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