Pauline Bartolone, Capital Public Radio, Author at ��ϳԹ�� News

Tougher Vaccine Exemption Bill In Calif. Clears First Hurdle

Pauline Bartolone, Capital Public Radio — Thu, 09 Apr 2015 20:27:13 +0000

A California bill that would allow parents to opt out of mandatory school vaccinations for their children only if they have a medical condition that justifies an exemption was endorsed by a state Senate committee but still has a long, controversial path before becoming law. The bill was introduced in the California Senate in response to a at Disneyland in late December that’s now linked to almost 150 infections.

With several hundred protesters outside the Capitol building in Sacramento Wednesday, the bill sparked a debate about individual rights and responsibilities.

Vaccine opponents, who have been relatively quiet during the measles outbreak, turned out in force. They wore American flags, and one child held a sign that said, “Force my veggies, not vaccines.” The opponents say eliminating California’s current exemption that allows parents to refuse vaccinations for their children based on personal beliefs will threaten their ability to do what’s right for their kids.

“I think that everybody should be able to make their own choice,” said Lisa Cadrain of Los Angeles, who fears vaccines would harm her daughter. “I am afraid that her big beautiful blue eyes will not focus on me anymore, and she won’t be the kid that she is.”

Anti-vaccine protesters gathered inside a hearing room in the Capitol building in Sacramento Wednesday, but the bill that would make it harder to opt out of immunizations passed the state Senate health committee. (Photo by Pauline Bartolone/Capital Public Radio)

Some opponents fear that the vaccinations are linked to an increase in the number of cases of autism in the country, but scientific studies show between vaccines and autism spectrum disorder.

Inside the hearing, parents who support the bill also talked about protecting their kids — from children who aren’t vaccinated. Democratic state is on the Senate Health Committee and said she’s a strong proponent of vaccinations.

“Our individual rights aren’t without limits, and in this particular case, your insistence on your right really could harm my children or my grandchildren,” Wolk said.

Parents also testified in support of the bill, including Ariel Loop, whose baby son Mobius contracted measles in the Disneyland outbreak. Now 7 months old, he was too young to be inoculated when he was exposed to the virus.

“I understand being skeptical and wanting to research and do what’s best for your child,” Loop said. “I had actually looked into the alternate [vaccination] schedules myself. But there’s no science in support of it, and I’ve got to go with science. I don’t know better than all of these doctors.”

Children their first measles, mumps and rubella vaccine between 12 and 15 months of age. When enough of a given population is inoculated protects babies less than a year old and other people who can’t be vaccinated from being exposed to the diseases.

The Senate health committee passed the bill 6 to 2 on Wednesday. That was just the first step – the legislation has many more hearings before it could become law. Meanwhile, , and have also considered legislation to limit families’ rights to opt out of mandatory vaccinations, and all of those efforts have stalled. West Virginia and Mississippi are that allow no exemptions to their vaccine laws for personal beliefs or religion.

This story is part of a reporting partnership that includes , and .

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Insurance Choices Dwindle In Rural California As Blue Shield Pulls Back

Pauline Bartolone, Capital Public Radio — Fri, 30 Jan 2015 10:00:56 +0000

After the insurance exchanges set up under the first went live in late 2013, Lori Lomas started combing the website of on a hunt for good deals for her clients. Lomas is an agent at , in the Sierra Nevada mountain town of Quincy, Calif.; 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.”

Lori Lomas, an insurance agent with Feather Financial in Quincy, California, has noticed that her clients in San Francisco have many more health carrier options than her mountain neighbors. (Photo by Pauline Bartolone/Capital Public Radio).

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 , 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 — and — 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. helps support KHN coverage of California.

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Limited Insurance Choices Frustrate Some Patients In California

Pauline Bartolone, Capital Public Radio — Thu, 15 Jan 2015 21:46:56 +0000

When Dennie Wright went to sign up for Affordable Care Act insurance last year, it wasn’t a hard decision. His insurance agent told him he had only one insurer – Anthem Blue Cross – that he could buy from on the exchange, .

