Margaret Murray on COVID-19, Medicaid, ACA plans, and the Digital Divide

Margaret Murray is founding CEO of the Association for Community Affiliated Plans (ACAP) and a member of our editorial advisory board. We spoke with her a couple of weeks ago. Here are some highlights of the interview that have been edited for length and clarity.

About ACAP
We were set up about 20 years ago by 14 health plans that were owned by community health centers, and some of that a lot of people know Neighborhood Health Plan in Massachusetts, Neighborhood Health Plan in Rhode Island, AlohaCare, CareOregon. And over time we have been evolved so that now we represent Medicaid plans that are nonprofit, or are owned by nonprofits, and focused on the low-income programs. All of our members serve Medicaid clients and about half also serve dual eligibles in Medicare in some fashion, and about a quarter also serve people in the [ACA] marketplaces. 

The response of ACAP members to the COVID-19 outbreak
Many people are surprised to learn that Medicaid does impose cost sharing, both copays, and coinsurance. Sixteen  impose some type of cost sharing on hospitalization. Sometimes it's pretty significant - up to $140 a day in Arkansas. And so our plans and oftentimes our contracts require them to impose copays although they can choose not to.

So as this COVID pandemic was unfolding our plans were very seriously talking about this. And immediately, we said that we will not impose any copays on testing. Later that became the law. But we were out in front of that. And then similarly, on the treatment, our plans have come out and made a commitment that they will waive copays, deductibles, coinsurance -all of that-for the treatment of COVID, as well.

And then, in addition, they went a little bit further. They also said that they would waive prior authorization for anything related to the treatment and diagnosis of COVID. And then they went even further, and they said that they would waive early medication, refill limits on prescriptions.

And to the extent allowed by law, [they are] encouraging and supporting telehealth

The effect of the cost of COVID-19 care on ACAP members
It's really too early to say. Oftentimes don't get claims in for 30 days. It’s going to be a little bit of time before we see the claims. But we are very concerned about the impact since the plans are making this commitment. They're waiving the copayments for the beneficiary, but it's the providers who typically collected that and so the providers are being made whole and our plans are taking on that expense of the copays, which was not included in [their] rates, and then, of course, [also]the underlying payment for the treatment.

So one of the things that we are very concerned about is just the impact on our plans. And as I said, we clearly don't know what that is yet, but we were glad to see that the Medicare Advantage rates that just came out this week are healthy and will hopefully support.

What her organization wants from the federal government
Going forward, as these things unfold in 2021, we would like to see a risk corridor in Medicare Advantage.

We'd also similarly like to see some type of reinsurance or risk corridors reestablished for the marketplace, for the quality of the Qualified Health Plans because our QHPs are also taking on
treatment costs that they did not necessarily expect.

Then for Medicaid, which is the bulk of our business, we want to make sure that the states continue to preserve actuarial soundness. Some states are starting to ask for waivers of actuarial soundness, which is very concerning to us because our plans have reserve requirements that the states impose.

If they're paying out more than they're getting in premiums, they may be out of compliance with the reserve requirements. So there's a very big concern that the rates need to be actuarially sound for Medicaid

So those are the three things that we'd like to see the from federal government - enforce actuarial soundness and then allow and fund  some type of reinsurance or risk corridors in both Medicare Advantage as well as the marketplace.

Enrollment in ACA plans and job loss
There are certain qualifying events that allow enrollment, and one of those is losing your health insurance because you lose your job, which is obviously happening to a lot of people and those people can then enter the marketplaces. And if their income has decreased, they can get subsidies, which is great. But there's a lot of people who never had health insurance to begin with, who cannot enter the Obamacare marketplaces. And it appears that the reason the administration is not allowing a special enrollment period, unlike how they did it for hurricanes in the past, that is because they don't want to acknowledge the importance of Obamacare and the marketplaces to the health system. So we are profoundly disappointed that they made this decision. And surprised. It's an easy fix. Eleven states where they run their own marketplaces have already opened for special enrollment periods, including here in Maryland, where I live, and 10,000 people have walked in the door.

