After the insurance exchanges set up under the Affordable Care Act first went live in late 2013, Lori Lomas started combing the website of Covered California on a hunt for good deals for her clients. Lomas is an agent at Feather Financial, in the Sierra Nevada mountain town of Quincy, California; she’s been selling health policies in rural communities for more than 20 years.

But in 2013, she noticed a troubling change that surprised her: For many clients, insurance options decreased.

“I just started running quotes for people,” Lomas says, “and began realizing that in [some] zip codes, the only thing that shows up is Anthem.”

In addition to Anthem Blue Cross, Blue Shield of California used to sell policies to individuals in every county in the state, according to the Department of Managed Health Care, one of California’s two teams of health insurance regulators. But by 2014’s open enrollment period, Blue Shield had pulled out of 250 zip codes throughout the state, including four entire counties: Alpine, Monterey, Sutter, and Yuba.

The gaps are particularly felt in the top third of the state, where thousands of residents now have only one choice of insurer if they want to buy a health plan on the exchange.

That’s in contrast, Lomas says, to other spots, like the San Francisco Bay Area, where she’s also been helping clients find policies on the state exchange. “I’d do it for them,” she says, “and, wow, there are six insurance companies or seven insurance companies. I think that was when I first realized how, truly, we were getting the shaft up here.”

Blue Shield of California declined an interview with NPR. But in a written statement, the company reported that it’s not selling in certain areas of California because it could not find enough health providers willing to accept a level of payment that would keep premiums low. According to the statement, the company also is not selling in areas where there is no contracted hospital within 15 miles.

Because of the broad changes in the individual health insurance market under the Affordable Care Act, “there is no accurate apples-to-apples comparison between the individual market in 2013 and the individual market in 2014 and beyond,” Blue Shield said, adding that “coverage areas were designed to meet regulatory guidance and with patient access to care in mind.”

Blue Shield of California is acting within the law, says Shana Alex Charles, director of health insurance studies at UCLA’s Center for Health Policy Research. She says Blue Shield could have offered to pay health care providers more. But, at the same time, she adds, insurance companies can’t be forced to operate at a loss.

“There’s no public charge that says they have to be in those zip codes,” she says. “If they determine that it’s not within their company’s best interests to remain there and sell their product there, then they won’t be there.”

That’s generally allowed under the federal health law — plans don’t have to sell throughout an entire state, for example. Consumer advocates say there is often a lack of doctors in rural areas, and agree that insurers shouldn’t sell plans where there isn’t a good network. But UCLA’s Charles says consumers lose when there are not many insurers to choose from.

“Competition breeds choice,” she says, “and people that are competing against each other, work to keep the consumer as happy as possible, so that the consumer will chose them. Competition in the marketplace is a good thing, in that it does keep companies, in some sense, honest.”

Two other companies — Assurant Health and Moda Health — are selling health policies in Northern California, but not on the state exchange. So if consumers choose to buy those plans, they can’t get the subsidies offered under the federal health law.

Assurant Health says it sells individual policies in every California zip code and covers out-of-state care. Moda Health just started selling individual policies in California for 2015.

This story is part of reporting partnership that includes Capital Public Radio, 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.

Consumers who received too much in federal tax credits when buying insurance on the health law’s marketplaces last year got a reprieve of sorts from the Internal Revenue Service this week. Although they still have to repay some or all of the excess subsidies, the IRS won’t ding them with a late payment penalty if they don’t repay it by the April 15 tax deadline.

“They’re trying to make this work,” says Timothy Jost, a law professor at Washington and Lee University who’s an expert on the health law.

Under the law, people with incomes between 100 and 400 percent of the federal poverty level ($11,670 to $46,680 for an individual in 2014) who did not have insurance through their job could qualify for tax credits to make premiums more affordable. They could elect to have these subsidies paid in advance directly to the insurance company, and many did. A typical tax credit was about $3,000 annually.

The amount people received was based on an estimate of their 2014 income. At tax time, that amount has to be reconciled against consumers’ actual income on IRS Form 8962. If consumers or the marketplace underestimated their 2014 income, they may have received too much in tax credits and have to pay back some or all of it.

