A group of Wall Street analysts predicted Friday that enrollment in health law insurance plans will be higher than the 9 million projected by the Obama administration because insurers are aggressively courting new customers and more small businesses are likely to send workers to the online exchanges in 2015.

Health sector analyst Carl McDonald of Citi Investment Research said he expects about 11 million people to enroll in individual health plans, based on his firm’s survey of clients in October.

“I’m more optimistic,” McDonald said at the 19th annual “Wall Street Comes to Washington” roundtable, sponsored by the Jayne Koskinas Ted Giovanis Foundation for Health and Policy.

More aggressive outreach by insurers and fewer glitches with the online marketplaces will create a “robust 2015,” agreed Ralph Giacobbe, an analyst at Credit Suisse.

But the analysts noted continuing challenges for insurers, from improving what McDonald called a “pretty poor” first-year effort to inform consumers about which doctors and hospitals are in their networks, to controlling spending as high-priced drugs hit the market.

Insurers are also projecting that this year’s enrollees will be younger and healthier than those who signed on in 2014, when the average age was 41, McDonald said.  That was a problem for insurers who based this year’s premium rates on the expectation they would see younger customers, he said.

The analysts agreed that enrollment would be unaffected by the Supreme Court’s decision to hear a lawsuit challenging the provision of subsidies to residents of states that are relying on the federal exchange. Only 14 states ran their own marketplaces this year.

Nick Leventis, an independent health care sector analyst, said concerns about the case are overblown because the government “could easily give some type of waiver to the states to shift from the federal to the state exchange.”

But McDonald was less sanguine, although he said insurers are already discussing workaround ideas with state insurance officials.  Still, he said that not all of the states would act if the court invalidated the subsidies.  Some governors and state legislators would be unlikely “to do anything to help reform,” he said.

Giacobbe predicted that governors and lawmakers in such states would be under great pressure, not only from the hospital and insurance industries, but also from consumers, to find ways to keep the subsidies flowing.

It’s hard to take away a program once people are using it, he said, predicting, “This is not going to derail the ACA.”

Should subsidies be cut off by a ruling from the Supreme Court, the marketplaces where the subsidies were no longer available would essentially cease to function since all but the sickest customers would likely drop coverage, the analysts 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.

2015 joint AaNA Board of Directors and Labor Council seats Term Jan. 2015- Dec. 2016

Just days before the health law’s marketplaces reopened, nearly a quarter of uninsured said they expect to remain without coverage because they did not think it would be affordable, according to a poll released Friday.

That was by far the most common reason given by people who expect to stay uninsured next year, according to the latest tracking poll by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Forty-one percent of individuals without health insurance said they expected they would remain uninsured, while about half said they plan to get coverage in the coming months.

The law includes subsidies to reduce premium costs and cost-sharing assistance for those who qualify, although it was not clear if the uninsured knew that.

Despite heavy news coverage and marketing from insurers about the re-opening of enrollment, about 9 in 10 of the uninsured said they didn’t know when the health law’s open enrollment period began (Nov. 15). That was similar to the findings in last month’s Kaiser poll.

More than 8 in 10 of the uninsured said it is at least somewhat important to them to have health insurance, with 62 percent saying it’s very important. Seven in 10 said health insurance is something they need.

Other findings in Kaiser’s November poll include that most of the public reports their families have not been directly impacted by the health law, with more (24 percent) saying they have been hurt than helped (16 percent).

Forty-six percent of those surveyed hold an unfavorable view of the law and 37 percent view it favorably, a slight change from last month’s survey, where 43 percent of those questioned held an unfavorable view of the law and 36 percent a favorable one.

With the midterm elections giving Republicans control of the Senate and increasing the party’s majority in the House of Representatives, Americans were divided about whether the debate between the two parties over the health law would increase, the poll found. Forty-seven percent expected it, while 42 percent predicted it would stay at about the same level.

There’s a variety of opinion about what Congress should do next with the health law. Twenty-nine percent of the public supports the law’s repeal, 17 percent favors scaling the law back, 20 percent wants the law to move ahead as is, while 22 percent chooses expanding the law.

Republicans are more likely to favor repeal (52 percent) or scaling it back (24 percent), while Democrats are more likely to favor moving ahead with the law in its current form (40 percent) or expansion (34 percent). Independents fall in between, but lean toward repeal or scaling back.

The poll was conducted from Nov. 5 through 13, using a telephone sample of 1,501 adults. The margin of error is +/- 3 percentage points for the full sample and +/- 9 percentage points for the uninsured.

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

Dean Schillinger is a primary-care physician at San Francisco General Hospital. He first came to the city in 1990 at the peak of the AIDS epidemic. “At that point, one out of every two patients we admitted was a young man dying of AIDS,” he says.

Today, that same ward is filled with diabetes patients.

“I feel like we are with diabetes where we were in 1990 with the AIDS epidemic,” Schillinger said. “The ward is overwhelmed with diabetes — they’re getting their limbs amputated, they’re on dialysis. And these are young people. They are suffering the ravages of diabetes in the prime of their lives. We’re at the point where we need a public health response to it.”

