Author: Ashley Cohen

An updated version is available for download, which incorporates February Exchange Board meeting news/developments.

A health benefit exchange is a health insurance “marketplace” where individuals can shop for coverage based on price and quality. The Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010 by President Barack Obama, requires that states either create their own Exchanges or join a federal Exchange by January 1, 2014. The federal law allows states flexibility in constructing their Exchanges in terms of their relationships with public programs, governance, outreach, roles of brokers and CAAs, and whether they will be statewide or regional. Just over six months after the bill was signed, California became the first state to pass legislation creating a health benefit exchange. Estimates show that approximately three million currently uninsured individuals will be eligible to purchase coverage in California’s Exchange.[1]Since the legislation was signed into law, California has charged forward in setting up its statewide Exchange. This paper will summarize the framework set for the California Health Benefit Exchange, provide updates on its inception and present important decisions that will need to be made over the next few years.

Creating the California Health Benefits Exchange: Progress to Date.pdf (1.7mb)

Creating the Health Benefit Exchange (December 2011).pdf

Updated (3/7/12)
Creating the Health Benefit Exchange: Progress to Date (February 2012).pdf

Tuesday’s Exchange Board meeting (agenda) was full of fast-paced and exciting updates, followed by an expert panel intended to give framework for qualified health plan (QHP) requirement determinations.

During his Executive Director update, Peter Lee noted that the Small Business Health Options Program (SHOP) solicitation has been released, the Board is in the process of reviewing applications for Outreach and Enrollment/Assisters, and they just finished final amendments for the QHPs solicitation (they added that the vendor should be able to determine cost-sharing and supplemental benefit offerings). Yesterday, it was announced that the QHP grant was awarded to PricewaterhouseCooper.

The next series of Exchange Board meetings will be designated to these three key issues, in addition to a focus on potential implications of the Basic Health Plan (BHP) in April. The goal is to have key decisions made on these issues before applying for the Level II grant mid-June, which means very tight timeline. In Lee’s words, “We are moving fast and we need you to move fast with us.” The Level II grant will fund the Exchange’s operations through the end of 2014.

A $6M of the $39M Level I Grant has been obligated and the Board submitted details in a quarterly report at the end of December.

California Health Benefit Exchange Timeline

Tuesday’s meeting was focused on QHPs. Three expert panels provided presentations and reactions related to 1) An overview of the California market, regulatory structure and major purchasing strategies, 2) Purchasing in action: Examples of major purchasing strategies and consumer reactor, and 3) Plan, provider and consumer reactors.

Panel 1: An Overview of the California Market, Regulatory Structure and Major Purchasing Strategies – Highlights

The first panel was made up of health policy researchers from the California HealthCare Foundation (Marian Mulkey), Kelch Consulting Group (Deborah Kelch), and UC Berkeley (James Robinson).

Marian Mulkey provided a snapshot of California’s current health plans and products.

The following pie chart shows all health insurance carriers by share of revenue (2010). Total revenue is $105B, $86.9B of which is DMHC and $18.1B of which is CDI. Marian noted that Kaiser has a higher share since they tend to offer a more comprehensive benefit package, which has a higher cost.

All health insurance carriers by share of revenue, 2010 (Total: $105B)

All health insurance carriers by share of revenue, 2010 (Total: $105B)

This next pie chart is a breakdown of individual market enrollment by carrier for Californians (2009) out of 2 million enrollees. Note that Anthem has the highest percentage of enrollment at 40% and Kaiser has the lowest at 17%. This is likely due to the high cost of Kaiser plans (again, due to their more comprehensive benefits package).

Individual market enrollment by carrier for Californians, 2009 (Total: 2M)

The following pie chart shows the small group market enrollment by carrier for Californians.

Small group market share (Total: 2.5M)

The chart below shows the selection of HMO, PPO, POS or HDHP/SO insurance among covered workers.

Enrollment of covered workers.

This chart from the Kaiser Family Foundation shows the extreme variance in estimates for deductibles and coinsurance under a “Silver” level plan (70% AV) in the Exchange, reflecting great uncertainty surrounding plan offerings in 2014.

Estimates of plan designs to meet actuarial value thresholds, 2011

Kelch provided an overview of the regulatory environment for health coverage in California. A 2011 CHCF report found that:

• During the first half of the decade, there was a noticeable increase in CDI covered lives (1.2% in 2003 to 2.6%);
• CDI regulates the majority of commercial individual coverage and DMHC regulates the majority of the insured group market; and
• 93% of covered lives under CDI are in products offered by eight companies that also have affiliates with products licensed by DMHC, including two companies that offer the same types of products (PPO plans) under CDI and DMHC, and must meet different regulatory requirements.

