With the debut of the Affordable Care Act’s (ACA) Health Insurance Marketplaces on October 1st, Americans are starting to use these new online markets to shop for and purchase affordable insurance coverage. As these Marketplaces begin operating at full capacity, federal and state policymakers as well as other health reform stakeholders can now focus on evaluating the progress that is being made towards the ACA’s goal of expanding public and private insurance coverage to the nation’s uninsured and under-insured.
Ultimately, the answer to this and a host of other questions will be answered in part through the same streamlined and coordinated Marketplace and Medicaid/CHIP eligibility and enrollment systems that will fundamentally change the way that Americans shop for insurance coverage in the years to come.
Through the process of implementing these new systems, it has been recommended that standard performance metrics be developed and used at the federal level to assess differences between states and to evaluate national health reform outcomes using data that is aggregated from state and federal systems. Moreover, individual states might benefit from these performance metrics since they can be used by a state to evaluate and enhance their own implementation and evaluation efforts. Standardized measures could also be leveraged more broadly by researchers, advocates, policymakers and others looking to assess the law’s effect on population health or a particular sub-group of interest.
This post will discuss the federal Marketplace and Medicaid reporting requirements and provide some examples of how Massachusetts has used additional data sources and metrics to evaluate the state’s Marketplace – the Health Connector – and the impact of the state’s 2006 health reform law.
Marketplace and Medicaid Reporting Requirements
As the primary agency responsible for implementing the Medicaid expansion and development of the new Marketplaces, the federal Centers for Medicaid and Medicare Services (CMS) – in close collaboration and consultation with the states – has recently finalized a number of data collection and reporting requirements for tracking an individual’s progress in enrolling in affordable health coverage; including creating an account, applying for affordable coverage options, shopping, selecting, and enrolling in a plan that meets the consumers preferences. CMS notes that these requirements are focused on both (1) establishing accurate and timely data for monitoring and reporting purposes, and (2) tracking and evaluating the effectiveness of Marketplace and Medicaid/CHIP eligibility and enrollment processes.
State-Based Marketplace Reporting: CMS – through the Center for Consumer Information & Insurance Oversight (CCIIO) – has released two sets of performance metrics for State-Based Marketplaces. The first set of metrics will be reported to CCIIO on a weekly basis during open enrollment (i.e., from October 2013 to March 2014) and then monthly after that. Table 1 summarizes the 6 categories of metrics which will include over 100 data elements.
Table 2 summarizes the second set of metrics that were finalized in the first week of October 2013, and which will be reported to CCIIO on a quarterly basis starting in January 2014. These metrics – which are primarily focused on applications, eligibility, and enrollment – include over 800 data elements in the following 12 categories:
Medicaid/CHIP Reporting. In addition to Marketplace reporting, CMS – through the Centers for Medicaid and CHIP Services (CMCS) – released a reporting template in August 2013 for Medicaid/CHIP eligibility and enrollment performance indicators. Starting in October 2013, states are required to submit weekly and monthly reports to CMCS on a host of indicators primarily focused on tracking individuals’ interactions with the call centers, the number of applications received, processing time for determinations, number of pending applications, total number of individuals determined eligible or ineligible for Medicaid/CHIP, and total enrollment.
CMS has noted that, whenever possible, it has attempted to align these new performance indicators with data that states collect to monitor their current Medicaid program. CMS has also sought to coordinate the Medicaid performance indicators with the outcome metrics developed for Marketplaces.
Although some high level data has been publicly reported from the first weeks of open enrollment — such as the number of accounts created and enrolled in private health plans — it will likely take several months of experience before we can expect comprehensive and consistent reporting on the metrics that are described in the tables above.
The Massachusetts Health Connector – established in 2007 as the agency responsible for operating the state’s Health Insurance Exchange – has been tracking metrics and business analytics to support improved customer experience as well as operational efficiency.
In addition to collecting and reporting measures similar to those that CCIIO will be requiring from state Marketplaces, Massachusetts has established additional approaches for tracking insurance coverage outcomes and the impact of other key features of the Massachusetts 2006 health care reform law. However, to track these outcomes, Massachusetts had to collect and analyze data from a number of sources beyond that available within the Marketplace or the Medicaid agency. For example:
- Coverage Rates. Overall changes in coverage were tracked using data from the Current Population Survey (CPS), the Massachusetts Household and Employer Insurance Survey, and the Massachusetts Health Reform Survey. Using these sources, the Health Connector established that the overall rate of insurance coverage rose from a baseline of 93 percent in 2006, up to 97-98 percent in 2011 as a result of the state’s health reform efforts. The Massachusetts Division of Health Care Finance and Policy reported that over 400,000 residents gained insurance between 2006 and 2010: 193,000 through expansion of the Medicaid program, 159,000 through the subsidized Commonwealth Care program, and approximately 77,000 through the growth of individually purchased insurance. The Health Connector continues to play a key role in providing subsidized insurance to eligible individuals and currently has over 200,000 members enrolled in the Commonwealth Care program.