Wright lives in a modest house overlooking a pasture in Indian Valley. It’s a tiny alpine community at the northern end of the Sierra Mountains, close to the border with Nevada. He lives in one of 250 zip codes where Blue Shield of California stopped selling individual insurance policies in 2014.

Dennie Wright and his wife Kathy go over health bills, related to care he got across the state line in Nevada. (Photo by Pauline Bartolone/Capital Public Radio)

“That was new to us, you know, Covered California. Anthem Blue Cross was the insurance carrier. Then of course, three months later I have a heart attack,” says Wright.

More than once, he was flown across the state line to Reno for care. Wright and his wife, Kathy, now have piles of medical bills and insurance paperwork. Anthem Blue Cross covers emergencies when they happen out-of-state but not routine doctor care in another state.

But Wright says traveling to doctors within California is not as safe or as convenient for him as going to Reno.

He continues to see the Nevada doctors who put a defibrillator in his chest and saved his life. Anthem Blue Cross will pay for some of the bills, but the Wrights still don’t know if everything will be covered.

There are other insurance options for Wright, but not through Covered California. Although he didn’t need a subsidy, he was left in the same position as people in his area who do need financial help to buy insurance. Lower income people cannot take their business to a competitor, because the exchange is the only place customers can use federal subsidies to help them buy health insurance. And for those people, Anthem is the only option.

“I mean, you should have some choices, especially if you’re going to have one that’s not going to cover you in the places you choose to go,” Wright says.

Covered California Executive Director offered a different impression of choices in the marketplace last July.

“In every corner of the state, consumers will have at least two plans to choose from, and in most areas, where most of the Californians live, they can choose between five or six plans,” said Lee during an event to announce the marketplace’s 2015 plans and premium rates.

But in in Northern California, there are zip codes where there is only one choice of insurer. There are areas around Monterey and Santa Cruz on California’s Central Coast that also have only one carrier.

Blue Shield of California said it had to stop selling individual plans in areas where it didn’t have a contracted hospital nearby. It said it offered doctors certain rates to keep the premiums low, but not enough doctors accepted those payment rates.

Covered California estimates that statewide, there are 28,896 Covered California customers who have only one choice of insurance carrier, slightly more than 2 percent of the total exchange membership as of November 2014.

Dennie Wright lives in rural Northern California, where many areas have just one insurer selling plans on Covered California. (Photo by Pauline Bartolone/Capital Public Radio)

Lee says now, the exchange is working to increase the range of choices in places where there are none. But he says the situation existed long before the exchange.

“The challenges of northern, rural counties have been there for a long time and are still a challenge that we’re trying to address head-on,” says Lee.

Lee says the exchange is now discussing how to bring more insurer competition to these areas in 2016.

“We aren’t the solution to all the problems that have always been there in terms of challenges in rural communities, and that’s something we’re certainly looking at how to improve access and choice, and we’ll continue doing that,” says Lee.

Covered California should help increase the number of insurers, says consumer advocate Anthony Wright from . And he says policy makers should also lean on insurers and providers to participate in that market.

“Some of this is a combination of putting pressure on the insurers, and some of this is trying to do work to actually increase the number of providers on the ground in these areas, whether through more training, [or] incentives to be in some of these more rural areas,” says Anthony Wright.

Wright, the advocate, says more insurers in the marketplace makes it more likely people can get the care they need.

“At one level, we’re trying to make a functioning market, but it still means that consumers are at the mercy of the market.”

This year, people who want more choice than what Covered California offers must venture into the broader health insurance market if they can afford it.

This story is part of a reporting partnership with , and .

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A Single Insurer Holds Obamacare Fate In Two States

Pauline Bartolone, Capital Public Radio — Mon, 22 Sep 2014 05:04:06 +0000

This story is part of a partnership that includes , and Kaiser Health News. It can be republished for free. (details)

Here’s a health law pop quiz: Which two states have the least successful Obamacare health insurance exchanges?

