By Jane Norman, CQ HealthBeat Associate Editor

November 20, 2012 -- The long-anticipated next steps in a complicated regulatory dance involving the federal government, states, and health insurers were laid out by the Obama administration last week, and federal officials acknowledged that there is much more work ahead.

The 131 pages of proposed rules overhauling individual and small-group coverage in the health insurance market carry out the health care law's overarching aim of making sure that, beginning in January 2014, sick people who have been denied coverage in the past are able to buy health policies. And the states, which are responsible for regulating insurance, will have to adopt the Department of Health and Human Services regulations. States also will have to make sure that coverage is priced fairly and is accessible.

"These reforms are really at the heart of the Affordable Care Act," said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, in a noon call with reporters. The limitations of the current market are apparent, the rule notes: In 2011, only 10.8 million people were enrolled in the individual insurance market, while 48.6 million lacked insurance.

The comment period for the proposed rule ends Dec. 26, and Department of Health and Humans Services (HHS) officials say they understand the fears of insurers about the speed of this major transition and its impact on their bottom lines. "We solicit comments on additional strategies consistent with the Affordable Care Act that The Centers for Medicare and Medicaid Services (CMS) or states might deploy to avoid or minimize disruption of rates in the current market and encourage timely enrollment in coverage in 2014," the rule says. That could include a "transition period for certain policies," according to HHS.

Reaction from the insurance industry was not overly critical. "We appreciate that the proposed rules issued today seek to minimize coverage disruption, and we look forward to working with the department to achieve this goal," Karen Ignagni, president and CEO of America's Health Insurance Plans, which represents the industry, said in a written statement.

Under the law's mandate for guaranteed issue, insurers must cover any applicant who applies (only five states now authorize that in the individual market) and allow policyholders to renew as well. Insurers are no longer allowed to discriminate on the basis of pre-existing conditions; they are allowed to take only age, tobacco use, where someone lives and family composition into account.

Women can't be charged higher rates because of their gender or medical history. Most of the best selling plans today vary rates based on gender, says HHS.

Age, Tobacco Use, Geography

Within those broad parameters the proposed rules cover a staggering range of important and complex questions:

• They maintain the 3 to 1 age band for premiums required under the law, though they allow ratings tied to age to rise year by year through a person's life, so premiums increase slowly and steadily and not when, for example, a five-year mark is hit. Still, a 64-year-old person can't pay more than three times as much as young person under the 3 to 1 rating specified in the law. All premium rates tied to age would be the same over 64. Insurers wanted the current 5 to 1 rating bands to remain in place.
• They interpret the law to mean that the 3 to 1 age band was intended to apply only to adults age 21 and older, not children or teens. The bands are to be determined based on a policyholder's age at the time the policy is issued or renewed, though HHS says it will listen to comments on whether birthdays should be used instead.
• They suggest that state high-risk pools created in the law be continued for some unspecified period beyond 2014 while insurers transition to the new system. The pools, which enrolled about 90,000 people nationally in September and have $5 billion in funding set to end in December 2013, are intended for use by individuals who can't obtain insurance easily because of their pre-existing conditions. "We are examining ways in which states could continue" the pools, HHS says.
• They propose that each state can establish no more than seven rating areas within which premiums are set. The rating areas would apply equally to all non-grandfathered coverage in the individual and small group markets, inside or outside the health insurance exchanges.
• They require insurers to submit data on their rates and proposed increases to the secretary of Health and Human Services. The secretary won't approve or reject such rate increases. The data will be used to monitor trends in health insurance, Cohen said. This is a change from an earlier rule laying out how the federal and state governments will review insurance rates. HHS estimates the administrative cost at $7,000 per insurer.
• They propose that health insurers put all of their non-grandfathered business in the individual market in one single risk pool and all of the small-group business in a separate single risk pool. States could merge the two into a combined pool if they're seeking to spread risk more widely. Student health insurance coverage sold through colleges would be placed in the individual market pool, though HHS asks for comment on whether a separate pool for students should be kept.
• They come down on the side of generating premium rates for employee and dependent coverage in the small-group market on a per-member basis. This way, factors that are allowed to figure in to the rate of premiums, like tobacco use, could be associated with specific employees and dependents.
• With little clarity or consistency on how states now define tobacco use for rating purposes, regulators suggest that questions be asked about smoking when people apply for insurance through the exchanges.

