With state- and federally-run exchanges due to open for business in just a few days, how are states reaching out to maximize enrollments? You might be surprised.

Maryland has chosen to trade on the popularity of reigning Super Bowl champs, the Baltimore Ravens, while Oregon has decided to capitalize on its image as a friendly, outdoorsy state with abundant natural resources and a love of flannel. Others have employed quirky, yet iconic characters in hopes of being memorable. For example, Minnesota’s campaign features folklore hero Paul Bunyan and his companion, Babe the Big Blue Ox.


While it’s fun to check in on some of these efforts, at the end of the day it’s serious business. As everyone knows, for public exchanges to be successful, lots of people must visit them and buy insurance plans.

Which of these campaigns do you think will be winners?

Colorado was the first state to launch an ad campaign for its health insurance exchange back in May. One ad features a woman jumping up and down surrounded by baseball players as if celebrating a sports victory while a voiceover intones, “When health care companies compete, there is only one winner: you.”

Maryland, mentioned earlier, has enlisted the Baltimore Ravens to help boost awareness by running ads before and after the team’s Gameday TV show. Why football? Research revealed that 71% of the uninsured population in Maryland has watched, attended or listened to a Ravens game in the past 12 months. State exchange officials faced some controversy, however, when they attempted to recruit Baltimore Ravens players to appear in the ads — an idea that did not fly.

Massachusetts chose baseball instead, running ads featuring endorsements from Boston Red Sox players, including former pitcher Tim Wakefield.

Taking a different tack, neither Kentucky nor Oregon mention exchanges directly in their ads, beyond links to their exchange websites. Kentucky’s animated commercials are meant to evoke empathy for those who have difficulty obtaining insurance. Some Oregon ads feature guitar-toting musicians walking through idyllic Oregon scenery singing original songs with folksy melodies and lyrics reminiscent of American folk anthems. Others have a more urban theme with a rap song as their centerpiece.

Playing against type, California takes a no-nonsense approach to advertising its health insurance exchange. It runs ads in both English and Spanish that feature people going about their everyday lives, foregoing the flashier tactics of other campaigns. “You won’t be seeing movie stars,” says the exchange’s Executive Director Peter Lee. “You won’t be seeing rock stars. You’ll be seeing real people.”

New York takes a similar approach, with its ads depicting a cross-section of New Yorkers from diverse age groups, ethnicities, and geographies.

But our favorite campaign so far is Minnesota’s, which features Paul Bunyan and Babe the Big Blue Ox getting into various scrapes that just result in the need for medical attention.  These ads feature gems like a distressed Paul Bunyan calling out, “Babe, get your blue ox over here!” In keeping with the state’s tagline of “Land of 10,000 Lakes,” the ads conclude with, “Minnesota, Land of 10,000 reasons to get health insurance.”

For a good laugh, check out this ad, in which Paul Bunyan has an accident while water skiing.

 [Photo Credit: Dwayne on Flickr via Creative Commons 2.0]

Less than two weeks remain until state health insurance exchanges under the ACA being accepting enrollments. As states prepare to either implement their own exchanges or let the federal government set up shop on their behalf, some states are expressing concerns that they will not be ready in time, while others are confident. Advertising and informational campaigns are amping up in anticipation of the launch, with all states working to educate their residents about their options under the new system.

The State Exchange Table continues to provide the latest information on carrier participation and plan rates as they occur.

Latest Developments:

State Run Exchanges-

California: Politico identified California as one of the three “swing states” – states with the largest uninsured populations that play an outsized role in the success or failure of Obamacare.  Together, Texas, Florida, and California make up one third of the nation’s 46 million uninsured. State officials in California have already provided $43 million for consumer outreach and have hosted numerous town halls and other informational events.

California also faces a potential delay in launching its online enrollment for Covered California, the state’s health insurance exchange. A spokesman for the exchange cited continued testing of the technology for enrollment as an obstacle to timely implementation. Despite the projected delays, a Covered California rep confirmed that consumers will be able to enroll over the phone or in person on time, beginning October 1st.

