Being Uninsured Is Bad for Your Health: Can Medical Homes Play a Role in Treating the Uninsurance Ailment?

Dr. DeVoe's reflections are timely. Key insurance provisions of the Affordable Care Act (ACA) are less than three months away. Levitt et al estimate that ACA could reduce premium costs for those currently buying insurance on the individual market by nearly $2,700 every year. Yet, confusion about the ACA reigns. According to a recent poll by the Pew Research Center, 44% of Americans believe that the ACA has been repealed, overturned by the courts, or just don't know that it is the law. Most people don't know who is eligible for subsidies, how much they will save or how to enroll.

For these reasons alone, Dr. DeVoe is absolutely correct. Patient- centered medical homes (PCMHs) will need to assist families with health insurance enrollment and continuity. However, without adequate education, tools and the types of systems that Dr. DeVoe describes, PCMHs will struggle to help. Finding practical ways for PCMHs to share their materials, tools, and systems with each other will flatten the ACA learning curve.

All clinicians and staff will need to familiarize themselves with the key features of the ACA. The famed Kahn Academy, has produced a short video where Salman Kahn explains key features of the ACA in plain language and diagrams (https://www.khanacademy.org/humanities/american-civics/v/ppaca--or-- obamacare).

Eligibility for expanded Medicaid and for subsidies for private insurance through health exchanges is based on household income and family size using the federal poverty level. The federal poverty line is currently at $11,490 for a single adult and $23,550 for a family of four. Families, in states that have opted for Medicaid expansion, are eligible for Medicaid coverage if their household income exceeds these limits by one third, (i.e. 133% of federal poverty). In all states, uninsured patients and families with household incomes up to four times these levels are eligible for some subsidy for purchase of private insurance on their insurance exchange.

The Kaiser Family Foundation (http://kff.org) is an excellent source for information about ACA. It has recently produced a user-friendly online tool that simplifies the process for estimating patient/family eligibility: http://kff.org/interactive/subsidy-calculator/.

In addition, CMS posts phone numbers to call for more information about health exchanges by State (https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/).

PCMHs can also establish partnerships with local Departments of Social Services to facilitate enrollment in Medicaid and help resolve glitches that arise.

PCMH staff can bookmark the websites for the online insurance exchanges in their state as soon as they go up. These are the sites that patients will use to select health plans and enroll in them. Patients with low ehealth literacy will undoubtedly benefit from guidance from practice staff in using these sites.

Last, PCMHs can establish partnerships with local insurance navigators (funded through ACA) who can personally guide patients through the process. Linkage to these local navigator programs will enable practices to extend their reach. These are described more fully at http://kff.org/health-reform/issue-brief/navigator-and-in-person- assistance-programs-a-snapshot-of-state-programs/

Assisting patients in this challenging process should become a core function for all PCMHs. Perhaps, NCQA and CMS will agree with Dr. DeVoe and begin to recognize assistance with insurance continuity as a key feature of PCMHs and Meaningful Use.

Competing interests: ?? None declared