Definitions of Family

In one area that may turn out to be tricky, regulators ask for comments on how to define which family members may be included on the same policy. Insurers now have "considerable flexibility" subject to federal and state laws, the rule says. Stepchildren, grandchildren, foster children and children under guardianship are sometimes included, sometimes not.

Officials also ask in the rule whether they should specify minimum categories of family members or whether to leave that question to states and insurers. But Cohen, in the call, said the intent is to leave this up to states. "We are not regulating on that," he said.

In more detail on guaranteed issue, the proposed rule says insurance companies must offer coverage to and accept any individual or employer in a state that applies for such coverage regardless of health risk, status or medical claims or costs, with limited exceptions. The insurance market rules apply to all non-grandfathered health coverage in a state market, they add. So even certain "closed blocks" of business would be available to new enrollees, again with a few exceptions, the rule says.

The proposal also acknowledges that insurers may incur some one-time fixed costs in the course of complying with the final insurance market rule, including administrative and marketing costs. HHS asks for information on the nature and magnitude of those costs, which insurers likely will be happy to provide. States also are asked to tally up their costs if they have to make changes related to age bands or geographic rating areas.

Figuring it all out

Health experts and groups spent a long afternoon trying to digest the details of the proposed rule, which was accompanied by two others, one on the law's wellness programs and another on exchanges.

The 3 to 1 age band is strongly disliked by insurers, who say it will drive up premiums for younger people and thereby lead them to pay penalties instead. But the senior advocacy group AARP praised both the idea and the way HHS is approaching it. "We understand the importance of stopping insurance companies from charging exorbitant premiums to older Americans, and this proposed rule will finally put limits on this discriminatory practice," Nancy LeaMond, executive vice president, said in a written statement.

But Ignagni of AHIP warned that "for health insurance exchanges and new insurance market rules to work, coverage needs to be affordable and there needs to be broad participation in the system." She said the age band "may incentivize young, healthy people to wait to purchase insurance until they are sick or injured, driving up costs for everyone with insurance."

Once the rule is final, states in the months ahead will have to adopt the federal standards so that their laws don't vary. In some states, insurance commissioners will be able to take many of these steps on their own to change regulations, but in other states it will take action by state lawmakers, health policy experts say.

The proposed rule says that states would continue to apply their own laws on insurance coverage. But if any state law conflicts with the federal law, that state law would be pre-empted, HHS says—though with the customary bow to states' rights. "Throughout the process of developing this proposed rule, CMS has attempted to balance the states' interests in regulating health insurance issuers and Congress' intent to provide uniform protections to consumers in every state," HHS says.

The rule is the second in major insurance changes required by the law. Earlier, in September 2010, as part of the health care law (PL 111-148, PL 111-152), the so-called Patient's Bill of Rights went into effect and allowed young adults up to age 26 to stay on their parents' insurance policies, banned lifetime limits on essential health benefits and ended the practice of rescission, in which insurers would drop people when they got sick.

• Fact Sheet

By Rebecca Adams, CQ HealthBeat Associate Editor

November 20, 2012 -- After months of delay, the Centers for Medicare and Medicaid Services has finally released a proposed rule that establishes the essential benefits that health insurance plans must offer under the health care law.

The proposed rule also included standards on how the actuarial value of plans would be determined.

Separately, the Centers for Medicare and Medicaid Services (CMS) issued a guidance to states on the types of benefits that Medicaid programs must include if they expand coverage under the health care law (PL 111-148, PL 111-152).

Under the essential benefits proposed rule, health plans in the individual and small-group markets—both in and outside of the new exchanges—would have to provide coverage in the 10 categories of services that the health care law requires.

Essential health benefits have to equal those offered in a typical employer plan in a state, which serves as a benchmark plan. If a state doesn't choose a plan as a benchmark from one of several options, then Department of Health and Human Services (HHS) officials will use the largest small-group plan in the state as the default. Government officials could switch the choices of benchmark plans after 2015.