Colorado: Colorado recently released finalized rates for plans on its public health insurance exchange, joining 13 states and the District of Columbia in doing so. The state operates a clearinghouse exchange, meaning they approved all 242 plans submitted under its state-run program, Connect for Health Colorado.

Colorado state insurance commissioner Marguerite Salazar expressed concern over the approaching “bumps in the road” to implementation of the state’s health insurance exchange. Yet unknown are the robustness of the online system and residents’ level of familiarity with buying their own insurance. As the October 1st deadline approaches, an estimated 200,000 uninsured Coloradans wait to enroll. Despite her concerns, Salazar is confident that Colorado will have a functioning exchange by the deadline.

Connecticut: Connecticut announced plans to open “storefronts for Obamacare,” boutique-style spaces with the aim of educating the public about the state’s health insurance exchange, Access Health. The first wave of storefronts will be in low-income areas, with the goal being to inform “hard to reach” populations that spend less time online or watching the news. The eventual goal is to have locations throughout the state.

The intent behind the storefronts is to address the issue of “How do we bring health care into the community?” Styled after Apple retail stores, the locations will have brokers on hand to walk consumers through their options and advisors similar to Apple Geniuses to help individuals with more complicated and specific issues.

Florida: Florida, identified by Politico as a “swing state” in determining the success or failure of Obamacare, has an estimated 3.9 million uninsured individuals under 65. Enroll America, a non-profit group dedicated to encouraging Floridians to enroll, currently has 27 staffers on the ground, with plans to hold information sessions, knock on doors in neighborhoods with high concentrations of the uninsured, and set up tables at community gatherings.

Idaho: Idaho recently debuted a new health insurance exchange website, www.yourhealthidaho.org.  The state only voted to approve a state-run exchange in March, so the site will initially serve simply as a gateway to the federal website, but Idaho officials hope to have a state-run online enrollment site up and running by the end of the year.

Illinois: To be prepared for the impending open enrollment period, Illinois is hiring a team of 800 temporary workers to serve as “in-person counselors.” These counselors will  help consumers apply for coverage and will answer questions and explain differences between the insurance policies offered on the new online marketplace. Training sessions began in July and will continue through the October 1st enrollment start.

Kentucky: Health workers in Kentucky are doing outreach amidst the corn dog stands and cotton candy vendors at state fairs to educate Kentuckians about the state’s health insurance exchange, called Kynect. Workers attempted to simplify the complexities of the new system, distilling the program down to three simple phrases: “We are Kynect – part of the new health care law,” “Do you know anyone who doesn’t have health insurance?” and “You may qualify for Medicaid or a tax credit based on your income.”

Michigan: Michigan’s newest health insurance company, Consumers Mutual, has launched an educational campaign around enrolling in health insurance that features “billboards, radio spots, TV spots, and print and digital advertising.” The ads center around “Healthee” – a red and black animated character that guides viewers through the enrollment process.

Despite resistance from Michigan Republicans in the legislature, Governor Rick Snyder is advocating for increased outreach to inform individuals about health insurance exchanges.  Coalitions such as Michigan Consumers for Health Care support the outreach effort aided by the $2.5 million federal grant for “navigators.”

Nebraska:  Nebraska released its health insurance exchange rates, which initially appeared to be higher than other state exchanges. However, rates do not take into account the yet-unreported federal subsidies to be made available and therefore may be subject to change. The rates also do not apply to individuals covered by employer health plans or Medicare.

The state convened for the first meeting of the Nebraska Exchange Stakeholder Commission, a panel of Nebraskans in charge of oversight and advice for the new health insurance exchange.  The 11 member panel includes “consumer representatives, small-business owners, a farmer and taxpayer advocate, a health insurance agent, a hospital administrator, a doctor and an insurance company representative.”

New Mexico: State officials announced that implementation has begun on outreach efforts to educate the state’s residents about their options under the new, state-run exchange in advance of the open enrollment date.  J.R. Damron, M.D., Chair of the New Mexico Health Insurance Exchange (NMHIX) Board, stated “We are launching this comprehensive system to make sure that all New Mexicans understand the new health coverage options and give them the information as well as local help to get signed up.”

