In December 2019, Governor Brian Kemp asked the federal government to approve a plan that would make seismic changes to private health insurance in Georgia. In July 2020, Gov. Kemp revised his plan and released it to the public for comment. The revised plan is made up of two parts: 1) Reinsurance—which would help to lower premiums; and 2) the Georgia Access model—which would force consumers to enroll in coverage through for-profit insurance companies and web brokers instead of the unbiased and centralized enrollment platform that consumers know and trust (healthcare.gov).

Federal law allows states to make changes to the Affordable Care Act (ACA) so long as a comparable number of consumers have coverage that is at least as comprehensive and affordable as they would have under the ACA, and the changes do not increase the federal deficit. Unfortunately, the second part of Gov. Kemp’s plan does not meet this standard and poses real risks to families and individuals in Georgia.

Part I: Reinsurance

Reinsurance is a tool that some other states have used to lower premiums for consumers and attract more insurers to their marketplaces. Reinsurance is a system that pays insurance companies for a portion of the costs of consumers who have unusually expensive health needs. When these outlier costs are shared between the state and insurers, insurers are able to lower premiums for everyone.

Georgia’s reinsurance program is designed so that it would lower premiums more in areas of Georgia that have higher insurance premiums. Southwest Georgia has consistently had some of the highest premiums in the U.S. Georgia’s plan predicts that premiums may drop by 10% across the state, with rural areas seeing bigger drops than urban areas.

If approved by the federal government, Georgia’s reinsurance program would go into effect for 2022 insurance plans.

Part II: Georgia Access model—Georgia consumers at a disadvantage

The second part of Gov. Kemp’s plan would make it more difficult for Georgia individuals and families to shop for comprehensive coverage, understand their options, and take advantage of financial help to lower the costs of their plans. It would put insurance companies in the driver’s seat, leaving consumers in the back seat with little control.

Gov. Kemp proposes to dismantle healthcare.gov and instead force Georgians to use profit-driven insurance company websites, e-brokers, or agents to shop for coverage

More than 500,000 Georgians bought affordable, comprehensive coverage through the ACA marketplace (also called healthcare.gov) in 2021. Nine out of ten Georgians who purchased coverage on healthcare.gov received financial help to lower their premiums and other out-of-pocket costs.

The ACA marketplace is the most widely used and only unbiased place that consumers can shop for comprehensive health coverage. Consumers know all available plans will cover their health needs, they are offered financial help if they qualify, and they are notified of their eligibility for Medicaid or other public coverage programs.

Under the Governor’s plan, Georgia consumers would be the only people in the U.S. forced to go without this resource and instead rely on private entities for shopping and enrollment. For-profit insurance companies, online brokers, and even some insurance agents will display comprehensive, ACA-compliant plans alongside short-term plans or plans that do not cover all services.

Under this system, insurance companies and brokers, who are regularly incentivized to enroll consumers in plans that offer the highest commissions, will push consumers to plans that do not fit their health needs or financial situation. They are not obligated or incentivized to help qualified Georgians enroll in Medicaid or PeachCare, or provide other safety net referrals.

This part of the Governor’s plan does not add any new ways for people to shop for health coverage (consumers can already shop with brokers or insurance companies). Instead, it only serves to shut off the most trusted and widely used path for Georgians purchasing their own coverage.

Likely result: Georgia consumers will struggle to navigate a decentralized enrollment system with numerous websites, translate the sales lingo of insurers, and disentangle conflicting information. For many, it may be harder to find a plan that they feel good about. Others will get lost in the process altogether and unintentionally become uninsured.

Governor Kemp’s plan to change private health insurance in Georgia turns back the clock to a time when consumers were at the mercy of health insurance companies. Under this plan, consumers would have a harder time shopping for comprehensive coverage and run a real risk of enrolling in plans that do not cover the essential health benefits or leave them on the hook for tens of thousands of dollars. It is likely that some Georgians would end up uninsured because of the confusing, decentralized system, increasing Georgia’s 3rd in the nation uninsured rate.

In December 2019, Governor Brian Kemp asked the federal government to approve a plan that would make seismic changes to private health insurance in Georgia. Gov. Kemp’s plan is made up of two parts: 1) Reinsurance—which would help to lower premiums; and 2) the Georgia Access model—which would undermine comprehensive coverage for the 500,000 Georgians who now have comprehensive coverage through the marketplace and put future enrollees at risk.

Federal law allows states to make changes to the Affordable Care Act (ACA) so long as a comparable number of consumers have coverage that is at least as comprehensive and affordable as they would have under the ACA, and the changes do not increase the federal deficit. Unfortunately, the second part of Gov. Kemp’s plan does not meet this standard and poses real risks to families and individuals in Georgia.