Panel 2: Purchasing in Action: Examples of Major Purchasing Strategies and Consumer Reactor – Highlights

This panel consisted of representatives from various other purchasing pools, including the Massachusetts Connector (John Kingsdale), CalPERS (Ann Boynton),  and Unite HERE Health in Las Vegas (Elizabeth Gilbertson), an expert from Catalyst for Payment Reform (Suzanne Delbanco), and a consumer reactor from Health Access (Beth Abbott).

John Kingsdale, Wakely Consulting Group, provided recommendations on QHP certification criteria based on findings from the Massachusetts Connector. He recommended requiring that plans have:

• Minimum regulatory requirements alone;
• Specific product type (HMO, PPO);
• Overall price/quality/access ranking;
• Breadth of service area or intent to grow;
• Access for special populations;
• Use of FQHCs & safety-net hospitals;
• Willingness to participate in Medi-Cal & CHIP;
• Willingness to participate in SHOP & Individual CHBE;
• Multi-year commitment to CHBE;
• Commitment to market CHBE and support navigators;
• Supportive of delivery system reform;
• Standards of inter-operability w/ CHBE; and
• Availability of plan data on quality/service.

He also recommended NOT limiting the number of participating plans (at least at first) and presented advantages (transparency and ease of comparison shopping) and disadvantages (can inhibit innovation and initial administrative burden for plan) of benefit standardization. Based on this, his recommendations included:

• Broad choice especially important for SHOP and unsubsidized households;
• Standardization should be based on customer preferences;
• Considerable value in early experimentation & evolution of policy; and
• Flexibility is crucial, especially in any effort to standardize designs.

Kingsdale said California should consider a mix of standard/unique designs.

Panel 3: Plan, Provider and Consumer Reactors – Highlights

The third panel was a stakeholder panel that included representatives from the California Hospital Association (Duane Dauner), the California Medical Association (Dustin Corcoran), Small Business Majority (John Arensmeyer), the California Association of Physician Groups (Don Crane), and the California Association of Health Plans (Charles Bacchi), and a consumer reactor from the California Pan-Ethnic Health Network (Ellen Wu).

In a joint presentation, Corcoran and Dauner provided recommended QHP contracting strategies in order to provide high-quality and affordable health care:

• Accessibility, timeliness and risk
• Patients should not suffer from inadequate access to care and should receive the right care in the right place at the right time.
• Providers should not suffer financial consequences caused by inadequate networks. Patients should have clear understanding of cost sharing, quality and network and service limitations.
• All QHPs should adhere to uniform standards for access, timeliness and financial risk.

• Broad and comprehensive networks
• QHPs must provide for the total needs of patients (not a narrow network focused solely on price) including wellness, primary and specialty care, education and research.

• Streamlined enrollment – no wrong door
• Providers are a “door” for many seeking care for the first time. Hospital emergency rooms and physician offices – must be given the resources, training and tools to ensure enrollment for all seeking care and coverage.

• Starting from a point of affordability is key.
• Next year and a half will be spent building the networks who will care for the projected 4.4 mil eligible for Medi-Cal & subsidies
• IOM analogy: One goes grocery shopping with a budget in mind, instead of loading the cart only to be surprised at the checkout counter

• Coverage is truly comprehensive only if there are broad networks of providers.
• The millions of newly insured patients will demand access to doctors and hospitals

They also indicated that California has historically low health expenditures. The per capita health costs are below many other states, 8% below the U.S. average and growing at a slower rate than any other state.

California has one of the lowest per capita expenditures compared to other U.S. states

The reason for this reduced per capita expenditure is the consistently lower utilization levels due to high enrollment (50%) in HMOs.

All of the panel presentations can be accessed here.

Upcoming Meetings

The March meeting, which will be held in Fresno, will focus on the Outreach and Assistance landscape. In April, the Board will focus on the SHOP landscape. At the May meeting, options for the three issues will be presented and decisions will be made at the June meeting.

We are excited to host a thoughtful discussion on the creation of California’s Health Benefit Exchange on Wednesday, February 22 from 11:30am – 2:30pm at both the Community Clinic Association of LA County (Los Angeles) and the California Endowment (Sacramento). The two locations will connect via video conferencing. At the workgroup, we hope to present an updated version of ITUP’s Exchange paper, along with our comments on the IT system and federal Essential Health Benefits (EHBs) bulletin.

Agenda items will include outreach and enrollment, determination of EHBs and developing an efficient IT system (CalHEERS). We will also take some time to touch on the issue of “Assistors.”