New York: Health insurance company Aetna pulled out of the New York state health insurance exchange, called New York State of Mind. This is the latest in a series of opt-outs by Aetna. Other states it has opted not to participate in include Maryland, Ohio, Georgia, and Connecticut.  The health insurance company sites risk associated with the initial launch as the reason for opting out. “We have taken a prudent risk-based approach to both our overall exposure and exposure within a given marketplace,” Chief Executive Officer Mark Bertolini said.

Rhode Island: Rhode Island released its final rates for individuals and small businesses under the state-run exchange, known as HealthSource RI. Health insurance providers for the state are Blue Cross & Blue Shield of Rhode Island, United HealthCare, and Neighborhood Health Plan of Rhode Island.

Tennessee: Tennessee is calling on churches as well as secular channels to inform individuals about the federally-run health insurance exchange. Experts estimate that 30,000 uninsured individuals will enroll in the exchanges come October 1st through one of the state’s four health insurance providers – BlueCross BlueShield of Tennessee, Cigna Healthcare, Coventry Health & Life, and Community Health Alliance.

Washington:  Washington state launched an ad blitz to publicize its online health insurance marketplace, called Washington Healthplanfinder. The goal of the advertising is to sign up 130,000 uninsured people by the end of 2013 and 280,000 in 2014 via the online enrollment tool.  The state has received $26.3 million from the federal government allocated for marketing and outreach efforts.

Federally Facilitated Exchanges-

Alaska: Alaska regulators have approved two companies to provide health insurance under the state’s federally-run health insurance exchange: Premera Blue Cross Blue Shield of Alaska, the state’s largest insurance provider, and Moda Health. Senator Hollis French has high hopes for the exchange – the details of which will remain relatively in the dark until the January 1st start.  State law prohibits releasing the rates until that time, but French is hopeful they will reflect the savings experienced by other states. “We hope that Alaskans experience the same reduction in cost that other states have seen as the exchanges go into effect and roll out their estimates,” he said.

Arizona: The Department of Health and Human Services (HHS) and AARP will be taking the lead on helping Arizona residents sign up for the federally-run health care exchange come October 1st.  A combination of bilingual resources and “user-friendly” websites will be used to walk Arizonans through selecting and enrolling in a plan.

Georgia: College administrators at the University of Georgia received a $1.66 million federal grant to train and deploy “navigators” to walk Georgians through the process of enrolling in health insurance under the new federally-run exchange starting October 1st. According to federal requirements, the navigator will dispense “fair, impartial and accurate information that assists consumers with submitting the eligibility application, clarifying distinctions among (qualified health plans) and helping qualified individuals make informed decisions during the health plan selection process.”

Missouri: A St. Louis-based non-profit, Missouri Foundation for Health, will vote “to supply $1.1 million worth of posters, wallet cards and other promotional materials about the exchange” to educate Missourians about the federally-run exchange. Missouri residents largely remain in the dark as the open enrollment period nears. Missouri is one of the 19 states that has opted to let the federal government run its exchange and has done little thus far to publicize the program within the state.

Montana: Montana released rates for its federally-run insurance exchange. Rates are available from three carriers offering plans to state residents – Blue Cross Blue Shield of Montana, PacificSource, and the Montana Health CO-OP. Montana Commissioner of Securities and Insurance, Monica Lindeen, said she was “pleasantly surprised” by the rates despite initial concerns about the program. She also appreciated the fact that Montanans with preexisting conditions will not denied coverage or priced out of the market.

Texas:  Politico identified Texas as a “swing state” that could make or break Obamacare depending on how many of its residents enroll in insurance exchanges starting October 1st.  With the second highest uninsured population after California (Texas has an estimated 5.8 million uninsured people under 65), Texas is essential in reaching enrollment goals set by the federal government.

In an effort to educate Texans about how to use the federally-run health insurance exchanges, the local branch of the United Way (Tarrant County) applied for grant money to help train and deploy navigators. The United Way received $5.9 million and aims to reach 62,000 Texans in face-to-face meetings and 500,000 through phone calls and community meetings, according to the organization’s president, Tim McKinney.