The proposed rule would extend the deadline for states to select a benchmark plan until the comments are due, which is on Dec. 26. Originally, states were supposed to select their plans in the third quarter of this year, before Oct. 1.

HHS officials had previously issued bulletins on both essential health benefits and actuarial value. The agency received more than 11,000 comments on both documents.

Wider Drug Coverage

One change from the bulletin is that the proposed rule would allow for broader coverage of different prescription drugs.

Under the bulletin, HHS officials had been considering only requiring coverage for at least one drug in each category and class. But comments poured in complaining that this could hurt some patients.

"A large number of commenters raised concerns about the comprehensiveness of prescription drug benefits under this potential approach," the rule said. "Specifically, many commenters indicated that a requirement to offer one drug per category and class could result in insufficient access to medications for individuals with certain conditions."

The change included in the proposed rule would require coverage either at least one drug in each class, or the number of drugs that the benchmark plan offers—whichever is more. Most current small-group plans cover more than one drug per class, so in many plans, insurers will have to cover at least two drugs in each class. The Pharmaceutical Care Management Association, which represents pharmacy benefit managers that seek discounts from drugmakers, had been worried that federal officials would mandate broader drug coverage than they ended up requiring. Some advocates had pushed for coverage of all or most of the drugs within a class.

"When plans have more flexibility to design clinically based formularies, they can negotiate bigger price concessions from drug makers and offer more affordable, generous prescription drug benefits to patients," the group said in a statement.

Actuarial Flexibility

The health care law sets up different levels of health plans. For a so-called "bronze plan," the actuarial value must be 60 percent, leaving consumers to pick up 40 percent of the costs. In a silver plan, consumers pick up 30 percent of the costs. In a gold plan, consumers pay 20 percent of costs. And in a platinum plan, consumers pay 10 percent of costs. Insurers also can offer catastrophic-only coverage for certain people.

Under the proposed rule, HHS said that consumer-driven plans, such as health savings accounts, could be acceptable if they meet all of the law's requirements.

HHS officials said they are giving plans some flexibility if they are close to meeting the value requirements to reach a certain threshold. If a plan's actuarial value is within 2 percentage points of the standard that would allow it to be offered within the bronze, silver, platinum or gold category, HHS officials will allow it. For instance, a silver plan could have an actuarial value of between 68 percent and 72 percent. The rule also would allow insurers in the small-group market to set higher deductibles in order to reach a certain coverage level.

Another clarification HHS officials made is that when insurers are tailoring their benefits, they don't have to offer the exact same benefits as the benchmark plan, but any substitutions that they make have to be within the same kind of benefit. Those limits on the kinds of changes insurers can make will mean fewer differences among plans.

"We thought they would be able to swap across categories of benefits, but it's clear now that it's within a category," said Avalere Health LLC Director Caroline Pearson. "You can't swap maternity care with rehab services."

If a benchmark plan is missing any of the 10 categories, then the proposed rule says that the state or HHS can supplement the plan in that category.

The proposal also spells out when states would have to pay insurers for state-mandated benefits beyond those that are required by the health care law. But because of the way the proposal works, that's unlikely to happen.

The health care law will not allow subsidies to pay for the cost of benefits required by state law that go beyond the essential health benefits required by federal law. States also would have to compensate health plans for such coverage.

HHS officials proposed that state-required benefits enacted on or before Dec. 31, 2011—even if they are not effective until a later date—would be counted as essential health benefits. That means states would not have to pay for these state-required benefits. Officials clarified that state-required benefits include those affecting the care, treatment, and services that a state requires insurers to offer, but not state mandates on cost-sharing, reimbursement methods, or the types of providers that can provide different services.

The regulation contains a number of details about specific services, such as clarifying that "pediatric" services mean care for anyone who is younger than 19 years old.

Varying Reactions to the Rule

Some critics of the health care law offered a measured response to the rule.

"We appreciate the administration's outreach and general restraint in these proposed regulations," said National Retail Federation vice president and employee benefits policy counsel Neil Trautwein. "It is important that essential health benefits echo available market coverage today. More extensive but unaffordable coverage would help no one in the end."

But insurers said that while the rule is better than the original bulletin, they still were not thrilled.

