By John Reichard, CQ HealthBeat Editor

November 14, 2014 -- Obama administration officials Friday touted a wider selection of plans and stable premiums as they previewed Saturday’s launch of 2015 enrollment in the federal healthcare.gov insurance exchange.

The application has been winnowed down to 16 screens. Ninety percent of the renewal application for the 7.1 million people who got coverage this year is already filled out using previously submitted information. Officials portrayed the sign-up process as a cakewalk compared to last year’s fiasco of frozen screens and weeks-long delays in gaining access to insurance.

A Centers for Medicare and Medicaid Services official said the process will so much simpler that it will be possible during the Nov. 15–Feb. 15 open enrollment window to compare plans and enroll in coverage using a smart phone.

“With 25 percent more issuers participating in the marketplace in 2015, more than 90 percent of consumers will be able to choose from three or more issuers—up from 74 percent in 2014,” a White House official said. The officials added that there are 77 more health insurance issuers selling plans in the exchanges for 2015, a 25 percent increase over 2014.

The official said some 200 enrollment events will take place this weekend across the country as part of the launch.

According to CMS, consumers on average can choose from 40 health plans, up from 31 in 2014.

Navigating the complexity of picking and enrolling in a plan depends on getting in-person help, enrollment officials say.

Adding to the complexity of the sign up process is that officials will be trying to enroll millions more Americans who lack health insurance at the same time they are handling the renewal process for the first time. And there’s really only a month to complete the process to have coverage by Jan. 1.

“All consumers shopping for health insurance for 2015—even those who currently have coverage through the Marketplace—should enroll or re-enroll between November 15 and December 15 in order to have coverage effective on January 1, 2015,” CMS said in a statement.

They shouldn’t just reenroll in an existing plan without checking on their options, said CMS Administrator Marilyn Tavenner. “Consumers should shop around, with new options available this year they’re likely to find a better deal.” 

By John Reichard, CQ HealthBeat Editor

November 10, 2014 -- Insurance exchanges, or marketplaces, created under the health law will enroll significantly fewer Americans in the coming years than originally forecast by the Congressional Budget office, the U.S. Department of Health and Human Services said on Monday.

Officials emphasized that their “bottom up” projection of between 9 million and 9.9 million Americans enrolled and paying premiums at the end of 2015 still represents a 25 and 40 percent increase over 2014 totals.

The CBO projected a total of 13 million paying exchange enrollees in 2015, 24 million by the end of 2016, and 25 million thereafter. Officials Monday said they don’t expect to hit the 24 million mark in 2016 and were vague about when they may reach the “steady state” enrollment figure of 25 million.

The lowered projections came as officials touted improvements in the healthcare.gov website, now in the late stages of preparations to handle enrollment in 37 states for the health law’s second sign-up period starting Nov. 15.

The site has seen “tremendous improvement” and will be “simpler, faster, and more intuitive” to use, one official said in a telephone press briefing. Visitors to healthcare.gov were able as of Sunday night to “window shop” by comparing plans, covered benefits, and provider networks without having to submit an application.

Health and Human Services Secretary Sylvia Mathews Burwell said at a midday appearance that federal officials have performed numerous technical tests over the past five weeks, including some to see how many users can be on healthcare.gov at one time and end-to-end testing to make sure that the website’s components work well.

“Open enrollment this year will be a positive experience for the consumer,” she said. However, Burwell noted that renewing existing policyholders’ coverage could pose challenges. “Anytime you do something for the first time, that’s hard and you worry.”

“We will have outage. We will have downtime, but the most important thing we can do about that is make sure we are prepared,” Burwell said. When something goes wrong, “what we need to do is be transparent fast and get it fixed,” she said.

Monday’s enrollment projections were the latest in a series of setbacks for the health law (PL 111-148, PL 111-152). The statute will be the target of repeated attacks once Republicans assume control of both chambers of Congress next year. Its subsidy program and insurance consumer protections could be thrown into chaos if a Supreme Court review of the legality of subsidies under healthcare.gov leads to a mid-2015 ruling canceling aid for almost 5 million Americans.