Utah: According to state insurance officials, Utahns will have at least 99 plan options through the new online health insurance marketplace. Participating insurers are Altius Health Plans, Arches Mutual Insurance Co., BridgeSpan Health Co., Humana Medical Plan of Utah, Molina and SelectHealth. Utah is unique in that it is the only state that will be splitting coverage between the state and federal government, with the federal government running the marketplace for individuals and the state of Utah operating Avenue H, an exchange that caters to small businesses.

A recent article in the Washington Post highlighted states that have opted not to expand Medicaid eligibility to previously ineligible populations under the ACA. While these states will have an increase in the number of uninsured people who have coverage starting in 2014, the numbers will not be nearly as high as they would be if they had chosen to expand Medicaid to more people.

This could have a huge impact on the perceived success or failure of the ACA. Here’s how.

Impact of states opting out

Simply put, the main goal of the ACA is to get millions more Americans covered by health insurance. A key provision for achieving this in the original law was to provide a continuum of affordable healthcare coverage by 1) providing federal funds to states to expand Medicaid to include people under 65 years of age living at 138% or below the poverty line and 2) offering private health plans for sale on public exchanges with federal subsidies available for people under 65 years of age living at 400% or below the poverty line.

Another provision of the ACA for meeting this goal was the “individual mandate,” which requires all individuals to have health insurance by 2014 or pay a penalty.

When the U.S. Supreme Court ruled on the constitutionality of the ACA in 2012, it upheld the individual mandate but allowed individual states to decide whether to expand Medicaid. According to data from the American Health Line, as of September 6, 2013, 16 states have opted out and another 7 are leaning toward opting out.

According to an Urban Institute report, 7 million adults ages 19 to 64 would have qualified for Medicaid in the states that have opted out, had they chosen to expand the program.

Recognizing that individuals who qualified for Medicaid in the opt-out states would not be able to afford the private plans that will be offered on the public exchanges even with federal subsidies, the federal government exempted them from the individual mandate.

So even though the individual mandate was left intact by the Supreme Court ruling , the net effect of states being able to opt out of Medicaid expansion is that fewer uninsured people will end up getting insurance as a result of the ACA.

Magnitude — and locations — of the problem

The two maps below illustrate the magnitude of the impact. The first map shows the percentage of people under 65 living at or below 138% the poverty line who do not have health insurance. These individuals would benefit most from Medicaid expansion.

The second map shows the percentage of people under 65 living at or below 400% the poverty line who do not have health insurance. This individuals would qualify for either Medicaid or for federal subsidies they could use to purchase private health plans on public exchanges.


[click on image to expand]

With both supporters and critics of the ACA eager to point to its success or failure, the number of uninsured people who get coverage under the ACA will no doubt be a talking point for both sides on cable news shows starting in January 2014.

Stay tuned.

A new study asks and answers three essential questions about the ACA-authorized public health insurance exchanges scheduled to open for business on October 1, 2013: Can people select the best policies? Do they know how well they are doing? Does the design of the sites change their performance?

The study, “Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture,” was based on six experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. According to the study’s co-authors, professors from Columbia Business School, Hebrew University of Jerusalem, University of Pennsylvania Law School, Columbia University Department of Psychology and University of Miami, the results suggest, “there is significant room for improvement.”

Their conclusions: “Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly.”

That’s the bad news. The good news is that the study also showed that performance can be improved “markedly” through the use of just-in-time education, defaults that pre-select options based on individuals’ usage, and cost calculators.

In other words, when public exchanges use “smart” web-based tools, individuals end up with a much more realistic estimate of their expected health care costs and are able to select plans that better meet their needs.

In our experience operating the nation’s largest private Medicare exchange, we agree that sophisticated profilers, calculators and decision support tools can help people make better health care coverage decisions. But even in a world where automated help systems, interactive websites and specialized mobile apps are now capable of performing a wide variety of tasks that used to be the domain of live human help, we believe there are still situations that require a human touch. Buying health insurance is one of them.

On that front, there is also good news.

