Linda Bloomberg and Matthew Fiedler recently provided comments to the Department of Health and Human Services and the Department of the Treasury about the Georgia Access Model. The Georgia Form of Access is a component of a Georgia Section 1332 waiver that would change how people enroll in health insurance in Georgia. The form will eliminate use of the Georgia HealthCare.gov registry platform and associated federal outreach activities. Instead, enrollment in individual market plans will occur exclusively through private insurance agents and brokers, and enrollment in Medicaid will occur exclusively through the state.
The request for comment asks whether developments since departments agreed to waive Georgia Section 1332 should change the departments’ assessment of whether the Georgia Model of Access meets legal requirements for Section 1332 exemptions, including the requirement that waivers cannot reduce the number of People who have insurance coverage. Departments specifically inquired about changes in federal law and policy and newly available evidence or experience that would influence assessments of how various factors affect enrollment in health insurance coverage.
In this letter, the authors discuss two developments since the Georgia waiver was approved in November 2020, raising the possibility that the Georgia Access Model will reduce coverage:
- During 2021, the Centers for Medicare and Medicaid Services (CMS) announced significant new spending on Marketplaces and Medicaid-related outreach activities, including increased marketing budget and new grants to assist individual enrollment under the Navigator program. These policy changes have increased the number of people expected to receive insurance coverage if the Georgia Access Model is not implemented. Since these activities would not occur in Georgia if the state’s proposal was implemented, these policy changes do not change the number of people who would be expected to receive insurance coverage if the Georgia model was implemented. Thus, these policy changes increased the likelihood that implementation of the model would reduce coverage.
- Research released in parallel with or after a departmental review of the Georgia exemption (and thus likely too late to fully include it in that review) has provided evidence that (i) outreach activities currently conducted by the federal government increase insurance enrollment, (ii) Private marketing activities are less effective at increasing insurance enrollment than similar public activities for every dollar spent and are more likely to direct people to plans that do not meet ACA benefit criteria, and (3) are less likely to reduce public outreach efforts to increase outreach efforts own. These findings reinforce the case that eliminating current federal outreach activities will reduce insurance enrollment in Georgia while making it implausible that increases in private outreach efforts would be large enough to offset this decline, as Georgia officials suggested in the exemption application materials.
The new evidence described above joins previous evidence, which was reviewed in the letter, that raised questions about whether increases in private outreach and registration efforts would replace the loss of HealthCare.gov and associated federal efforts. The loss of the Georgia HealthCare.gov registration portal is likely to make it more difficult to navigate the registration process, which previous research conducted in different contexts indicates has reduced enrollment significantly. Previous evidence also shows that private insurance brokers are less likely than navigators to engage in outreach and education efforts, and that brokers are less likely to provide assistance to low-income people, racial and ethnic minorities, and people who are not fluent in English.
In summary, when accounting for the current policy landscape and both recent and past evidence, Bloomberg and Fiedler concluded that implementing the Georgia Access Model would measurably reduce insurance coverage in Georgia. They believe that this reduction in insurance coverage would be even greater if coverage provisions similar to those in the Rebuilding Better Act, passed by the House, become law. Read the experts’ full letter here.
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