Even officials’ boasts of a much smoother healthcare.gov experience were clouded Monday by a Washington Post report saying that the administration has prepared an extensive backup plan if the site functions poorly, and that notices that were supposed to be in hands of existing enrollees by Nov. 1 telling them whether they likely qualified for subsidies had only been mailed to 1 million of the 7 million enrollees by the third week in October.

The White House appears to be banking on its ability to say that the exchanges are outperforming expectations going into the 2016 election season by turning in a total sign-up tally exceeding 9.9 million next year. The exchanges beat CBO’s year one projection of 7 million despite technical glitches and other frustrations, and awareness of the law and its penalties for going without insurance suggest that the 9 million to 9.9 million target will be easy to attain.

But officials say they face tough challenges because the second enrollment period only runs to Feb. 15, compared to last year’s six-month signup window. They also have to process renewals of existing coverage for the first time.

Officials are projecting that 83 percent of the current 7.1 million enrollees will renew their coverage for the 2015 plan year. That means they’ll have to get around 4 million new enrollees to reach the target.

The updated figure takes into account people whose applications had discrepancies that prevented confirming eligibility for enrollment or subsidies based on citizenship and immigration status and their level of income.

At the end of May, 966,000 enrollees submitted citizenship or immigration information on their applications that did not match HHS data, officials said. A total of 1.2 million submitted income information officials couldn’t confirm. After repeated requests for additional data, a total of 112,000 people lost their coverage because they failed to provide the needed information.

Only 120,000 households out of the 1.2 million who submitted income information that couldn’t be confirmed will have subsidies adjusted on Dec . 1.

“These folks are not losing coverage but will see an increase in their costs,” an official said. Officials emphasized that important coverage gains have occurred under the health law despite the lowered projections—a 26 percent drop in the uninsured population after the first year of the law.

Rebecca Adams contributed to this report.

By Rebecca Adams, CQ HealthBeat Associate Editor

November 12, 2014 -- Enroll America, the advocacy group that helps consumers sign up for health law coverage, raised $20 million for outreach efforts this year, down from $27 million last year. The group’s president said the organization “will need to work even harder and smarter” than last year to reach consumers.

The sign-up period, which starts Saturday, is half as long as the one for 2014. Many of the uninsured are harder to find. Federal and state officials also will be renewing coverage for consumers during open enrollment season because insurance bought through the marketplaces ends on Dec. 31.

Enroll America President Anne Filipic said Wednesday that even with the lower fundraising total and the new challenges, she expects the group to reach more people through targeted approaches. It will spend less time knocking on doors and making phone calls in favor of working with small businesses, and talking to owners, customers and workers.

“Based on what we learned last year, we are able to use those dollars more effectively,” said Filipic on a call with reporters.

She also noted that funding has come from an expanding list of organizations, with growth on the state and local level. That mirrors a similar trend in the implementation of the health care law (PL 111-148, PL 111-152), moving from a national effort to one that is taking shape on the community level.

About 66 percent of Enroll America’s funds came from philanthropies, including the Robert Wood Johnson Foundation. Another 17 percent was from hospitals with a similar share from other health industry groups and individuals. Donors include the American Hospital Association, Ascension Health, BlueCross BlueShield of Tennessee, Blue Shield of California, the Catholic Health Association of the United States, Catholic Health Initiatives, the Colorado Health Foundation, Health Care Foundation of Greater Kansas City, Houston Endowment, Independence Blue Cross, Kaiser Permanente and the Kansas Health Foundation.

Since the end of the first open enrollment period in April, the number of groups partnering with Enroll America has almost doubled, said Filipic.

One new tool that Enroll America is offering this year is an online appointment scheduler that will allow people in 14 states to reserve time with trained helpers who can walk them through the health care enrollment or renewal process. Organizations that help sign people up, such as community health centers and Planned Parenthood, have to pay what Filipic called “a nominal fee” to activate an icon on Enroll America’s website that will let consumers schedule an appointment.