You may guess a state in the Deep South where political opposition to the law is fierce. Or maybe ? It passed a state law saying consumer advisors funded by the Affordable Care Act aren’t allowed to advise consumers.

In fact, Iowa and South Dakota are the two states where the ACA insurance marketplaces struggled the most. In both, just 11.1 percent of residents eligible for subsidized insurance signed up for it – the lowest rates in all 50 states and the District of Columbia, from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

What happened in Iowa and South Dakota? The answer lies in commerce, not politics. The individual insurance market in both states is dominated by one insurer, . The company chose not to sell on the ACA exchanges in the first year, locking its consumers out from buying subsidized plans from the company. And it is staying out of the Iowa and South Dakota exchanges for Year 2.

So it’s a tough choice for consumers. If they make under 400 percent of poverty, they can get federal subsidies for coverage, but only if they buy on the exchange.

Before last year’s enrollment, Wellmark had 87 percent of the individual market in Iowa and 73 percent of South Dakota’s market.

“It makes the exchange less attractive if a dominant insurer’s policies aren’t available there,” says Larry Levitt, a senior vice president of KFF.

Levitt says the lack of “marketing muscle” from such a big player as Wellmark depressed exchange enrollment in those states in 2014.

“There are a lot of people out there who are eligible for help who aren’t getting it,” he says, adding that enrollment in those two states would probably get a boost if Wellmark joined the exchange.

The insurance company says selling through healthcare.gov could lead to technical problems and data discrepancies in the enrollment process. Wellmark says that could affect consumer subsidies and eligibility.

“How data is transferred between the system, government entities and ultimately, health insurers continues to be problematic,” Wellmark spokeswoman Traci McBee writes in an email. “Because we rely on this information to serve our members, we need to ensure the information we receive is timely, secure and accurate.”

Levitt says data discrepancies do complicate business for insurers, but he doesn’t think that would be the overriding factor for the insurer. “There are certainly many insurance companies that have been able to manage that process so far,” he says.

Wellmark says despite not selling on the exchange in 2014, it sold more ACA-compliant plans through its website and insurance agents than any of their competitors did in the two states.

Wellmark’s Competition in Iowa

Iowa’s federal-facilitated partnership exchange has two state-wide insurers – an Aetna company called , and the nonprofit, consumer-owned .

Cliff Gold, chief operating officer of CoOportunity Health, says its Iowa enrollees are “decidedly older and less healthy” than its policyholders in Nebraska, and that’s partly because Wellmark decided not to join the exchange.

“If one wanted to cleanse their risk pool, there is no better way to do it than to stay off the exchange where presumably lower-income, less healthy people would come on,” says Gold.

Gold says Wellmark’s decision to allow Iowans to renew non-ACA-compliant plans was the other major factor.

“It keeps a lot of people out of the open market,” says Gold. “All of the old plans have medically underwritten people in them, so they’re healthier than average risk pools.”

Medical underwriting was the process that insurers used to exclude people with pre-existing conditions before the Affordable Care Act. Consumers would have to fill out detailed health history forms, and if an insurer didn’t want to take on the risk of someone who had high cholesterol or back pain, it didn’t have to. Insurers can’t do that anymore under the health law, but they can work to keep customers they already have – and have already screened.

CoOportunity Health has proposed a 14.3 percent premium rate increase for 2015, which Gold says, is double what it would have proposed had Wellmark canceled its non-ACA compliant policies and entered the exchange.

Its competitor in the exchange, Coventry Health Care of Iowa, says its decisions are not swayed by what Wellmark does. The company’s president is committed to selling through the exchange in the future. It has proposed an 8.7 percent average premium increase for its plan holders in 2015

Year 2 and Beyond

Iowa’s Insurance Commissioner, Nick Gerhart says he and the governor of Iowa encouraged Wellmark to participate in the exchange, but Wellmark decided not to.

“We really don’t interfere with those types of decisions,” Gerhart says. “[Wellmark] made their decision and we have to respect that.”

