Georgia: OK, Gov. Kemp, make me eat crow this fall. Seriously.

A couple of weeks ago I wrote about how the Georgia state government, which for years has been among the more ACA-hostile GOP states, and which has spent the past several years actively attempting to get out of having any official ACA exchange platform whatsoever, has seemingly done a complete 180 and now supposedly wants to go the other way:

Georgia GOP leaders have proposed a bill that they hope will lead to a state takeover of the health insurance exchange marketplace for Affordable Care Act plans.

...Traditionally a majority of Georgians shop for ACA plans on the federally run marketplace website, healthcare.gov. Eighteen states use their own marketplace website, according to the Kaiser Family Foundation. The key feature of these sites is they allow shoppers to objectively compare their options for price and coverage.

It’s unclear exactly what the state’s replacement would be.

As I noted at the time...

If this was any other state besides Georgia--even any other GOP-controlled state--I'd say good for them since it would presumably just mean that they were the latest state to move to their own state-based exchange (which is how the ACA was originally envisioned anyway).

This would give them the ability to hook the SBM into their state databases for auto-enrolling residents receiving SNAP benefits/etc into $0-premium coverage, or to integrate supplemental subsidies as nearly a dozen states do today, and so forth. There's several upsides to moving to an SBM, up to & including reducing the user fees (although those have been significantly reduced on the federal exchange in recent years anyway).

HOWEVER, this is Georgia under Gov. Brian Kemp:

Under the Trump administration, Gov. Brian Kemp proposed to block Georgians from shopping on healthcare.gov, and instead lead them directly to private health insurance companies and brokers. Georgians already have access to those private industry sellers, but Kemp aides said that blocking healthcare.gov and further promoting the private companies would benefit Georgians.

The Biden administration suspended Kemp’s proposal.

In fact, Kemp's "Georgia Access" plan would have gone even further than that:

The Georgia Access model would eliminate the use of HealthCare.gov, transitioning consumers to decentralized enrollment through private web-brokers and insurers. The state would establish its own subsidy structure to allow for 1) the subsidization of plans that do not comply with all the ACA’s requirements; and 2) enrollment caps if subsidy costs exceed federal and state funds.

...What Georgia's waiver would do is something very different which would completely undermine many of the primary reasons the Patient Protection & Affordable Care Act was passed in the first place.

Thankfully, the Biden Administration shut the waiver down in no uncertain terms...

The Departments have reviewed the State’s letter and are suspending implementation of the Georgia Access Model effective August 9, 2022. CMS will continue to operate the FFE in Georgia, and Georgia consumers will retain access to HealthCare.gov for plan year (PY) 2023 to purchase qualified health plans in the individual market. Georgia may submit a corrective action plan to bring the Georgia Access Model into compliance with the statutory coverage guardrail for the Departments’ consideration to resume implementation for PYs 2024–2026.

As for the development a couple of weeks ago, I further noted that:

The Kemp administration took credit too, noting that it spent $5 million on advertising for a website it set up leading people to insurance companies and brokers, GeorgiaAccess.gov. A spokesman for the state Office of Insurance said the website drew 334,000 unique views — meaning the site was viewed from that many different computers or phones.

The article doesn't clarify what period of time those 334,000 website visits took place over, but I'm assuming it was over the 3-month Open Enrollment Period from November 1 - January 31st. If so, that'd be around 3,700 site visitors per day, which isn't particularly impressive. My own website has often exceeded that level of traffic.

They spent $5 million to generate 334,000 visits, or around $15 per site visitor to date. By comparison, I spend exactly $0 in advertising for ACASignups.net.

The thing is, GeorgiaAccess.Gov doesn't actually let you enroll in anything. Unless I'm missing something, as far as I can tell, it's what I referred to in my website developer days as a "brochure" website...it's literally just a WordPress site with perhaps dozen pages of text, images and links to other websites. I have no idea how much they spent on developing the website itself, but if it was more than a few thousand dollars at most they got ripped off. Don't get me wrong, it looks nice, but it's literally just an informational site (it actually says that at the bottom of the page).