"While additional flexibility on essential health benefits is a positive step, we remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today," America's Health Insurance Plans president and CEO Karen Ignagni said in a statement. "It also is important to recognize that the new EHB requirements will coincide with the new restrictions in age rating rules that also go into effect on January 1, 2014. Both of these provisions may incentivize young, healthy people to wait to purchase insurance until they are sick or injured, driving up costs for everyone with insurance."

The benefits rule also lays out a timeline for when those offering coverage in a federal exchange or state partnership exchange must become accredited.

State officials had been pressuring HHS officials to issue the regulation, saying that without details it was difficult to make decisions on such questions as whether to use a state-operated exchange, a state-federal partnership or a federal exchange.

The Office of Management and Budget had received the rules on Nov. 9.

In addition to the essential health benefit rules, CMS officials sent a guidance letter to Medicaid directors. It offers details about what types of benefits should be provided for low-income adults if states choose to expand their programs.

HHS officials also released a major rule on insurance market changes and one allowing wellness programs to beef up incentives for patients to practice healthy behavior.

By John Reichard, CQ HealthBeat Editor

November 20, 2012 -- Federal officials recently released a proposed rule that would increase the allowed amount of financial rewards or penalties associated with meeting certain goals in employer wellness programs designed to promote good health or prevent disease among workers.

As is proscribed in the health law (PL 111-148, PL 111-152), the maximum permissible rewards would increase in 2014 from the current ceiling of 20 percent of the cost of health coverage to 30 percent. However, the proposed regulation says that when it comes to programs designed to prevent or decrease tobacco use, the maximum reward could be increased to as much as 50 percent.

Federal officials say this proposal also would protect individuals from unfair underwriting practices that could otherwise reduce benefits based on someone's health status.

The proposal was issued jointly by the departments of Labor, Treasury and Health and Human Services. It applies to fully insured as well as self-insured plans offered by employers.

The 81-page proposal describes two distinct types of wellness programs: those that provide incentives simply for participating; and those that are "health-contingent."

Examples of the latter include programs "that provide a reward to those who do not use, or decrease their use of, tobacco," said an HHS fact sheet. Or, they include programs "that provide a reward to those who achieve a specified cholesterol level or weight as well to those who fail to meet that biometric target but take certain additional required actions," the fact sheet added.

The proposal establishes certain safeguards for employees in health-contingent programs. Programs must be "reasonably designed" to promote health or prevent disease. To meet that designation, they have to offer a "different, reasonable means of qualifying for the reward to any individual who does not meet the standard based on the measurement, test or screening."

They have to not be "overly burdensome" and offer a reasonable chance of improving health or preventing disease. They also have to be available to all "similarly situated individuals."

Various factors would come into play to determine if an employer has offered a reasonable alternative standard of performance, such as if the worker had a particular medical condition warranting such an alternative, If, for example, the alternative was defined by a medical professional designated by the employer, and the worker's own doctor determined that the alternative was not medically appropriate, the alternative would have to be redesigned to meet the recommendations of the worker's physician.

The proposal isn't playing up the potential of stronger rewards and penalties to lower health costs any time soon. For example, it says that when employers offer rewards related to a wellness program, it typically is to participate and isn't tied to performance, such as achieving a certain cholesterol level.

The proposal apparently aims to increase the number of participatory programs that provide rewards by clarifying that additional consumer safeguards do not come into play unless performance standards are involved. "The departments hope that these proposed regulations will help dispel the confusion," the preamble to the proposal states.

The departments express doubt that the ability to increase penalties and rewards from the current 20 percent standard will cause dramatic changes in wellness programs soon.

"Few health-contingent wellness programs today come close to meeting the 20 percent limit," the proposal says, adding that the usual reward percentages range from 3 percent to 11 percent. "Therefore, the departments do not believe that expanding the limit to 30 percent (or 50 percent for programs designed to prevent or reduce tobacco use) will result in significantly higher participation of employers in such programs," the proposal says.

HHS also unveiled two other proposed health law rules—one on insurance markets and another for essential health benefits in the new insurance exchanges.

