Dan Diamond, California Healthline, Author at �鶹Ů�� Health News

Oscar Wants To ‘Revolutionize’ Health Care. But Will It Even Survive Covered California?

Dan Diamond, California Healthline — Mon, 10 Aug 2015 16:11:47 +0000

Covered California made it official last week: After two years in the wilderness, UnitedHealthcare will return to the state’s individual insurance market and begin selling health plans on California’s exchange later this year.

Not much can overshadow news about the nation’s largest insurer — except maybe a story about one of the smallest.

Hi, Oscar.

That’s the clever framing that founders of the buzzed-about startup health insurer ��and advertisements. And the company will soon introduce itself to Californians; Covered California also confirmed that Oscar will start selling plans in Los Angeles and Orange County.

But can Oscar’s services live up to its press clippings? And is the New York-based company ready to compete in a brand-new market, more than 3,000 miles away from its home base?

Why Covered California Let Oscar In

California’s exchange is infamous for its selectivity; unlike nearly every other exchange across the country, the number of plans participating in Covered California last year.

“Choice is important,” Covered California’s director Peter Lee said at a January 2015 board meeting, not long after that the exchange had turned away Moda Health, a popular Oregon-based insurer. “But adding more plans that are either not by price, network, or design substantially different is not necessarily an advantage for consumers.”

Yet Oscar’s entrance into the California market seems almost preordained.

CEO Mario Schlosser and his co-founders have a Silicon Valley pedigree — they have youth, Harvard degrees, and experience with firms like Instagram, Microsoft and Vostu. They’re backed by venture capitalists like Peter Thiel.

They’ve got an Internet company-like valuation: After officially launching in New York two years ago, Oscar is at $1.5 billion — despite having just 40,000 members.

(In comparison, UnitedHealthcare is valued at $115 billion and has about 45 million members. A smaller rival insurer, Health Net, is valued at about $5 billion — and has more than 3 million members.)

And Oscar’s staff evangelizes about its product in a way that’s familiar to anyone who’s spent much time in the San Francisco startup scene.

“Health care is broken; we’re trying to fix it,” Oscar’s reads. “Backed by a renowned set of investors and advisors, we’ve set out to revolutionize health care.”

“Oscar was created by people with a background in technology,” co-founder to the Covered California board in January 2015, as the company began to lay the groundwork for its arrival. “Oscar’s founders were frustrated with the available health insurance choices and thought there was a better way to provide health insurance coverage.”

Oscar has tried to distinguish itself through Web savvy, like its personalized search engine for members, and mobile-friendly services.

And that tech-heavy message resonated with Covered California, spokesperson Lizelda Lopez told California Healthline.

“While our examination of Oscar’s experience in New York gave us confidence they understood the complexities of operating in a state-based Exchange environment, and could be successful in California, that was not our principal reason for adding them,” Lopez said via email.

“The level of innovation they bring to the marketplace is what we found most compelling.”

Oscar’s Hype vs. Oscar’s Reviews

One of the state’s leading consumer advocates is hailing the move to add Oscar.

“I think it’s positive that [Oscar] is coming into the California market,” California Insurance Commissioner Dave Jones told California Healthline. He’s been critical of Covered California’s selectivity in the past. “The more insurers the better,” Jones added.

But as Oscar starts to introduce itself to Californians, there’s still a big question about the company: How much is skillful marketing, and how much is actual breakthrough innovation?

For instance, CEO Schlosser touted Oscar’s “unique set of features for its customers, including 24/7 telemedicine and incentivized health and fitness goals.”

It’s worth noting that Anthem, already one of the major players on the exchange, 24/7 telemedicine service. And many insurers are debuting or have already launched their own wellness services, too.

Schlosser also said that Oscar’s simple message and ease-of-use will set it apart. “As in New York and New Jersey, the Oscar approach suits the needs of Californians looking for accessible, transparent and human health care in the current consumer health care landscape,” he told California Healthline.

But more than a few New York-area customers have complained that Oscar’s smooth packaging hasn’t always delivered a similarly smooth experience with the health care system. Some customers have warned that they were misinformed about Oscar’s provider networks and copays.

“Agree with the rest here,” a user named on Yelp. “Slick on the surface. Bad coverage for the money.”

Another disgruntled Oscar to the much-read blog “Valleywag” last year, sharing personal communications with the company and even posting pictures of the bill.

“In the emerging health and wellness markets, startups like Oscar intimately disrupt and destroy their customer’s lives through incorrect datasets where an A/B testing mentality results in exorbitant fees, angry hospital administrators and patients with no recourse except to bankrupt themselves paying bills they didn’t expect,” the customer wrote.

Can Oscar Succeed in California?

It’s tough to know how much stock to place in Oscar’s grouches. Despite all the disgruntled online reviews, Oscar’s mediocre 2.5 stars on Yelp in New York are downright luxurious compared to the one star for United Healthcare and other insurance companies.

