In Depth: How Will COVID-19 Impact Health Insurance Access & Policy?

May 20, 2020

COVID-19 Testing Site at Pease Air National Guard Base
Credit Dan Tuohy/NHPR

The pandemic has highlighted the gaps in our health insurance system, such as Americans who remain uninsured, or under-insured, even after decades of debate on health insurance policy. Now, with millions of people losing their jobs, some will also lose coverage, adding into the complexity of this problem – and sparking a search for new solutions. 

Air date: Wednesday, May 20, 2020. 


GUESTS:

  • Dan Gorenstein - Executive producer and co-host of Tradeoffs, a podcast exploring our confusing, costly, often counterintuitive health care system. He was formerly a senior reporter for Marketplace’s Health Desk and a reporter at New Hampshire Public Radio. 
  • Tyler Brannen - Director of Health Economics at the New Hampshire Insurance Department. 
  • Jeremy Smith - Outreach coordinator and program manager of the New Hampshire Navigator, a nonprofit helpline that provides health insurance enrollment assistance. They can be reached at 877-211-6284. 

 

Transcript:

This is a computer-generated transcript, and may contain errors. 

Laura Knoy:
From New Hampshire Public Radio, I'm Laura Knoy, and this is The Exchange.

Laura Knoy:
Today, our in-depth series on COVID-`19 and health care continues with insurance. Even before the pandemic, the country was engaged in a long political debate about gaps in health coverage with large numbers of Americans uninsured or underinsured. Now, with possibly millions more joining them as they lose their jobs and their employer sponsored insurance, concerns about coverage are again front and center. Also is the discussion over how to address this. So that's what we're tackling this hour on The Exchange and listeners. Let's hear from you. What's your health insurance status and how is that changed? What concerns do you have about coverage? What ideas do you have to make this situation better? Our guests are Dan Gorenstein, executive producer and host of Tradeoffs, a podcast exploring our health care system.

Laura Knoy:
Dan was formerly a senior reporter for Marketplace's Health Desk and a reporter for us at NHPR.

Laura Knoy:
Also with us, Tyler Brannen, director of health economics at the New Hampshire Insurance Department, and Jeremy Smith, outreach coordinator and program manager of the New Hampshire Navigator. That's a nonprofit helpline that provides health insurance, enrollment assistance. Welcome to all of you. And Dan, I want to start with you. What were the major complaints about health insurance in this country even before the pandemic?

Dan Gorenstein:
Sure, Laura. Thank you. Thanks for having me. It's an honor and privilege to be here. You know, the big complaint was that I think a lot of people know this, that individuals were really concerned about how much money that they were having to pay, both in their monthly premium, as much as well as the deductible that they had, how much money they had to pay out of pocket before the full insurance covered. And so this would be copays, coinsurance. Sometimes people were paying thousands of dollars out of pocket before their insurance would cover things like prescriptions and doctor's visits. And this was putting a lot of pressure on consumers and then in workers.

Dan Gorenstein:
And then you had a lot of employers who were really frustrated by seeing, you know, year over year increases in how much they had to their share of how much they had to pay for their employees coverage growth. You know, six percent, eight percent, 12 percent growth year over year and this sort of runaway kind of train. And people just were really everybody felt pinched by this pre-COVID.

Dan Gorenstein:
And then also sort of at a higher level, there are just the general concerns around the connection between jobs and insurance. And, you know, we saw this certainly with the Great Recession, when people lost their jobs, when some people lost their jobs, their insurance went away with it. And this is been a critical issue for people for a long time that that that connection, that wedding of insurance to jobs and whether or not that's the most effective system we have.

Laura Knoy:
So I want to ask you about that, Dan. Yeah, for sure. But Tyler, how about here in New Hampshire? How much if you heard those same concerns that Dan just mentioned, reflected even before coronavirus?

Tyler Brannen:
Yeah, they're they're definitely legitimate concern and we hear them all the time. I mean, just to be clear, representing the New Hampshire insurance department.

Tyler Brannen:
We focused on kind of as a private commercial insurance market that typically is employer sponsored coverage as well as the individual market. It's worth sort of acknowledging there are people in Medicare, there are people in Medicaid. They may be getting their coverage through a commercial or private carrier as well. And that's a little bit of a different dynamic. But I think to the extent that we're focused on that commercial market and the people and their concerns in New Hampshire, it is going to be about cost.

Tyler Brannen:
We've had relatively rich benefits. We've had relatively broad network. We've had relatively good access to health care services through our insurance products. And we had companies that have been stable in that New Hampshire market for a long time as well. There've been a few that have come and gone. But but compared to some other markets in the country, we've been relatively blessed in New Hampshire. So I think to extent there is sort of a focus of complaints. It is going to be largely about cost, obviously, to an extent to some of the insurance products. And that, of course, is done in part so that it's not just high cost sharing. There's sort of sometimes more effective ways to encourage people to use the healthcare system in some ways, as well as sort of a limit just at a really high deductible. But cost is definitely going to be the focus both on the consumer and from an employer perspective, I think, at least in New Hampshire.

Laura Knoy:
Sure. And talking about the complexity, that's where you come in. Jeremy, you worked directly with Granite Staters who need coverage before we get into the specifics of the work you do, Jeremy. What do you hear from people here in New Hampshire about their issues with coverage? What are some of the common complaints?

Jeremy Smith:
I think the main complaint that we see is just people have a really hard time understanding what options is available to them and if they qualify in the process of getting a price quote or seeing what program might be best for them.

Jeremy Smith:
What we usually see is in a lot of people that's in this boat right now, they've had employer coverage for most of their life and they've never had to shop for insurance before. So it can be extremely confusing to them. I mean, they've never had to go through the process of having to shop for insurance. And a lot's changed since the Affordable Care Act rollout.