By John Reichard, CQ HealthBeat Editor

November 20, 2012 -- Missing from last week's massive release of hundreds of pages of proposed rules filling in the details of the sweeping redesign of the insurance market, set in motion 32 months ago by passage of the health care law, were details on an entity looming ever larger in delivering the fruits of that legislation: the federally facilitated exchange.

By the end of the day, however, it appeared that officials had made considerable progress on the regulatory front, with insurers and states now having to scramble to conform to the new mandates.

During a press call about the rules that are ushering in unprecedented changes in the cost and components of health coverage, Gary Cohen, a senior official at the Centers for Medicare and Medicaid Services (CMS), said that "we will be putting out additional guidance on the federally facilitated exchange in the near future."

Cohen did not elaborate.

How that exchange will operate, and how and whether it will be adequately funded early on, remains largely a mystery, even as the number of states opting to send their residents to the federal exchange increases.

The list of states that say they won't help implement the health care law (PL 111-148, PL 111-152) by opening their own exchanges or by partnering with federal officials to do so grows almost by the day—and makes up huge swaths of red-state America. That means the federal government will call the shots in those areas when it comes to the terms and conditions of subsidized coverage offered to small businesses and uninsured residents.

Federal officials, meanwhile, have continued to press the case in recent days for states to build their own exchanges by extending deadlines for developing and submitting plans to open the new marketplaces.

Cohen, who heads the Center for Consumer Information and Insurance Oversight at CMS, said during the briefing that it makes a big difference whether a state runs its own exchange or the federal government does it. There are "many" differences, he said.

For example, "the determination of what products are sold in the exchange has to be made by the exchange. So if the state is running the exchange, it can decide what products are available to be sold in the exchange. If a state isn't running the exchange, then we at CMS will be making that decision."

Another difference Cohen added relates to how the costs of running the exchange are assessed and collected. "If a state is running an exchange, a state gets to decide how those costs should be assessed. Should it be assessed only on companies that are selling products in the exchange? Should it be assessed on the entire insurance market? Should it be assessed in taxes. That's totally up to a state. Otherwise, it's going to be up to us to determine," he said.

But "there will be no difference for consumers," he asserted. Consumers "will have the same access to quality affordable care whether the state is running the exchange or whether the federal government is running the exchange."

Cohen also was unable to provide details yet on nationally available plans that have to be offered in each exchange. "We're expecting something out on that shortly," he said.

Cohen voiced no uncertainty, however, that even with slipping deadlines and missing details, coverage will expand as scheduled under the law.

That "absolutely" will happen on time, Cohen said. "Absolutely, we will be ready," he said. "There will be an exchange in every state open for business on October 1st next year."

But will insurers that are preparing under still-emerging rules and guidance documents have plans ready to sell by then, too?

"Yes," he said.

Following the release of the proposals on insurance rules, essential health benefits and wellness programs, the big questions about implementation may be shifting away from the lack of regulatory guidance toward other issues, such as the cost of the coverage that will be available in the exchanges given all the new requirements.

Tim Jost, a Washington and Lee University law school professor, said his preliminary read on the regs was that they "seem pretty comprehensive." Asked what remains to be done on the regulatory side, Jost said, "The only thing I can think of is further information on the federally facilitated exchange. Also, no rules yet on the individual and employer responsibility provision, and [there are] still some gaps in the premium tax credit rules."

The recently released proposed rules revealed some new requirements insurers will be facing in addition to those they had been anxiously waiting for because of the Obama administration's pre-election holdup of regulatory proposals.

For example, insurers will now have to submit all rate hikes to HHS even though the department will only review planned increases for reasonableness in states that do not now conduct such reviews.

"We've changed the reporting requirements although not the review requirements," Cohen said.

He said the reason all rate hikes will have to be submitted to HHS in 2014 is because a provision of the health law requires the HHS secretary to monitor premiums both inside and outside of exchanges. "We need to look at rates across the market," he said. The data is needed to implement "premium stabilization" provisions that limit insurer losses initially stemming from high cost cases, he added.

Insurers meanwhile said the regulations and other health law requirements would have consequences in the form of often unaffordable premiums in exchanges.