But experts agree that Oscar will face at least one major challenge in California: How can the company compete in a state that’s already dominated by a handful of health insurers?

“We still have a problem with the degree of concentration that the top four insurers have,” Jones told California Healthline, pointing out that Anthem, Blue Shield, Health Net and Kaiser Permanente, are collectively responsible for 94% of all enrollment on Covered California. As California Healthline previously reported, small health plans have attracting customers on the state’s exchange.

Oscar’s advertising strategy will be interesting to watch. The company gained awareness in New York City thanks to ubiquitous, clever ; Southern Californians aren’t known for their love of public transportation.

(Oscar declined to comment on the company’s goals for the next enrollment period.)

And in the growing retail insurance market, where customers often shop by price, Oscar is not slated to have the — or the biggest, most recognizable name. That could scare away some would-be customers, several experts told California Healthline.

“I agree that Oscar’s price may be prohibitive for many people, but they may have decided to compete on network and choice,” said Dylan Roby of UCLA’s Center for Health Policy Research.

He pointed out that Oscar does have one ace in their hole in Southern California: They’re including UCLA Medical Center in their network. The pricey hospital had been of nearly every other Covered California plan.

“They are an EPO plan,” Roby added, “so perhaps they will try to draw the smaller group of people who want UCLA doctors and no gatekeeper as would occur in an HMO product.”

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Most Insurance Exchanges Just Got Bigger. Covered California Is Getting Smaller.

Dan Diamond, California Healthline — Thu, 21 Aug 2014 05:01:00 +0000

Kynect. Maryland Health Connection. The Washington Health Benefit Exchange.

Every one of those state insurance exchanges added new carriers in preparation for Obamacare’s second open enrollment period this fall.

Covered California did not.

Instead, the Golden State took a different approach: Its exchange is getting smaller.

Dwindling Participation. Diminished Returns?

When Covered California unveiled its initial slate of 13 carriers last year, their low rates��— but so did their mix.

While Covered California couldn’t boast Aetna or UnitedHealthcare, which instead elected to leave the state’s individual market, four major insurers were on board: Anthem Blue Cross, Blue Shield of California, Health Net and Kaiser Permanente.

And the exchange also had drawn in��, like Ventura County Health Plan, which were going to compete for share on the individual market for the first time.

“For me, the story is [these] new participants,” Micah Weinberg of the Bay Area Council toldCalifornia Healthline��last summer. “Who exactly they are, and how they are being offered in these marketplaces, is worth watching.”

But Ventura County quietly��. A second small carrier, Alameda Alliance, was��. And earlier this summer, a third carrier — Contra Costa Health Plan — was forced to��, citing state rules around offering on- and off-exchange plans.

That’s left Covered California with 10 plans — which would be a bounty for nearly any other state. Not so across California’s vast, 164,000-square-mile expanse, where many regions are essentially dependent on a lone insurer.

As “Road to Reform” tracked throughout last year’s enrollment period, the seven small insurers ended up splitting just a fraction of Covered California’s customers, while the “big four” insurers were��of all sign-ups across the state.

“It’s not just an issue of market concentration,” California Insurance Commissioner Dave Jones (D) told��California Healthline. “It’s the absence of choice that exists for some consumers in some parts of California.”

Exchange supporters counter that the market is efficient, pointing to the state’s strong enrollment in year 1 of Obamacare exchanges and the��recently announced for year 2.

“It’s a clear sign that the system in place is working,” Charles Bacchi, the incoming CEO of the California Association of Health Plans,��last month. “Covered California is making it possible for individuals to purchase quality health coverage at affordable rates.”

Concerns Around Competition, Access

The debate over the number of carriers, the cost of premiums, the range of doctors in Covered California’s networks — it all can be boiled down to a single question:

Has Covered California done a good enough job covering California?

Several experts credited the exchange with one big win: Creating more options for shoppers.

“I think competition did increase [given] new entrants into the individual market,” UCLA’s Dylan Roby told��California Healthline.

Roby rattled off the carriers that joined — Chinese Community Health Plan, LA Care, Molina, Sharp and Valley Care — and noted that Cigna and Assurant continue to offer off-exchange plans, too. As a result, California ended up with 17 carriers in the individual market in 2014, compared with 10 in 2010, Roby says.

That’s one potential reason more insurers may not have wanted to flock to join Covered California. Another hypothesis: The existing plans did such a good job signing up consumers last year, there’s less reason for new competitors to try and jump in.

“I do wonder whether the upside potential for new entrants in a state like California is more limited,” compared with states that enrolled less of the potential marketplace population, Kaiser Family Foundation’s Larry Levitt mused. According to��, nearly 43% of potential customers signed up last year in California; in contrast, Maryland’s insurers enrolled less than 17% of eligible customers. Maryland Health Connection has subsequently announced two new insurers for next year.