Jeremy Smith:
So a lot of people remember what options was available to them, maybe 10 or 15 years ago, but they haven't really kept up with what options are available now. So it's extremely frustrating to them to look at all these different options and see, you know, what might be best for them and their families.

Jeremy Smith:
So in some cases, people just give up and they don't want to have the hassle having to try to look at all the different things that might be available to them.

Laura Knoy:
Wow, that's really interesting. So people who for years, Jeremy just had their employer say, you know, you can pick option A or option B or guess what, folks? Option B as their only option this year. And people say, OK, whatever. Now they have to make those choices themselves. And some of them, it sounds like, Jeremy, they're just throwing their hands up.

Jeremy Smith:
Yeah, absolutely. And then, you know, the other thing that's frustrating for some people, too, is they don't really know where to turn for help and they'll ask their neighbors or their friends or family what they went through. And if that particular person had a bad experience, the first person just discounts the whole process and they don't want to look at it. And unfortunately, you know, in today's market, everything is extremely reliant on your specific family situation. So a lot of it's family size and income base. So, you know, it's not a one size fits all.

Jeremy Smith:
So if your neighbor qualified for one program, you may not qualify for the other. So it's hard to get it rely on information for a lot of folks just by talking to family and friends.

Laura Knoy:
Well, and while we're talking about helping people figure this all out, your help line, Jeremy, as the New Hampshire navigator is eight seven seven two one one six two eight four eight seven seven two one one six two eight four. And as always, we'll put that information on our Web site so people can look it up on the Web, too, if you didn't catch that. You know, Dan, in a recent episode of your podcast, you reflected on what you just touched on a moment ago, this long history of employer sponsored insurance and how when a lot of people lose their jobs, either in 2008, as you mentioned, the recession or as we're seeing right now, they may lose their coverage. Just step back for a moment. Dan, please. Why do we do it this way in America?

Laura Knoy:
Well, here the subject of 10 podcasts, I'm sure, but yeah.

Dan Gorenstein:
Yeah, no, I did an episode on this for Marketplace back in twenty seventeen. And there are a couple take to really answer this question with specificity. You've got to really kind of comb through the history here.

Dan Gorenstein:
And in World War II, the National War Labor Board put in place a wage cap. So employers, you know, there's a real shortage of workers with so many people, so many men serving overseas. And but because of the labor board's decision putting in this wage cap, employers are really scrambling to try to figure out how you bring in other. What's what's the incentive getting other workers. And so what the labor board ruled was that health insurance was exempt so employers could sort of dangled health insurance as a benefit to attract the best and the brightest. And then also simultaneously, the IRS decided employer contributions to health insurance premiums were tax free, which meant workers paid less out of pocket. And that really this is sort of quirk Laura, was the genesis of why we ended up with this sort of employer based insurance system, which many other Western countries do not have.

Dan Gorenstein:
And so over the years, there have been multiple attempts, up until the 90s there. I think there were three attempts right after World War Two. Nixon tried, tried it as well to have universal coverage. And many times industry, often doctors, played a large role in lobbying to kill this this concept. So that's some of the backstory of why we have the system we do.

Laura Knoy:
Well. And good job summarizing about 60 years of history there. But, you know, this was talked a lot about doing the Affordable Care Act debate. Dan, this idea of uncoupling your employment with your insurance. So we've gone back and forth, as you said, on this for a long time. How do you hear, Dan, the pandemic now changing this conversation, if at all? The idea that for most people, health coverage is tied to your job?

Dan Gorenstein:
Yeah, I mean, I think for some people, this has really been a moment, a case study in this. This is a perfect example. This illustrates why this is a bad idea. I'm not taking that position necessarily. But I think some people clearly say, look, why should you lose your job and lose your health insurance at the same time? And the fact that this is different than the Great Recession. Right. This is that this is a health crisis. Like the last thing. This is not good for anybody to lose access to health care when there's a health global health pandemic going around. So this is definitely, I think, raised questions that are really important. And it puts a pin on like how difficult our system is making it for us.

Dan Gorenstein:
At the same time, I think some of the fundamental underlying questions about how you would actually construct universal health care have not gone away and questions about the costs have not gone away either. So it really at the end of the day, it shines a light and is asking it's forcing people to ask questions. But my sense is there's so much attention covered. 19 itself is taking up so much oxygen in the room, Laura, and I'm sure with the other guests thing here, but that there's really just not a lot of talk that I'm hearing yet about, hey, that's push for universal coverage.

Laura Knoy:
Well, today on The Exchange, again, this is our in-depth series that we're doing this week, uncovered 19 and our health care system. And every day we've been looking at a different aspect of how this pandemic has affected providers and patients. We've looked at telehealth. We've looked at rural health. Tomorrow, we'll look at the health care workforce. For today, we're looking at insurance and how the health and economic upheaval caused by this virus is highlighting longstanding complaints about health coverage in this country. Well, also going to talk about the options for folks who are underinsured or uninsured. There have been some changes because of the pandemic. And we'll find out more this hour. And Tyler, to you. So there has been a lot of focus on how many people might become newly uninsured due to the job losses that we're seeing now. But this just estimates at this point, we don't really know. How is the insurance department trying to keep track of this, recognizing that it's, you know, it's a slippery number?

Tyler Brannen:
Yes. No, it's a great question. And it's still hard for everybody to answer. The department has been meeting with the carriers every two weeks to talk about what's going on with their enrollment and things. But I think they're going to the best way to think about this problem is in sort of three phases.