Almost three quarters states are running Obamacare marketplaces via the federal government so federal government control can that special enrollment period and so we hope at some point cooler heads will prevail on this, whether in the administration or in the Congress.

Job loss and Medicaid
If Medicaid is now at 80 million people, we could be close to 100. So would be a significant impact, probably differing by states. So one of the things are plans are concerned about is what will this do to their reserves if they suddenly take on all these people and it could be in a very short time period and their reserve levels. We also worry about network adequacy bringing on all these other people when a lot of their providers are being shut down. Will they have the network adequacy that they need? So those are two big things for our plans.

Distribution of federal money to providers
Our plans, of course, are very concerned about the financial stability of the hospitals and the community health centers and the providers. One of the things that the administration has said is, because they won't do the special enrollment period and they're not really pushing Medicaid, is that they've said, well, we'll give I think they said $30 billion out to providers to care for the uninsured. People who are uninsured and have COVID, which is great. And I think that monies will be well spent on those people, but there's a lot of uninsured people that don't have COVID who've lost their health insurance or never had it to begin with.

Doctor and hospitals that are seeing a lot of people through Medicaid managed care, are they going to get that money? We know that children's hospitals don't see a lot of Medicare patients and pediatricians, that kind of thing.

We are concerned that because in Medicaid 70% of the beneficiaries are in Medicaid managed care versus fee for service. So we are bringing that up to the administration and to our colleagues at the associations of the provider groups.

And however they get the money out to the Medicaid providers, and that's much more complicated because the federal government doesn't have a direct link, because of there are 56 Medicaid programs, that they take that issue into account.

Reduced provision of medical services offsetting COVID-19
I think really the jury's out and we're telling our plans, you need to document everything, try to get providers to document everything. Even with the social distancing, we know with the telemedicine, there's lots of phone calls being made, and video conferences. So there is some of that is still going on, although it's the elective surgeries in the hospital that that are being stopped. So we have to just wait and see.

Layoffs of health plan employees
I've only heard of one health plan laying people off and that's at Boston Medical Center, which is very tightly tied to the hospital. And I think it was because of that tight relationship with the hospital. But besides that, we haven't heard of anything.

COVID-19 and short-term insurance
We very concerned people who bought what we call junk insurance, which other people call short-term limited duration plans. There are a lot of people who are going to learn, unfortunately, the limitations of the short-term limited plans. They typically don't include drugs. They have annual lifetime limits. Unfortunately, I think a lot of people are going learn the hard way, why we call them junk insurance. 

Shortcomings of healthcare system revealed
I think that as other people have said that this is really exposing the weaknesses of our current system. And while there’s probably a place for copays, but certainly the high deductibles that we see in both employer-sponsored and self-insured as well as the marketplace can be very difficult for people. When this is all over, I'm hoping that will take to step back and say really what should both our health and social support system look like to prevent this kind of thing. You may not be able to prevent a pandemic, but you can prevent some of these ancillary problems that it is causing.

Support for Medicare for all
We've said that the real goal is coverage for everybody, and there's multiple ways to do it. We think obviously, health plans are a better way to do it, because you get someone looking across the whole person doing care management and that kind of thing. So we would continue to advocate for universal coverage, whether it's through Medicare Advantage for all or Medicaid for all or public option. We want to see that everybody has coverage in this country.

Personal experience with COVID-19
No one in my what I call my inner circle has been directly affected but the outer circle is starting to fill in, so it's definitely feels like it's coming closer. I have two teenage sons that are doing teleschool. One is actually still working in a garden store, but he wears his mask every day. We're definitely seeing how this has played out for young people and definitely also seeing the digital divide for children like mine that have computers at home and strong WiFi and can you do tetelschool right away. They're going to be fine. But for kids that don't have that, it must be just terrible. To see the kids falling further and further behind.