“In California, the number of remaining uninsured includes harder-to-reach groups,” Levitt added in an interview. “You also have a market largely dominated by four carriers.”

“For any new entrant to gain meaningful market share, they’d have to be able to price very competitively, and that requires having good contracts with providers.”

California’s low premium hikes for 2015 could further suggest that the exchange is working. Robert Wood Johnson Foundation on Tuesday��finding that state Obamacare markets that were less competitive saw the highest premium hikes, and vice versa. (RWJF did not examine California.)

But there’s also reason to be wary of Covered California’s current strategy, the state insurance commissioner tells��California Healthline.

Jones stressed that he’s a supporter of Covered California — “It’s been a very good start,” he repeated — but the dwindling number of participating plans has concerned him.

“That has enormous consequences for pricing and insurers’ ability to charge excessive rates,” he said. “Which has enormous downstream consequences for consumers and the prices they have to pay.”

He also suggested that Covered California has boxed itself in by relying on the big four plans in parts of the state.

“If the [exchange] disagrees with the price that Anthem, Blue Shield, Kaiser, or HealthNet are charging — they have no real bargaining power to get a lower price, because Covered California can’t afford to kick them out of the exchange,” Jones added.

Looking Forward

“Road to Reform” surveyed a dozen experts, and nearly all of them felt that while Covered California was relatively successful last year, there’s room for the exchange to grow.

“I would like to see more choice in some regions of the state,” Roby acknowledged. Ideally, there would be “at least four to five plans in each area, with one or two being lower-cost, local-initiative, [not-for-profit] plans like L.A. Care.”

CAHP’s Bacchi thinks exchange operations will only improve with more experience.

“We expect to see this robust competition among insurers to continue and possibly expand as we gain more experience with this new marketplace,” he told��California Healthline. “All of this should help moderate premium growth in the future.”

“I wouldn’t be surprised to see new entrants into the market next year,” adds Weinberg of the Bay Area Council. “The national payers have been expanding their participation in public marketplace and even a lesser known name, Assurant, is filing in 16 states this year” — although California isn’t one of them.

Two national payers that aren’t coming back to California any time soon: Aetna and United. Because both pulled out of the California market, they can’t be allowed back in until 2018. And given current laws and taxes that��Anthem and Blue Cross, Jones wouldn’t be surprised if they stay away.

“Until we make sure we have a level playing field, I think we’re going to continue to see United and Aetna stay out of the market,” Jones said.

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From Zero To 3.3 Million Sign-Ups: How California ‘Won’ The Obamacare Race

Dan Diamond, California Healthline — Mon, 28 Apr 2014 11:44:00 +0000

This story originally appeared in

Joel Ario says he meant it as a compliment.

It was January 2011, and Ario — the White House’s point man on exchanges at the time — was having dinner with Diana Dooley, California’s newly installed HHS secretary. And seeking to praise California, Ario told Dooley that her state had emerged as one of the nation’s “pace cars” when it came to implementing the Affordable Care Act.

Dooley quickly corrected him, Ario recalled in an interview with��California Healthline��last week.

“[Dooley] told me, ‘Pace cars don’t actually win the race,'” Ario said. “‘We want to be the����𲹻��car.'”

Forty months later, California’s clearly pulled ahead of the pack.

No state signed up more residents during Obamacare’s first open enrollment period, or grew its Medicaid rolls by a larger amount.

But not all glitters in the Golden State. While Covered California drove national enrollment — nearly one in five of all 8 million national ACA sign-ups went through the state’s insurance exchange — its faltering website and sometimes spotty service made for an occasionally bumpy ride.

“Road to Reform” interviewed Ario and more than 10 other ex-officials and experts — many of whom also spoke with��California Healthline��last fall on the��— to assess the state of the state’s Obamacare implementation, and what roadblocks loom ahead.

How California Grabbed Pole Position

As many of those experts predicted in interviews last fall, California’s early investments ended up staking the state to its later lead.

For example, the state and advocates focused on successfully growing California’s Medicaid program, a decision that’s been somewhat overlooked in recent months with all of the attention on the exchange. More than 600,000 state residents got coverage through California’s early expansion of Medi-Cal, the��. And “we spent literally tens of millions of dollars [reaching out] to the lowest-income people,” says Daniel Zingale of the California Endowment.

The state and community groups also planned to pour more than��into exchange-related awareness and outreach, and while some of the marketing materials were panned as being too dry and earnest — Covered California made a commitment to stay away from “funny” advertisements — the final numbers speak for themselves, several state officials told��California Healthline.

Even when the exchange’s website crashed under demand in early October, California was able to weather its early difficulties and bounce back — a pattern of flexibility that generally persisted throughout the enrollment period.

