Setting up a health benefit exchange is so complex that the simpler aspects sometimes can get lost, said Ted von Glahn, a senior director at Pacific Business Group on Health.
"One of the fundamental objectives of the exchange, and the Affordable Care Act generally, is to get people to sign up," von Glahn said. "You can really turn off a lot of people, in terms of the online experience, from coming into the exchange and choosing a plan."
Von Glahn helped create a new PBGH report that looked at one basic and vital component of the enrollment process at health benefit exchanges: the moment when online participants choose a health plan.
There are only a few yardsticks that can effectively measure enrollment success, he said, but online enrollment success is one of them. "So you wouldn't want one of the metrics to be that people log off," von Glahn said. "You have to keep your eye on the ball to make that step as easy as possible, so you don't lose people who are eligible."
PBGH, a not-for-profit business coalition based in San Francisco, released the third and final installment of the report this week. It is based on a series of 2,100 interviews conducted in 2012 with low-income participants chosen to mirror the demographic makeup of expected enrollees in state exchanges in 2014.
Language, Cultural Differences Play Key Role
Many of the people eligible for the exchanges are not proficient in English, come from other cultures, have limited education or have never had health care insurance, von Glahn said. Signing those people up, especially online, takes a little extra care, he said.
"So they've already gone through a series of screens to determine eligibility, and they've already been asked for a lot of information," he said.
"There's some level of fatigue at that point, and that's the other aspect that has people nervous," von Glahn said. "Really, we're zeroing in on just one step in the process, but that's a big one."
The exchange board has spent a lot of time and effort planning for that step and many other enrollment steps along the way, said Andrea Rosen, interim health plan management director for Covered California.
"The priority for us is enrollment," Rosen said. "To have multiple pathways to quick enrollment is really important. And at the same time, we want people to be happy with their choices."
That means the exchange incorporates as much information as people want in the enrollment process, she said -- and doesn't bombard people with numbers and choices, if they don't want them.
"No one is going to pretend that benefit design is for the faint of heart," Rosen said. "It's not. You still have a lot of categories, and there are a lot of moving parts in a medical plan." For instance, she said, there are four different categories of mental health coverage to choose from and six categories of home health services. It's hard for anyone to figure out all the coverage options, Rosen said, let alone someone who has linguistic, cultural or educational issues.
"Given that benefit designs are complex to begin with, that's why we're doing focus groups and [conducting] testing on usability," Rosen said. "We're spending $43 million on outreach and coordination with community-based groups. We will have assisters to help, and agents who also are certified. We have a lot of different ways, whether that's quick and simple, or more complicated, to help people through the process."
The exchange board adopted standardized plan designs, which should make comparing and choosing plans much simpler, Rosen said. "Our goal for consumer simplicity is to have most of the plans available in these standardized designs," Rosen said.
Comparing coinsurance and deductibles and flat fees for different procedures and visits can be a nightmare for consumers, she said. "So, for instance, in this silver plan there's a 30% coinsurance for labs, but maternity is a flat fee, while this other one charges $50 for a scan," Rosen said. "How are you going to compare any of that? It truly is a big deal to have standardized cost sharing."
Diversity Makes Task Tougher
The biggest issue in trying to simplify, explain and direct people to the plan that makes the most sense for them is the language issue, according to Chad Silva, policy director for the Latino Coalition for a Healthy California. And part of that linguistic challenge also is cultural, he said.
"California is very challenged in that way because we're so diverse," Silva said. "And it's cultural, as well." For instance, he said, LCHC has worked with a group of Oaxacans in the Fresno area. "They come from a very rural area in Mexico, where views on health care are very different," Silva said. "They don't trust Western medicine that much, and they haven't had access to it, so imagine trying to sign them up online [for the exchange]. You're bringing somebody in who has a challenge seeing a physician in the first place -- and now you're talking about picking a plan? So that's a huge barrier."
Silva said enrolling this population, and making sure each enrollee buys into the proper plan, is going to take a lot of work -- even without the many challenges inherent in the population.
"We just did open enrollment [at work], and it took me hours to choose a plan," Silva said. "So yes, that is an important spot. Getting them enrolled in the right plan is going to be really important."
The exchange's assisters will be a big help, Silva said, as long as they're linguistically and culturally literate. He said he also appreciates the exchange's commitment to connect with community-based organizations. But there's one avenue that still needs to be explored, he said -- encouraging insurers to provide paid assistants for potential enrollees.
"There is such a commercial stake among the plans," Silva said, "and I think they should invest some money into reaching that population. The plans have a great personal stake in it, they want to enroll as many people as possible. They should pay to do that."
Helping People Make the Right Choices
According to von Glahn, when literacy is an issue and there's little support to make decisions, the choices people make on their own health insurance are often wrong. "You might as well flip a coin," he said. "Whether they made the right choice or not, it's a coin flip."
It's important to design a system that doesn't scare off or wear out participants, von Glahn said. Directing people a little or "nudging" them toward a health plan is a good idea, as von Glahn put it.
"This whole notion of choice architecture, which is a fancy word for providing assistance while people are considering health plan options, it's pretty critical," von Glahn said.
"You want to nudge, but don't shove," he said. "Because we do know there are half a dozen things that matter to people. So you want to nudge them to consider certain aspects, but you don't want to curtail their opinions or needs, you still want to give people choices of what they want to choose."
Most people want a quick experience when choosing health plans, von Glahn said. "The vast majority of people, they don't want to go through the details," he said. "Of course, there are other aspects to the choice, but you have to respect that people want that quick choice."
For instance, he said, people care about the doctor they're seeing, or the hospital they visit, and that provides the framework for the choice of health plans. "Let them choose how they want to choose," he said. "Give them options, a little nudge, but also make sure they're aware of the other choices, too."
The PBGH report, designed to help exchanges across the country, not just Covered California, urges exchanges not to hurry through key parts of the enrollment process, despite a short time frame.
"The set-up of the exchange by October of 2013 is a really big job. The starting gun was fired a long time ago," von Glahn said.
"So there will be a natural tendency to prioritize the work between now and the fall," he said. The enrollment step is one area "you don't want to give short shrift."