The commissioner says his division hasn’t received consumer complaints about Wellmark’s market decisions, and lower income consumers had other plan options.

But Gold says Iowans may be paying more for health coverage in the current marketplace as a result – whether it be people in grandfathered plans who aren’t getting cheaper coverage through the exchange, or CoOportunity Health planholders who will pay a higher rate next year.

KFF’s Larry Levitt says while Wellmark may have the “luxury” of choosing their marketplace this year, eventually, the non-ACA compliant plans will expire, and the exchange’s tax credits will attract more customers.

“It’s only a matter of time until they come in,” he says.

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Calif. Bill Would Protect Estates Of Many Who Received Medicaid

Pauline Bartolone, Capital Public Radio — Thu, 28 Aug 2014 15:49:49 +0000

This story is part of a partnership that includes , and Kaiser Health News. It can be republished for free. (details)

A bill passed by the California legislature this week is putting Gov. Jerry Brown in a delicate position: Sign the measure and support consumer demands for a change in the state’s policy on recovering assets from Medicaid enrollees or keep the current system that generates about $30 million used to provide Medicaid benefits to more residents.

Anne-Louise Vernon from Campbell, Calif. recently enrolled in Medi-Cal, but then found out the state could use proceeds from her home to recover costs of her health care. (Photo by Pauline Bartolone/Capital Public Radio)

The governor typically does not comment on bills until he receives the actual text from the legislature. His Department Of Finance, however, opposes the bill, pointing out that the recovered assets help the state provide services to others.”

The bill that just passed the legislature this week, would prohibit the state from trying to recoup some of the money spent on older Medicaid enrollees for ordinary health coverage by recovering assets after they die.

Federal law requires states to recoup money spent on institutional care, such as nursing homes, by Medicaid, the state-federal health care program for low-income people. But it also allows states to recover costs from people after they die if they received basic medical services through Medicaid at the age of 55 or older.

In California, advocates of the bill say the current law is complicating enrollment in Medi-Cal, the state’s Medicaid program, with some people refusing to sign up, and others terminating enrollment for fear of not being able to pass on their estate. The state has enrolled 2.2 million people into Medi-Cal under the Affordable Care Act.

According to , California is one of 10 states that recovers funds from estates of Medicaid beneficiaries 55 and older for basic health services. The other states are Colorado, Iowa, Massachusetts, Nevada, New Jersey, New York, North Dakota, Ohio and Rhode Island.

Consumer Reports names an additional 11 states, including Washington, where Medicaid beneficiaries “don’t need to worry” because officials have decided not to pursue the asset recovery. Washington state officials had been planning to do asset recovery but backed off after a last winter stirred public complaints.

Anne-Louise Vernon had been looking forward to signing up for health insurance under Covered California. She hoped to save hundreds of dollars a month. But when she called to enroll, she was told her income wasn’t high enough to purchase a subsidized plan.

“It never even occurred to me I might be on Medi-Cal, and I didn’t know anything about it,” said Vernon.

She said she asked whether there were any strings attached.

“And the woman said very cheerfully, “Oh no, no, it’s all free. There’s nothing you have to worry about, this is your lucky day.’” she recounted.

Vernon signed up for Medi-Cal on the phone from her home in Campbell, Calif. Just months later, she said she learned online about a state law that allows California to take assets of people who die if they received health care through Medi-Cal after the age of 55.

“So I called Medi-Cal and asked specifically, ‘Does this mean what I think it means?’” she said.

It means Medi-Cal managers can take part of her estate later for health care costs she’s accruing now. Vernon said she’s panicked and worried. She doesn’t get a monthly bill – so she’s not sure what she’ll be accountable for.

“I feel as though right now, if I could go to do the doctor and I felt I knew where I stood, there are a number of appointments that I’d be making right now,” said Vernon. “But I feel so unsettled about this whole estate recovery thing that I’m afraid to go to the doctor.”