Meanwhile, the other purported pace cars couldn’t keep up, largely because of technical failures. Maryland’s website stalled out. Oregon’s never got out of the gate. Even vaunted Massachusetts had problems with its exchange’s engine.

California’s aggressive pursuit of Obamacare implementation allowed the state to maximize year one of coverage expansion, experts say. For example, when Covered California released its latest enrollment update last Thursday, the sheer totals were striking. As of April 15:

1.4 million people had signed up for private plans through the exchange — about��;
1.9 million people had enrolled in Medi-Cal, with 1.1 million coming through the exchange and 600,000-plus coming through the Low Income Health Plan; and
1.3 million Latinos had��through the exchange or Medi-Cal.

The Golden State’s coverage gains look even more eye-popping when extrapolated nationwide.

As Larry Levitt of the Kaiser Family Foundation has��, Covered California ended up enrolling 42 percent of its projected��. (Kaiser Health News is an editorially independent program of the Foundation.)

If every state had kept up with California’s pace, national exchange enrollment would have topped 12 million.
If every state had been limited to Massachusetts’ pace? National exchange enrollment would have been around 3 million.

Lessons From The State

For all of California’s pre-planning, the state’s health care leaders had to make several important decisions during the open enrollment period.

One key moment: When California was forced��to choose whether it would allow residents to keep plans that didn’t meet ACA requirements, after the White House punted the decision to the states. After a��, California ultimately said no — and Ario thinks that decision will end up being “a big advantage” for the state.

“That means the risk pool is going to be better,” he said, suggesting that more young, healthy enrollees ended up picking new plans through the exchange rather than keeping their old, non-compliant policies.��(Since leaving the White House, Ario now tracks health reform implementation as a managing director with Manatt Health Solutions.)

Covered California also pivoted when Latino enrollment lagged estimates, nearly doubling its Latino-related marketing in the first quarter of 2014 and partnering with a prominent advocate, Dolores Huerta. That had an impact, officials now say: The proportion of enrollees who self-identified as Latino went from 18 percent of all sign-ups in October through December to 32 percent in the first weeks of March.

California’s leaders had shown flexibility before, too. After Gov. Arnold Schwarzenegger (R) made a prominent,��to the ACA in 2010, the statehouse changed hands later that year. And a smooth hand-off was no guarantee, Zingale notes.

“We had one candidate for governor [in 2010] who said she’d support the repeal,” he says. “We had one candidate for attorney general who said he’d join the Supreme Court case against the law.”

But Kim Belshé — Dooley’s predecessor as HHS secretary, under Schwarzenegger — thinks the eventual, seamless transition helped get California where it wanted to go.

“Our state’s success is a testimony both to the early action and foresight of Governor Schwarzenegger and the 2010 Legislature,” Belshé tells��California Healthline, “and to Governor Brown and his Administration [who] stepped behind the wheel and steered the course of implementation so ably and successfully.”

Frustrations Persist

Still, nearly every expert — and the head of Covered California himself — acknowledges that not everything went to plan.

“I will be the first to admit our launch has not been perfect,” Peter Lee, head of Covered California, told a U.S. House of Representatives committee earlier this month. “Many have compared it to building the car while driving 70 miles an hour.”

“We did have a colossally bad opening day,” Zingale ruefully reflects. “We were like the ‘Ishtar’ of [debuts] … October and November were rough.”

Zingale and others reiterate that they’d grade Covered California’s overall performance as very good, or even great. But they note that several problems persistently plagued the state’s efforts.

Website breakdowns:��While not as bad as other states,��Covered California suffered its own share of website outages, and ensuring that the online provider directory was accurate also proved consistently problematic.

Addressing those issues will be an area of focus moving forward, state officials say.��“We’ll be working throughout the summer to improve our online platform experience,” Larry Hicks, a Covered California spokesperson, tells��California Healthline.

Consistent service issues: The exchange also grappled with off-line problems: In February and through mid-March, about one-third of callers to Covered California got a busy signal and less than 5 percent of calls to Covered California were answered within 30 seconds,��for the��Los Angeles Times��last month. “Overall, 40 percent of exchange customers surveyed said they found the enrollment process difficult,” Terhune added.

There were less visible back-office problems, too. Covered California didn’t expect that so many health insurance brokers would be interested in getting certified, notes Micah Weinberg of the Bay Area Council.��“They planned for 3,000 and ended up with over 10,000,” according to Weinberg. “So there were delays getting brokers training and certified, and it looks like brokers overperformed their expected enrollments while other channels underperformed.” And brokers and community assisters didn’t��on time.

Outreach to minority communities: Several experts pointed out that while Covered California hit its enrollment goals, there were some potholes in the approach.