Tyler Brannen:
The first is that in the very near term and we're already a month or two into that, and then there's kind of the mid-term, which is going to be perhaps to the end of the year. And then shortly after that, a lot of new enrollments take place on January 1st. And then there's going to be kind of a longer term impact. And the good news is the very short term. It looks as though there aren't a lot of drops. There is. Employers are keeping furloughed employees on. There are sort of the carriers have given the employer some grace period in terms of paying the premiums. And of course, that's sort of the normal cycle that they have a certain amount of time to pay the premiums anyway.

Tyler Brannen:
Similarly, individuals may have some of these benefits, too. So sort of the short term kind of drop off and things that that so far so good. And part of that, of course, there's going to be the results of some of the social distancing and some of the support that has been there for employers and individuals. But when that starts to change and dry up, I think that's one of the biggest threat that's going to be the economy. And we just end up with employers and individuals who can no longer continue paying those premium or actually even potential major shifts. And so the underlying health status of those people that's going to create, I think, some some challenges for our market over time. And that, you know, we'll see that perhaps over the next nine months.

Tyler Brannen:
Longer term, I think we're a little bit more optimistic. Insurance markets tend to do best when there's some predictability and stability in those markets. And what we don't have in the short term is any of that. So that's going to be the problem.

Laura Knoy:
Yeah, predictability and stability of kind of gone out the window. No matter what we're talking about these days, tilers. So it sounds like when we hear numbers like we heard this morning, you know, 16 percent unemployment. New Hampshire, you know, wow, that sounds crazy. But you're saying that doesn't mean all those people who are newly unemployed are losing their insurance. It sounds like there's a lot of flexibility in the system that has been put in there right now. Is that right, Tyler?

Tyler Brannen:
Yeah, that's correct. Through some of the assistance, and I think, though, it is worth noting there, there is even before they covered emergency. There was concern that we may see additional shifts from that of the group market to small employers, large employers to the individual market. There are some tax changes and well, as well as some sort of developmental changes that may lend itself to people sort of pursuing insurance and then individual market. And we did. Talk about some of the challenges with that part of it is just sort of understanding the benefit design, understanding how to shop for those products and and really sort of making sure consumers are getting what they want. That being said, there potentially are some advantages in going down down that road if that market grows.

Jeremy Smith:
Insurers may develop new products for the people who are used to being in the group market. We may even see some additional interest among carriers in that market. And that's that's sort of true nationally as well as locally. New Hampshire does have the benefit of three carriers in the individual market right now, which sounds low, but it's actually pretty good. It's it's you know, it's not great when you've got to it's obviously horrible and you're one or zero. But most markets in the country only have two or three carriers that really have a dominant presence. And there are a lot of reasons for that. But I think to the extent we start to think about how this is going to evolve, there are going to be certainly some challenges. And hopefully consumers will sort of take the initiative that they need to to to stay covered and to learn about their options. And both the insurance department as well as other resources in the state exist. We've got a great consumer services division and obviously the carriers are a great resource.

Laura Knoy:
Well, and just to clarify and Jeremy, want to ask you you about what Tyler just said, but just to clarify, Tyler, so group market is companies who buy insurance for their employees and individual market is people sort of going out on the what are called the Obamacare marketplaces and buying it for themselves, is that correct?

Tyler Brannen:
Yeah, yeah. That's that's the big difference. And we did talk about sort of the history of why we have so many people enrolled in employer sponsored insurance, which does have some advantages, among them sort of administrative efficiencies. You tend to ask for a benefits person involved, and those people have come together through their employer for reasons unrelated to health insurance. That lends itself to a certain amount of predictability when a carrier insures those people, when it's an individual who scored is choosing on their own. That creates sort of additional concerns around what we call risk selection, how sick the person is, how they're going to choose their products, and a certain amount of unpredictability. Those people also tend to be very price sensitive. There are the premium subsidies in the individual market, but those people may be more likely to choose a scaled down set of benefits, perhaps a network that doesn't include all of the hospitals, or they may actually look for other areas, sort of grey forms of coverage, whether they be sort of short term, short term policies or other policies that aren't regulated as well in those coverage options may not give them the protection that they might have otherwise expected. I realize I'm stating the obvious by saying that a lot of individuals don't know what they actually got when they bought their insurance products.

Laura Knoy:
Well, and again, as somebody mentioned earlier, a lot of us are just used to the boss doing it for us, you know, and we check the box and we're all done and we don't have to think about it. So this is where you come in, Jeremy, what do a lot of people not know about this or should be aware of right now?

Jeremy Smith:
Yeah, I think the main thing is the marketplace on health care dot gov. I mean, it's still relatively new to most people and they don't really understand how that works.

Jeremy Smith:
And, you know, to summarize, for most people, you know, about eight in 10 consumers, if they can't get insurance through their job, they can qualify for what's called the advanced premium tax credit, which is essentially a monthly subsidy that you can qualify for to help pay on the health insurance plan that you pay. And the amount that you'll get each month is based on your family size and your income. So so that's the easiest way to think about that. And a lot of people, they just don't understand how that subsidy works or how they might qualify for it or how much they would get. So that for most people, I mean, they would qualify for that monthly subsidy. And then, of course, most people they've heard about COBRA. And I understand that's usually pretty pricey. So the marketplace is definitely, you know, an alternative place to shop for health insurance that people don't really fully understand at a time. So usually what we can do is talk to them about how that tax credit works, that monthly subsidy, and, you know, explain how it will help lower the price of their plan that they pick right away. So that's the most important thing that we're able to explain for people.

