Health Insurance at Ground Level: An Interview with Karen Marriner

Contributor: Harris Contos, DDS, WG’80
To learn more about Harris, click here.


image011.pngHealth policy in America, what is to be made of it…?  Often it is described as pluralistic; pragmatic; a mix of the public and the private; “ecclesiastical, eleemosynary, entrepreneurial, elected” (as described by Bill Kissick); flexible; diverse, and perhaps most familiarly, incremental, implying that a national health insurance scheme, some form of a “Medicare for all” (now over 50 years since enactment), for reasons of both efficiency and equity, would ultimately come to pass in the United States.

With the enactment in 2010 of the Affordable Care Act after a long and perhaps characteristically difficult and contentious gestation, the United States moved a bit further down the incrementalist pathway with healthcare coverage - or perhaps more accurately stated as “the opportunity for healthcare coverage” – extended to millions heretofore without.  In that regard, the act did signify the most major health policy development since Medicare.

But with the election of Donald Trump, the political climate has changed, and rather than going further down the incrementalist path, or even pausing along it to regroup for the next step along it, incrementalism stands to be replaced with “decrementalism” (not seen since the repeal of the Medicare Catastrophic Coverage Act in 1989), an inchoate effort to undo the ACA, to be replaced by… well, no workable offering has emerged.

Yet, even apart from the dramatic shift in the political firmament, questions have arisen on just how “affordable” and workable the Affordable Care Act has been.  Much has hinged on creating markets through the various health insurance exchanges, yet many of these exchanges are not functioning as hoped – having underestimated their costs early on, commercial insurers have now been significantly increasing their rates, withdrawing from the exchanges, or consolidating, leaving less choice for consumers, another tenet underlying the ACA.  Yet, even without those fairly recent developments, the ease of getting desired coverage – even with subsidies for those for whom the “individual mandate” could be burdensome – has been proving difficult. 

The theory is that the creation of insurance markets coupled with knowledgeable, informed consumers would inject necessary competition in the healthcare industry and result in a better patient experience (and possibly outcomes).  As with most theories, however, the devil is to be found in the details.  Or for another perspective from Allen Blakeney, who helped start the modern Canadian healthcare system, North America’s first tax-financed universal healthcare system in 1962, when asked his view of the Affordable Care Act, termed it “a painfully small step.”  What is meant by this – despite the incorporation of such provisions as elimination of pre-existing conditions and lifetime caps, children able to stay under their parents’ coverage, and certain preventive procedures at no cost to the patient, all regarded as major achievements in the ACA – is that the ACA still lacks genuine universality, is administratively complex and inequitable, relies upon a market approach through the creation of insurance exchanges and the consumer/patient being willing and able to decide rationally within them, circumscribes the role of government by not offering a “public option,” and leaves pricing largely to the negotiations between insurance companies, providers, and health systems rather than with the federal government.

As to the former point, Blakeney was referring to wrestling with the Canadian medical establishment, which went on strike as North America’s first tax-financed universal healthcare system was launched in 1962.  The Canadian physicians wanted to continue billing patients fee-for-service as usual, with the patients then sending the bills to the government for whatever they’d get reimbursed.  The Canadian government said “uh-uh, that’s not the way it works, that would undercut the single-payer concept of the law, physicians are to submit their bills to the government’s Medical Care Insurance Commission, which negotiates rates with physicians.”  While the points you make have some weight to them, they are essentially mandated benefits.  What the Canadian law did was to give a prominent place for a government agency to affect healthcare pricing in a tax-financed universal system.  The ACA isn’t universal, doesn’t have a public option, and government influence over pricing is more removed.  I think those are the large conceptual issues Blakeney was referring to, and I think justifiably he called the ACA a small step as a result.   

To see more closely just where the devil lies in the ACA and just how painfully small this seemingly major health policy measure is, we asked Karen Marriner, MBA, Licensed Health/Life Insurance Agent of                    

Q: Please give us a bit of your background, educationally and vocationally.  Please tell us what it means to be certified for an exchange and what knowledge/competencies that involves.

A: Education: I actually started out as a professional cook, which involved going to NY Technical College for a Hotel and Restaurant Management AA degree. I headed out to California to work in kitchens in San Francisco, then decided to start a catering business, and a few years later decided to apply to UC Berkeley and get a BS in Nutrition and Clinical Dietetics. After graduation I decided that a business education was what I really needed, so I went to visit June Kinney in person and she told me I would only be considered if I had a few years of management experience under my belt (I can’t believe that I remember just what she said "’manage something, anything, not just yourself as a clinical dietitian." - 1988). That’s how I ended up managing the food production process at a large hospital in Oakland.

After earning my degree at Wharton, I spent about ten years in employee benefits consulting, which is where I discovered that the technology of automating benefits administration was what I really enjoyed. The next five years were spent diving deeper into the tech side. I designed and implemented administration systems that were just beginning to integrate with payroll systems. I was having more and more interaction with clients in this tech role, and so when I had the chance, I moved into sales and account management with, at first benefits administration, and then health and wellness vendors.  Because of my experience and network within the benefits consulting community, I was having more and more interaction with benefits consultants and brokers who needed wellness expertise. Their clients were reading all the studies about employee productivity. Everyone who represents an insurance broker must have a state license, so that’s how I ended up selling health insurance. In October of 2013, I figured I would get some use out of my license by becoming certified to place business with the new state exchange, Covered California. There were so many individuals and families in need of quality help. 