- Health Connector Contribution to Non-Subsidized Coverage. In addition to offering subsidized coverage for those living in families under 300 percent of the federal poverty level, the Health Connector’s Commonwealth Choice program offered insurance products in the non-subsidized individual (non-group) market. In order to evaluate the contribution of the Health Connector to the improved coverage rates, the proportion of individuals purchasing insurance through the Health Connector – as opposed to directly from carriers – was evaluated. As reported in the Health Connector’s Annual Report for 2008, data from the state’s Division of Insurance was used to determine that among the 32,000 new buyers of non-group (individual) insurance nearly 50 percent bought coverage through the Health Connector in the first year of operations. The Health Connector continues to play a key role in the non-group market with membership currently at 40,000 enrollees.
- Impact of Individual Responsibility and Employer Mandate. Based on an analysis of recent state tax data, among those tax filers who filed the state tax form that is used to report health insurance status, over 96 percent of tax filers were insured at some point during 2010. 44,000 tax filers were assessed a penalty in tax year 2010 because they were uninsured despite having affordable insurance available to them.
- Impact on Employment Based Insurance. Massachusetts was concerned that the newly affordable insurance options could potentially “crowd out” existing employer sponsored insurance (ESI). The yearly Massachusetts Household and Employer Insurance Surveys were used to measure ESI and found that this was not the case. In fact, over the period from 2005 to 2011, employers offering health insurance increased from 70 percent to 76 percent, which was better than the 69 percent national average.
Based on initial review of the Marketplace and Medicaid data collection and reporting requirements, it appears that CMS will primarily be emphasizing establishing baselines, monitoring the eligibility and enrollment process, and informing program integrity efforts at the state and national levels. CMS will also be requiring standardized reporting from the beginning of implementation, which will facilitate comparison across states and aggregation of information at the national level over time.
Given the complexity involved with the initial rollout of Marketplace and Medicaid eligibility and enrollment systems, states will likely find it challenging to initially meet all of CMS’ reporting requirements. Accordingly, it will be important for state reporting leads to work closely with their information technology (IT) staff to ensure that their system is accurately producing the data required by CMS.
If states determine that there are gaps in their ability to initially meet the CMS’ requirements, it is recommended that states work with CMS to level set expectations and develop a timeline for when they will be able to report their metrics. Over time, however, it is expected that state IT systems being built to support health reform should be used to automate most of the reporting required by the ACA. It is also important to note that given the timeline for collecting and reporting statistics for the Marketplace eligibility and enrollment process, it is likely that reliable data for the outcomes of the initial enrollment period will not be available until early 2014.
Beyond CMS’ reporting requirements, we anticipate that there will be a need and opportunities for states to collect and analyze data from a broad array of sources to evaluate the role of Marketplaces in achieving national and state policy goals as well as tactical and business oriented metrics that measure operational efficiency, customer service and effectiveness of outreach efforts. Thus, establishing a broad baseline dataset prior to or as close to the start of ACA implementation is critical in order to track the impact of these reforms. To do this, states should take this opportunity to leverage investments in new systems and data sources to better understand ACA implementation as well as their own state specific goals.
States should also take this opportunity to explore the development of an infrastructure to collect, integrate and analyze data from multiple sources (e.g., All Payers Claims Database, Health Information Exchange, etc.) to understand the impact of the ACA on insurance markets, access to care, and ultimately – the impact on population health. Similarly, it will be important for agencies involved with measuring the impacts of health reform to establish strong collaborative relationships across various state agencies, constituents of the health care market, and other stakeholder groups as part of this effort. Relevant data typically resides within various data sources in the state, and timely access to data will be important for measuring and tracking progress. In addition, this will encourage administrative efficiencies, rather than promoting redundancy in data reporting.
Finally, while national policy makers are seeking to standardize goals, measures, and data sources, it is important to keep in mind that different states will measure success differently – based on their market dynamics and population – with the overarching goal of using the tools offered by the ACA to best serve the health care needs of their citizens.
Note: The authors would also like to acknowledge Michael Chin and Natasha Dolgin for thier research assistance as well as helpful comments and input on preliminary drafts of this post.