Phase I: Reinsurance

Reinsurance is a tool that some other states have used to lower premiums for consumers and attract more insurers to their marketplaces. Reinsurance is a system that pays insurance companies for a portion of the costs of consumers who have unusually expensive health needs. When these outlier costs are shared between the state and insurers, insurers are able to lower premiums for everyone.

Georgia’s reinsurance program is designed so that it would lower premiums more in areas of Georgia that have higher insurance premiums. Southwest Georgia has consistently had some of the highest premiums in the U.S. Georgia’s plan predicts that premiums may drop by 10% across the state, with rural areas seeing bigger drops than urban areas.

If approved by the federal government, Georgia’s reinsurance program would go into effect for 2021 insurance plans.

Phase II: Georgia Access model—a bad deal for Georgia consumers  

The second part of Gov. Kemp’s plan would undermine the benefits of reinsurance while also endangering the health and finances of Georgia consumers. Georgia is the first state to propose these complicated changes, putting Georgians at great risk of being guinea pigs in an unwise policy experiment. The second phase of the plan would make three major changes:

Limits the amount of financial help available to moderate and middle-income consumers and families when they purchase comprehensive health coverage. Nine out of ten Georgia consumers who purchase coverage on healthcare.gov get financial help that lowers their monthly premiums or reduces their deductibles and co-pays. Under the current system, every Georgian who qualifies gets financial help. The financial assistance helps people who make between 100-400% of the federal poverty level (an individual, $12,760-$51,040 or a family of 4 making $26,200-$104,800) by limiting their health spending to a small percentage of the household’s budget.[i]

Under Gov. Kemp’s plan the state would offer the same financial assistance to consumers but would limit the total amount of help available. The state’s budget for financial help could easily be exhausted if more people enroll in coverage than the state predicts or if premiums rise faster than expected. People who shop for coverage after the financial assistance limit is reached would be put on a waiting list and would not get any help in the meantime.

Likely impact: Some moderate- and middle-income Georgians would be forced to choose between going uninsured or paying the full price for coverage (which could be as much as their yearly income).

Erodes the requirement that insurance plans cover all essential health services and the financial protection that limits yearly health spending for individuals and families. The Governor’s plan introduces two new kinds of health plans: copper plans and disease management plans. Copper plans would feature cheaper premiums than current bronze level plans but would balance that with higher deductibles and co-pays. The disease management plans would be tailored to meet the needs of people with certain chronic diseases (like diabetes or HIV) and would have unspecified flexibility about how they cover the ten essential health benefits, like mental health or prescription drugs.[ii]

In order to offer these new kinds of plans, the Governor’s plan asks to “waive” (or set aside) two key ACA requirements: 1) the requirement that all plans sold on the ACA marketplace (healthcare.gov) cover the ten essential health benefits; and 2) the protective limit on annual out of pocket health spending for consumers.

Under the current system, the ACA limits a consumer’s out-of-pocket spending each year based on their income. Gov. Kemp’s plan would eliminate that spending ceiling, which is already too high for most Georgians to afford. Georgians are struggling with the difficult combination of premiums, deductibles, and other out of pocket costs, and copper plans with even higher (or even unlimited) spending caps would only exacerbate this problem.

The Governor’s plan would also eliminate the requirement that insurance plans cover the ten essential health benefits. The proposal states that for the first year Georgia will ensure all plans cover those services but makes no commitment about later plan years. The proposal says that disease management plans will have “flexibility” around how thy cover the ten essential health benefits (EHBs) with little detail about how Georgia would ensure that these plans offer comprehensive coverage for consumers who may enroll in them.

Likely impacts: Consumers could be on the hook for drastically unaffordable out of pocket costs and they could be left with insurance plans that do not meet their needs because they are not required to cover the essential health benefits.  

Dismantles healthcare.gov and instead forces Georgians to use profit-driven insurance company websites, e-brokers, or agents to shop for coverage.gov (also called “the marketplace”) is the most widely used and only unbiased place that consumers can shop for comprehensive health coverage. Consumers know all available plans will cover their health needs and they are offered financial help if they qualify and notified of their eligibility for Medicaid or other public coverage programs.

Under the Governor’s plan, Georgia consumers would be the only people in the U.S. forced to go without this resource and instead rely on private entities for shopping and enrollment. For-profit insurance companies, online brokers, and even some insurance agents will display comprehensive, ACA-compliant plans alongside short-term plans or plans that do not cover all services.