Schillinger and other researchers at the University of California at San Francisco are setting up a project called Sugar Science, to spell out the health dangers of too much added sugar in our diets. The project aimed at consumers includes a user-friendly Web site and materials such as television commercials that public health officials can use for outreach. Health departments from San Francisco to New York City have agreed to participate.

There’s a reason the word “science” is part of the project’s name. The UCSF team distilled 8,000 studies and research papers and found strong evidence that the consumption of too much added sugar overloads vital organs and contributes not just to Type 2 diabetes but also to heart disease and liver disease.

Although there are no federal guidelines that recommend a limit on sugar consumption, the American Heart Association (AHA) urges cutting back dramatically. The average American consumes the equivalent of 19.5 teaspoons a day in added sugar. The AHA says men should reduce that to no more than nine teaspoons and women should consume less than six teaspoons. The World Health Organization (WHO) is proposing similar limits.

Laura Schmidt, a professor of health policy at UCSF’s medical school, is also part of the Sugar Science team. “Right now, the reality is that our consumption of sugar is out of whack,” she says, “and until we bring things back into balance, we need to focus on helping people understand what the consequences are.”

Schmidt is quick to point to the food environment as a driver of the increase in obesity over the past generation. “The only major change in the diet that explains the obesity epidemic is this steep rise in added sugar consumption that started in the 1980s,” she says.

That sugar isn’t just making us fat, she says, “it’s making us sick.”

The Sugar Association, however, says that some of the information presented by Sugar Science conflicts with a 2002 Institute of Medicine report and conclusions by the European Food Safety Authority in 2010. Andy Briscoe, president and chief executive of the association, notes that federal data shows that the per capita consumption of natural sugar, which comes from sugar cane or sugar beets and is called sucrose, is 34 percent lower than it was 40 years ago. He adds that sugar critics often lump together the consumption of sucrose and high-fructose corn syrup, which is used extensively in sugar-sweetened beverages, such as soda, sports drinks and energy drinks.

“Natural sugar in moderation can be part of a balanced, healthful diet and lifestyle — and has been safely used by our grandmothers and their grandmothers for decades,” he said in a statement.

John Bode, president and chief executive of the Corn Refiners Association, said in a statement, “The focus on any one particular food or ingredient is a disservice to consumers and distracts from the broader need for balanced diet and exercise.”

Although Schmidt says the Sugar Science team, which includes researchers from the University of California at Davis and Emory University, is not “anti-sugar,” she says that it looked at all the evidence, including the reports cited by the Sugar Alliance. Schmidt says more recent reports from the AHA and the WHO reflect the newest health findings. Sugar Science is funded by a grant from the Laura and John Arnold Foundation, a Houston-based philanthropic organization.

Schillinger concurs, saying Sugar Science has no political agenda and wants to generate “credible science, what we understand and don’t understand about sugar.”

It’s about knowing how much sugar is too much, researchers say.

But knowing how much sugar you’re eating can be challenging. Some key facts on the Sugar Science Web site are these:

– Added sugar is hiding in 74 percent of packaged foods, including some products that are considered healthful and may not be viewed as sweet, such as yogurt, pasta sauce and salad dressing. (Proposed changes to nutrition labels would include a separate line for added sugars.)

– Overloading on fructose, a common type of added sugar, can damage your liver — just like too much alcohol.

– One 12-ounce can of soda a day can increase your risk of dying of heart disease by one-third. That same soda can have as many as nine teaspoons of sugar. (Sugar is listed by grams on nutrition labels; four grams of sugar equals one teaspoon.)

The site also includes tips for cutting down on sugar. The easiest way to do so, the researchers say, is to stop drinking sugar-sweetened beverages.

More than one-third of added sugar in the American diet comes from sugary drinks. The Sugar Science researchers also recommend reading nutrition labels. Although there are 61 names for sugar on ingredient labels, the UCSF team says that “if the chemical name has an ‘ose’ at the end — as in dextrose, fructose, lactose — it’s likely to be added sugar.”

This article is part of a partnership that includes KQED, NPR and Kaiser Health News.

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

Many consumers who signed up for health coverage through online insurance exchanges discovered their doctors were not in their plans’ networks.

While narrow networks aren’t new, they have emerged as one of insurers’ major levers for keeping costs down under the Affordable Care Act. Consumers have been attracted by lower premiums, but are often distressed at the restrictions. Lawsuits in California allege that some insurers duped customers into thinking their networks were larger by posting inaccurate provider lists.

But such plans can be designed right, says Gary Cohen, a former Obama administration official who helped oversee the launch of the federal health website. As examples, he cites integrated systems, such as Kaiser Permanente, and also accountable care organizations which encourage coordination of patient care while providing incentives to reduce costs.

Cohen, who now runs his own consulting firm, was deputy administrator and director of the Center for Consumer Information and Insurance Oversight in the Centers for Medicare & Medicaid Services until March. He sat down recently with Kaiser Health News’ Julie Appleby. An edited version of their conversation follows:

Q: You’ve written recently that narrow network policies can be done correctly by focusing on quality as well as cost. What are the pros and cons of smaller networks?