“I’m not a marketing expert,” UCLA’s Dylan Roby tells��California Healthline, “but I’ve heard some pretty compelling arguments from the Latino community about the disconnect between their typical process for purchasing [insurance] and the campaign targeted at Latinos … the Enrollment Counselor model has been pretty successful once it got going, but the late start and lack of a paper application in Spanish until Dec. 30, 2013, was harmful to the overall effort.”

The end of open enrollment means that��state leaders must grapple with new challenges, too.

1. The safety-net could be stressed:��A “coverage expansion” isn’t equivalent to “coverage for all,” and safety-net providers already are reporting an uptick in visits — even as many immigrants and lower-income residents still find themselves left out of the ACA’s new plans but still need access to care,��for KQED’s “State of Health.”

2. Disparities in costs: The ACA’s insurance market reforms shine a light on how much an identical insurance policy costs in different parts of the state, Kaiser’s Levitt points out, “and the disparities are eye-popping.” For example, Levitt says that a policy in San Francisco can cost 50 percent more than the same policy in Los Angeles. “That’s due to big differences in the underlying cost of health care across the state,” he adds. “Will this create market or political pressure to do something about that?”

3. Keeping the exchange on budget:��Covered California officials last week said they needed to boost the exchange’s fiscal year 2013-2014 budget by��, mainly citing the scramble to spend more on information technology. But unlike other states — which may need to trim their exchange budgets moving forward, because enrollment didn’t measure up — that’s not the case in California, officials say. “We are positioned to cover all our expenses through our revenue, because our enrollment was so large,” according to Covered California’s Hicks. “It’s not a concern.”

Don’t Declare ‘Mission Accomplished’ Yet

The key question that’s looming:

Has California won the race to implement Obamacare, or is the state just leading after a lap?

Even Covered California’s Lee concedes that the state has a ways to go.

“Although we have closed our first open-enrollment period, we are not declaring success. This is not the finish line, but it is a very good beginning,” the exchange director��in a blog post this week.��

Other experts agree. The early enrollment numbers are terrific, Zingale says, “but it’s too early to hang the Mission Accomplished banner,” especially given the ongoing areas of focus.

“It’s been a bumpy, and unpredictable ride, so far” he notes, and “I doubt that it’s over.”

Belshé laid out some of the state’s top priorities. “With the initial open enrollment just completed, we turn to retention of enrollees, the next open enrollment period, and ongoing Medi-Cal enrollment,” she tells��California Healthline.��“And, we turn to the critical issue of access and health improvement.”

“Enrollment is not the end point but the starting point for better care, better quality, and better health,” Belshé adds.

For his part, Ario believes that the Golden State has moved ahead of the pack — just as Dooley suggested it would, all those years ago.

“I think California is��the��lead car,” Ario concluded this week.

“If Massachusetts was the state that got ACA passed originally, California is the state that’s getting it legitimated for the nation.”

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Most Small Health Plans Struggle To Thrive In California Insurance Marketplace

Dan Diamond, California Healthline — Thu, 09 Jan 2014 13:14:54 +0000

This story comes from��

YoungSoo Cho was in a good mood.

And for good reason.

Cho’s in charge of marketing for Chinese Community Health Plan, the smallest of the eleven health plans participating in Covered California. And like other executives at CCHP — which traditionally serves about 15,000 members of San Francisco’s ethnically Chinese community — Cho has been ambitiously working to grow the plan’s business by one-third this year.

“Our exchange target enrollment through the end of March 2014 Open Enrollment Period is +4,950,” Cho told��California Healthline��via email back in December.

But when “Road to Reform” checked in with Cho this week, he said that number didn’t apply anymore; CCHP needs to come up with a new one. That’s because the plan had received 5,036 applications as of last week, the halfway point of the enrollment period.

“Our sales manager just beat his annual goal,” Cho joked.

Small Plans Often Edged Out

CCHP’s early, obvious success is testament to Covered California’s potential to drive improvements in access and coverage, especially by introducing��.

But for other small health plans — who were hoping the insurance exchange would be a vehicle to pick up new members– it hasn’t been a smooth ride.

One small health plan��. Another was��. And a third is openly��.

That’s in sharp contrast to the experience of the four��largest��plans on the exchange — Anthem, Blue Cross, Health Net, and Kaiser — which are hoovering up new members, based on the most recent data available. (Kaiser Health News is not affiliated with Kaiser Permanente.)

About 96 percent��of Covered California customers are picking among the “big four” plans, according to��of October and November enrollment figures. (Based on off-the-record interviews with several health plan officials, a similar trend continued through December).

Exchange officials take issue with that characterization. “While the majority of enrollment across the state is in four plans, it’s different when you look region by region,” Executive Director Peter Lee said in December.

However, a region-by-region look shows that’s not true. “Road to Reform” analysis reveals that those four plans commanded 100 percent of sign-ups in nine of Covered California’s 19 regions, and captured at least 95 percent��of market share in seven other regions.