Jeremy Smith:
Then, of course, the other option that people don't fully understand either is the state's expanded Medicaid program. And, you know, the rules changed with with the rollout of the Affordable Care Act. You know, it used to be you had to be very low income in order to qualify for Medicaid. But when the expanded Medicaid came through, it changed the rules. So now they look at, as, you know, your your current monthly income that you have coming in and your family size. So if your income is under a certain amount, you and your family in almost all cases can qualify for expanded Medicaid, that that doesn't cost you anything per month. And, you know, it's really great coverage. A lot of people are really happy with it. So people don't understand that they may qualify for that. And for that, you can sign up anytime. You can sign up for expanded Medicaid. Year round. And, you know, you don't you don't have to have a special enrollment period. So if you've seen a change in your income recently, that's another option for a lot of people. And the income limits are much, much higher than they ever were before the expansion of the Affordable Care Act.

Laura Knoy:
So I'm glad you mentioned enrollment period, because I think that's a source of confusion and frustration for people. You know, the deadline by which you have to sign up for health insurance. Are there deadlines? Let's say I lost my job tomorrow and I lost my health insurance. How much time would I have Jeremy to sign up for insurance?

Jeremy Smith:
Yeah, that's a great question. So if you qualify for expanded Medicaid, you can do that any time, as you just said. Yeah, yeah.

Jeremy Smith:
Where we come into the time limit is if you want to plan on the marketplace, on health care, dot gov, or if you're looking at trying to keep your plan through COBRA, you would have 60 days from the time that you lost your employer plan to be able to sign up for one of those plans.

Laura Knoy:
Cobra, again, is the an extension of the employer coverage that you used to have. And I know Dan You did a whole podcast on that. And we'll talk about that in just a moment.

Laura Knoy:
But I have to ask you about these enrollment periods that Jeremy mentioned.

Laura Knoy:
Dan, even before the pandemic, there was some pushback on this idea of you can only sign up, you know, in November and that coverage is good until next November. People's jobs, people's lives are a lot more messy than that. Even before the pandemic, we had the gig economy where people are kind of in and out or some people were freelancers. I just wonder how, again, this crisis that we're in right now, this twin crises of health and economics, is affecting people's feelings about this, these strict deadlines by which you must sign up.

Dan Gorenstein:
Well, there is, And Jeremy and Tyler know more about this than I do, Laura. But there's a catastrophic provision here. If you have a catastrophic life event which losing your job qualifies as. Right. You were you are eligible to go onto the exchanges, the ACA marketplaces, and buy coverage. So there there's been sort of a short circuit, a short wiring there, cut, put, put in place for people to be able to help them in a moment like this. So it it does relax some of that that rigidity that you're talking about. But I think that, you know, what Jeremy and Tyler are talking about here, and I think most of your listeners understand, is that health care is a product so damn confusing. It's really, really tricky to understand all of the nuances here. And there are so many rules, right. For something that we all sort of buy in need. It is shockingly complex.

Dan Gorenstein:
And I think one of the things that's been interesting to me, at least about the legacy of the Affordable Care Act, is it really sort of for some of us, it took this decision, this buying decision out of the hands of employers and put it in the hands of individuals, and that has forced more and more of us in this country as time has gone on over the last decade to begin to familiarize ourselves and to try to learn a little bit more about how this very complicated but essential product actually works. And I know that there's more I know there's efforts at the state levels, at local levels, at national levels to try to help increase the intelligence of the consumer here. But it's it's really tricky.

Laura Knoy:
You know, I asked Tyler how the insurance department, Dan, was going to track the number of newly uninsured people here in New Hampshire. How about nationally? Dan, there've been estimates. But do we really have a sense of the scale of people who might be newly uninsured because of this?

Dan Gorenstein:
So the as I was looking that up this morning at the Economic Policy Institute, a think tank in Washington, D.C., a left leaning think tank has an estimate that about 16 million people as of early May had lost jobs and health insurance, and that's out of about 35 million total who had been laid off or furloughed again.

Dan Gorenstein:
That's as of May nine. So it's it's a lot of people are.

Laura Knoy:
All right. After a short break. We will talk more about options for those people who are newly uninsured, as well as options for people who have been uninsured or underinsured for a long time.

Laura Knoy:
That's all as we continue our in-depth series this week covered 19 and health care. We'll hear from you as well.

Laura Knoy:
This is The Exchange. I'm Laura Knoy.. All this week, The Exchange is going in-depth with a special series Uncovered 19. And our health care system. Every day we've been examining a different aspect of how this pandemic has affected providers and patients. Today, we're looking at insurance and how the health and economic upheaval caused by this virus has highlighted longstanding complaints about health care coverage in this country. We've got three guests, Dan Gorenstein, executive producer and host of Tradeoffs, a podcast exploring a healthcare system. He is a former senior reporter for Marketplace's Health Desk and a reporter for us at NHP. Also with us, Tyler Brannen Directive Health Economics at the New Hampshire Insurance Department, and Jeremy Smith, outreach coordinator and program manager of the New Hampshire Navigator. That's a nonprofit help line that provides enrollment assistance. And by the way, the number for the helpline is eight seven seven two one one six two eight four. And that number is on our website as well. We'd like to hear from you. And all of you, let's talk more about some of the options that you touched on in our earlier segment. For those newly jobless Granite Staters or for those who, as I said, have been uninsured or underinsured for a long time.

Laura Knoy:
And Jeremy, want to start with you, but hear from everybody. So you touched on these. But just remind us, what are the options for somebody who loses their job tomorrow or whose employer never offered coverage? Just give us the list. Jeremy, if possible options.

Jeremy Smith:
Yeah. So there's a few options for people. The easiest ones, maybe for a lot of folks to check into is maybe going onto a spouse's plan. So if you've lost your coverage but you're married and your spouse has family covered, offered that be in place to check in to to see if you could qualify.