However, in other states, the tool only provides contact information for local groups that help with enrolling. That function is similar to a feature on healthcare.gov, the federal enrollment website, that identifies local groups that can help.

Filipic acknowledged that the upcoming enrollment period will be challenging for supporters of the law.

“What actually worries me more than anything is how consumers could easily by confused by all the different messages out there,” said Filipic. With messages aimed both at those whose coverage needs to be renewed and , with some information targeting people whose coverage needs to be renewed and others targeting the still uninsured, Enroll America “put a ton of effort this summer and fall into developing streamlined messages that allow us to reach all consumers.”

Filipic’s concerns about a barrage of messages could be overcome if different groups work together to keep information simple.

“The reality is the policy behind the scenes is a little complicated but the messaging can be pretty straightforward,” said Filipic.

By John Reichard, CQ HealthBeat Editor

November 13, 2014 -- Only 76,000 people working for 12,000 small employers were covered through plans offered by the health law’s small business exchanges as of June, the Government Accountability Office reported Thursday.

That figure—reflecting 18 state-based small business exchanges—is vastly lower than Congressional Budget Office projections, said House Small Business Committee Chairman Sam Graves, R-Mo.

The Congressional Budget Office estimated that 2 million employees would enroll in so-called SHOP coverage this year, Graves said in a press release. The health law requires each state to have a Small Business Health Options Program (SHOP) that is administered either by the state or through the federal government.

The Obama administration still hasn’t released enrollment numbers for the “federally facilitated” SHOP exchanges it runs in 33 states. It says, however, that they are comparable to the numbers for SHOPs created on their own by 17 states and the District of Columbia.

The low enrollment figure gives Republicans another opening to attack the health law as they prepare for the next session of Congress and a new series of attacks on the overhaul.

“Obamacare’s SHOPs have been fraught with errors and high costs from the beginning,” Graves said.

GAO detailed the slower-than-scheduled startup of the SHOPs and the features they offer.

The exchanges were supposed to open in all states by Oct. 1, 2013. In all but four states, SHOPs were accepting enrollment applications by that date but important promised features were typically not ready, including online enrollment, and “employee choice” features.

Though insurer competition in the SHOPs was supposed to drive down premiums, the GAO found prices comparable to coverage outside of the exchanges.

The typical small business owner that provides coverage also picks the plan. The idea of SHOPs, in part, is to give their employees a menu of coverage options to choose from. Many state-created SHOPs offer this feature, but none of the federally facilitated ones do, GAO found.

The same is true of online enrollment, which exists in most of the state-run SHOPs but not at all in the exchanges operated by the federal government, the report said.

What small business owners have gained, however, is the ability to see plan information such as premiums and benefits online on web sites in all of the states.

And federal officials are preparing to implement online enrollment for federally run SHOPs for 2015, GAO said. Employee choice will be available next year in 14 states with SHOPs operated by the federal government, though 18 states took up a government offer to delay that feature until 2016.

Enrollment figures for the federally run SHOPs will be made public early next year.

Most bosses are offering their workers a menu of coverage options in states where the option is available, the study found. “Exchange officials in Kentucky and Rhode Island said that approximately 65 and 61 percent of enrolled employers, respectively, decided to offer their employees a choice of plans,” GAO said.

The added features will bring many more customers to the SHOPs, exchange backers say. So too will more aggressive marketing, closer coordination with insurance agents and the fact that employers after 2016 won’t be able to renew coverage that doesn’t comply with the health law, which will make them more likely to start shopping at the small business exchanges.

Others predict the SHOPs won’t be a big draw because the tax credits they offer small businesses end after this year. The exchanges may not be able to charge lower premiums.

By John Reichard, CQ HealthBeat Editor

November 12, 2014 -- Directors of leading state insurance exchanges painted an upbeat picture of their upcoming open enrollment periods, saying Wednesday they’ve hired more customer service representatives, added storefront sites to provide personal assistance, tweaked websites to more easily connect visitors to insurance agents, and made it easier for uninsured people to window shop for a plan.

