Health Insurance Under The Patient Protection And Affordable And .

individuals and qualified small employers shop for, select, and enrollin high-quality, affordable private health plans that fit their needs atcompetitive prices. Exchanges will also assist eligible individuals toreceive premium tax credits and cost sharing reductions or helpindividuals enroll in other Federal and State health care programs. Byproviding one-stop shopping, Exchanges will make purchasing healthinsurance easier and more understandable and will put greater controland greater choice in the hands of qualified individuals and smallbusinesses” (DHHS, CMS, & CCIIO, 2012d)State HIE marketplaces are a cornerstone of the PPACA and their role in ensuringhealth insurance coverage for the uninsured, including at-risk/vulnerable populations willbe the subject of this dissertation research. The DHHS is the designated ExecutiveBranch department tasked with establishing and promulgating agency rules, regulationsand guidance associated with the establishment of HIEs at the state level.1.2Purpose of ResearchA principal component of the PPACA is the provision of health insurancecoverage for uninsured U.S. citizens.A major goal of the Act is the provision of nearuniversal health insurance coverage for the first time ever in the United States. Anadditional goal is the provision of accessible, affordable, and quality health care for allU.S. citizens while reducing the cost of care associated with all health services.In aneffort to reach these goals and to meet the statutory requirements of the law, states aremandated to establish HIE Marketplaces (Congress, 2010, pp. Part III, Sec 1321). Tocarry out this mandate, states have been given three options for establishing their HIEmarketplace:1) establish a State Based Exchange, 2) establish a State Partnership3

Exchange, or 3) default to a Federally Facilitated Exchange (DHHS, 2012b). Regardlessof the option chosen, HIEs will serve as public marketplaces for the purchase ofaffordable health insurance, and the individual exchange is viewed as a key factor inensuring the enrollment of eligible individuals into qualified health plans (QHPs).To reach uninsured and at-risk/vulnerable populations, the law requires HIEs toestablish navigator programs.HIE navigator programs will use community basedorganizations and consumer service agencies to provide outreach and education touninsured and at-risk/vulnerable populations, aimed at enrolling them into health plansoffered through the exchange. Researchers generally agree that there is no one singledefinition for what a navigator program is, or for what it does. However, for this researcha distinction will be made between what are known as patient navigator programs andnavigator programs established under HIEs. HIE navigator programs will be defined as afederal mandate for the facilitation of outreach, education, and enrollment of atrisk/vulnerable populations into qualified health insurance plans. For this research, thoseprograms that assist patients in facilitating the delivery of clinical health services will bereferred to as traditional patient navigator programs. The use of these programs tofacilitate the delivery of health services for illnesses, such as cancers, where research hasdocumented disparities in treatment and care has been a longstanding practice.While the DHHS does not provide a formal definition for at-risk/vulnerablepopulations in any of the guidance it has prepared for establishment of HIEs or navigatorprograms, the Centers for Disease Control and Prevention (CDC), an agency within theDHHS defines other at-risk/vulnerable populations as4being“ defined by socio-

economic status, geography, gender, age, disability status, risk status related to sex andgender, and among other populations identified to be at risk for health disparities” (CDC,2013).For purposes of this research, the terms at-risk/vulnerable populations and atrisk/vulnerable groups will be used interchangeably, and will refer to those individuals orgroups noted in the CDC definition with the exception of geography and disability status.Also, because they are generally covered by Medicare, Medicaid, or State Children’sHealth Insurance Programs (SCHIP), elderly individuals and children will not beincluded in the definition of at-risk/vulnerable populations for this research.Morespecifically, this research will focus on low-income, racial and ethnic minority groups,culturally diverse groups with limited English proficiency, and groups whose medicalcircumstances render their receipt of care especially burdensome without support andadvocacy. Also, for this study, uninsured employees of small businesses will also beconsidered an at-risk group because of their economic circumstances. In researching adefinition of vulnerable populations, it was discovered that the term at-risk/vulnerablepopulations can be viewed differently depending on the research discipline, (e.g. healthcare, sociology, psychology, criminal justice, emergency preparedness, etc.), and includeany number of at-risk/vulnerable groups (Ruof).HIEs are viewed as a key factor in the enrollment of vulnerable, uninsured, andotherwise eligible individuals into affordable, qualified state health plans. They willserve as marketplaces where consumers will be able to purchase individual healthinsurance through non-group health plans that have been approved by the state.5