"We appreciate that the proposed rules issued today seek to minimize coverage disruption and we look forward to working with the department to achieve this goal," said Karen Ignagni, president of America's Health Insurance Plans.

But "for health insurance exchanges and new insurance market rules to work, coverage needs to be affordable and there needs to be broad participation in the system," she cautioned. "We remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today."

By John Reichard, CQ HealthBeat Editor

November 21, 2012 -- It wasn't quite everything you always wanted to know about the Center for Medicare and Medicaid Innovation. But remarks this week by an official about what is essentially the overhaul law's laboratory for health care redesign were an eye-opener.

They revealed not only how intent the center is on its work, but the comments also underscored the center's potentially extraordinary impact.

For example, Hoangmai Pham, a senior adviser at the center, estimated that the center has a staff of 300 and has spent close to half of the $10 billion allotted to it over 10 years under the health care law (PL 111-148, PL 111-152). That's so even though the law is months away from its third anniversary.

"It's possible we're halfway through our funding already," said Pham, who spoke at a meeting this week sponsored by the Washington, D.C.-based Center for Global Development. "But that was what the administration wanted, which was to front-load this," she said.

Pham said the views she expressed were her own and that she was not speaking on behalf of the Obama administration or the Centers for Medicare and Medicaid Services (CMS).

The center has made large bets on several pilot projects to fulfill the health care law's imperative that it find ways to improve quality and lower costs. In addition to spurring efforts by doctors and hospitals around the country to organize team-based care of Medicare patients, the center has launched a broad-based campaign by hospitals and community organizations to reduce deaths from cardiovascular disease. Other ambitious projects include encouraging statewide health system redesigns in five states by combining the health care purchasing power of business and government. The thinking is that if purchasers unite behind a common payment strategy that rewards efficiency and quality rather than producing a higher volume of services, doctors' offices and other providers will have no choice but to rethink the way they deliver care to eliminate ineffective practices.

Another big focus: Get doctor's offices to quarterback the overall care of the chronically ill. The sharpened oversight will help patients keep up with good preventive care. And easing interaction with patients through email, websites, and weekend and evening hours will better maintain their health.

One-time opportunity

The plain-spoken Pham said the center is under the gun and has a fleeting opportunity. "There is a level of political will and market investment out there, and will to change, that we're not likely to see replicated any point in time soon if we blow this. So it's a one-shot deal."

But if the center is able to make the most of its opportunities and does uncover a promising approach, it can really make a difference.

It won't take an act of Congress to put a promising strategy into effect nationally by extending it to all Medicare, Medicaid, or Children's Health Insurance Program (CHIP) enrollees, for example.

The health care law gives the Health and Human Services secretary the authority to scale up nationally payment and health care delivery models that the CMS Office of the Actuary determines has the potential to save Medicare, Medicaid or CHIP expenditures.

"Historically, even when Medicare demonstrations have proved that an intervention was effective, we had to wait for Congress to act and to allow the expansion, and this removes that burdensome step," Pham said.

"We are also given unique waiver authority," she noted. That power lets the center waive specific payment rules and eligibility criteria to carry out projects. "So far, we've been told what we are not allowed to do is to curb benefits."

Also, unlike other demonstrations, "CMS does not need to obtain approval from the White House's Office of Management and Budget of the models initiated under the Innovation Center's authority," Robert Berenson and Nicole Cafarella of the Urban Institute observed in a February 2012 analysis of the center.

But pursuing innovation in health care without running afoul of laws and regulations is no simple matter. Meetings with lawyers are frequent, Pham said. "It's really all about the lawyers."

Broader cooperation is a hallmark of innovation, but that can mean stumbling over antitrust law. "We have a Department of Justice that I learned very thoroughly this year doesn't actually work with the White House," Pham noted.

The center is keen on developing data and sharing it with its partners to evaluate and refine their work. Pham indicated that there's lots of contact with partnering organizations in the projects it funds. The Center has made "huge investments" in what she called shared learning. "If you have one shot and no do-overs, you do not leave any data on the table," she said.

There's also an emphasis on not continuing to pursue approaches that clearly do not show promise. The White House Domestic Policy Council is interested in the question of how the center makes a decision not to pursue a given approach, Pham said.