The California law has been on the books for two decades. Elizabeth Landsberg of the said it turns what was intended to be a safety net program into a long-term loan program and undermines the security that families might pass on to the next generation.

“So in most cases it’s modest family homes that we’re talking about, and so the state will most often come back and put a lien on that home, and unfortunately it does force the kids to sell the homes sometimes,” said Landsberg.

Landsberg said the law is unfair under the Affordable Care Act, because other people buying insurance and getting premium subsidies through Covered California aren’t subject to the same rules.

“For the first time people have to have health coverage. So it’s created an inequity where the lowest income people could lose their assets, and other higher income people who are also getting publically-subsidized health coverage have no worries,” said Landsberg.

During the past 20 years, the state of California has recovered almost a billion dollars that paid for long-term care and basic health services through Medi-Cal.

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Fast Track For Primary Care Docs At One Calif. University

Pauline Bartolone, Capital Public Radio — Thu, 07 Aug 2014 12:02:49 +0000

Some doctors in the state of California will soon be able to practice after three years of medical school instead of the traditional four. The American Medical Association is providing seed money for the effort in the form of a $1 million, five-year grant to the University of California at Davis.

UC Davis medical student Ngabo Nzigira interacts with a patient at a Kaiser Permanente clinic in Sacramento. (Andrew Nixon/Capital Public Radio)

Student Ngabo Nzigira is in his sixth week of medical school and he’s already interacting with patients, as he trains under the guidance of a doctor at Kaiser Permanente in Sacramento. (KHN is not affliated with Kaiser Permanente).

In a traditional medical school, Nzigira wouldn’t be in a clinic until his third year. In this accelerated course, students can shave up to $60,000 off their education debt. Still, Nzigira initially had hesitations.

“I thought ‘Oh man, you want me to put the intensity and stress that is medical school in four years, you want me to condense it down to three years? I’m not sure about that,’” Nzigira says. But, after learning more, he became convinced it was a good path for him.

The curriculum cuts out summer vacations, electives and the residency search. It’s designed to get primary care physicians into the field faster, says Dr. Tonya Fancher, director of the program, called Accelerated Competency-based Education in Primary Care, or ACE-PC .

“There’s a huge problem, a huge shortage of primary care physicians,” Fancher says.

UC Davis says more people gaining health insurance coverage under the Affordable Care Act is expected to compound the need for primary care, and one of the goals of the new curriculum is to make family medicine a more appealing and lasting choice for young doctors.

“Students come into medical school, they’re passionate about patients, passionate about primary care, and then that wanes over time,” Fancher says. “Part of it is probably the debt that they accrue in school, and part of it are the models of primary care that they’re traditionally exposed to.”

Texas, Georgia and New York . And both the AMA and the Association of American Medical Colleges as part of the redesign of medical education. The physician groups want students to advance based on their competency, not a set time frame.

UC Davis’s ACE-PC medical students are guaranteed a residency, another training step before facing patient expectations on their own.

Outside the Sacramento health center where Nzigira and other students are getting their first experiences in clinical practice, people were not troubled by the idea of a faster track through medical school. Angela Woodard says even doctors with four years of training may have trouble treating patients.

“So them going to school a shorter time is not going to make it any worse,” Woodard said.

Patient Joe King isn’t too concerned either, “as long as they maintain the same critieria of standards that primary care doctors have to meet,” he said.

This story is part of a reporting partnership that includes Capital Public Radio, NPR and Kaiser Health News.

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Covered California Rates Up Modest 4.2 Percent

Pauline Bartolone, Capital Public Radio — Fri, 01 Aug 2014 09:00:51 +0000

Covered California says health care premiums will go up modestly for most people buying coverage on the state exchange next year by an average of 4.2 percent.

People get information at a Covered California table at Union Station on the health insurance exchange’s opening day (Photo by Anna Gorman/KHN).

“We enrolled a lot of people, they’re healthy, and that’s kept rates down,” Covered California Executive Director Peter Lee said at a press conference on Thursday in Sacramento to announce the rates.