In any event, that was the situation until recently...when the story about Georgia wanting to "take over" their ACA marketplace, which could mean just about anything under the circumstances.

Well, Louise Norris gave me a heads up about the latest development...and assuming everything is on the up & up, it looks like they really have decided to do this the right way after all. Via the Georgia Insurance Dept. website:

Georgia State-Based Exchange Blueprint Letter

FEBRUARY 15, 2023

The State of Georgia is in a unique position relative to other states that previously transitioned off the Federally-facilitated Exchange (FFE), as much of the work to transition occurred prior to submitting the State-based Exchange Blueprint Application (Blueprint).

On Tuesday, February 14, 2023, Georgia Insurance and Safety Fire Commissioner John F. King submitted a letter to the Centers for Medicare and Medicaid Services ("CMS") offering additional context regarding the State's operational and technical readiness to transition to a State-based Exchange (SBE).

The letter itself is 11 pages long, but there's some noteworthy sections:

...Over the last three years, Georgia made substantial investments in the Georgia Access Model under its 1332 Waiver and was fully prepared to transition off the FFE for plan year (PY) 2023. A key pillar of Georgia Access was the State’s public-private partnership model. This model incentivized private sector investment and innovation in our market to expand access to affordable, quality healthcare coverage and reduce the uninsured rate. The State now intends to operate Georgia Access as an SBE and implement a state portal for consumer plan shopping and selection alongside the portals offered by our private-sector partners.

In other words, their original plan to avoid using either the federal or a state-based exchange has gone kaput, so they've decided to go with a full SBE as their Plan B. Assuming their newfound turn of heart is real, I hereby rescind my prior skepticism and welcome the move.

The State collaborated closely with CCIIO to complete the required operational readiness reviews (ORRs), develop program policies and operations, develop an eligibility system that integrates with state and federal systems, engage community stakeholders, and develop a public awareness campaign. The State provided the details of Georgia Access program and technical operations in the Georgia Access Operational Report which was reviewed by CCIIO throughout the spring and summer of 2022. This report was last updated and submitted to CCIIO on July 22, 2022. The State also collaborated closely with CCIIO’s Marketplace Information Technology Group (MITG) on its technical project plan and transition approach. As a result, Georgia already made significant progress toward establishing the program and technical elements required of SBEs.

The State conducted an analysis to determine the gaps between the Georgia Access Model as originally designed under the 1332 Waiver and the federal regulatory requirements for SBEs. The analysis concluded that the original Georgia Access Model under the 1332 Waiver met nearly all federal regulations for SBEs either as designed or with minor modifications. There are four program areas that were not part of the original Georgia Access design that are new requirements for an SBE: a state consumer portal, a Navigator program, a Certified Application Counselor (CAC) program, and a Small Business Health Option Program (SHOP). The State is committed to expediting the standup of these programs and is confident it can successfully implement for PY 2024.

Holy cats. If they're really that far along (and assuming the plan is approved by CMS), Georgia will be moved directly from HealthCare.Gov onto their own technical platform this fall. I believe every other state which has made the move from the federal exchange to a state-based exchange (Pennsylvania, New Jersey, Maine, etc.) has taken at least two years to do so (the first year operating as a "federally-facilitated" SBM).

While several activities are still in progress, many of those activities are almost complete. The State is making significant progress toward meeting all SBE requirements and is confident it can implement an SBE for a go-live date of November 1, 2023.

As I noted earlier, the current Georgia Access website is essentially a simple informational site with links to a bunch of 3rd-party insurance brokers & carrier sites. According to this letter, however:

The State’s website was ready to launch for PY 2023 in compliance with all Exchange website requirements except for the items listed below. The following changes will be incorporated for the website launch for PY 2024:

• Consumers will have the ability to apply for, receive eligibility determinations, shop, compare, and select a QHP via a self-service State consumer portal. The State’s technology vendor will build this consumer portal, leveraging the existing single, streamlined application (SSApp) for the Agent Portal.