Boosters of the center have high hopes for its success. Noted surgeon and New Yorker contributor Atul Gawande, in particular, has spoken in glowing terms of the model of continuing testing and innovation embodied in the innovation center.

At first glance, the health care law appears to give that approach longevity by making it a permanent fixture of health policy. The Urban Institute paper says, for example, that the health law appropriated "$10 billion for the Innovation Center every 10 years, into perpetuity."

But delivering results is tough, and key Republicans on Capitol Hill are deeply skeptical of the value of the center, which suggests its future is uncertain if political power shifts in coming years.

Pham said it is not all that hard to improve quality, as it turns out. But she added that it is "much harder to reduce costs." And she alluded to the ongoing political challenges that the center faces. "A lot of people are not sure this is what government should be doing," she said.

By John Reichard, CQ HealthBeat Editor

November 19, 2012 -- Those spearheading a broad-based, privately funded educational campaign to enroll the uninsured in health plans as part of the health care overhaul are in the closing stages of pinpointing what messages they will use and which audiences the effort will target.

The campaign's goal is to fully develop its strategy by year's end and to launch in mid-2013, in time for the Oct. 1 start of the open enrollment period in the new state insurance exchanges.

Although previous expansions of such government coverage programs as Medicaid and the Children's Health Insurance Programs signed up people at a much slower pace than expected, officials with this initiative, called Enroll America, hope they will be able to move far faster. That's because of the unprecedented size of the effort and the sweeping nature of the coverage it will be touting.

Rachel Klein, executive director of Enroll America, said in a recent interview that it has 55 partnering groups and expects to add additional ones now that the election is over and full implementation is a go. One group it is waiting to hear from is America's Health Insurance Plans (AHIP), which provided seed money for the effort.

"We've been keeping AHIP updated about our work, and Karen Ignagni felt that the best time to consider AHIP's further involvement would be after the 2012 elections," Klein said, referring to the lobby group's president.

But there are big challenges. One is the uncertainty about where Medicaid will be expanded because state-by-state battles involving governors, legislatures and health care lobbies—including hospitals—will play out over a number of months and not be resolved quickly. "We're looking to see where it makes sense for us to do our work," Klein said.

Another is the huge size of the population the campaign aims to reach. Klein said that according to one survey, 78 percent of the nation's uninsured aren't aware that there is going to be coverage available for them. Enroll America estimates that up to 40 million uninsured people will be eligible for coverage through expansion of Medicaid and subsidies to buy coverage in insurance exchanges.

"That is really a significant information challenge," she said. "I think it's hard to overestimate the amount of work that will be needed in order to get the word out."

But the 55 organizations committed to the enrollment effort results in a diverse effort and a breadth of involvement that will be "groundbreaking," she said. Groups include Families USA, the American Hospital Association, AARP, the United Way, the Catholic Health Association, Catholic Charities USA, Aetna, Kaiser Permanente, the NAACP, SEIU, CVS Caremark and the National Association of Community Health Centers.

Klein said that hospitals and community health centers will be particularly effective in helping to enroll the uninsured and their families because of the large number of people they treat who do not have coverage.

The fact that help is available to so many also will help, she added.

Expansions in the past were much more limited. "For example, if you look at the Children's Health Insurance Program, it was for kids, and for kids in a certain income bracket. And so with this new coverage we'll be able to say that there really is something for everybody in a lot of the states."

The multimillion dollar campaign will include paid advertising on TV and radio.

But hands-on help will be needed as a follow-up to such messages. "I think in-person assistance is going to be very crucial," she said. She said the campaign is working with its partners now to determine the scope and nature of those in-person efforts.

"We are right now actively developing a message for our public information campaign that we intend to launch in the middle of next year," Klein said.

"We have just finished a nationally representative survey and some focus groups that will help us identify a message that will reach the broadest number of uninsured individuals. We are in the process of sifting through that data identifying the message."

The questions the campaign will be seeking to answer as part of that process are "who are the different target populations? Where do they live? What are the kinds of concerns that they have about being uninsured? What are the key motivators that will help them seek out new health coverage? And how can we best and most effectively and efficiently reach them?" Klein said.