By Rebecca Adams, CQ HealthBeat Associate Editor

December 16, 2014 -- About 500,000 people will have more time to finish applying for health law coverage starting Jan. 1 on healthcare.gov, the federal website handling enrollment for 37 states, federal officials said on a call with reporters last week.

The deadline for signing up for new benefits or switching plans was Tuesday at 3 a.m., Eastern time. Federal officials responded to a surge in website and call center traffic by offering a little more time for some people. The individuals who are being called back to complete their applications were among the 1.6 million people who phoned call centers in the past few days.

The Centers for Medicare and Medicaid Services (CMS) will release updated enrollment statistics reflecting this week's activity on Dec. 23.

Almost 2.5 million people had enrolled in or renewed coverage since the Nov. 15 start of open enrollment as of the close of last week, according to a recent weekly snapshot that CMS released. About 52 percent of them were updating their coverage.

Those numbers include people who have not yet paid their first month's premium, which is necessary to begin coverage.

More than 4 million people since Nov. 15 have submitted applications for coverage, which is the first step for getting coverage before selecting a plan.

If consumers did not switch plans by Tuesday and are not among the group who will be called back, they will be automatically renewed into the same plan or a similar plan with the same subsidy level.

Roughly 335,000 people will be shifted into a different plan because their insurer stopped offering the plan they had this year, said officials.

Consumers who notify officials next week that they want to switch plans will see those changes take effect Feb. 1.

CMS Deputy Administrator Andy Slavitt called the first month "a strong start." But Slavitt and marketplace CEO Kevin Counihan indicated they have a lot of work to do every day to try to improve the customer experience.

"Not everything has worked perfectly or can work perfectly for every consumer," Slavitt told reporters.

People who called the help centers between Dec. 6 and Dec. 12 had to wait much longer than usual to speak to a representative—an average of 13 minutes and 12 seconds, compared to a four-week average wait of 5 minutes 59 seconds.

The healthcare.gov website had a peak volume on the site at the start of last week of 125,000 concurrent users. Slavitt said that CMS officials used a feature known as the "waiting room" for a 90-minute period. Several thousand people creating new accounts had to wait for an average of about three minutes each, he said. The delays did not affect people who already had accounts.

That scenario was far better than during the first couple of months last year.

The statistics released last week do not reflect state-based marketplaces. Ten of the 14 states running their own health exchanges have extended their deadlines past Dec. 15 for coverage that takes effect on Jan. 1, said Counihan.

Federal officials assume that there will be unanticipated problems that they cannot predict now, but Counihan said they will find a way to fix them.

"What I can tell you is we can smooth it out," he said.

One example of how federal officials have already worked on a looming problem is that they found a way to alert insurers when a consumer terminates coverage with the company. Health plan officials were surprised earlier this fall when federal officials initially said they wouldn't be able to provide this information. Insurers worried that patients would be billed twice in the same month. But earlier this month, CMS began providing files to insurers with information about customers who are switching companies. However, CMS officials are not warning companies when one of their customers switches to a new plan offered by the same company.

Slavitt said that some consumers who are automatically renewed may be satisfied with their coverage, while others may decide to switch after getting a bill. People have until Feb. 15 to change their coverage.

"We have a lot of challenges ahead of us," said Slavitt.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 17, 2014 -- State-run marketplaces such as California and New York's reported a higher volume of applications for health law insurance in the past few days, even though they extended deadlines for coverage that takes effect on Jan. 1.

In California, more than 592,000 people who applied for coverage were found eligible for Medicaid or private insurance for individuals, said Yolanda Richardson, chief deputy for the Covered California state marketplace. She spoke on a call for reporters with exchange directors from New York, Kentucky, and Washington state.

Covered California officials said that since open enrollment began on Nov. 15, 157,361 people were determined eligible for marketplace coverage. Another 144,178 people went on to choose a plan for private marketplace coverage.

Last year, only about 109,000 people picked a plan in the first two months of the open enrollment period, Richardson noted on the call, which was organized by the advocacy group Families USA.

The numbers in California don't include people who renewed coverage.

