Eighty-one percent of people in Quest, the state's health insurance program for the poor, chose their health plan this year during an enrollment period that critics said would be chaotic but wound up working smoothly.

The state Department of Human Services wanted people to choose, to promote competition, as Summerlin Life & Health Insurance Co. entered a Quest market that had been dominated in the past five years by the Hawai'i Medical Service Association, Kaiser Permanente and AlohaCare.

People who failed to choose were automatically assigned to a health plan based on an algorithm that favors the lowest bidder, which was AlohaCare.

The department had estimated that 165,000 people would be eligible for Quest, and 134,494 people enrolled. During the enrollment period from April to July, 107,621 people chose their health plan and 26,873 were assigned to a plan. Of those auto-assigned, 1,872 ended up choosing a plan during a 90-day grace period that ended in October.

The 19 percent of people who were auto-assigned to a health plan was substantially higher than the department's estimate last year of 5 percent. But several people who provide healthcare to the poor said there have not been significant disruptions.

The department agreed to what it described as a "bullet-proof safety net" to discourage disruptions after the enrollment plan was scrutinized by the state Legislature. The safeguards included the 90-day grace period and assurances that people would still be covered if they show up for medical treatment and discover they have been assigned to another health plan.

According to the department, less than 3 percent of people typically change health plans during open enrollment periods when there are no consequences for not choosing. By forcing people to choose — and auto-assigning those who do not to other plans — the department hoped to increase competition.

Lillian Koller, the department's director, said the enrollment plan achieved its goal of creating more competition between health plans while adding benefits for people in Quest. For example, health plans were required to offer four disease management programs, for asthma and diabetes and then two others for either congestive heart failure, HIV/AIDS, high-risk pregnancy and obesity.

"I know it encouraged competition and gave people choices," Koller said. "And people in huge percentages exercised that choice, which I think is the thing that's so stunning here."

AlohaCare, which had previously been the lowest bidder, fought the enrollment plan when the department proposed it last year, claiming it would be too disruptive and would lead to 15 percent to 20 percent being auto-assigned to other health plans. AlohaCare believed at the time that Summerlin would be the lowest bidder this year.

Koller claimed that AlohaCare was trying to protect its market share since, as the lowest bidder, it received many of the people displaced when other health plans had dropped out of Quest.

State lawmakers considered capping the number of people who could be auto-assigned at 5 percent, but Koller argued that the move was a ploy to help AlohaCare, and it was defeated.

Not only did AlohaCare remain the lowest bidder this year and get the bulk of people who were auto-assigned, it also became the only plan available in Quest on Moloka'i and Lana'i, replacing HMSA.

AlohaCare and Summerlin officials were not available for comment. Others who work with the poor, however, said concerns about potential disruption were real.

"We got lucky," said Richard Bettini, chief executive of the Wai'anae Coast Comprehensive Health Center.

AlohaCare concentrates on the Quest market and many of the people auto-assigned were in AlohaCare and were simply assigned back after open enrollment. Bettini says there would have been problems if another provider was the lowest bidder and upwards of 20,000 people were switched.

"That would have been mass confusion. And for what value?" Bettini asked.

State Rep. Josh Green, D-6th (N. Kona, Keauhou, Kailua-Kona), a Big Island doctor and chairman of the House Health Committee, said last year that lawmakers would be watching the department to see how many people were auto-assigned. "I think we're going to call them on it in a big and nasty way if it's substantially higher than 5 percent," he told The Advertiser.

Green said recently that he is not surprised the department's estimate was off but said the most important thing is that the enrollment plan was not disruptive.

"It doesn't surprise me that it was much higher," he said. "I don't think they were being entirely straight with us."

Koller said the 5 percent estimate was based on similar enrollment plans in the past and was not a prediction or guarantee. She said predictions by some critics that people in Quest, including those who speak limited English or are transient, would either be confused or would not want to choose their own health plan were refuted.

"We proved the opposite," she said.

Reach Derrick DePledge at ddepledge@honoluluadvertiser.com.

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