Affordability has traditionally been the factor excluding these groups from the pool ofhealth insurance options generally available to the public and through employersponsored group health plans. Based on eligibility requirements and conditions set forthin the law millions of vulnerable individuals will be eligible for subsidies to helppurchase health insurance through HIEs, thus making health insurance affordable (S. R.Collins, Robertson, R., Garber, T., Doty, M.M., 2013; Cunningham, 2010).However, the use of HIEs and mandated navigator programs to facilitateenrollment of at- risk/vulnerable populations into insurance programs is new, both to theinsurance market and to individuals who have never purchased or enrolled in healthinsurance plans. Therefore, the purpose of this research will be to examine the role ofState Based HIE marketplaces and navigator programs in ensuring health coverage for atrisk/vulnerable populations who have traditionally been excluded from private insurancemarkets and publicly financed health programs.1.3Research AimsThis research has three specific aims. The first is to provide an overview ofhealth reform and the PPACA mandate for the establishment of HIEs and their role inmaking health insurance coverage available for vulnerable U.S. citizens. This aim willinclude an examination of: 1) health reform efforts in the U.S. and how we have reachedthis point of near universal coverage; 2) federal requirements for the establishment anddesign of HIE marketplaces; and, 3) how HIE marketplaces operate in the State ofMassachusetts and in European national insurance markets.6

The second aim of this research is to provide a review of the governance structure/business model, governance appointment and composition of State Based HIEs. Evenwith a set of minimum guidelines from the DHHS, states have been given considerablelatitude in designing and implementing their state HIE marketplaces (Blavin, Blumberg,Buettgens, Holahan, & McMorrow, 2012).This includes the business model, andgovernance structure under which they operate, including the apportionment,appointment and composition of their governing authority.Thirdly, this study will examine the use of traditional navigator programs in thedelivery of clinical health services.It will examine the strategies used to engageindividuals in seeking care, explore the at-risk/vulnerable populations served bytraditional navigator programs, and examine the characteristics that navigators mustpossess to be effective facilitating services. HIE navigator programs are mandated at aminimum to provide outreach, education, and enrollment of at-risk/vulnerablepopulations into approved qualified health plans.Also, while not officially termednavigator programs, public and private organizations such as the American Associationof Retired Persons, officially sanctioned employee unions, and certain group purchasinginsurance plans have used navigator program strategies to facilitate enrollment oftargeted groups of individuals into group insurance plans. Thus, the use of navigator likeprograms outside the field of health service delivery aimed at enrolling specificpopulations into insurance programs has been a long standing practice.Navigator programs in HIE marketplaces, while not delivering patients to a pointof service for the provision of care, will nonetheless guide and facilitate the same kinds of7

socially, economically, culturally and medically at-risk individuals to enrollment inhealth insurance plans.To be successful, it is theorized that exchange navigatorprograms will need to incorporate many of the characteristics and strategies proven to besuccessful in facilitating vulnerable patient groups into programs of care. A review of theliterature is expected to identify strategies associated with successful patient navigatorprograms.These strategies will be explored to determine if their adoption by HIEnavigator programs will garner the same success in reaching at-risk/vulnerablepopulations for enrollment in HIE qualified health plans.Early Research on HIE and Navigator Program DesignThe PPACA HIE marketplace is in its infancy. Therefore, no quantitative data toexamine the success of enrolling at- risk/vulnerable populations into HIE marketplacesexists. Thus, an empirical research approach using information or experiences from avariety of sources as well as information empirically derived from evidence basedpractice will be used for this research. Early HIE marketplaces and navigator programswill undergo changes as markets mature, health plan options change, and state andfederal rules and regulations governing their operation evolve. An empirical researchdesign will allow for a qualitative review of how HIEs are established and designed tofunction at implementation. It could also aid in the development of a baseline for futurestudies.The value of this early research on HIE governance and navigator program designis that a synthesis of state government and legislative actions, data and information fromhealth research organizations, literature review findings, and rules, regulations and8