Interest in Medicaid, known in the state as Medi-Cal, also is strong. Officials said 216,423 people were enrolled and another 74,965 appear to be likely eligible for Medi-Cal but haven't gotten their final decisions yet.

So far this year, Medi-Cal enrolled more than 2.2 million consumers. Medicaid enrollment takes place year-round, unlike the health law marketplace, which has an open enrollment period ending Feb. 15.

The state of California has a backlog of 44,173 people who are waiting for a Medi-Cal decision, down from 99,900 people in late November. But Medi-Cal officials say the number of people in that group who are actually eligible for coverage is less than 2,000 people. The state was scheduled to hold a court hearing on last week on a lawsuit related to the backlog.

People who want their marketplace plan benefits to kick in on Jan. 1 have until Dec. 21 to pick a plan, said Richardson. The federal marketplace had a Dec. 15 deadline for such coverage to take effect.

"The interest here in California continues to be strong," she said.

New Yorkers have until Dec. 20 to choose which marketplace plan they want.

New York Health Benefit Exchange officials say that as of last week, 194,333 New Yorkers have gotten coverage through Medicaid, children's health coverage or a marketplace plan during this year's sign-up period.

More than 60 percent of the newly enrolled consumers were Medicaid beneficiaries, Exchange Executive Director Donna Frescatore told reporters.

An agency spokesman said that 123,644 New Yorkers have enrolled in Medicaid through Dec. 16. Another 52,543 have signed up for a marketplace plan, and 18,146 enrolled in Child Health Plus, which is coverage primarily for children.

Like California, the New York numbers do not include people who were already enrolled through the marketplace in 2014 and are now renewing their coverage for next year. In the first open enrollment period, about 960,000 New Yorkers signed up for coverage.

Ten of the 14 state marketplaces have later deadlines for coverage taking effect Jan. 1 than the federal marketplace that 37 states rely on. Washington state exchange director Richard K. Onizuka said residents have until Dec. 23 to enroll for benefits that start Jan. 1. The Kentucky deadline for Jan. 1 benefits was Monday.

Marketplace directors said it's unclear why some people who were eligible last year didn't sign up until this year or what may be motivating them this time. Richardson said that California will do surveys to try to answer those questions.

Frescatore also said New York will do surveys on the demographics of enrollees and may seek information about consumers' reasons for seeking coverage. She added that outreach is helping raise awareness in New York. About 10,000 in-person assisters "really hit the ground running" in trying to sign people up for coverage in this open enrollment period.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 16, 2014 -- Young adults were the group most likely to gain insurance in the United States in the first half of this year. But even after the improvements, they remain more likely to be uninsured than people over 45 years old.

About 19 percent of people enrolled in a health insurance plan through the federal or state marketplaces were between the ages of 18 and 29, according to new data from the National Center on Health Statistics released last week.

Those numbers fall short of what insurers would prefer. A Kaiser Family Foundation analysis last year found that if young adults between the ages of 18 to 34 years old made up about one-fourth of the population in the individual market, the costs for health plans would be about 2.4 percent higher than the insurers' revenues from premiums.

Most segments of the population gained insurance between 2013 and the first half of 2014, according to the data. Improvements were found among several categories of people, including all Americans, people under the age of 65, and young adults between the ages of 19 and 25.

The decrease in the uninsured rate among young adults from 19 to 25 years old was striking: 26.5 percent of young adults in 2013 didn't have insurance, compared to 20.1 percent in the first six months of this year.

Coverage provided through the government, such as Medicaid, was a part of that increase. About 16.1 percent of young adults in 2013 had public coverage, compared to 19.6 percent of young adults in the first half of 2014.

The percentage of young adults who had private coverage—including marketplace plans—rose from 58.1 percent in 2013 to 61.2 percent in the first half of 2014.

Among all adults between 18 and 64 years old, the percentage who were uninsured at the time they were interviewed fell from 20.4 percent in 2013 to 17.0 percent in the first half of 2014.

About 12.3 percent of people who were 45 to 64 years old were uninsured at the time of their interviews from January to June of this year.