COHEN: One [important aspect] is access. Everyone has to receive care for the services covered by their policies. We also want people to have choice — to be able to choose which doctors and hospitals they go to and have the highest quality of care. We also want to try to control costs. Those various objectives may run into conflict. So there has been a lot written, a lot of complaints about people who couldn’t go to the doctor they used to go to, or who couldn’t find a particular physician close to where they live. This has gotten a lot of attention and caused regulators to want to look at whether further regulation of networks is appropriate. [But] not all narrow networks are the same.

Q: Critics say the new marketplace plans rely mainly on insurers choosing network providers based on price. Do you share that concern?

COHEN: I do share that concern. We need to encourage types of networks like accountable care organizations where providers and hospitals and insurance companies are sharing in [financial] risk and working together in managing care to make sure higher quality [is delivered] and costs are controlled. That kind of network is fundamentally different than a network simply based on what the cost of reimbursement is from the insurance company.

The challenge to the insurance industry is greater transparency. People have got to know when they buy a plan what it is they are getting. So far it has proven very difficult for insurance companies and for some of the marketplaces that have tried to put up provider directories to provide accurate, up-to-date information on just who is in the network and who is taking new patients.

Q: What is being done in the federal and state marketplaces to make sure information on particular doctors and hospitals is available?

COHEN: Both the federal government and a number of states now are making a requirement that these directories be provided and updated on regular basis. The question is, what kind of enforcement will we see? If insurers can’t provide up-to-date information, that risks the whole concept of these narrow networks.

Q: In some states, all or most of the plans being sold on the marketplaces are narrow networks. Many don’t offer out-of-network coverage at all. Should regulators require insurers to offer both broad and narrow network plans?

COHEN: I think the market really is providing that choice. [Consultant] McKinsey & Company did a study showing that 90 percent of people have the choice of a broad network. Generally speaking, a lot of the BlueCross BlueShield plans do offer both a broad and a narrow network.

Q: How do insurers select these networks? Should they disclose that?

COHEN: If a network is designed not just to be lower cost, but is designed to be higher quality, more efficient and therefore lower cost, then it’s important people understand that. And the criteria used to select the physicians and hospitals in the network [should] be made known to the public. If I am convinced that one network I’m being offered has higher quality of care, I might choose that network even if it meant I had to travel a little further to see doctor or wait a little longer for an appointment.

Q: Are any insurers doing that yet?

COHEN: A lot of these new types of organizations are just beginning to happen now in the wake of the ACA and in wake of what Medicare is doing with its ACO program. We don’t have a lot of data yet but as time goes by, we will. We need to rethink our measures of what is an adequate network. Typically we look at the time it takes to get to a doctor’s office or to get an appointment, but with increased use of telemedicine where people will see physicians in video calls or by email, some of those measures may be less important. Not unimportant, but less important.

Q: You warn that regulators could get in the way of creating good narrow networks. How?

COHEN: We have to recognize we have a physician shortage in this country that has nothing to do with the ACA or with what networks insurers create. When you listen to regulators from very rural states, what they will say is, “We don’t have enough doctors, regardless of what the network looks like.” We need to be sensitive to local conditions. Travel time to see a doctor is different in a densely populated urban area than in a rural area. We should look at what is the quality of care being provided in this network and is it serving the population well, rather than just looking at time and distance.

Q: What about data on how many patients had to go out of network for coverage? Are any insurers reporting that?

COHEN: That data is required and will be reported. We are still in the first year of people going to see their doctors with policies they purchased through the marketplaces. We will learn a lot more as we go forward as to what their experience really has been that will help inform what steps industry should take and regulators should take to make sure people are getting access to the care they need.
Q: This time last year, open enrollment had just begun through the state and federal marketplaces. The rollout for many was disastrous, marred by a myriad of technical problems. What’s different this year?

COHEN: Ironically, one of the biggest concerns going into open enrollment [last time was] polls showing people didn’t even know what the program was about. As a result of all the publicity we got because of the problems, we certainly cured that in a hurry. Everyone in the country was aware of healthcare.gov as a result of what happened.

We have broader knowledge of the ACA and the marketplaces in general [this time]. On other hand, folks who didn’t sign up the first time around may be a little harder to reach than the ones who did. One thing that emerged from the first open enrollment [is] it does matter if people have contact with someone in their community they trust to get information, as opposed to just getting it over the internet, or from radio or TV.

Q: What’s the biggest challenge facing the Obama administration concerning the health law in the next year?

COHEN: The challenge facing all of us, including the Obama administration, is really to make the case for what has been called the triple aim: better [health care] access for more people, better customer experiences and better outcomes at lower cost.
A lot of interesting things are being done, some prompted by the ACA, some prompted just by changes in the health market. We need to look at what works and what doesn’t [and] encourage what works. That’s why this whole question of narrow networks is critical. We need to see if we can make the case that smarter networks result in better outcomes, more efficient care, less overtreatment and lower costs.

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