The only exceptions:

Region 4 — San Francisco County — where the big four has 78 percent��of the market, and CCHP has carved out the remaining 22 percent;
Region 8 — San Mateo County — where CCHP has 8��percent of the market; and
Region 19 — San Diego County — where Sharp Health Plan, which is offering policies on the individual market for the first time, has 10 percent��of new sign-ups.

What Gives These Plans an Edge?

A range of factors is driving consumer interest, executives at both CCHP and Sharp Health Plan say. And they stress that they’re still mulling the causes even as new enrollment data come in. But to some extent, the simplest explanations may be the right ones.

CCHP’s Price, Tailored Offering

In the case of CCHP, while the plan may not be well-known beyond San Francisco’s ethnically Chinese community, it’s offering some of the most competitive rates in the state, and maybe the nation.

Christina LaMontagne — vice president of health at NerdWallet, a consumer analytics service that offers a popular Obamacare Plan Finder tool — points to��showing that in the San Francisco area, the average uninsured 27-year-old can get a Bronze plan for $4 per month from CCHP. That’s miles ahead of the plan’s nearest competitors.

And based on��, CCHP is the only non-Big Four plan listed as the “least expensive” plan available in its region.

“Our price advantage is crazy,” Cho concedes. He notes that CCHP comes by its advantage based on actuarial data drawn from its existing members and efficiencies running its current HMO model. And some new customers, perhaps 20 percent, will sign up with the plan based solely on its low rates.

Yet there’s also a nuanced explanation, Cho notes. CCHP historically has been crowded out by some of the larger plans — when employers offered coverage to their workers, they would tend to contract with insurers like Kaiser, for example. But the exchange has made CCHP more broadly available to customers who may have been previously locked out.

CCHP is well-positioned to capitalize on its unique features: There are more than 180,000 ethnically Chinese residents of the San Francisco area who��aren’t��members of CCHP and might be interested in a plan better catered to their language needs and traditional popularity of therapies like acupuncture, Cho says.

(KQED’s “State of Health” blog offers��on CCHP’s marketing strategy and attempts to go beyond its traditional customer base.)

Sharp’s Brand Equity

Meanwhile, Sharp Health Plan’s success story can’t be due only to its rates — which are competitive, but are basically in line with the San Diego market. Instead, its promising debut on Covered California is likely driven by its strong regional brand presence.

Although the two-decade-old plan is new to the individual market, it’s already familiar to many San Diego residents; the plan serves 70,000 members in its commercial book of business, CEO Melissa Hayden-Cook told��California Healthline.

An added advantage: The health plan’s parent company, Sharp HealthCare, is the largest private employer in San Diego and caters to almost one-third of the market through its integrated delivery system.

Plan executives say there was built-in interest waiting for them, too. “There has long been a demand for an individual product from Sharp Health Plan, and Covered California provides a great opportunity for us to enter that market and serve the community,” Hayden-Cook told��California Healthline��by email. And “we believe that the brand equity we have built up in the community over the years has really paid off during this enrollment period.”

What’s Next

Since Covered California’s customers began signing up on Oct. 1, 2013, both CCHP and Sharp Health Plan have essentially held steady in capturing market share in the regions they serve. And if present trends continue, that means both plans could pick up several thousand additional members before open enrollment ends in March.

But Sharp Health Plan executives say they’re already pleased with their sign-up numbers — although perhaps any figure would do.

“We did not have a concrete enrollment goal for the first year of the program,” Sharp’s Hayden-Cook said. “We don’t believe [anyone] could accurately predict what enrollment would be given the unknowns about health care reform.”

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Should Obamacare Be Delayed — And More to the Point, Can It?

Dan Diamond, California Healthline — Thu, 17 Oct 2013 10:32:29 +0000

This story comes from��

Social security numbers allegedly��in clear sight. Page after page of��. And no clarity on when it will all be fixed.

Just another day of trying to log in to healthcare.gov.

Two weeks after its launch, the federal health insurance exchange is a “,” says The Washington Post’s��Ezra Klein. Some officials deserve��, according to Robert Gibbs, who until February 2011 was one of President Obama’s closest advisers.

And those are the Affordable Care Act’s supporters.

Even the��on Tuesday that healthcare.gov had “way more glitches than I think are acceptable.”

Those glitches could take months — or�� — to fix, according to reports. But there’s a key deadline looming: Jan. 1, 2014, when the ACA’s individual mandate takes effect.

Under the mandate, millions of Americans who were expected to use the exchanges to obtain health insurance will face fines if they haven’t purchased coverage by Feb. 15, raising the question of whether the mandate or other Obamacare provisions should be postponed — an uncomfortable position for an administration already trying to implement a politically divisive law.

But at this late date, what parts of the ACA can legally be delayed?

“In a sense, all of it,” Timothy Jost, a Washington & Lee law professor, told��California Healthline. But “there’d be a high political price to pay. And delay could result in litigation.”