• The State will post the required Exchange financial information and reports to the website.

• The website will provide information on additional consumer assistance information available under the Exchange, including Navigators and CACs.

• The Georgia Access Eligibility System eligibility calculator has been developed and will be available to consumers at the start of Open Enrollment (OE) 2024.

There's another important feature which will supposedly be incorporated into the Georgia Access SBM...one which no other state-based exchange offers right now, to my knowledge:

Following the FFE model, Georgia will allow certified web-brokers to partner with the Exchange to offer consumer shopping, plan selection, and enrollment. The technical Application Program Interfaces (APIs) with the Georgia Access Eligibility System have already been developed and were previously tested with web-brokers. These web-brokers were assessed for operational readiness and business compliance for PY 2023. The State will reassess web-broker readiness for PY 2024, including retesting APIs and validating business and technical compliance. The State will only allow web-brokers that are certified by the FFE as Enhanced Direct Enrollment (EDE) entities to participate on the Exchange.

That's potentially HUGE. EDEs are 3rd-party web brokers which have been authorized by CMS to integrate themselves with HealthCare.Gov's back end, such as Health Sherpa and W3LL (full disclosure: Both of these also have banner ads on this site). To give you an idea of what a big deal this is, Health Sherpa alone claims to have enrolled a stunning 4.2 million Americans in on-exchange Qualified Health Plans (QHPs) during the 2023 Open Enrollment Period...which is a minimum of 33% of all 2023 QHPs sold via the federal exchange this year. They may have actually sold more like 40% or more of the total; if you include smaller EDE partners, it's likely that well over 50% of all federal exchange QHPs were sold by them combined.

However...the same isn't true of the 18 existing state-based exchanges. They sold a combined 4.1 million QHPs (probably closer to 4.2 million when the final numbers are in), but none of them integrate with EDEs yet to my knowledge. In fact, it's quite possible that one of the reasons for this years discrepancy between FFE and SBE enrollment (aside from Medicaid expansion, which is the main factor) is the massive growth of EDE enrollment on the federal exchange.

Interestingly, integrating EDE vendors with state-based ACA exchanges is also one of the main recommendations mentioned in a recent article by Amy Lotven of Inside Health Policy:

Miller also hopes that any refresh would add the enhanced direct enrollment (EDE) option offered by healthcare.gov that lets web-brokers and insurers enroll consumers without having to go through the federal eligibility hub.

The EDE entities bring in a good portion of enrollment, but no state exchange has implemented the system. But Miller says some are thinking about it. He advises any state that moves forward to use the same technology as CMS.

Former CCIIO Director Randy Pate, who led the implementation of the EDE system while at CMS, also says that any state that transitions to an SBM should build in the EDE from the ground level.

Well, it's entirely possible that Georgia will end up being the first state to do exactly that. Virginia is on track to make the move to a full SBM this fall as well, but I don't know whether theirs will include EDE integration or not.

I should note that if this goes through, Georgia would actually be the second fully GOP-controlled state to do so. States like Kentucky and Pennsylvania established SBEs under Democratic Governors, but Idaho is the only fully GOP state which started out hosted via HealthCare.Gov which later split off onto their own full SBM, back in the fall of 2014.

Their attitude in doing so was exactly what the Obama Administration & Democratic leadership had hoped other red states would take way back in 2010 when the ACA was originally signed into law...basically, "We hate this law but we're stuck with it, so we might as well make the best of it that we can by controlling some of it ourselves."

You can see this attitude reflected in multiple press releases and reports from the Your Health Idaho exchange, such as this one:

In terms of operating costs per enrollment, we are anywhere between 60% and 80% lower than any state in the country. YHI has lived up to the request of the legislature and Governor Otter when we were created in 2013 to do it better, cheaper, and minimize federal intervention.

In any event, assuming everything is as presented, I may have to issue a big mea culpa to the Georgia administration this fall...and I'd be more than happy to do so.

Stay tuned...