How much people have to repay is based on their income and is capped at $2,500. People with incomes over 400 percent of the poverty line have to repay the entire amount, however.

This penalty reprieve only applies to the 2014 tax year. The IRS will allow people to repay what they owe on an installment basis. But be forewarned: Interest will continue to accrue until the balance is paid off.

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.

Medical homes are a simple, compelling idea: Give primary-care doctors resources to reduce preventable medical crises for diabetics, asthmatics and others with chronic illness — reducing hospital visits, improving lives and saving money.

But it’s not so easy in practice.

New reports show that two big experiments run by the health law’s innovation lab, known as the Center for Medicare & Medicaid Innovation, delivered mixed early results in enhancing primary care. The programs reduced expensive hospital visits in some cases but struggled to show net savings after accounting for their cost.

Consultants evaluated the first year’s results for the Comprehensive Primary Care Initiative, a four-year program in Colorado, New Jersey and several other states; and the Multi-Payer Advanced Primary Care Practice Demonstration, a three-year test in eight states including New York and Pennsylvania.

The CPC initiative cut costs by $168 per participating Medicare beneficiary, thanks largely to declines in hospital admissions and emergency visits, compared with results of practices not part of the initiative. Results were “more favorable than might be expected” in the test’s first year, said a report by Mathematica Policy Research.

But that wasn’t enough to cover the extra $240 per patient that HHS paid practices to hire extra nurses, improve electronic records, set up 24-hour call lines and make other adjustments. The goal was to identify high-risk patients, keep them on the right medicines and diets and steer them to lower-cost treatment.

“As a taxpayer — are we really making a difference?” said David Nash, dean of Thomas Jefferson University’s School of Population Health and an authority on improving care quality. “I can’t tell from this report.”

Nor was there a big change in quality-of-care indicators, such as follow-up visits after a hospital discharge and making sure patients got recommended diabetes tests. The reports gave little information on whether the added resources improved patients’ health, saying it was too soon to tell.

But those who believe medical homes, also known as patient-centered medical homes, are one answer to America’s expensive, uncoordinated health system found encouraging spots in the evaluation.

“The numbers don’t take your breath away,” said Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, a consortium of payers and caregivers. “But … the fact that the early results look as good as they do we take to be very good news.”

Almost all practices that signed up were still participating in the $322 million CPC test at the end of the first year. The complex tasks of identifying patients who could benefit from extra management and setting up care plans “proceeded relatively smoothly in the first program year,” Mathematica said.

Other payers including state Medicaid programs and commercial insurers joined Medicare in the CPC experiments to give primary doctors extra resources to coordinate care. Together they generated substantial extra revenue — $70,045 per clinician for a median practice — for about 500 participating primary practices.

“It is especially promising to see savings from reduced emergency department, hospitalization and readmission rates so soon,” the National Committee for Quality Assurance, which certifies medical homes, said in a prepared statement. Getting medical homes to their full potential “will likely require a longer commitment to the principles of coordinated care,” it said.

Another innovation-lab model, the multi-payer primary care demo, or MAPCP, did produce a small savings for Medicare — $4.2 million — after counting extra patient-management fees, according to an evaluation by RTI International.

MAPCP payers reimbursing primary doctors for care management also include state Medicaid programs and numerous insurance companies.

Although private insurers’ results aren’t included in the MAPCP evaluation, the report said some are unhappy with the program. Commercial insurers may be more impatient than government agencies to see care-coordination money for primary doctors pay off with lower overall costs.

“Payers are noticeably frustrated with the lack of data showing either a positive return on investment or an improvement in health outcomes for participants,” said the evaluation. “Multiple payers” have said they intend to quit Pennsylvania’s MAPCP test, it said.

Both MAPCP and the CPC initiative had start-up challenges involving training, communication and data management, the evaluations said.

Patrick Conway, HHS’ top innovation and quality officer, called the results “promising” in a blog post and said the cost reductions in the CPC program “were nearly enough” to cover agency fees paid to doctors for care management.

There has been little information released by HHS on another medical-home test, a three-year, $57 million experiment involving federally qualified health centers that ended last year.