Jost was among several experts who spoke with��California Healthline��about the health insurance exchanges’ bumpy rollout, the ripple effects for the mandate and other provisions, and what it could all mean for implementing the ACA.

What Agencies Can and Can’t Do

When considering a delay to Obamacare, it’s important to understand the difference between statutory��and discretionary��deadlines.

For example, the ACA’s language directly calls for many mandatory deadlines — like rolling out the individual mandate or implementing a slew of��on Jan. 1, 2014.

But the agencies also have had considerable leeway on how they’ve chosen to apply the law — like choosing an Oct. 1 launch date for the exchanges, a deadline that retrospectively seems ambitious.

And many discretionary deadlines end up getting missed; in the case of the ACA,��. That’s sometimes because CMS and other agencies just weren’t given enough funding to hit the deadline on time — a common problem when implementing the costly and ambitious ACA, Nick Bagley, a law professor at the University of Michigan, told California Healthline

Those missed deadlines can be��, Bagley writes at The Incidental Economist.��And they usually don’t lead to legal problems.

“When an agency has delayed, but does not have to act by any statutorily imposed deadline, courts are more deferential to the agency’s priorities and are less willing to compel an agency to take action,” according to a��report from March. “However, if a delay becomes egregious, courts will compel an agency to take prompt action.”

Postponing a statutory deadline can be a bit more tricky, and politically risky too. When the president in July announced that he was��the ACA’s employer mandate by one year, he drew broad scrutiny and handed a��to Republicans. But constitutional law experts��that the delay was legal and within the executive branch’s rights.

And remember: Missed deadlines and implementation delays aren’t exclusive to Obamacare.

“Probably every presidential administration has at some time delayed” a key provision of a law or the law itself, Jost noted.

Could Individuals Sue Over Exchange Problems?

Still, the ACA isn’t like most laws: Because of its huge scope, Obamacare introduces new pressures on individuals and industries, and it’s already been at the center of several major legal battles.

About 7 million Americans were expected to purchase coverage through the federal and state exchanges next year, a number that will shrink if the exchanges’ problems continue to grow. And that raises several scenarios that could involve the courts. If the exchanges continue to be faulty, but the mandate and its penalties take effect:

Could individuals sue, citing their difficulty in attempting to enroll or obtain premium tax credits?
Or, could insurers — who have made investments and undertaken reforms to prepare for ACA implementation — sue over lost revenue?

Experts acknowledged that both situations are possibilities, but they also cautioned that we’re still weeks away from either being a reality.

“The law states that a person will not be penalized for failure to carry insurance if she has been uninsured for less than three months,” Nicole Huberfeld, a law professor at the University of Kentucky, told California Healthline.��And because the individual mandate has yet to take effect, “I don’t think an individual or an insurer would have standing at this time to challenge the difficult opening of the federal exchange,” she added.��

“No one is injured yet, and no statutory deadlines pertaining to the exchanges have passed.”��

And there are still other ways of obtaining health insurance coverage to comply with the law, Bagley, Jost and others pointed out. The use of paper applications is already on the rise, Politico’s��last week, and the White House this summer awarded a $1.2 billion contract to a firm that’s expected to process more than 6 million paper applications through March.

The Delays We Could See

But every expert surveyed by California Healthline��acknowledged that the faulty launch of healthcare.gov has introduced new stress on the ACA’s rollout and the White House’s enrollment goals.

How could the administration relieve some of that pressure? In an email to��California Healthline,��Kip Piper, a former state Medicaid official and White House budget officer, pointed out several provisions that could conceivably be rolled back:

The open enrollment period: Allow individuals to sign up for the exchanges past March 31, 2014, Piper suggests.��
The compliance deadline for the individual mandate. Make this better match up with the end of open enrollment, Piper added, rather than the current gap where the deadline falls in the middle of February — six weeks before the end of open enrollment.
The process for individual mandate exemptions.��Although the exchanges are technically responsible for this, “the system is not developed [or] ready yet,” according to Piper.

The chorus of voices calling for postponements will grow louder every day with healthcare.gov’s continued — and very visible — woes, experts agreed. And some say the site should be taken offline until it’s more serviceable.

“The problem with the Obama administration keeping this open is [it’s] five times harder to fix something like this on the run,” industry analyst��The Washington Post’s��Klein. “If it would’ve taken a month to fix it during the shutdown, it’ll take three or four or five months to fix it while it was running.”

If the federal exchanges’ problems are miraculously solved in the coming days, these issues may end up being moot. But should healthcare.gov’s glitches continue into next year, at least one expert will be ready to appeal — not to the courts, but to a higher power.

“If the website’s still down … God help us,” Jost said.

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Pawlenty: The Other Republican Health Reformer

Dan Diamond, California Healthline — Thu, 26 May 2011 10:40:05 +0000

This story comes from .

