HHS Secretary: States like Georgia will eventually see the merits of Medicaid expansion

Sylvia Burwell, head of the Health and Human Services, on open enrollment, Medicaid expansion in Georgia, and the CDC’s continued fight against Ebola.
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Back in June, opponents of the Affordable Care Act lost their last major challenge when the U.S. Supreme Court ruled in favor of its premium tax credit—a key component to the national healthcare law. Now, for the first time since the law’s inception, open enrollment appears to be, well, actually focused on signing up uninsured Americans for health insurance.

Between November 1 and January 31, men and women eligible to enroll for medical coverage—including 304,000 metro Atlantans—can once again shop for a variety of different plans at HealthCare.gov. To help promote the Health Insurance Marketplace, U.S. Department of Health and Human Services Secretary Sylvia Burwell visited Atlanta earlier last Friday to drum up support for open enrollment for the health-insurance exchange. The White House recently named Atlanta as one of 20 cities involved in its “Healthy Communities Challenge” aimed at signing up more people for healthcare plans. The winning city will land a visit from President Barack Obama.

During her Atlanta stop, Burwell visited a Castleberry Hill salon to spread the word about open enrollment. She then stopped by a “Health Insurance Storefront” on Luckie Street, where people can enroll for health insurance at a brick-and-mortar location, and gave a few remarks alongside Fulton County Chairman John Eaves and Georgia House Minority Leader Stacey Abrams. From there, she swung by Manuel’s Tavern, where she chatted with local community leaders before heading over to the Centers for Disease Control and Prevention.

At the Poncey-Highland watering hole, Burwell chatted with us about the current open enrollment period, Georgia’s rejection of Medicaid expansion, and the ongoing work to fight Ebola. This interview is condensed and edited for clarity.

For starters, how’s open enrollment going in metro Atlanta during this signup period, compared to past years?

Here in Atlanta, we began with a large with number of folks who are uninsured and eligible. Progress has been made, but we know it’s a city where more can be made. You also have good support for it. That’s how we selected Atlanta as [one of 20] Healthy Communities. So it’s a combination of the two.

With regard to the beginning of open enrollment and our goals, we think we can move the numbers of the [national] marketplace to 10 million by the end of next year. But it’s important to keep people focused on the uninsured. It’s not about the means by which you get there, but what we want is people to have access to insurance and healthcare.

So far, we’re doing what we did last year, putting out the numbers to date on a weekly basis. Those numbers are overall, not state-by-state at this point. We know 500,000 people did planned selections and enrolled in that first week. I would describe it this way: Off to a solid start, but we have a lot of work to do.

This is the first year of open enrollment where there’s not a major issue hanging over the signup period, whether it’s a broken website, or a U.S. Supreme Court challenge. How much does that help your cause in a place like Atlanta?

We feel fortunate to not have the challenges you described, and we have learning under our belt in listening to the consumer. The number of people we’re targeting is much smaller. That’s a good problem to have. These folks clearly haven’t come [to sign up] in two years. There’s a higher threshold with them. It’s challenging, but we’re going to work smarter and better with some of the headwinds not existing as much. There’s still great progress to be made in Atlanta and Georgia at large.

When you say “smarter and better,” what do you specifically mean?

Specifically, smarter and better has to do with affordability. We’ve studied it. We’ve worked with consumers currently in the Marketplace. Surveys of those outside the Marketplace by Kaiser and others show us that affordability is the primary issue. So it’s really understanding the major issues and then communicating about it. You’ve heard me say there are 7 out of 10 [people who can get a healthcare plan for less than $75 per month]. It’s getting that information out to consumers so they can think about it.

The second thing is continuing to learn how to improve the site. Speed of the site is up. Backend stuff we’ve done. For some young people, they care about speed. There’s specific technical things with the website. But then it’s how we do outreach—we’re focused on local markets and that’s why we have 20 cites that we’ve named Healthy Communities. We know this happens on the ground in local communities through local stakeholders.

Given the early struggles of the Affordable Care Act, is it inevitable that a certain percentage of people—such as the portion of the 15 percent of Georgia residents who are uninsured despite being eligible—won’t be willing to sign up? Or do you think you can work past those challenges?

I think we can overcome that. The question of what went before is something that’s overcomeable [sic]. It’s now about determining what are the other decisions people are making their decisions on. That’s why communicating about affordability is so important. Communicating about the fee [for not signing up] is also important.