Jeremy Smith:
Of course, the other option is COBRA, which is a continuation of your current plan through your job, except that you're paying full price for it and you'd have 60 days to sign up after you lost your current coverage. The other one that we've been talking about is a plan through the health and health care dot gov. Through the marketplace. And there's a there's a different there's a lot of different companies that offer plans on there. And the price you end up paying is income based. So so that's the other option. And you would have 60 days to sign up for one of those plans after you lost your current coverage as well.

The other option that people look into sometimes is what's called it's a short term limited benefit plan. And these plans aren't exactly like traditional insurance if you've had it through your job. And they tend to be cheaper, but they also don't cover nearly as much. So for some folks, they look into those. It's kind of kind of like catastrophic health insurance for some folks. But it's just really important that, you know, what you're signing up for, if that's the route that you're going to go. So for most folks, that's going to be your main options. And then, of course, I've already touched on the expanded Medicaid program for people, and that one is based on your current monthly income to see if you qualify for Medicaid and you can sign up for that year round.

Laura Knoy:
Yeah, and some people, as you said earlier, Jeremy, might be surprised that they actually do qualify under the expansion. Also, one other option. Correct me if I'm wrong, Jeremy, if you're under 26 and your parents have coverage, you can also go on their coverage, is that right?

Jeremy Smith:
Yes, absolutely, that's a big one, and that was, you know, one of the game changers when the Affordable Care Act rolled out as they got to stay on their parents plan for that long. So there'd be another thing that you did check into as well.

Ok, well, and Tyler, I got to ask you, before we go to our listeners about those short term insurance plans that Jeremy and Jeremy mentions, I'm imagining, Tyler, that a lot of people might want to look into that because they're hoping that their unemployment is temporary. They're hoping that they'll get hired back or that they'll find another job once things open up a little bit more. So what do you think, Tyler, folks need to know about those short term insurance plans? Just kind of patch you over until things get better?

Tyler Brannen:
Yeah. I think it's been addressed to the extent that they they may not include the benefits that people expect. They're not regulated as health insurance products. So they don't have to meet all of what's referred to as the essential health benefits health insurance mandate. And a lot of a lot of the other sort of requirements that are in place to protect consumers for those, you know, when they buy health insurance products.

Tyler Brannen:
So it is certainly a buyer beware kind of scenario when you do pursue those types of products and and most people don't go that route. But obviously, we're not in a common situation. So maybe something for for somebody to explore on a short term basis. I do want to follow up kind of on the other piece to this, too, is I mean, it's been reference to the premium subsidies that are available for people when they go through The Exchange or the marketplace. And that's that that's that health care dot gov website. It is specific to New Hampshire for the products that you're going to see up there. And those premium subsidies go up to 400 percent of the federal poverty level. So I think when people think of kind of premium subsidies or tax credits, they may go, well, I won't. I won't I won't be actually eligible for those before. And a percent of the FPL level is that's close to one hundred thousand dollars for a family of four. And actually, if you're lower on the spectrum, you can even get cost-sharing subsidies. And then, of course, if you're low enough, you can go enroll into it to Medicaid. So those are certainly things worth considering. The other thing is we've always referenced this Cobra. There's also sort of state continuation, which is very similar, and that deals with sort of employers that might be a bit smaller and entirely.

Laura Knoy:
What's that called?

Tyler Brannen:
It's considered state continuations, the covers of federal law. Most states have kind of built on top of that with some of the same opportunities for people. But I think probably in most cases, if somebody has lost their employer sponsored insurance, The Exchange is going to offer them better options, at least at a price point that that sort of employer coverage that they had.

Tyler Brannen:
It's most likely gonna be more expensive and obviously won't give them the same kind of choice. And to the extent that there's additional information that saw it on COBRA or the state continuation, all of that is actually available on the insurance department Web site, sort of FAQ, there's detail that may be helpful for people to explore before they sort of jump into any particular direction.

Laura Knoy:
Sure. And lots of numbers there, Tyler. So just to make sure I got it right. You talked about the FPL. That's the federal poverty level. So were you saying, Tyler, that some folks might be surprised that they actually qualify for pretty hefty subsidies? They might think that the subsidies are only for very low income people. So just give that to us again, that the FPL, federal poverty poverty level and who qualifies?

Tyler Brannen:
Yeah, yeah. So it's the federal poverty level differs depending on whether it's for an individual or family for Knoy.. The examples I like to come up with is it's just that if you've got a family of four to 400 percent of the federal poverty level, there's an annual income of around one hundred thousand dollars. So there is also the opportunity when you go in through this this website, like your insurance, and make an estimate about your your your annual income. You can make adjustments over time, which you would obviously want to be focused on, because that's how you end up with too much of a premium subsidy during the year that you're going to end up with a tax bill. And that's not necessarily a less desirable outcome, but it is available for people on Trump basis and it often does result in much lower cost insurance than they would have otherwise expected. So I think that's worth noting. The other thing that I did want to mention is New Hampshire has also taken steps forward to submit an application to the federal government to implement a mechanism for that individual market.

Tyler Brannen:
That mechanism will make use of sort of federal funds to actually lower premiums by what we're hoping is going to be about 15 percent next year.

Laura Knoy:
Well, that's a lot.

Tyler Brannen:
We are focused on that individual market in the state. And all of this started before the whole covered emergency. But fortunately that, you know, the timing of things, it's going to be a benefit, I think, as we go into 2021. And so I think I sort of re-emphasize, you know, make sure that people understand their options going through that health, their health care dot gov Web site in the individual market, because for many people, that may be the best. And and like I said, under two, I think it's 250 percent of the federal poverty level, people will actually get car-sharing subsidies as well. So not just a premium subsidy, but actually help with covering cost sharing, which, of course, we started the conversation with sort of the premiums, the money out of pocket concerns that people have. And I think some of the biggest complaints. When you have about. Sure.

