Nurses ratify agreement with PeaceHealth Ketchikan Medical Center

UnitedHealthcare can’t have its cake and eat it too. That’s the message from the California health insurance marketplace, which turned aside a request from the nation’s largest health insurer to sell statewide on the exchange because it opted not to join when the effort was getting off the ground in 2014.

California is one of a handful of states that adopted policies to encourage insurers to participate in the marketplace by creating waiting periods of up to three years if insurers didn’t participate the first year. Among the others is New York, Oregon, Colorado and New Mexico, according to a study conducted by researchers at Georgetown University for the Commonwealth Fund.

“I think it helps the willingness of carriers to participate over the long haul if they think there’s a level playing field, and it’s good for consumers if the exchange is managing competition and has rules of the road to abide by,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms.

Last month, California modified its position. Marketplace officials, who had originally said insurers could be locked out for three years if they didn’t join the marketplace in 2014, announced  that some insurers — including UnitedHealthcare — could apply to sell in 2016, but only in a few areas that had a shortage of carriers.

Anthony Wright, executive director of Health Access California, a consumer advocacy group, supports the move by Covered California, as the state’s exchange is called. The dozen or so insurers that agreed to sell on the exchange the first year took a risk in an untested setting, knowing they would likely be signing up sicker-than-average people who might be expensive to cover, Wright says.

“You don’t want to undermine your word to the plans that came in in year one,” he says.

But California’s insurance commissioner says that restriction is bad for consumers.

There’s nothing in the [health law] about protecting market incumbents,” says Dave Jones. “There’s a lot about expanding choice and competition.”

In most state marketplaces, any insurer that meets published criteria can sell plans. But California and some other states have adopted an “active purchaser” approach that allows them to decide which carriers can sell on their exchanges or determine plan design details, among other things.

Under the policy announced in January by Covered California’s board, plans are prohibited from applying to sell statewide in 2016 unless they were newly licensed since August 2012 or are Medicaid managed care plans. Plans that didn’t meet those criteria may apply to offer coverage in just five of the state’s 19 regions where fewer than three carriers currently sell plans.

A spokesperson for Covered California says the policy is a good compromise. It benefits insurers like UnitedHealthcare, which may have some limited participation in the California exchange before 2017. It may also help consumers in areas where coverage hasn’t been very competitive.

Benjamin Goldstein, director of public relations at UnitedHealthcare, said in an email, “We look forward to working with state officials to expand plan choices and affordable access to health care for consumers through our participation in Covered California in 2016.”

In 2014, the company, sold plans in just four state marketplaces; this year it added 19 for a total of 23 states.

In the end, concerns by states that they needed to provide an incentive to get insurers to participate in the exchanges may have been overblown, particularly in big markets like California and New York.

“It was a cautionary policy that didn’t turn out to be necessary in most cases,” says Caroline Pearson, a vice president at Avalere Health.

Just because several insurers offer coverage on a state exchange doesn’t mean everyone has many plans to choose from, however. In many regions of the country, especially rural ones, selection continues to be limited to a few carriers. That is the situation in Northern California, where thousands of residents have only one choice on the marketplace.

Nationwide, insurer participation on the exchanges continued to grow in 2015. The number of issuers offering plans grew by 25 percent, topping 300, according to the Department of Health and Human Services.

“More consumer choice often results in lower premiums and innovation in benefit design in terms of finding ways to reduce costs,” says Pearson.

How that shakes out in California remains to be seen. Although UnitedHealthcare’s participation will be limited next year, other insurers may enter the market. For example, Oscar, a new insurer that currently sells on the exchanges in New York and New Jersey, wrote the Covered California board to express interest in selling statewide. As a new insurer, it can sidestep the restrictions placed on UnitedHealthcare.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

“Repeal and replace” has been the rallying cry for Republicans since the Affordable Care Act was signed into law in 2010. But now that most of the law’s provisions have taken effect, some health experts are pitching ways to improve it, rather than eliminate it.

An ideologically diverse panel at the National Health Policy Conference Monday presented somewhat different lists of ideas to make the law work better. But they all agreed on one thing: The Affordable Care Act is too complicated.

“We took the most complex health care system on God’s green earth, and made it 10 times more complex,” said Jon Kingsdale, the first head of the Massachusetts health exchange created under that state’s forerunner to the ACA.

Kingsdale, now a health policy consultant, said many of the problems with implementation of the law over the past year and a half were not due to incompetence on the part of those doing the work, but rather that “implementing the ACA has been an impossible job.”

Several panelists pointed out that the way financial aid for those with moderate incomes is determined is bound to fail because it is based on looking at tax returns that are more than a year old.

“People have to estimate their income in advance,” said Judith Solomon of the liberal Center on Budget and Policy Priorities. “And they have to know who will be in their household,” she said. That means people are expected to be able to predict marriages and divorces, and whether grown children will getting jobs and moving out of their parents’ basements. “We shouldn’t rely on two-year-old tax data as the back-end check” to determine who is eligible for tax credits and how large they should be, Solomon said.