About 1.4 million people purchased insurance on the marketplace in California for 2014, the first year Affordable Care Act insurance was available. California is one of the states that created its own exchange, and it is an “active purchaser” under the law, which means it can negotiate with insurers directly on rates.

The low rate hike is an average, Lee noted: “Not everyone is going to see only a very small increase. Health care is personal. For some, premiums might go up 15 percent, not very many. But for them, they have the ability to shop.”

Lee says the rates were developed over time though rigorous negotiation with insurers. The marketplace barred insurers from changing geographic areas and incorporated children’s dental care in every plan, he said.

Insurers say Covered California’s active role did help keep rates lower. But Charles Bacchi of the California Association of Health Plans says the industry is not expecting medical costs to rise dramatically either.

“It really puts us in a strong position to have good enrollment in year two. Which is really critical to making this a success in California,” Bacchi said.

Consumer advocates are pleased with the proposed rates, which are pending review from California’s insurance regulators.

“Let’s be clear, health insurance is not cheap or easy, there’s a lot more work to do,” said Anthony Wright, executive director of Health Access. “But what an improvement this is from the past. These efforts are making health insurance cheaper and easier than it would have been.”

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Washington And Other States See New Insurers On Exchanges

Pauline Bartolone, Capital Public Radio — Mon, 30 Jun 2014 09:00:23 +0000

This story is part of a partnership that includes , and Kaiser Health News. It can be republished for free. ()

SEATTLE — Washington State’s health insurance exchange is looking to be an attractive marketplace for new health insurance carriers, according to an early analysis of insurer premium rate filings by

Four new insurers have applied to sell individual policies in the state’s exchange next year, making Washington among the states with the highest number of new exchange entrants of the 12 states where preliminary 2015 rates have been filed, according to McKinsey. If insurance regulators approve the new carriers, Washington will have 12 insurers on the exchange in 2015, up from eight participating this year.

Washington’s not the only state attracting new health insurance business. Michigan also has four new exchange applicants, and five new carriers have applied in Indiana, the state so far with the highest number of new insurance carriers showing interest, according to the of state insurance department rate filings that McKinsey is doing.

“[There’s] definitely an increase in the competition that will be available in the carrier options to consumers,” said .

UnitedHealthcare of Washington, Health Alliance Northwest Health Plan, and Columbia United Providers are among the new insurance exchange applicants, according to Washington State’s Office of the Insurance Commissioner.

Hutchins Coe said McKinsey hasn’t drawn conclusions about what brought new carrier interest to the state. But officials said the interest shows their exchange is working.

“The first year went fairly well for us,” said Michael Marchand, a spokesman for the Washington Health Benefit Exchange. Marchand says 2014‘s enrollment of 164,062 private plan holders was “smooth,” and that the exchange’s marketing has been successful.

“There’s a brand identity to it, and I think that’s something that’s attractive to any carrier,” says Marchand.

More insurers in Washington’s exchange could bring more choice to certain areas of the state and enable consumers to find a plan that’s a better fit for them, Marchand said.

One of the new exchange applicants, Illinois-based Health Alliance, says it’s applying to participate in Washington Healthplanfinder not for the private plan customers, but because it wants to expand its Medicaid managed care business. The Washington agency that oversees Medicaid plans says it encourages managed care plans to also sell coverage through the exchange.

“State budgets around Medicaid are growing and are creating financial difficulties for a lot of states,” says Jeff Ingrum, CEO of Health Alliance, based in Urbana-Champaign, IL. The insurer was founded by the Carle Clinic Association, and now has business in Nebraska, Iowa and Washington. Ingrum says the company is well suited to help payers and health systems transition away from the fee-for-service reimbursement model.

“We see [Medicaid] as a potential for growth because states are looking to manage care to help them keep the costs under control,“ Ingrum says.

Health Alliance says it will only be offering exchange products in one region of the state, where they have been writing Medicare Advantage plans since the beginning of 2014.