Laura Knoy:
Ok, so cost sharing subsidies may be more widely available for people who have to go out and buy individual plans than they might have realized. And also, due to some efforts that you're talking about, Tyler, premiums could go down as well.

Laura Knoy:
I want to go to our listeners who got some e-mails coming in. Io wrote to us. Io says, I feel like the issue is that the U.S. needs to move to providing health care to citizens and end this problem once and for all. So that's referencing our earlier conversation about why the U.S. does it this way. Linda wrote in and says, I'm listening to the show today and just want to put out there that I qualified very quickly for Medicaid when I claimed unemployment. I was unemployed for two weeks and realized I should check into getting Medicaid. The process was easy. My caseworker was very kind and helpful. So now I'm covered for a whole year under Medicaid. Wow. Linda, thank you for writing in. And thank you to you, too. So, Dan, what do you pull out of Linda's pretty positive story there with Medicaid?

Dan Gorenstein:
Medicaid is arguably the backbone of our health care system. And in many ways, for. For many people, Medicaid is serves predominantly low income people. Lots of kids who come from low income families and a lot of people with disabilities. And it really it's the law. It's the nation's largest health insurance program, serving about 77 million people around the country. And it's been a political football, as you know, Laura, since 1965 when it was created. It's been a huge political football in Concord where as a reporter at New Hampshire Public Radio, there are always fights about how much the state would spend on Medicaid, because it is I can't remember if it's the biggest line item, but certainly one of the biggest line items for the state. And it costs it costs a fair amount of money. The federal government provides, on average, about a 60 percent match. So for every dollar, the federal government's picking up 60 cents, leaving the state about 40 cents of the costs. And, you know, in a time like this, Medicaid isn't really a goal. It's a critical program for people who are losing a job and able, like Linda, who are able to qualify for this program. And you're able to be able to get service, get access to coverage. I think one of the really interesting things about this moment time, Laura, with Cauvin, is that. You know, the way most doctors and hospitals get paid is by what's called fee for service.

Dan Gorenstein:
When you actually, like walk into the doctor and you get a service, there's the doctor or the hospital can get reimbursed for that service. But as we all know right now, going to the doctor, going to the emergency room, going to the hospital. That's one of the most dangerous places you can be. And so these these hospital halls, these these doctors, these clinics, they're they're kind of financially under the gun because people aren't walking in. And so one of the real interesting, unique challenges that COVID is presenting for Medicaid programs in New Hampshire and around the country is how how can the Medicaid programs continue to support the doctors and hospitals and other counselors and medical providers that serve the patients when they're financially constrained? That's a really difficult thing. And so we've talked to a couple of Medicaid directors around the country who are really struggling with, hey, our case loads are growing. That means we're gonna have to spend more money. But also we have providers who are having a hard time keeping the lights on and we need to keep them afloat, too, so they can be there when people need them. It's a very, very difficult challenge. And the recession, of course, is making this even greater because as states lose their revenue, the pressure to somehow make cuts to Medicaid will only grow.

Dan Gorenstein:
Yeah, it's a real dilemma here.

Laura Knoy:
Because Medicaid is half funded by the states and half funded by the federal government. What you just said, Dan, reminds me of the show we did on Monday where we talked to the heads of two rural hospital systems who described exactly what you're talking about.

Laura Knoy:
A quick question for you, Jeremy. Again, based on Linda's email, are there some people who don't even consider Medicaid? They think that that is for low income people. And, you know, that's not me and I'm not touching it. Is there sort of above a psychological barrier to checking out Medicaid? Jeremy?

Jeremy Smith:
Yeah, absolutely, I mean, that's probably the biggest shock that most people have when they call us and we start talking to them about their situation and we tell them it looks like you're going to qualify for Medicaid tonight. Yeah. They're definitely a little bit shocked, usually just because, as I said in the beginning, people are just used to getting their insurance through their employer and they haven't kept up with the road changes over the last seven years. So, you know, they're usually pleasantly surprised and really happy that they can get that kind of coverage.

Jeremy Smith:
So, you know, with most of the applications that we've been doing since COVID started have been Medicaid applications.

Laura Knoy:
So really, instead of people buying individual coverage on. Right.

Jeremy Smith:
I mean most people qualify for Medicaid versus get going into the marketplace. So it's been really good for a lot of people.

Laura Knoy:
That's really interesting. We got an email from Diane, which maybe I'll throw to you Jeremy and you, Tyler. Diane says, Please say more about how to access expanded Medicaid. So, Tyler, I want you to take that first.

Tyler Brannen:
Well, I may not be the best person to I'm insurance department, but but one of those those avenues is actually through that health care dot gov Web site. It'll determine your eligibility and and likewise eligibility for whatever level of premium subsidy. And indeed, I did actually reach out to the HHS prior to this call just to get a better sense of what's happened with the Medicaid numbers. And as you would imagine through June excuse me, through April 30th, there has been a notable uptick.

Tyler Brannen:
So there are more people signing up for Medicaid. And depending on what sort of class people fall into, it's largely between sort of a foreign temperature increase. But it's certainly a good option for for people who might be eligible for that type of coverage.

Laura Knoy:
Well, that's interesting. So health care dot gov where most people know to go and shop for their own insurance on the marketplaces. You're saying, Tyler, you can also find out there whether you qualify for expanded Medicaid.

Tyler Brannen:
Yeah, it's sort of kind of a one front door type approach, though, to the extent that you're looking for health insurance and it sort of gets you to the right place and determines their eligibility. And I mean, one of the first part is whether or not you are eligible to sign up sort of outside of the annual enrollment period. And this goes back to that special enrollment period, which has to come from a loss of your employment or marriage or some other sort of qualifying event.

