initiatives, implemented by the Trump Administration, contributed to the user fee carryover.
• Navigators argued that, in order to effectively assist consumers during a COVID enrollment period and future enrollment periods, they would need increased funding, primarily in order to rebuild a significantly diminished workforce and to re-establish assistance services that have been eliminated under the Trump Administration.
• Consumers experienced a myriad of challenges during the 2021 Open Enrollment period, including difficulties estimating annual income due to recent job loss or receipt of unemployment benefits, receipt of failure to file notices due to IRS backlogs in processing income tax returns, and policies discouraging enrollment among eligible immigrants.
• Due to both general and pandemic-related difficulties experienced by many consumers during the 2021 Open Enrollment period, Navigators advocated for reopening the federal marketplace for an additional enrollment period.
• Navigators suggested that, should a COVID enrollment period be opened, the federal government renew investments on marketing and advertising, which were cut by 90 percent under the Trump Administration.
  • Navigators and assisters in the state-based marketplaces recommended that federal marketing efforts be conducted with their input, due to their marketplaces’ unique timing and administrative differences.
  • In addition, Navigators urged the federal government to enact targeted outreach strategies to reach consumers who may face unique barriers to enrollment, such as those who do not speak English, those who are not American citizens, and those who have been uninsured for a long time.
• Navigators expressed frustration with the quality of the assistance offered through the federal marketplace call center, and with the design of the online application on the federal marketplace website.

Why it Matters

Now that an additional COVID special enrollment period has been mandated, the Biden administration has the opportunity to make several improvements to the marketplace in order to better meet the needs of uninsured consumers and assisters. This brief outlines a number of priority issues for the administration. 

Chartock, B. et al. Arbitration Over Out-Of-Network Medical Bills: Evidence From New Jersey Payment Disputes, Health Affairs, January 2021

In this article, Health Affairs researchers assess outcomes from New Jersey’s first full year of arbitration decisions by linking this data to Medicare and commercial insurance claims data. Over 2,000 disputes filed between January 1 and December 31, 2019 are analyzed.

What it Finds

• Providers won 59 percent of arbitration decisions, while health plans won the remaining 41 percent.
  • Providers tended to win disputes over more costly services more often than disputes over lower-cost services.
  • The most common provider specialities that participated in arbitration disputes include orthopedics, general surgery, plastic surgery, and trauma and emergency medicine.
• The eightieth percentile of provider billed charges seemed to significantly influence arbitration decisions; 67 percent of all decisions were awarded to the party that bid closest to the eightieth percentile of charges.
• Among all cases, the mean arbitration award amount was $7,222, and the median award amount was $4,354.
• The mean and median award amounts were 9.0 and 5.7 times higher than the median in-network price for the same set of services.
  • Thirty-one percent of cases were decided for amounts that were over 10.0 times the median in-network price. 
• The mean and median arbitration award amounts were 12.5 and 9.5 times Medicare prices.
  • Forty-five percent of cases were decided for amounts that were over 10.0 times Medicare prices.
• Within New Jersey’s final-offer arbitration system, health plans and providers both tended to bid above in-network rates, although the median health plan bid amount was 1.6 times the median in-network price for the same set of services, while the median provider bid amount was 10.6 times the median in-network price.

Why it Matters

Health Affairs researchers conclude that, due to the structure of its final-offer arbitration system that relies on provider billed charges, New Jersey’s arbitration system seems to favor providers and will likely lead to inflated costs for many health care services. Policymakers looking to implement a more efficient arbitration system in other states may use these findings to inform an alternative approach.