About 6.3 million people were covered by marketplace plans during the second quarter of 2014 from April to June. That was up from about 3.7 million in the period from January to March, according to the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention.

State-based marketplaces did a better job than the federal marketplace operated through healthcare.gov. Adults in states relying on healthcare.gov were more likely to be uninsured than those in other states.

Federal officials have said that about 6.7 million people were covered by marketplace plans in October. About 85 percent of them received subsidies for the coverage under the health care law (PL 111-148, PL 111-152).

Americans have until Feb. 15 to sign up for marketplace coverage for 2015. The deadline for people who want to get new benefits or re-enroll in benefits that start Jan. 1 was this morning.

Among people under age 65, 62.8 percent—or 168.3 million people—were covered by private health insurance plans at the time of their interviews.

People who lived in states that expanded Medicaid under the law also saw big gains in coverage. The percentage of adults who were uninsured in Medicaid expansion states fell from 18.4 percent in 2013 to 14.1 percent in the first half of 2014. Among adults under 64 years old in states that had not expanded Medicaid, the percentage of uninsured decreased much more modestly—from 22.7 percent in 2013 to 20.2 percent in the first six months of 2014.

There was no significant change in the percentage of children who were uninsured at the time of interview, according to the data, largely because kids are the most likely Americans to have coverage. The Children's Health Insurance Program plays a major role in insuring children. The funding for the program runs out Sept. 30.

The data released last week were based on data from interviews with 56,784 people.

By Melissa Attias, CQ Roll Call

December 16, 2014 -- Americans stand to lose $65 billion in tax credits to help purchase medical coverage if the Supreme Court upholds a challenge to the health care law's insurance subsidies, House Energy and Commerce Democrats said in a recent staff report that outlines the number of people in each congressional district at risk of losing assistance.

The report lists the congressional district, the name of its representative in Congress, the number of people who could lose subsidies in 2016 and the annual value of the lost aid for residents of districts in states using the federal insurance exchange healthcare.gov. Last month, the high court agreed to hear a challenge to the subsidies that help lower- and middle-income people in those 37 states buy health coverage under the overhaul (PL 111-148, PL 111-152).

The lawsuit–King v. Burwell–argues that the statute only allows the subsidies in the exchanges set up by the states themselves and that an IRS rule providing them in all states is illegal. Citing Kaiser Family Foundation statistics, the report states a ruling against the government could take subsidies away from more than 13 million Americans in 2016.

"As today's report makes clear, if the law's opponents succeed, they will deprive Americans of $65 billion in tax credits, making it more difficult for millions of middle class families to have the health insurance coverage they need," Henry A. Waxman, who released the report, said in a statement. The Californian is the top Democrat on the Energy and Commerce panel and will retire at the end of the session.

Among the districts that would be affected is the Ohio district represented by Speaker John A. Boehner, who said Republicans would renew their commitment to repeal the 2010 overhaul in the next Congress in a Nov. 5 op-ed with Senate Minority Leader Mitch McConnell, R-Ky. The report says 19,000 people in his district would lose subsidies in 2016, worth a total of $91 million.

While the chart lists data for 35 states using the federal exchange, two newcomers in 2015–Oregon and Nevada–are not included.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 15, 2014 -- Tennessee Republican Gov. Bill Haslam has unveiled the outlines of a two-year plan to expand his state's Medicaid program that would include vouchers for private insurance and require beneficiaries to pick up some of the costs of their care.

Haslam faces a difficult task in creating a plan that will pass muster with both federal officials and reluctant Republican legislators. However, Haslam has spoken with Health and Human Services Secretary Sylvia Mathews Burwell about the plan, and last week some state critics softened their opposition. Last week, state Senate Speaker and Lt. Gov. Ron Ramsey said publicly that he might be able to persuade lawmakers to accept the proposal.

Haslam said that more than 200,000 Tennesseeans could gain coverage under the move to broaden eligibility to people earning up to 138 percent of the federal poverty level, as allowed under the health care law (PL 111-148, PL 111-152). More than half of those people are employed.