Laura Knoy:
Interesting. Go ahead, Jeremy. Diane's question, please say a little bit more about how to access expanded Medicaid.

Jeremy Smith:
Yes. So, as Tyler mentioned, health care dot gov is an option, but for some people, that's not the best route. Health care dot gov always asks for your estimated annual income.

Jeremy Smith:
So if you've made a lot of money up until now and now you're only on unemployment, that may not work for you. So that's one of the flaws in health care dot gov, as it always goes off annual income for people. That's had a drastic change in their going off what they're making right now at their monthly income. They're going to be better off going to the New Hampshire easy Web site. So that's an H easy dot in H dot gov. And that's where you can do an application to apply for Medicaid. So if if you think you're going to qualify based on your, you know, reduced income and you're only getting unemployment, that that's what I'm advising people to do, is go ahead and go directly to the state's Web site. And then, of course, if you have questions, the number one thing to do is call somebody at our program and we can actually assist you with the application process.

Laura Knoy:
Ok. And again, Diane, we've got Jeremy's organization's number on our Web site. But the number is eight seven seven two one one six two eight four. So coming up, I do want to ask a little bit more about COBRA.

Laura Knoy:
Dan Gorenstein, you've reported extensively on that. So we will definitely talk about that. And we'll take more of your questions and comments.

Laura Knoy:
This is The Exchange. I'm Laura Knoy. All this week, The Exchange has been going in-depth with a special series on the impact of COVID-19 on New Hampshire's health care system.

Laura Knoy:
And today, we're looking at the ins and outs of insurance and how the impact of the corona virus has been shaping the debate over how to cover people, how to pay for care, and some of the changes that our guests are telling us about. We're talking with Jeremy Smith, outreach coordinator and program manager of the New Hampshire Navigator. That's a nonprofit help line that provides it health insurance, enrollment assistance. Tyler Brannen is also with us, director of health economics at the New Hampshire Insurance Department, along with Dan Gorenstein, executive producer and host of Tradeoffs, a podcast exploring our health care system exchange listeners. Let's hear from you.

Laura Knoy:
What questions do you have about insurance, especially if your job status has changed? What's your health insurance status right now? What worries do you have? What questions do you have?

Laura Knoy:
And all of you, Ginger in Hooksett writes, A few years ago, I found myself unemployed and got health coverage through the Affordable Care Act. I qualified for a lower costs due to my lack of income at the time. However, Ginger says, because I had been making a decent salary on either side of my unemployment at the end of the year, I had to pay back the difference on the cost of my health insurance. That really hurt. I did not have the income at the time to pay full cost and was still behind on everything for a long time. Once I was employed again. Wow. Ginger, that is complicated and disappointing. And Jeremy, can you address what happened there?

Jeremy Smith:
Yeah, absolutely. And then unfortunately, we do see this happening for folks. What happens is if you do an application on health care dot gov and it says that you're eligible for the monthly subsidy, the advance premium tax credit, that's based on the estimated income that you used at that time. So let's say that you estimated your income at thirty thousand for the year and then, you know, things change throughout the year and you get back to work and you end up making forty or fifty thousand for that year.

Jeremy Smith:
What happens is when you file your tax return for that year, you have to pay back the difference because you've got too much of a tax credit, too much of the monthly subsidy. So when you file your taxes, you have to pay back either a pro-rated amounts or all of it, depending on how much over the income estimation you went over. So the main thing we can do to to tell people that remedy this is remember what you put on your application as your estimated income. And then as things change throughout the year, update your and your your application with the new estimate. And you can either log back into your account or call the call center or you can work with the program like ours, a navigator, and we can help you make those updates throughout the year.

Laura Knoy:
Wow. Ginger, I'm glad you wrote. And Jeremy, that would make me worry if I were newly unemployed. But we're hopeful that I would be hired back by my employer.

Laura Knoy:
You know, once things open up more, that would make me hesitate to sign up for anything at all and just kind of cross my fingers and hope I don't get sick. Jeremy.

Jeremy Smith:
Yeah, and unfortunately, we are seeing situations like that because, you know, we're letting people know that the subsidy, it's definitely going to go off of your entire yearly income. So if you get back to work and you make, you know, a lot more than you originally intended. It's definitely possible that you may have to pay back those subsidies that you've been getting.

Jeremy Smith:
So that is something to consider. And it is part of the process, unfortunately. So, you know, it's a great piece of education for people that they need to consider when they're signing up.

Laura Knoy:
Wow. Well, Ginger, thank you for writing in. And let's take a call, gentlemen. Jennifer is calling in from Pembroke. Hi, Jennifer. You're on The Exchange. Go ahead.

Caller:
Yes, good morning. My husband and I are currently covered under my health insurance, but we are selling our home and moving to North Carolina. Hopefully the first week of July. And I plan on staying out of work till the beginning of September. My husband feels it would be prudent for us to continue through COBRA. And I'd be anxious to hear your advice on that.

Laura Knoy:
Well, I'm so glad you called Jennifer, because Dan Gorenstein. You have reported extensively on COBRA. Now, just remind listeners who aren't familiar with it that we're not talking about a snake here. What does that stand for and how does it work?