Solomon said one of the changes she would make is to create a hardship exemption for people expected to pay back tax credits that were too big because they underestimated their incomes. Currently those earning more than four times the poverty line (just over $95,000 for a family of four) are required to pay back all tax credits for which they were ineligible, which can be thousands of dollars. Solomon would make the sliding scale more generous, allowing more leeway for middle income taxpayers.

Joseph Antos of the conservative American Enterprise Institute suggested simply repealing the individual mandate requirement once and for all. “Ninety percent of the uninsured won’t pay any penalty anyway because they’re exempt,” he said, referring to the many situations in which taxpayers can avoid the sanction.

Rather, Antos said, the individual mandate could be replaced with a requirement that people who do not maintain continuous insurance coverage could be screened out or made to pay more by insurers if they have pre-existing health conditions.

Sabrina Corlette of Georgetown University said she would eliminate the provision of the law that allows insurers to charge higher premiums to tobacco users. Several states have done that on their own. “It prices out of coverage low- and moderate-income people who could most benefit,” she said. “And there’s no evidence that it encourages people to quit.”

Corlette also said she would urge lawmakers to get rid of the requirement that some insurers offer multi-state plans. Such plans have not worked to boost competition as intended, she said. At the same time, they have “confused consumers – who think the plans offer multi-state networks, which many of them don’t.”

The panelists acknowledged that none of the changes is likely as long as Republicans control Congress and continue to pursue a strategy of repeal and replace.

Kingsdale warned that the coming tax filing season could deepen political opposition, as people who remained uninsured are assessed their first penalties and those who got too much in tax credits are expected to pay the government back.

“It’s going to be a bonanza for H&R Block, and a disaster for people who were supposed to be helped the most by the ACA,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Valentine’s Day is right around the corner and what better to celebrate then with some sweet treats. We dug up this delicious ECG cookie recipe from Erica’s Sweet Tooth.  The recipe consists of chocolate roll-out cookies with some royal icing with some ECG patterns. Chocolate Roll-Out Cookies 3 cups all purpose flour 3/4 tsp salt 1/2 tsp Continue Reading

Valentine’s Day is right around the corner and what better to celebrate then with some sweet treats. We dug up this delicious ECG cookie recipe from Erica’s Sweet Tooth.  The recipe consists of chocolate roll-out cookies with some royal icing with some ECG patterns. Chocolate Roll-Out Cookies 3 cups all purpose flour 3/4 tsp salt 1/2 tsp Continue Reading

Norma and Rodolfo Santaolalla have always worked but have never had health insurance.  When the Arlington, Va., couple tried to apply online for coverage under the health care law, it was just too confusing.

“I didn’t understand about the deductibles and how to choose a plan. It’s difficult. It’s the first time we’ve done that,” said Norma, 46, who cleans houses for a living.  Rodolfo, 47, is a handyman. “That’s why we came here, to ask them to help us.”

“Here” was the Arlington Mill Community Center, where help was available on a recent Saturday as part of a national effort to increase Affordable Care Act enrollment, especially among Latinos.

Hispanics represent about a third of the nation’s uninsured, and for a number of reasons, signing them up has been harder. According to the latest government statistics, as of Jan. 16, two months into the current open enrollment period, just 10 percent of those who had enrolled in the 37 states served by healthcare.gov are Latino. Despite a concerted effort by officials and health law advocates to reach Latinos, that’s up only slightly from 7 percent during the first few months of last year’s enrollment.

Experts caution that those numbers are reported by applicants and there’s no requirement that anyone signing up for coverage on healthcare.gov state their race or ethnicity. Nonetheless, the Department of Health and Human Services and pro-health-law groups have stepped up their efforts through media campaigns and with a greater emphasis on the kind of in-person assistance the Santaolallas and many other Latinos are seeking.

In fact, nearly a third of the ACA’s media budget this year is focused on Hispanic media, tripling the 10 percent spent on reaching Latinos last year, according to HHS Secretary Sylvia M. Burwell.

Providing in-person assistance, however, takes time.  A session can easily run 90 minutes to two hours, and several meetings are often needed to explain how insurance works and what the various options are. Even though applicants may qualify for the law’s tax credits, many will have to still pay a premium each month. And people who have been doing without health insurance might not feel the need to pay for it.

Still, since October 2013, 2.6 million Latinos ages 18 to 64 gained insurance through the health law, according to HHS.  As of last June, the percentage of Latinos without health insurance dropped from 36 percent to 23 percent, with the highest gains in states that adopted the health law’s Medicaid expansion, according to a Commonwealth Fund analysis. That’s important to the success of the overall health law, because uninsured Latinos tend to be young and healthy. They are likely to use fewer medical services and thus will help offset the cost of sicker people in the insurance “risk pool.”

To enroll, though, some Latino applicants have to work through extra paperwork and overcome language barriers.

Joaquin Barahona, 41, is a construction worker. He’s never had health insurance, and when he did go to the doctor, he paid cash.