Health reform��– who passed it, how it works and whether it’s legal��– is all but certain to remain a leading issue in the run-up to the 2012 elections.

Even though the rhetoric has cooled, last year’s health care overhaul remains divisive. Kaiser Family Foundation tracking polls consistently find a national split in public opinion about the law.

Fears over Medicare reform appear to have steered Tuesday night’s special congressional election, a harbinger of where Democrats hope to focus national debate.

The scrutiny has been so great, former Massachusetts Gov. Mitt Romney (R) recently delivered an unusual speech intended to both defend and distance himself from his state’s near-universal health care law.

Among the GOP’s bushel of would-be presidents, Romney’s dramatic health reforms command all the press��– but rival Tim Pawlenty may have overseen the more radical changes, at least on paper.

Before taking a prominent, if largely symbolic role resisting last year’s national health care overhaul, the former Minnesota governor signed off on a series of legislation that refashioned his state’s health care system. Here’s a primer on those changes and where Pawlenty stands on broader reforms.

Minnesota’s Ambitious Reforms

In officially declaring his candidacy for president this week, Pawlenty argued that he “know[s] how to do health care reform right,” adding, “I’ve done it at the state level. No mandates, no takeovers, and it’s the opposite” of the reform law.

Pawlenty is pointing to a package of reforms passed in 2008, which:

Established a new statewide health improvement program, focusing on obesity and personal health;
Increased health care data collection and reporting;
Expanded insurance offerings for low-income residents;
Developed tools to encourage consumer advocacy and increased health care decision-making; and
Supported major payment reform and care redesign.

While other state reform efforts, like Massachusetts’ health care overhaul, focused on expanding coverage first and controlling costs second, Minnesota’s reforms were heavily weighted toward payment reform. A joint report from the Commonwealth Fund and National Academy for State Health Policy noted that Minnesota’s “landmark legislation” contained numerous provisions with “significant potential to achieve overall health care cost savings.”

For example, legislators introduced new provisions to encourage development of patient-centered medical homes and backed a change that brought capitated-type payment to the state’s Medicaid program. The state also is developing a new “provider peer grouping” system, which would require providers to publicly report their compliance with recommended measures of care. The plan is intended to steer patients to low-cost, high-performing providers.

Plan Not Without Challenges

While Pawlenty has touted his reforms, Minnesota Public Radio suggested that the changes have yet to deliver on the key ambition: reining in costs.

For example, the state’s baskets-of-care experiment��– where providers can receive bundled payments to deliver a set of health care services��– “hasn’t really lived up to its potential,” according to MPR.

As of February, no providers had signed on to the state’s baskets of care, out of concern that the bundles paid too little and lacked comprehensive services, putting them at risk of losing funds for each patient seen. Some providers had worked out similar agreements with private insurers, notes a research fellow at the University of Minnesota’s School of Public Health.

Meanwhile, the state’s experiment with accountable care organizations introduced new challenges for participating hospitals and affected patients.

In early 2010, Pawlenty signed off on a deal to cut annual spending on Minnesota’s General Assistance Medical Care program��– which at the time covered about 32,000 low-income adults, many of whom were homeless and had chronic conditions��– from $219 million to $91 million. Under a radical shift, four state hospitals agreed to become “coordinated delivery systems” and provide medical and sometimes social services to an unknown number of GAMC patients beginning in June 2010, while receiving lump sum payments from the state.

However, many hospitals opted out of the program, arguing that serving an unknown number of patients with a reduced budget would not be feasible, especially given that GAMC patients cost an average of about $12,000 annually to treat and often have multiple chronic diseases.

The remaining participating hospitals later encountered logistical challenges in enrolling and triaging GAMC patients, many of whom switched providers under the model. Three of the four organizations quickly reached their cap on GAMC patients, which meant that about 18,000 former GAMC clients were receiving charity care or no care at all by fall 2010.

Outlook: Pawlenty Retains Focus on Health Spending

Minnesota’s bumpy road to realizing Pawlenty’s health care goals reflects a core tenet of health reform: even the best-intended plans tend to meet real-world complications. Achieving the state’s ambitions may require reforms to the reforms. But “as Minnesota learns, so will the nation,” the Commonwealth Fund researchers noted.

Meanwhile, Pawlenty has retained his focus on health care. His national campaign kicked off this week with a pledge to overhaul Medicare as part of a greater approach to addressing federal spending.

While complimenting a Medicare reform plan by House Budget Committee Chair Paul Ryan��– a controversial proposal to privatize the program��– Pawlenty has said he would develop his own strategy to rein in health costs. His ultimate proposal would base care payments on “better health care outcomes and better results,” Pawlenty told the Daily Caller.

Pawlenty’s approach to health care will certainly get more attention as his presidential campaign continues.

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