If state legislators and federal officials approve the plan, the state would become the 29th jurisdiction, including the District of Columbia, to expand Medicaid.

"This is an alternative approach that forges a different path and is a unique Tennessee solution," said Haslam. "This plan leverages federal dollars to provide health care coverage to more Tennesseans, to give people a choice in their coverage and to address the cost of health care, better health outcomes and personal responsibility."

Haslam said his approach would provide a voucher that is worth slightly less than the average per-person cost for Medicaid, which is known in Tennessee as TennCare. The money would be used to pay for premiums and out-of-pocket costs for private insurance. One option that beneficiaries could use the voucher for would be to buy coverage through an employer if that is available. State officials are leaving open the possibility that consumers could use the voucher in future years to buy private plans through the marketplace created by the health law, but those details have not been settled yet.

Tennessee would require people covered by the expansion benefit to pay for any costs above the value of the voucher.

"This structure empowers individuals to make a choice about which plan is better for their needs and to manage their healthcare expenses to avoid additional costs," said a summary of the plan.

The state wants to create a new program modeled on health reimbursement accounts. Consumers would get money for earn additional money for their accounts by participating in healthy behavior programs. The account could then be used to cover out-of-pocket expenses like copayments.

Newly eligible people who participate in the health account-type program and whose incomes are above the federal poverty level would have to pay premiums and copayments for services. All enrollees, including those with incomes below poverty, would have pharmacy copays.

Haslam said that the plan would not increase state budget costs because hospitals are willing to help pay for the program after the first two years. The federal government will pay all of the costs of new enrollees in 2015 and 2016, but then the federal contribution phases down to 90 percent of costs in 2020. The Tennessee Hospital Association agreed to cover the additional costs for the state, said Haslam.

The Centers for Medicare and Medicaid Services would still need to approve the proposal, but federal officials said the concepts in it appear to be ideas the administration could support. Once the state legislature passes legislation accepting it, the proposal would undergo a 30-day comment period at the state level before being sent to CMS. Then federal officials will have a second 30-day comment period before deciding whether to approve it.

"The administration is willing to work with any state interested in expanding Medicaid, and welcomes the news out of Tennessee," said CMS spokeswoman Marilyn Jackson. "The department has had productive discussions with Governor Haslam, and we look forward to the state submitting its plan to give low-income Tennesseans new options for health coverage."

Consumer advocates applauded the governor's announcement.

"This is an important moment," said Michele Johnson, executive director of the Tennessee Justice Center, a patient advocacy group. "We will look closely at the details of the governor's plan. Overall, we fully support its intention to keep Tennesseans' federal tax dollars in the state, cover working families and give them financial peace of mind."

By Rebecca Adams, CQ HealthBeat Associate Editor

December 18, 2014 -- Enrollment in Medicaid and the Children's Health Insurance Program (CHIP) grew by 9.7 million people in October, compared to a rolling average covering July–September of 2013. That's nearly a 17 percent rise in a little more than a year.

The total number of people in Medicaid or CHIP stood at 68.5 million in October, up from about 67.6 million in August.

In September and October, growth has been slower than in some periods earlier this year. The change from September to October was 428,311 more people, or about six-tenths of a percent.

That could change with the increase in publicity about health care coverage this month. The administration has urged people who want to enroll in or keep marketplace plans to sign up this month for benefits starting on Jan. 1.

States that implemented the Medicaid expansion and were covering newly eligible adults in October 2014 saw Medicaid and CHIP enrollment rise by more than 24 percent compared to the July–September 2013 baseline period. States that have not expanded Medicaid reported an increase of nearly 7 percent over the same period, the report said.

The largest increases over the past year were in Kentucky, which saw a nearly 71.5 percent increase in its Medicaid and CHIP population; Nevada, whose programs grew by nearly 68.1 percent, and Oregon, where programs grew by almost 64.2 percent.

A few states saw declines. Utah's Medicaid and CHIP population decreased by 5.8 percent over the past year, and Nebraska's programs fell by more than 2.7 percent over that time.