Under this system, insurance companies and brokers, who are regularly incentivized to enroll consumers in plans that offer the highest commissions, will push consumers to plans that do not fit their health needs or financial situation. They are not obligated or incentivized to help qualified Georgians enroll in Medicaid or PeachCare, or provide other safety net referrals.

This part of the Governor’s plan does not add any new ways for people to shop for health coverage (consumers can already shop with brokers or insurance companies). Instead, it only serves to shut off the most trusted and widely used path for Georgians purchasing their own coverage.

Likely result: Georgia consumers will struggle to navigate a decentralized enrollment system with numerous websites, translate the sales lingo of insurers, and disentangle conflicting information. For many, it may be harder to find a plan that they feel good about. Others will get lost in the process altogether and unintentionally become uninsured.

 Governor Kemp’s plan to change private health insurance in Georgia turns back the clock to a time when consumers were at the mercy of health insurance companies. Under this plan, consumers would have a harder time shopping for comprehensive coverage, run a real risk of receiving no financial help to purchase coverage, and may find that the only available plans in their area do not cover the essential health benefits or leave them on the hook for tens of thousands of dollars.

Want to know the latest on Gov. Kemp’s private health insurance plan? Check out this timeline and sign up for email updates here. We will let you know where things stand and how you can help protect affordable, comprehensive coverage for all Georgians.

[i] Kaiser Family Foundation, January 16, 2020. Explaining Health Care Reform: Questions about Health Insurance Subsidies. https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/

[ii] The ten essential health benefits are ambulatory services (also called outpatient care); emergency services; hospitalization; pregnancy, maternity, and newborn care; mental health and substance use disorder services (like counseling and therapy); prescription drugs; rehabilitative and habilitative services and devices (services and devices that help people with injuries, disabilities, or chronic conditions gain or recover mental or physical skills); laboratory services; preventive and wellness services (including chronic disease management); and pediatric services, including pediatric dental and vision services.

Matt Hiltman lowered his shoulder as his horse galloped down the windswept field, kicking up clods of earth in its wake. His steel armor gleamed in the bright sun, and the audience on the sidelines roared with anticipation. Two horses and two riders fast approached each other on a collision course. The crowd fell silent as wood crumpled into metal with a loud crunch, and Matt’s lance struck true. The opponent careened off his horse and tumbled to the ground. Cheers burst out across the tournament field. Another victory for a professional jouster.

A lifelong Georgian, Matt is a world-class, full-contact jouster who competed in the sport for five years while also pursuing studies at Georgia State University. “If I had to describe myself, I would say that I’m an adrenaline junky,” said Matt. Beyond scuba diving, hang gliding and other high-octane activities, Matt’s thirst for adventure also inspired him to study diverse fields at college, including geology, chemistry, biology and history. He graduated magna cum laude from Georgia State University with a major in philosophy and minor in psychology, looking forward to a career in law or another field where he could serve the greater good.

“I’ve spent a lot of my life and a lot of time thinking about how I can best help the world,” Matt said, “And I’ve got some ideas that I’d like to share.”

The future was brimming with opportunity when Matt’s life hit an unexpected obstacle. At age 29, Matt was hospitalized due to mental illness. “He had an episode of psychosis, and it became obvious at that point that he had bipolar I,” said his mother, Dianne. In Matt’s words, “It was a major shake to my foundation … to discover that my brain is a tool that can be corrupted.”

Bipolar disorder is a mental illness that causes intense shifts in a person’s mood, energy and ability to think clearly, according to the National Alliance on Mental Illness. People with bipolar disorder experience debilitating mood swings, known as mania and depression. About 4.4 percent of adults in the United States experience the disorder at some point in their lives, which generally starts showing symptoms when people reach their mid-20s.

Many treatments can help people living with bipolar disorder, including medications, therapy and lifestyle adjustments. People can lead successful lives after finding the right care regimen and combination of treatments, but that usually requires extensive trial and error. Doctors still have a limited understanding of how the brain works and how best to treat mental illness.

Once I’m healthy, I’ll be able to get out there and help people.
-Matt Hiltman

“It’s been difficult, it’s been very difficult over the last few years,” Matt said.

For Matt, health insurance has been a major barrier to finding the effective treatments that would allow him to begin recovery. Bipolar disorder caused him to lose his job and his health insurance. Untreated, the symptoms make it nearly impossible to work a full-time position with benefits. Matt doesn’t earn enough money to receive subsidies for individual health insurance, so he can’t afford coverage from the private marketplace. He also doesn’t qualify for Georgia’s current Medicaid program.

Watch Matt share his story in his own words.

“He can’t work ‘til his treatment is better,” said Dianne.