As for premium prices on Washington’s exchange next year, McKinsey & Company says some customers may see an increase next year. But 59 percent of subsidy-eligible people buying the lowest price silver plan on the exchange will see a rate decrease. Across the 12 states evaluated, about 22 percent of those consumers will see a premium decrease.

The new carrier participation, and their rates, are all contingent upon approval from insurance regulators. Washington’s exchange expects to have final carriers and rate information by late August.

Correction: An earlier version of this story said Medicaid plans in Washington are required to sell insurance on the exchange; they are encouraged to do so, but not required.

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Patients Often Win If They Appeal A Denied Health Claim

Pauline Bartolone, Capital Public Radio — Mon, 14 Apr 2014 15:21:04 +0000

This KHN story was produced in collaboration with

SACRAMENTO, Calif. — Federal rules ensure that none of the millions of people who signed up for Obamacare can be denied insurance — but there is no guarantee that all health services will be covered.

To help make sure a patient’s claims aren’t improperly denied, the Affordable Care Act allowing appeals to the insurer and, if necessary, to a third-party reviewer.

For Tony Simek, a software engineer in El Mirage, Ariz., appealing was the only way he was able to get additional treatment for sleep apnea. Though mild for many people, the condition had become life-threatening for Simek, who couldn’t get enough sleep.

“I had actually gotten to a place where I had fallen asleep while driving a vehicle,” Simek says. “That’s something that would normally have never ever happened to me.”

Simek’s doctor recommended he go to a lab to undergo another sleep study test to see if his night-time breathing machine needed adjustment. But his insurance company denied the test.

“I was rather surprised,” Simek says, “so I reached out to my doctor to find out why. My doctor had been told [by the insurance company] that it was ‘not medically necessary’ in their judgment of my health condition.”

Simek spent hours on the phone with the health plan, trying to get approval for the test. The insurance company responded with four denial letters. Simek has job-based health insurance through a California employer, so he filed an appeal with the California Department of Insurance.

“I have never had a problem with health insurance prior to this,” Simek says.

in Sacramento multiyear data from California and found that about half the time a patient appeals a denied health claim to the state’s regulators, the patient wins.

A sampling data from a handful of states before the health law took effect found that patients were successful 39 to 59 percent of the time when they appealed directly to the insurer. When appealing to a third party (such as the state insurance commissioner), patients also were often successful in getting the service in question – winning as many as 54 percent of such decisions in Maryland, for example.

“It’s often very worthwhile for a consumer to appeal,” says , who directs the private insurance program at Families USA, a nonprofit that supports the health law. “It’s a really important protection for people.”

Until a few years ago, Fish-Parcham says, the rules regarding such appeals varied by state and employer.

“Insurers often get it wrong the first time,” she says. “So if you’ve been denied a health care service, it might be because the plan didn’t understand why that service was needed and why it fit their guidelines.” Many consumers, she adds, are not exercising their appeal rights as much as they should.

Administrative errors are the source of many denials, says , a senior health policy faculty member at George Mason University.

“It can be an error on the health plan side,” he says. “Maybe they put somebody in the system wrong and they don’t know that [he or she is] eligible yet. Or a data entry error occurs, and the computer says, ‘Oh, we don’t pay for this service on that diagnosis,’ — that type of thing.”

Other denials, like Simek’s sleep test, are based on judgments of medical necessity. Insurers may consider a treatment experimental. Kongstvedt, a former executive in the managed health care industry, says such decisions require human discernment.

“The computer doesn’t — usually doesn’t — make that decision,” he says. “It simply flags it and then it gets reviewed — first by a nurse reviewer who then presents it, usually, to a medical director.”

Insurers say medical studies support their decisions.

“The more evidence that’s available about the appropriateness and effectiveness of a particular drug or treatment or technology — that’s what drives what’s covered,” says Robert Zirkelbach, spokesman for America’s Health Insurance Plans, an insurance industry trade group.

Zirkelbach says only about 3 percent of claims are denied. And, he adds, insurers support the strengthening of the appeals process under the Affordable Care Act.

