An exchange that offers a similar smorgasbord would probably be no different. Looking carefully at how your exchange will deal with the “too much choice” problem is important. How it limits the choices—if it does—reveals much about the exchange’s philosophy and how much it wants to satisfy insurance sellers, as opposed to helping buyers. Four or five different plans in each of the four tiers—bronze, silver, gold, and platinum plans—might be more useful than three dozen in each one that, in reality, offer only the smallest variations and complicate the shopping process for even the most competent customer.
Some exchanges, like California’s, will be known as “active purchasers.” That means they will negotiate with insurers, decide who can offer plans through the exchange, and set the rules for those insurers who participate. In other words, they will be hands on. Most exchanges probably won’t be, though, and will let any carrier participate. These will rely on the state insurance department to do the policing—and that could be problematic, given the history of weak state insurance regulation. It might mean insurers operating in those kinds of exchanges will have little oversight.
Key Question: How tough will your exchange be on insurance companies?
Do the networks have enough doctors and hospitals?
Maybe they will; maybe they won’t. That depends on what steps the exchange is taking to make sure there are sufficient doctors and hospitals for the newly insured. If people find their doctors are not in the plan, or a hospital covered by the plan is too far away, they won’t buy a policy, and that, too, can affect the mix of the risk pool.
And there’s the fear that insurers will omit providers in certain areas where there are clusters of patients with diseases they’d rather not insure. New York’s experience with AIDS is an example. In a fight with insurers over the availability of an out-of-network rider for insurance coverage, the Center for the Independence of the Disabled found that many HIV specialists were not in any provider networks. Matching up provider networks with diseases common to certain populations is a good enterprise project for an eager reporter.
Will the exchanges become like Medicaid? That is, will some doctors refuse to take patients with exchange coverage, because insurers selling through the exchanges offer lower reimbursement? This question zooms right in on the insurers’ fears that only sick people will buy coverage. Lower reimbursements might be one way they could cope with the high costs of insuring the sick, but if providers balk, people could have a problem. (Remember, insurers can no longer refuse coverage to those who are sick and need to make up their losses somehow.)
Key Question: What is your exchange doing to insure network adequacy?
How will the exchange sell its policies?
The trick, says one exchange expert, is “how to convince people to enroll in this unaffordable thing.” The answer, of course, depends on the outreach and the sales job. When Massachusetts beefed up promotion of its pioneer exchange, called The Connector, it bombarded fans at Red Sox games with advertising aimed at getting young men to sign up for insurance. It worked. But the Bay State has a culture of insurance. Whether the Illinois exchange will have similar success with White Sox fans or whether the Mississippi exchange hawking insurance at Ole Miss football games will reel in the sales is not known.
Some exchanges, like Connecticut’s, have gone out to listen to the people who will soon be their customers. Given the fact that the Kaiser Family Foundation just found that two-thirds of the uninsured population and more than half of the entire population don’t understand how the health reform law will impact them, such listening tours seem essential.