Nevada: Welcome back, Nevada Health Link!

 

On October 1st, 2013, the first Open Enrollment Period (OE1) under the Affordable Care Act kicked off to much hoopla. As everyone knows, the largest of the ACA exchange websites, HealthCare.Gov, infamously melted down at launch due to a multitude of hardware and software problems ranging from insufficient server capacity to poor workflow design to buggy coding and much, much more. However, as Steven Brill detailed in the March 10, 2014 issue of Time magazine, by early December, the worst of the problems had been resolved, and by the time the second Open Enrollment Period came along a year later, HealthCare.Gov had been completely overhauled, with additional improvements and enhancements every year since.

The difference has been dramatic: On October 1, 2013, only six people (not six thousand or six hundred...six) were able to actually make it all the way through the HC.gov interface and enroll in a healthcare policy. On December 15, 2016, six hundred and seventy thousand enrolled.

However, HealthCare.Gov was only the technical platform for about 2/3 of the country. Sixteen states launched OE1 utilizing their own website platforms: 11 of the 12 doing so today (Idaho didn't launch theirs until the second year), plus Hawaii, Kentucky, Nevada and Oregon (Arkansas and New Mexico were both supposed to launch their own full platforms at some point or another but both states eventually abandoned their plans).

Unfortunately, HC.gov wasn't the only ACA exchange to experience disastrous technical problems out of the gate. Seven of the state-based exchanges had major issues as well Hawaii, Maryland, Massachusetts, Minnesota, Nevada, Oregon and Vermont.

Minnesota and Vermont's sites were improved enough that they're functioning fairly well today. Hawaii's system hobbled along for a couple more years before they finally gave up, pulled the plug and moved everything to the mothership (including dissolving the state exchange board altogether). Maryland and Massachusetts scrapped their original platforms but maintained their autonomy by replacing them with brand-new systems (Maryland, in fact, basically leased theirs from Connecticut's properly-working version and swapped out the branding).

That left Nevada and Oregon, both of whose exchange systems were such a mess (Nevada's was developed by Xerox, Oregon's by Oracle) that both states gave up and shifted their enrollment platform over to HealthCare.Gov for the second year, where they've remained ever since. Kentucky did the same thing last year, not because of any technical problems (in fact, their exchange, kynect, was widely praised for operating almost seamlessly from day one and was much beloved by the locals), but for purely political reasons--incoming Republican Governor Matt Bevin decided to shut it down for...well, no reason whatsoever.

In any event, the point is that there's effectively four types of ACA exchanges:

• 28 "Federally Facilitated Marketplaces" (FFMs): HHS performs all Marketplace functions. Consumers as well as small employers and their employees in states with a Federally-facilitated Marketplace apply for and enroll in coverage through healthcare.gov.

• 6 "State-Partnership Marketplaces" (SPMs): The state conducts plan management and may administer in-person consumer assistance; HHS performs the remaining Marketplace functions. Consumers as well as small employers and their employees in states with a Partnership Marketplace apply for and enroll in coverage through healthcare.gov. To be perfectly frank, I'm still a bit vague about the distinction between FFM and SPM states, and they're usually lumped together anyway.

• 12 "State-based Marketplaces" (SBMs): States running a State-based Marketplace are responsible for performing all Marketplace functions for both the individual market and the Small Business Health Options Program (SHOP). Consumers as well as small employers and their employees in these states apply for and enroll in coverage through Marketplace websites established and maintained by the states.

• 5 "Federally Facilitated State-based Marketplaces" (FF-SBMs): States with this type of Marketplace are considered to have a State-based Marketplace, and are responsible for performing all Marketplace functions for the individual market and the SHOP, except that the state will rely on the Federally-facilitated Marketplace IT platform. Consumers as well as small employers and their employees in these states apply for and enroll in coverage through healthcare.gov.

The 5 FF-SBMs include Arkansas, Kentucky, Nevada, New Mexico and Oregon--all states which either planned to run their own site and never got around to doing so, or used to do so but then moved to the mothership. But here's the thing: Each of these states could move back onto their own platform whenever they want to do so. They're effectively piggybacking on HealthCare.Gov, renting out space, but there's nothing keeping them there forever.

As I noted way back on June 25, 2015:

It's even conceivable--unlikely, but conceivable--that a few years from now, after 1) The ACA has become even more firmly entrenched nationally; 2) the software/technology for running a state exchange has become even more streamlined, simplified, faster, easier to use, cheaper, etc etc; and 3) (hopefully) some changed attitudes/changed administration officials (ahem), a few states on HC.gov now may even decide to go ahead and move onto their own "full" exchange/website after all...completely of their own volition.

I realize that sounds pretty crazy now (since there'd be no financial incentive to do so), but anything's possible...and with King out of the way, at least that's a viable option now.

Well, guess what?

Nevada Appeal, February 10, 2018:

Nevada wants out of federal health exchange

Nevada's Silver State Health Insurance Exchange took the first step on Thursday to getting out of the federal healthcare.gov system and build its own exchange.

The Legislative Interim Finance Committee granted SSHIX $1 million from its own reserves to put together an RFP and find a private provider.

I think this is a fine idea for several reasons, but the exchange is looking at one reason in particular:

Heather Korbulic, executive director of the Nevada exchange, said they have to make a change because the federal exchange is raising its premium rates dramatically.

...She said when the federal charge rises to 3 percent in 2019, it will consume all but a tiny fraction of the 3.15 percent premium leaving the state almost nothing to run the front-end operation.

HC.gov basically allowed Nevada and Oregon to sleep on their floor for free in 2015 and 2016, then started charging a 1.5% rent, bumping that up to 2% this year, and 3% starting next year.

Korbulic said after extensive talks with vendors, she's confident the state can provide a state exchange for as little as a 1.5 percent premium.

So what's changed? As I noted 2 1/2 years ago...everything:

Nevada tied its state exchange to the federal healthcare.gov site after an ambitious attempt to build a state site using Xerox as a contractor failed. But Korbulic said things have changed dramatically since then and there are several vendors out their with proven systems. She said the RFP will focus on vendors who have exchange systems that have been running successfully for a year or more.

"There's nothing special that needs to be built for the Nevada exchange," she said adding the private vendor would pretty much provide an "off the shelf" system to Nevada.

Nevada isn't the only state which has taken a second look at moving off of HC.gov, by the way; back in spring 2016, Oregon was seriously considering it as well, for the same reason. I never heard any follow-up on that, however, so I'm assuming they decided to table the idea (Oregon has gone through two more enrollment periods on HC.gov since then, after all).

The only bummer here is that it sounds like Nevada's new exchange won't be ready to go by this November, but will have to wait for...OE7:

She said they'll use the $1 million to contract with a vendor as early as July or August and have the system up and running in time for open enrollment in the fall of 2019.