Matt sees hope in an advanced brain therapy called Transcranial Magnetic Stimulation. Unfortunately, he cannot receive this cutting-edge procedure without health insurance. Matt is stranded in his recovery process without any affordable health care options.

“There are several treatments that I don’t have access to because I don’t have health care insurance,” says Matt. “That’s frustrating knowing that I might feel relief . . . knowing that it’s out there, and I can’t get it, is very frustrating.”

While Matt and his family have struggled to access treatment, Georgia lawmakers have repeatedly rejected a policy that would provide affordable health coverage to Matt and almost half a million Georgians: Medicaid expansion. About 25 percent of uninsured Georgians who would qualify for coverage through Medicaid expansion suffer from mental illness or substance use disorder.

“He’s not afraid to work hard,” says Dianne. “He’s not unwilling. He just can’t right now. And there’s not anything we can do.”

A new wave of state leaders will have a fresh opportunity in 2019 to tackle Georgia’s growing health crisis and draw down federal funds to broaden health coverage. By allowing Georgians like Matt to access and afford needed medical services, lawmakers can help thousands statewide to get healthy and stay healthy. The policy is popular with the public as well, with more than 70 percent of Georgians supportive of Medicaid expansion according to recent polls.

He’s not afraid to work hard. He’s not unwilling. He just can’t right now. And there’s not anything we can do.
-Dianne Hiltman

For Matt, the idea of getting healthy brings him back to his dream of helping others. “Really it just comes down to . . . you know, once I’m healthy, I’ll be able to get out there and help people.”

Before he’s able to help others, Matt will need to find the right combination of tools to treat his mental illness. He and his family continue to pursue every possible lead, including out-of-state research studies and charity care. But without health insurance, Matt’s recovery appears stuck, and a promising future seems just beyond his reach. In the past, Matt’s hard work helped him succeed in the classroom and in the saddle. Now, his future success rests in the hands of the 236 men and women of Georgia’s General Assembly.

“Having affordable health care and health insurance would give me hope. It would give me more access to different treatments. Mostly, it would give me hope.”

If you or loved ones are living with mental illness, please consider visiting the National Alliance on Mental Illness – Georgia or calling their helpline at 770-408-0625 for more information and support.

To show your support for expanding health coverage in Georgia, please consider sending a short e-mail to your state lawmakers through an easy-to-use form.

Susie is the sole caretaker of her young granddaughter, but she has a hard time caring for herself because she is stuck in Georgia’s coverage gap. She makes more than $6300 annually, so she doesn’t qualify for Medicaid coverage as a caregiver, and she doesn’t make enough to receive financial help to buy health insurance through the Marketplace. Susie is currently undergoing treatment for cancer but because she lacks health coverage, Susie is only able to receive cancer treatments from a doctor that allows her to make low monthly payments. Susie has other chronic health issues that need to be managed but finds it difficult to receive consistent care without insurance. Because Georgia’s elected officials have not extended Medicaid to cover caregivers like Susie, she struggles to care for herself while working to ensure her young granddaughter receives the care and support she needs to grow up healthy and thrive.

Medicaid provides access to needed health care services for low-income soon-to-be-moms, new mothers, and very low-income parents of minor children. For mothers, Medicaid makes being a mom a little easier by ensuring that their children have access to the health care services they need to grow and stay healthy. For others, Medicaid would help them get or stay healthy so they can best fulfill the responsibilities of being a mothers or caregivers. Over 150,000 uninsured women like Susie would gain health insurance if Georgia’s decision makers extended Medicaid to cover low-income adults (those making less than $16,000 annually for an individual or $20,780 for a family of three).

Originally posted on HealthyFutureGA.org

Valerie is a mother of three children living in Lamar County. Medicaid covers all three of Valerie’s children, and they rely on the health coverage it provides for their varying health needs. Valerie sometimes has difficulty accessing the care and information the family needs because they live in a rural area, but acknowledges that Medicaid is a lifeline that makes it possible for her to focus on her family’s other needs. Without health insurance through Medicaid, Valerie would have to pay hefty medical bills to ensure her children receive the care they require.

Medicaid provides access to needed health care services for low-income soon-to-be-moms, new mothers, and very low-income parents of minor children. For moms like Valerie, Medicaid makes being a mom a little easier by ensuring that their children have access to the health care services they need to grow and stay healthy. For others, Medicaid would help them get or stay healthy so they can best fulfill the responsibilities of being a mothers or caregivers. Over 150,000 uninsured women would gain health insurance if Georgia’s decision makers extended Medicaid to cover low-income adults (those making less than $16,000 annually for an individual or $20,780 for a family of three).

Originally posted on HealthyFutureGA.org