guidance from the Department of Health and Human Services (DHHS), can offer acomprehensive snapshot of program operations at inception. Thus, this research couldprovide a baseline for improving the future design of exchanges. States that havedefaulted to a Federally Facilitated Exchange and those now implementing StatePartnership Exchanges may find this research of value should they move to State BasedExchanges in the future.Going forward, the empirical findings from this research could help to improvefuture navigator program designs. They could lead to increased program success foroutreach, education and enrollment of uninsured and at-risk/vulnerable populations intoHIE approved health plans.1.4Research QuestionsTwo research questions have been identified for this study: Research Question 1:Do business model and governance structuredesign including governing authority composition impact the effectivenessof State Based HIE agencies? Research Question 2:Do traditional navigator programs that facilitatehealth service delivery to at-risk/vulnerable populations provide evidenceof proven strategies that can be used by State Based HIE navigatorprograms for outreach, education and enrollment of at-risk/vulnerableindividuals into qualified health plans?9

To address these research questions, this study will examine evidence basedfindings on governance of agencies created by state legislative action. It will also explorethe strategies used by traditional navigator programs that can be adopted by HIEnavigator programs to facilitate outreach, education and enrollment of at-risk/vulnerablepopulations into qualified health plans.1.5Research Design and MethodologyThis dissertation will use a qualitative methodology for synthesis of data,information, and empirical research findings that have informed practice inorganizational governance and navigator program strategies. In some instances, publicuse datasets providing descriptive data on states, the demographics of their uninsuredpopulations, and their proposed HIE plans, are available for download from securedgovernmental websites. These datasets will be used where possible to synthesize datapertinent to this research and to generate descriptive statistics.The DHHS deadline for states to create State Based exchanges was in December,2012. States choosing to implement state partnership exchanges were required to notifyDHHS by February 15, 2013. According to a Kaiser Family Foundation Report on StateDecisions on Health Insurance, as of June 20, 2013, 16 states and the District ofColumbia had elected to set-up State Based exchanges, 7 states had declared an intentionto operate hybrid state – federal partnership exchanges, and 27 states had elected todefault to federal-facilitated exchanges (H. J. K. F. Foundation, 2013b). Inclusion andexclusion criteria are presented below.10

Inclusion criteriaThe sixteen states plus the District of Columbia that have elected to operate StateBased individual HIE marketplaces will be included in this study. Through exchangewebsites, these states have begun to communicate information with their citizens on thestatus of their HIE marketplaces and how they are designed to operate.They haveincluded information on the legislative action creating the exchange, information onapproved qualified health plans, and the purpose of the HIE marketplace. Also, stateinformation available on DHHS and CMS websites, as well as data collected and madepublicly available through DHHS reporting mechanisms will be used for this research.Specific sections of the PPACA as signed into law will also be cited in this research.Journal articles and reports on reform of the U.S. health system, uninsured and atrisk/vulnerable populations, health insurance marketplaces, navigator programs, and theeconomic implications of health reform have been published by highly respected healthpolicy and research organizations. These include Robert Wood Johnson Foundation, TheCommonwealth Fund, the Henry J. Kaiser Family Foundation, and Trust for America’sHealth, and others. Data collected and made available through these organizations’websites will also be used in this research.Research on traditional navigator programs that have guided at-risk/vulnerablepopulations has produc

Barack Obama. With goals of expanded health coverage, access to quality, affordable health care, and reducing health care costs, the law sought to ensure that eligible U.S. citizens had health insurance regardless of ability to pay or existing medical conditions. Key to meeting the goal of providing health insurance was the creation of state Health