Initially, there were three types of individuals who could be certified to help consumers enroll on a state exchange like CoveredCA:

  • Certified Agents - health/life/accident insurance agents licensed by the State. Agents have a direct relationship with the health plans (it’s called being appointed) on the exchange, and are compensated by the health plan. Compensation can be based on a per member per month basis, a percent of premium basis, or a per member per year basis.  
  • Certified Enrollers - certified by the exchange, not licensed agents, compensated by the exchange. These folks have been phased out beginning in 2017. Enrollees did a lot of their work in community clinics, with a high percent of their work helping consumers get enrolled in Medicaid. 
  • Navigators - non-profit entities that received grants from the exchange. They seemed to help in the same ways as enrollers. 

There are so many factors involved in selecting health insurance these days: the consumer’s taxable income, preferred providers, healthcare system usage patterns, pharmacy usage, etc. And consumers are perplexed. To be an effective agent, you really have to keep all of these factors in mind, have a lot of patience, be willing to do extensive education, and be willing to dig in and advocate on behalf of the client with health plans and provider offices. I developed a series of YouTube videos that explain aspects of our complex system - the visuals help consumers absorb and learn complicated concepts, they can watch with their spouses on their own schedule, they can rewind as needed, and the videos keep me from repeating myself too often!

Here’s a list of the competencies as I see it: analytical, organized, patient, empathic, good at follow-up, and creative at marketing and networking.

Content Areas: obviously you need to know how insurance policies are designed, which footnotes are critical, where the typical places are that are misunderstood and which can lead to large, unpredictable expenses, how the provider groups are organized, which aspects of the tax code intersect with insurance, and how the federal subsidy program works. I keep up with Medicaid, particularly eligibility, enrollment, and disenrollment. I am required to maintain my license with continuing education, including courses in ethics, Medicare, long-term care (this is not for exchange business - I also sell LTCI). 

Q: The Affordable Care Act seems to have been particularly fitting for people such as yourself and your family - this is "up close and personal" health policy for you - offering coverage when it simply wasn't available, or at far from an affordable price.  How long has it been since you've "jumped in," and how have initial experiences and expectations compared with more recent experience?

A: I left the corporate world in 2012 and began working for myself. At that time the only good coverage was through COBRA, which all employers with more than 20 full-time employees on 50% of the typical days in the previous year must offer. The coverage was very expensive but guaranteed, but remember it only lasts for 18 months. In Sept of 2013, our COBRA ran out, and I got my first taste of what it was like to find high quality health insurance in the individual market. We had to fill out a 20-page form, list all of our doctor visits for the past 3 years, all medications, and any diagnoses. For a family of 4 our premium was $1800/mo with a $6000 individual deductible. So when CoveredCA was launched, my family was my first client. Our premium fell dramatically, from $1800 to $500/mo because we were able to take advantage of the ACA tax credits. In addition, our coverage greatly improved due to the cost-sharing reductions, such as lower deductibles and co-pays.

I have many clients who tell me they would not have been able to leave their corporate jobs without the ACA. I’m thinking specifically of an attorney who worked in a large firm for his entire career and thought of striking out on his own, but with a family of 6, the health insurance alone would have been cost-prohibitive. The ACA is very supportive of the self-employed due to the tax subsidy structure, as well as the fact that health insurance premiums are tax-deductible. Many of my clients are seeing the light and opting for health savings account plans so they can reduce their taxable income even more to qualify for a higher subsidy.

Q: More broadly, how would you say things are working out for your "non-family" clients?  I guess I would say going from a figurative "lifesaver" of having health insurance available, to the actual workings of selecting a plan, and its costs, and just how workable the plan/network is? 

A: How workable is this whole thing? For young people, they have less concern about whether a specific provider is in the network and more concern about bottom line cost. Many are struggling to keep off Medicaid because their incomes are just on the cusp of 138% of the Federal Poverty Level (FPL). These young people are working in industries that don’t offer benefits: retail, fast food, and hospitality, primarily.  Other than struggling to pay their premiums, the system is working very well for them. They are on highly subsidized plans with very low out-of-pocket costs. They rarely use their benefits, but when they do, it’s not at the ER. They know about urgent care and primary care, and this year they’ll all be linked with a primary care doctor. CoveredCA is requiring all their health plans to identify a PCP for every member, even PPO plans where no referral is needed. 

For families and older single people, provider network is the number one concern. They’ll pay a higher premium as long as their beloved docs are included. The out-of-network benefits have gotten very thin, which means going out-of-network is cost-prohibitive for most of my clients. There are some issues cropping up regarding networks now, particularly with hospital systems.

For the most part, my clients are able to work within the networks that are offered in the individual market. Some carriers differentiate on-exchange and off-exchange networks, which adds another level of complexity for the consumer. I try and stay away from those carriers because it’s so easy to get confused and wind up out-of-network accidentally. 

Costs.  Complexity.  Confusion.  All are very real concerns about the ACA, and to one extent or another lay behind the mostly political effort behind the recent “repeal and replace” effort.  The failure of that effort has shown that indeed attention needs to be given, particularly to the matters of cost and the workability of the exchanges.  But ironically and curiously enough, “repeal and replace” failed because no politician was willing to risk being associated with the dismantling of Medicaid, a government program which, since the ACA, now enrolls more people than does Medicare, another government program.  The political support and popularity of each, now more recently Medicaid, is assured.  How the market-based insurance exchanges address the issue of cost, access, and equity may well determine if there may be a third major government sponsored program in the future, resulting in truly universal health coverage, American style.   


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