CMS Authorizes Web Brokers

In early August, the Centers for Medicare & Medicaid Services (CMS), which supervises the federally facilitated marketplace — the health insurance exchange operated by the federal government in 36 states – signed web broker entity agreements with several firms, including Towers Watson.
These agreements allow these firms to integrate with federal eligibility systems so that they can assist individuals every step of the way as they shop for and enroll in subsidized coverage through the federal exchange – including by offering live access by telephone to licensed benefit advisors. Once an individual selects a plan, his or her enrollment will go to the federally run exchange for processing.

Some firms plan to serve individual consumers directly. In contrast, Towers Watson will help employers provide health insurance education and enrollment services to their part-time and seasonal employees, pre-65 retirees and their dependents.

Federal Government Awards $67 Million for Navigators

In addition, on August 15th, the federal government announced that it has awarded $67 million to train “navigators” – non-profits, businesses, universities and local government institutions state and local communities enlisted to walk residents through the process of evaluating and selecting health plans that meet their needs.

Of the 105 navigators in 34 states awarded funding, United Way and Planned Parenthood are among the “big name” organizations chosen presumably to serve a broad audience. Other organizations such as Migrant Health Promotion, Inc. and the National Council of Urban Indian Health will cater to smaller, more targeted populations.

As the study referenced above points out, and most observers agree, the success of the public exchanges will rest on two things: the first is that consumers will be able to select the best policy for their needs. The second is that price competition, driven by effective consumer choice, will lower prices.

With web brokers authorized and navigators funded – and more likely on the way – that vision takes another step closer to becoming reality.

 Two surveys conducted by Towers Watson, parent company of Extend Health, and reported on in August, provide insight into what leading U.S. employers are expecting in health care costs next year and how the ACA might affect their long-term health benefits strategies.

The first survey of 382 Towers Watson clients – U.S. employers across eight industries representing five million active full-time employees – revealed that employers expect health care costs to increase 5.2% in 2014, down modestly from the 5.9% projected increase for 2013. Towers Watson conducted the survey of employers across eight industries in July and August.

A companion survey of 420 employers representing 8.7 million employees, designed to gauge planned responses to the Affordable Care Act (ACA), was conducted in July. It revealed that 74% of respondents said that they view health benefits as “very important” to their employee value proposition while 98% reported that they have “no definite plan” to stop subsidizing them.

Employers also said the trend of shifting some costs to employees will continue. For 2013, 13% of respondents to the ACA-related survey said they plan to increase employee premium contributions for single-only coverage by 5 or more percentage points; for 2014, the percentage of employers with the same intention rose to 22%.

Planned increases in employee contributions for dependent coverage will rise at a higher rate. For 2013, 21% of employers said they plan to increase employee premium contributions for dependent coverage by 5 or more percentage points; for 2014, the percentage rose to 34%.

At the same time, a growing number of employers said it is “very likely” they will discontinue subsidizing benefits for retirees in 2014 and 2015: for pre-65 retirees in 2014, 1% indicated so, increasing to 14% in 2015. For post-65 retirees in 2014, 16% indicated so, rising to 26% in 2015.

The survey also showed that between now and 2015, employers are considering a wide variety of other ways to offset rising costs, including implementing employee wellness plans and offering incentives based on health outcomes. Employers also intend to change plan designs, and work with vendors to use price and hospital quality transparency tools and evaluate new financial terms and performance standards beyond cost and operational performance of the plans.

Employers expressed a reluctance to embrace public health care exchanges run either by the state or federal government and displayed a general “wait-and-see mentality” as ACA deadlines get pushed back and some details of the law’s implementation remain unclear.

Meanwhile, 60% of employers said that the ACA’s excise tax will have a “moderate” or “significant” influence on their health care strategies in 2014-15. The tax is a 40% penalty tax on the incremental value of group health insurance coverage based certain premium thresholds for single and family coverage, indexed for inflation, which goes into effect in 2018.

Given that the federal government has predicted that up to 60% of current employer plans would be subject to this tax, expect to see employers step up efforts to contain costs between now and then – before it’s too late.

For more on the Towers Watson survey results, click here for the full press release.