Dive Brief:
- The U.S. Government Accountability Office (GAO) released three reports this week; two updating previous undercover investigations into fraudulent ACA plan applications, and one looking at consumer satisfaction with ACA health plans.
- The two undercover tests for the 2015 and 2016 coverage years continued, as in previous reports, to find the marketplace eligibility determination and enrollment processes to be vulnerable to fraud.
- The third study, which looked at five national surveys of qualified health plan (QHP) enrollees, concluded that most consumers who bought coverage through the exchanges were satisfied overall, though the study also identified some concerns about enrollee experiences.
Dive Insight:
The continued vulnerabilities to fraud, first reported in 2014, reveal an ongoing failure at the federal and some state marketplaces to remedy the issue, despite the CMS stating two years ago that, "We are examining this report carefully and will work with GAO to identify additional strategies to strengthen our verification processes."
The question remains as to whether/how much the vulnerabilities are actually being purposely or accidentally exploited and impacting federal spending for subsidies and other related costs, which the Congressional Budget Office (CBO) estimates will cost $56 billion for fiscal year 2017. As the GAO noted in its 2016 report, "The results, while illustrative, cannot be generalized to the full population of enrollees."
For 2015, the GAO reported attempting to submit 18 fictitious applications by telephone and online. Ten tried to fraudulently obtain subsidized coverage through the federal marketplace via New Jersey and North Dakota, and through the state marketplaces of California and Kentucky. Eight of the 10 failed the initial online identity check but all 10 were still ultimately approved.
For 2016, the GAO attempted to submit 15 fictitious applications for subsidized coverage via the federal marketplace in Virginia and West Virginia, as well as the state marketplace in California. All 15 were approved, though three were unable to successfully process their initial payments.
Regarding consumer satisfaction with the ACA exchanges' qualified health plans, enrollees revealed several concerns that have also been raised by industry stakeholders, the GAO said. These included being unable to pay their out-of-pocket expenses before reaching their deductibles, difficulty understanding their coverage terminology, and difficulty accessing care after enrollment. "These issues have also been identified in literature as longstanding concerns of the private health insurance market," the report noted.