When he tried to enroll in the health law in late January, at the Legal Services of Northern Virginia in Arlington, he found that the health law’s website couldn’t verify his identify. Now the Centreville resident will have to mail in additional documents, including his employment authorization card.

That same evening, Lusmila Morales, 53, also hopes to obtain ACA coverage. She sent in a paper application last year but never heard back and wanted to try again this year. She brought along her 17-year-old nephew to translate.

The Falls Church resident is applying for health insurance “out of necessity,” said her nephew, Daniel Palacios. She has arthritis but can’t afford the medication. She needs a mammogram and a physical but can’t afford the tests. In addition, her mom has diabetes and she wants to find out how her parents — who are both in their 80s and here legally but without the work history that would qualify them for Medicare –can get coverage under the health law.

But Morales couldn’t complete her application because she forgot her green card, which proves she is a lawful permanent resident of the United States. She would have to come back.

One of the most stubborn obstacles is the widespread fear in the Latino community that those who are eligible for coverage might endanger others in their family who are undocumented. That concern persists even though President Barack Obama and other administration officials have said repeatedly that no information on a health law application will be used for deportation purposes.

“The federal government can proclaim every day, every hour on the hour how immigration information in the exchange is not going to be used for deportation proceedings, but it’s still really scary,” said Alicia Wilson, executive director of La Clinica del Pueblo, a Washington, D.C., health center that provides comprehensive services primarily to the Latino community.

“You don’t want to be the family member that because you signed up for coverage you’re getting your grandmother, your uncle or your parent deported,” said Anthony Wright, executive director of the group Health Access California, a health care consumer group.

Mixed immigration status families also face special challenges when it comes to enrolling in the health law, Wilson said.  Some may be here legally but are not eligible for coverage under federal programs. Some may have children who were born in the U.S. but other family members who are undocumented.  Some may qualify for health insurance through a job while family members qualify for Medicaid or the Children’s Health Insurance Program.

“Each one of those insurance vehicles has a different enrollment process and different eligibility criteria, a different set of documents that you have to demonstrate, a different level of proof of who you are and a different schedule for enrolling and reenrolling,” Wilson said. He added that the identification process can be even more difficult for those who do not have a credit history.

The patchwork of state-based and federally based exchanges can also cause confusion, with some state governments more welcoming than others when it comes to Latino outreach and enrollment efforts.

Just over half of states have expanded their Medicaid programs, with Indiana the latest to make the change. According to HHS, if all states participated in the health law’s Medicaid expansion, 95 percent of uninsured Latinos might qualify for Medicaid, CHIP  or tax credits to help lower the cost of health insurance on the federal and state marketplaces.

In states like Virginia, which has not expanded its Medicaid program, individuals must earn at least $11,670 a year to qualify for subsidies to buy coverage on the exchange. Those who earn less fall into the “coverage gap” because they don’t qualify for their state’s existing Medicaid program and don’t earn enough money to qualify for the health law’s financial assistance.

“It’s heartbreaking to tell them,” said Leni Gonzalez, outreach and education specialist with Enroll Virginia. .

The fact that this year’s enrollment period is  three months shorter than last year’s further complicates efforts to enroll the uninsured.  And those who work with the Latino community say because so many in it have been uninsured for so long, it’s not surprising that it will take longer to increase their enrollment.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Almost 6.5 million consumers qualify for an average tax credit of $268 per month through the Health Insurance Marketplaces

It’s been more than two years since most health plans have been required to cover all Food and Drug Administration-approved methods of contraception without requiring women to pay anything out-of-pocket. But even though an unplanned pregnancy would cost an insurer a lot more than the contraceptives to prevent it, some insurers still try to limit what they cover.

In a recent twist, a reader wrote to Kaiser Health News saying that her daughter’s insurer had moved her generic birth control pill out of the zero copayment tier of her plan’s formulary into a higher tier that requires cost sharing of $19 per month.

That’s not surprising, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. Regulations that allow insurers to use “reasonable medical management techniques” to control costs open the door to excluding some generic pills from free coverage, Sonfield says.

The regulations allow a plan to charge for a brand-name contraceptive, for example, if an equivalent generic is available without charge.

But it doesn’t follow that a plan can charge for most generics as long as it offers some for free, Sonfield says.

“All generics aren’t the same,” he says. “All of the different formulations should be on the zero tier, but that isn’t clear in the current guidelines.”

The health law’s contraceptive coverage requirements are aimed at improving preventive care for women. Most health plans have to comply. Plans with grandfathered status under the law are exempt as are those covering employees of religious institutions and certain privately held companies whose owners have a religious objection to covering contraception for their employees.

This isn’t the only instance in which insurers have tried to sidestep the law’s contraceptive coverage requirements. Some insurers have refused to cover the contraceptive patch or vaginal ring, claiming that those methods use the same hormones as birth control pills. Administration officials said they were separate types of hormonal methods and grouping them together isn’t permitted.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.