“Health plans are committed to getting it right,” he says.

Appealing a denial was the right thing for Tony Simek. Ultimately, a California regulator overruled his insurer, and Simek got the test.

“I have been sleeping well ever since,” he says.

This story is part of a reporting partnership that includes , and Kaiser Health News.

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Health Workers’ Union Pushes Hospital Cost Control In California

Pauline Bartolone, Capital Public Radio — Wed, 05 Mar 2014 05:01:00 +0000

SACRAMENTO – A California health care workers’ union is collecting signatures to get two measures onto the ballot that it says would lower health care costs.

United Health Care Workers West, or SEIU-UHW, wants to cap what hospitals can charge to 25 percent above the actual cost of services. SEIU-UHW says on average, hospitals charge 320 percent above the cost of care.

The union also wants to cap CEO salaries at nonprofit hospitals to $450,000 a year.

“These two [initiatives] in combination will do more to bring down the cost of health care than anything else that’s been considered recently in California or anyplace else,” says SEIU-UHW President Dave Regan.

Members of the Service Employees International Union (SEIU) Local 1021 protest in front of Twitter Inc. headquarters in San Francisco at an affordable health care rally in February (Photo by David Paul Morris/Bloomberg via Getty Images).

He says hospitals are the biggest driver in health care spending.

“There’s a culture of pricing, and a culture of doing business that has just lent itself to driving the cost of care up,” says Regan.

But the California Hospital Association (CHA) says nobody actually pays the full amount that hospitals charge. Instead, insurers pay negotiated rates that vary, Medicare pays a price it sets, and Medi-Cal, as Medicaid is known in California, pays yet another rate. Medi-Cal’s rates are among the lowest rates paid to hospitals in the country.

The hospital association says capping charges would cut $12 billion annually from hospital revenues statewide, forcing cutbacks in staff and services.

“These are very dangerous and deceptive initiatives because they don’t get at the underlying causes of why health care costs rise,” says Jan Emerson Shea, vice president of external affairs at CHA.

She adds that the CEO salaries are justified.

“Running a hospital is the most complex business to run today…Essentially you’re running a city,” she says.

California-based health systems Kaiser Permanente and Dignity Health had two of the highest CEO salaries for nonprofit systems in the country, according to an analysis of tax files by Kaiser Health News. (KHN is not affiliated with Kaiser Permanente.) Former Kaiser Permanente CEO George Halvorson made $7.9 million in 2011. Dignity Health CEO Lloyd Dean made $5.1 million in 2010.

Health economist Dylan Roby at UCLA’s Center for Health Policy Research says the ballot proposals are an indirect way of putting price pressure on hospitals.

Roby says what hospitals charge is not the same as what they get paid. That’s partly because private insurers typically negotiate prices down, which means hospitals usually bring in less than 25 percent above the actual cost of care.

“Putting 25 percent [as] the upward bound is somewhat meaningless,” says Roby. “[That threshold is] still a little bit higher than a typical insurer is paying. It’s higher than Medicare is paying, and it’s certainly higher than Medi-Cal is paying.”

But Roby says capping what hospitals charge would protect uninsured and underinsured people from being overcharged for a service. He also says it could help bring more transparency to health care pricing.

When it comes to capping CEO pay at nonprofit hospitals, Roby says such a law would not necessarily save the health care system money.

He says the national average for the CEO salary at a nonprofit hospital is about $600,000 a year. But if CEO pay is cut, hospitals might spend the savings to shift the work load somewhere else.

“The CEO’s not going to say, ‘Well I’m going to continue doing the same exact amount of work for that $450,000,’” says Roby.

Seventeen Democratic California lawmakers have endorsed the ballot measures. The union expects to finish gathering the necessary 565,000 signatures by the middle of April, to meet a deadline to get the proposals on the November ballot.

This story is part of a reporting partnership that includes , and Kaiser Health News. Blue Shield of California Foundation helps support KHN coverage of California.

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