Peter Lee, executive director of Covered California, drew a sharp contrast to the gloomy atmosphere surrounding the health law’s coverage expansion emanating from Washington.

“I see huge interest in communities,” said Lee, formerly the head of the Pacific Business Group on Health, a health care purchasing group.

Lee made his comments on a press call sponsored by the advocacy group, Families USA, a strong supporter of the law. The lineup of exchange officials represented some of the most successful state marketplaces, among them New York, Kentucky, and Washington.

A Supreme Court challenge to the legality of subsidies in states using the federal exchange healthcare.gov would not affect such states, which set up their own marketplaces and whose authority to offer subsidy assistance isn’t in dispute.

“Do we see headwinds because of the fracases in Washington?,” Lee asked “Zero. Winds are in our sails.”

“There will be over 200 storefronts open across California and more ways to link people to individual insurance agents and certified counselors,” said Lee. “We have more than 25,000 certified and trained either insurance agents, county eligibility workers, or certified counselors.”

The marketing aims to drive people to the Covered California website to click on a green button to “find health care near me,” Lee said. “You can find local people, insurance agents, etc. to help you enroll.”

But the executives acknowledged that enrollment will be harder this year. They’re having to renew customers for the first time, face a shorter open enrollment period heavy with holiday distractions and must reach people they either missed with their messages last year or who skipped enrolling.

“It will be harder this year” Lee said. “We think it’s going to require more in person assistance and we’re going to be doing that.”

Kentucky surprised the nation last year by taking full advantage of coverage expansion provisions under law despite significant opposition to the statute in the state. Kentucky saw the second largest drop in the uninsured rate in the country as a result. Exchange director Carrie Banahan said she’s excited by a new mobile app her exchange developed with the hard-to-enroll “young invincibles” in mind. It’s designed to help users easily connect to individual enrollment help from insurance agents or other assisters.

New York got its renewal efforts off to an early start with letters to 300,000 families or households in mid-October. The letters told them the premiums they’d have to pay if they stick with their current plans in 2015, taking fresh calculations of their subsidies into account, said Donna Frescatore of the New York Health Benefit Exchange.

Richard Onizuka, head of the Washington Health Benefit Exchange, admitted that the state had to adjust its enrollment projections for next year because it had a higher than expected dropout rate from 2014 coverage. The state currently has about 140,000 exchange enrollees, a lower starting point than it expected for building enrollment next year. It expects to add 85,000 new enrollees next year, he said.

Onizuka said that coverage expansion lowered uncompensated care costs 30 percent this year in the state. But he noted that universities in the state are dropping health plans as coverage becomes available under the health law and state officials are focusing outreach efforts on students as a result.

Plan designs are part of the marketing strategy of the exchanges. Kentucky is keeping the plans and networks of existing enrollees the same to ease the reenrollment process. To respond to concerns about high out-of-pocket costs, Washington is emphasizing cost-sharing subsidies in silver plans and has cut front-end deductibles for one of its silver tier plans.

California stumbled in outreach to Latinos last year but hopes to bring in more Latino young invincibles by reassuring them that enrollment information they give on citizenship status won’t be used to deport family members who are undocumented, said Lee.

“About a third of Latinos that are citizens or have legal status are worried about signing up because a family member might be undocumented,” he said.

By Melanie Zanona, CQ Roll Call

November 12, 2014 -- Senate Republicans lacking a filibuster-proof majority next year will need to attract crossover votes from a shrinking pool of centrist Democrats if they are to have any hope of making legislative changes to the health care law.

They could find a willing partner in Michigan's Gary Peters, the lone Democrat in the Senate freshman class, who as a congressman voted with Republicans to weaken penalties on businesses and individuals that don't comply with the law's coverage requirements and who maintains the law can be improved.

“I’ve had the experience of being in the minority more than I like, but I believe you have to build personal relationships and find common ground to make things work,” Peters said in an interview, adding with a laugh that he'll have ample opportunities at new member orientation. Addressing the law's implementation, Peters said, “We need to move forward, but that doesn’t mean you can’t go back and revisit it and make it work better ... Nothing is carved in stone.”