Dan Gorenstein:
Consolidated Omnibus Budget Resolution Act is what WOW stands for. Simply, it's a program that lets workers stay on their employer insurance, but requires you to pay the entire premium. And I think what a lot of folks don't necessarily realize, even though nobody likes seeing how much is taken out of their check to cover their health care costs. On average, an employer is picking up about 80 percent of your premium. So that's then all on You. So COBRA becomes a very expensive option. But, of course, the devil's in the details here. And Jeremy certainly can speak to some of this. What kind of plan, you know? What kind of plan you have really is going to make a big difference? Are you in a high deductible plan? And have you sort of met that threshold? Are you already basically have you already sort of spent five thousand dollars and you're now insurance is sort of fully kicked in. So you can sort of reap whatever health benefits you need to get. That's that's a big question. And by going COBRA, that could actually be really beneficial for you. Right, because even though you have a higher premium than maybe a plan that you could find on the Exchanges, you don't have to sort of restart the clock with how much going to have to pay out of pocket. So there are lots of questions and details that are going to really depend on whether or not COBRA is the best option for you and really getting yourself to a navigator and having that conversation, getting into the nitty gritty and doing some back of the envelope math is going to be essential to figuring out the best way forward.

Laura Knoy:
Well, and as everybody has said this hour, so much depends on your own situation. I do remember once, Dan. Long time ago, I was in between jobs and I got Cobra. I was moving just like Jennifer, our caller. I could not believe how expensive it was. I think I was twenty five years old at the time and I thought, how much money you think I have folks, you know? It was really expensive. But I think you just reported recently, Dan, on some ideas that Congress is noodling around with about possibly helping folks with the cost of COBRA.

Dan Gorenstein:
Yeah, that's right. In the most recent legislation introduced by House Democrats, I believe was last week, they included a plan that would cover 100 percent of COBRA costs for people who had lost their jobs.

Dan Gorenstein:
So that's a potentially very attractive option for some people. I think that it was interesting when we were doing the reporting for that story, Laura. This is what happened during the Great Recession as well. And ultimately, what happened was that lawmakers passed the legislation creating a subsidy that paid for about 65 percent of premiums. Not 100 percent. And it only increased COBRA use by about 15 percent. And this is not a surprise, especially given the conversation we've been having. A big reason that not more people took advantage of the subsidies because a lot of people didn't even know COBRA existed. And the other reason was it was just too pricey. And I think what's really interesting when we'd have this COBRA conversation right now is it's it's certainly an option.

Dan Gorenstein:
But back during the Great Recession, the Affordable Care Act didn't exist.

Dan Gorenstein:
The ACA marketplaces weren't on the table. It wasn't a tool that people could use. And so some lawmakers in Washington and some economists, health economists have really been pushing this idea that maybe a better option is to have some legislation that would allow that you could increase ACA subsidies, instead, make them more generous for people so that the ACA plan that you could buy looked a little bit more like the health insurance you just lost when you lost your job. So that's that's one option on the table and other ideas to effectively give people a voucher. And you could take that money, that subsidy, and you could apply it to COBRA if you wanted. If COBRA was a better option for you, for somebody like Jennifer or a car, or you could take that subsidy and apply to the ACA marketplace and see what you could get there. So those are just a couple of ideas are being kicked around.

Laura Knoy:
That's interesting. So take the subsidy, but use it for whatever Avenue feels right for you. We got an e-mail from Doug in Mason that I want to throw to you, Tyler. Doug says, In choosing an insurance policy, one goes through all the research to see if what they cover, if they they cover what ails you, your condition, as it were, and that they cover the medication you're being prescribed. Doug says only to find out that after you've chosen and laid your money down, the company changes their policy with which they can do at any time. So they no longer cover the meds you and your doctor have said you need. Doug says there was legislation proposed to make that illegal, but I don't think it ever passed. Doug, thank you so much for writing. And Tyler, what about this? People go through the process. They're very careful. This plan is good for me for reasons X, Y and Z. And then two, three months down the line, the insurance company says now and I feel like covering that anymore. Is that allowed?

Tyler Brannen:
So there is some flexibility, but I don't think that it's quite as broad as maybe some people might have seen it.

Tyler Brannen:
Remember, the forms get reviewed by the insurance department and the benefit products have to include all the New Hampshire specific requirements. Insurance is regulated at the state level, and that gives states a lot of flexibility to decide what needs to be included in insurance products. On top of that, there are federal requirements that are referred to as these essential health benefits for many products that people, particularly in the small group and individual market, are going to face. There are also sort of expectations for what they call kind of as the minimum set of benefits that have to exist. That doesn't mean that benefits can't shift a little bit over time. And I think one of the examples of that are formulary is also something that could change after you buy insurance is the network could change. Doctor, you thought you'd have access to you're no longer to or a hospital you might have access to. When you looked at it, it's no longer in the network.

Tyler Brannen:
New Hampshire has the advantage of having those to the providers and the networks. That's less of an issue. Similarly, there are notification requirements that the formulary is going to change, but it is something we do hear from occasionally that somebody is concerned about a drug they were on and they no longer can.

Tyler Brannen:
And part of the reason that flexibility is given to insurance companies to re-evaluate the formulary, part of it might be sort of new information that comes out about the safety of the drug. Something else may be a new alternative comes down to the market, a drug that lower cost, more effective. There's sort of an interest, a general interest in checking people do that drug or something goes off on brand becomes generic and becomes much more cost effective. There was legislation that was introduced that would have essentially frozen the formulary. The challenge with something like that, that creates a fair amount of leverage with the drug companies that would turn say, OK, well, we know states are adopting policies like it. Once we're on the formula, we could change the price to the dragon. We perhaps go much higher than we were in the past.

Laura Knoy:
I see. So the flexibility is yes, flexibility sort of runs both ways. There's there's pros and cons to that flexibility from the consumer and the company perspective. I've got to wrap it up there. But, Jeremy, thank you very much for being with us. I really appreciate it. Yeah. Thanks for having me. That's Jeremy Smith, outreach coordinator, manager of the New Hampshire Navigator. Tyler Brannen, the insurance department is great to have you, too. Thank you. And Dan Gorenstein, thank you for your time. Was great to talk to you. Wonderful. This is The Exchange on NHPR.