There are roughly 304,000 metro Atlantans who are uninsured and eligible for open enrollment that you’re targeting with your visit. In Georgia, there’s more—over 400,000—who would also be eligible if state officials stopped blocking Medicaid expansion. As elected officials in Southern states mull the merits of Medicaid expansion, as Alabama Gov. Robert Bentley last week acknowledged he was doing, what do you think are the lasting consequences of opposing that policy?

The effects of the lack of expansion in states are on individuals’ health and financial wellbeing. We know the changes that have occurred, whether that’s the number of people who have trouble paying health bills, to what we’re saying in the expansion states with the numbers of the population coming in to have their diabetes treated, to the questions of the economics. We know that rural hospital closures are an issue across the country. That’s about the hospitals and their surrounding populations. But we also know there’s more closures in states that don’t expand. We know uncompensated care has been reduced dramatically. It’s reduced more in states that have expansion. There’s a whole list of things happening right now. Some of them are about individuals, and some of them are about community economics, and some of them are about the state’s economics.

Now there seems to be two ways of going about Medicaid expansion: the moral argument—that it’s the right thing to do—and the economic argument that has been used by Gov. Nathan Deal and Republican state lawmakers to argue against it. As states like Georgia continue to discuss Medicaid expansion, what does the road forward look like to you regarding both of those rationales in this policy debate?

The economics of the issue should be discussed—and what it means for different states. As recently as two weeks ago, Montana came in. You’ve seen a serious conversation in South Dakota. These are not Southern states. But they are deeply conservative states that have the same concerns about their economies as the state of Georgia. As people continue to debate, let’s look at the economic analysis of what it means to the state in terms of the funds that will come in, and what it means overall to the communities and the hospitals. What is going to happen is that support for Medicaid expansion will continue to build. You hear the Alabama governor. You’ve heard conversations in Louisiana. You saw that, while it didn’t get there, there was a serious effort in Florida. Even in these Southern states, you’re seeing those conversations.

As time and experience build, the governors will see it. We’re at 30 states plus D.C. We’ve added Pennsylvania under a Republican governor. We’ve added Indiana under a Republican governor. We’ve added Alaska under a Republican governor. It’s coming back up in places: Michigan, Arkansas, New Hampshire. We’re going to continue working through each of those states.

Do you see it as being just a matter of time before all join—some taking longer than others?

Yes. Because it’s a continuum of insurance. That’s what gets missed in the conversation. [If you get insurance through an employer], the company gets a tax break, and the company subsidizes your insurance. Whether you’re in Medicare, subsidized insurance for the elderly; whether it’s you and me, with employer-based care in which the tax benefit occurs; or whether you’re in the original Medicaid or Medicaid expansion, a population in which a large percentage is working, it’s a continuum of insurance. As a nation, we’ve come to recognize the importance of health insurance. People are subsidized in different ways at different levels. That’s going to happen because it’s getting built into the system of the nation.

This is a space where the market hasn’t worked in terms of information and transparency. That’s one of the most important things the Affordable Care Act does—now you can find out who in this country is receiving the most Medicare payments, you can find out what physicians are receiving payments from pharmaceuticals, you can find out what insurance companies want to raise rates more than 10 percent going into the season. That’s all information that didn’t exist before. The more we create transparency, the more we empower consumers, and support a market across the entire space.

Your final stop in Atlanta is at the CDC. Obviously, the CDC as well as Emory Hospital played major roles in the fight against the Ebola epidemic. Looking back to that saga, what are the biggest takeaways you got from that experience and the role of the region’s agencies in that international effort?

I’ll be meeting with some of the Ebola teams. You’ve probably seen the news that Sierra Leone is Ebola-free. We’ll discuss the progress that’s been made. In the CDC realm, it’s the commitment of the folks here—I think it’s over 3,000—that have gone to West Africa. I’ll meet with people who have gone three rounds. There’s an incredible commitment: One CDC person canoed blood samples [to get them delivered.] The commitment of the public servants in this country, whether it’s the work CDC did abroad and the people here in Atlanta, where your Department of Public Health did tracking and tracing of people. It wasn’t easy. And then there’s an institution like Emory Hospital that didn’t flinch, and was incredibly standup in doing something that was hard and risky, and then delivered with the utmost quality in the world.

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