The latest reports follow other research showing mediocre results for medical homes. A widely discussed study last year in the Journal of the American Medical Association found a medical-home pilot in Pennsylvania didn’t cut the overall cost of care.

But many of the medical-home experiments evaluated so far, including the Pennsylvania pilot, MAPCP and CPC, don’t include potent-enough incentives for doctors, say some reform advocates.

Rather than simply giving primary doctors extra funds to manage care, payers need to additionally reward them for cost and quality improvements and possibly penalize them for missing goals, they say. Similar incentives are found in accountable care organizations or bundled-payment arrangements that involve groups of caregivers working under a budget.

“If you change the economic incentives, you will change physicians’ practice behavior,” said Nash.

The CPC program intends to offer “shared savings” of cost efficiencies with primary physicians in its third year.

A medical-home program run by CareFirst BlueCross BlueShield in Maryland and the D.C. region that includes shared savings has more than paid for itself in total cost cutting while improving care, the company says.

After launching the arrangement for privately insured members, CareFirst got a $24 million grant from the HHS innovation lab to include Medicare patients. The company has hired outside evaluators to try to confirm its results, said Nielsen.

But she argues that cost savings aren’t the ultimate measure of medical-home success.

“If you put in incentives to save money you’re going to see practices save money,” she said. “But if all we do is save money and we don’t improve care, we’ll be cutting off our noses to spite our face.”

CPC and MAPCP are among dozens of experiments being run by HHS’ innovation center, which has a 10-year, $10 billion budget.

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

HHS proposes path to improve health technology and transform care

  Over five years after the global financial crisis, jobs are still scarcer than they used to be in the United States – but not everywhere! In true American spirit, for example, thousands of people looking for jobs – or better-paying jobs – have been trekking north and west to “men camps” in rugged states Continue Reading

Nearly half of Americans lacking health insurance during the first year of the health law’s marketplaces appeared to be eligible for government assistance, but two-thirds of them said they found the health plans too expensive or were told they didn’t qualify, according to a survey released Thursday.

Far fewer cited reasons often mentioned in political circles: a philosophical opposition to the 2010 health law or sign-up difficulties cause by the early technical problems experienced by the government’s healthcare.gov enrollment website, according to the Kaiser Family Foundation survey of 10,502 non-elderly adults. (KHN is an editorially independent program of the foundation.)

“Lack of awareness of new coverage options and financial assistance appear to be a major barrier,” the report said.

About 30 million Americans lack health insurance. Some of them are not eligible for financial assistance, either because they are not in the country legally or because their incomes are too high. Others live in a state that has not opted for a health law provision to expand Medicaid, the state-federal health program for the poor, to cover people earning up to 138 percent of the federal poverty level, which is $32,913 for a family of four.

Those people in the so-called “coverage gap” —about 4 million — don’t qualify for their states’ existing Medicaid program and don’t earn enough to qualify for the other financial assistance created in the 2010 health law. (As of this week, 22 states have not expanded their programs.)

The survey found that nearly six out of 10 uninsured people who appeared eligible for coverage through the health law did not attempt to get it last year. Cost was the main reason cited by more than half the people who seemed eligible for coverage but who remained uninsured.

When seemingly eligible people did try to obtain coverage, 37 percent said they were told they were ineligible and another 30 percent found the cost was too much, even with financial assistance. Under the health law, low-income people who earn too much to qualify for Medicaid have to pay between 2 percent and 9.6 percent of their incomes on premiums before the government subsidies start. Many of the plans also carry sizable deductibles and cost sharing.

“While premium subsidies are based on a sliding scale, it appears that many still find the coverage unaffordable,” wrote foundation researchers Rachel Garfield and Katherine Young.

While most people who were interviewed for the poll did not blame red tape in enrolling, six in 10 eligible people reported difficulty with at least one aspect of applying for insurance, including trouble collecting all the required paperwork or submitting an application.

The national survey was conducted between Sept. 2 and Dec. 15 and has  an overall margin of error of  +/- 2 percentage points At the time of the survey, few of the people questioned said they had plans to get coverage for this year.

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