Largely known for his work on manufacturing issues and the economy, Peters will succeed departing Michigan Democrat Carl Levin. In the House, he already has collaborated with Republican Sens.-elect Shelley Moore Capito of West Virginia and Cory Gardner of Colorado on efforts to overhaul student loans and streamline government programs, respectively. He also is co-chairman of the bipartisan Congressional Automotive Caucus.

Peters supported the passage of the 2010 law (PL 111-148, PL 111-152). But he broke from his party to vote in favor of a House Republican bill (HR 3522) that would allow companies and workers to keep health plans not in compliance with the law's coverage standards. He also backed legislation (HR 4118) to delay the penalty for individuals who fail to obtain health coverage, as well as a measure (HR 3811) that would require people to be notified if their personally-identifiable information has been compromised due to security problems within the law's insurance marketplaces, or exchanges.

“You always have to be thinking about representing your constituents first,” Peters said. “It should not solely be about party, as long as I feel comfortable, do my homework and can stand up and say why I voted that way.”

Peters is hardly a shoo-in for all of the Republican tweaks that are expected to be proposed in the next session. He voted against a House measure (HR 2575) that would change the health law's definition of a full-time workweek from 30 to 40 hours and fought numerous attempts to repeal the law altogether, indicating he would do the same in the Senate.

But he's likely to be a much-courted figure following the departure of some Senate Democrats who backed reopening the law to changes, including Kay Hagan of North Carolina, who cosponsored legislation (S 232) to repeal the law’s medical device tax, Mark Udall of Colorado, who introduced a measure (S 1699) to allow health plans not in compliance with the law to be offered for two more years, and Alaska's Mark Begich, who backed a package of Democratic bills that would have tweaked the law. Louisiana's Mary L. Landrieu, who introduced a measure (S 1642) that would have allowed people to keep their existing health insurance policies indefinitely, still faces a runoff election in December.

“I don’t think they’re going to find much common ground around the Affordable Care Act” in the next Congress, said Robert Blendon, senior associate dean for policy translation and leadership development at Harvard School of Public Health. “The issue is that there will be no blatant support [for changes] from the Democrats. There is nobody left on that side.”

Minority Leader Mitch McConnell, the next presumptive majority leader for the 114th, acknowledged in a post-election news conference that they do not have the 60 votes necessary to repeal the law. The Kentucky Republican said he does, however, plan to use the “power of the purse” to narrow its reach through spending bills and policy riders.

Beyond Peters, Democratic swing voters may include Joe Manchin III of West Virginia, Heidi Heitkamp of North Dakota and Mark Warner of Virginia, all of whom supported the Senate package of Democratic health care law changes. Joe Donnelly, D-Ind., has also been a vocal supporter of legislation (S 1188) to change the definition of full-time workers.

Democrats, such as Amy Klobuchar and Al Franken of Minnesota, from states with medical device makers have endorsed legislation to repeal the law's 2.3-percent excise tax on the devices. “This issue has been able to unite normally polarized members of the Senate in giddy camaraderie,” said Robert Moffit, senior fellow at the Heritage Foundation's Center for Health Policy Studies.

The GOP still faces roadblocks from within its own ranks, where more conservative lawmakers are likely to refuse supporting changes to a law they view as inherently flawed. Senate Republicans could force changes using budget reconciliation, where only a simple majority is needed. But even that process has limits, meaning that some compromise will still be necessary.

Jonathan Oberlander, a professor of social medicine and health policy and management at the University of North Carolina at Chapel Hill, said that altering the health care law could prove risky for Republicans, who have highlighted unpopular provisions to attack Democrats. Whether or not Republicans ultimately draw enough support, he said, could come down to strategy.

“If the end goal is to change the law, than you focus on the parts where you know you can peel off enough Democrats to do it,” Oberlander said. “But if your focus is to put vulnerable Democrats on the record or force the president’s hand, than you don’t care as much about getting to 60 votes.”