To register for the LA location, click here: https://events.r20.constantcontact.com/register/eventReg?oeidk=a07e5lxfnqb445bfa81&oseq=

To register for the Sacramento location, click here: http://events.constantcontact.com/register/event?llr=ocynpkcab&oeidk=a07e5lxjoh487d59a0c

Please feel free to e-mail me at ashley@itup.org with any questions.

A few weeks ago, UC Berkeley hosted a conference on the barriers to creating safety net Accountable Care Organizations (ACOs) in California. Stephen Shortell, Dean of the UC Berkeley School of Public Health, presented findings from his recent BSCF study that assesses safety net ACO readiness in two counties (Alameda County and Orange County) and examines legal and regulatory issues associated with forming safety net ACOs.

During preliminary interviews, researchers found that safety net providers expressed concerns about scarce capital, complicated health issues of safety net patients, and the lack of information technology and infrastructure.

A series of outreach interviews were conducted with CA safety net providers. Providers were asked 90 questions that required responses on a scale of 1-9 to assess their county’s readiness to create a safety net ACO. The 90 questions spanned 9 categories, including:

• Organizational mission and populations served (how many adjustments would need to be made to meet the requirements and the adequacy of the health workforce to serve the target population);
• Governance and leadership
• Partnerships (partner willingness to adjust services to meet target population needs and readiness of partners to provide care);
• Finance and contracts;
• IT infrastructure;
• Managing clinical care (cultural competency of providers, care management, behavioral health integration, and ability to deliver more cost-effective care);
• Performance reporting;
• Legal/regulatory issues, barriers and risk tolerance; and
• Overall assessment.

The following graph shows a response summary of 51 respondents (26 from Alameda County and 25 from Orange County).

Section-level responses can be seen in the following chart. It is interesting to note that the large range in responses, from the lowest end of the spectrum (1) to the highest end of the spectrum (9), provide very mid-level averages.

Shortell and his team found that the major areas to work on included the shortage of providers (specifically primary care), information systems to track cost and quality, mechanisms for distributing shared savings, HER functionality, and integrating behavioral health.

Recommendations made as a result of the study can be found in this report.

Summary of the Proposal

This morning, DHCS hosted a stakeholder meeting on the proposed transition of Healthy Families (HFP) to Medi-Cal. A recently proposed trailer bill would require all HFP enrollees with family incomes up to 250% FPL to transition to Medi-Cal over a 9-month period, beginning either October 1, 2012 or 90 days after the bill is enacted (which ever date is later).  There are currently 875,000 eligible beneficiaries who would be involved in this transition. The transition would occur in three phases.

The Transition Process

Phase 1 – 90 days after enactment or October 1, 2012

HFP beneficiaries enrolled in plans that are also Medi-Cal managed care plan should be enrolled in the same plan, unless they choose a different Medi-Cal managed care plan. This will involve 411,506 enrollees.

Phase 2 – No earlier than January 1, 2012

HFP beneficiaries enrolled in an HFP managed care plan that is a subcontractor of a Medi-Cal managed care plan will be enrolled into a Medi-Cal managed care plan that includes their current primary care provider, unless they choose a different Medi-Cal managed care plan. These individuals are the remaining HFP enrollees that live in counties with Medi-Cal managed care plans that were not included in Phase 1. This will involve 416,605 enrollees.

Phase 3 – No earlier than January 1, 2013

HFP beneficiaries residing in a county that is not a Medi-Cal managed care county will receive services under the Medi-Cal fee-for-service system. These individuals will receive services through managed care once DHCS expands managed care to those counties in June 2013. This will involve 42,561 enrollees.

Above: Breakdown of total numbers of members in each plan.

Above: Timeline of the entire process, starting with initial DHCS/MRMIB meetings and ending with 1-year reports.

Change in Enrollment Structure for Future Enrollees

In both the current and future enrollment paths, applicants can apply through the County Welfare Office (either in person, online, or by mail) or MAXIMUS (either online or by mail). In the current system, those who screen for HFP are sent to HFP MAXIMUS and those who screen for Medi-Cal are sent to the county. In the future system, MAXIMUS provides premium and case management support to those who qualify for Share of Cost, but all cases are sent to the county.

Current Enrollment Path

In the current enrollment path, MAXIMUS screens applications for no-cost Medi-Cal/HFP, grants accelerated enrollment to children eligible for no-cost Medi-Cal and sends applications to the county of residence for no-cost Medi-Cal or HFP determination. The county completed eligibility determinations and send applications to HFP when the children have a share of cost. Then, HFP MAXIMUS determines HFP eligibility, enrolls the child in a health plan, provides premium management, conducts annual renewals, and refers HFP cases to counties for Medi-Cal determination when family income drops.

Future Enrollment Path

In the future enrollment path, MAXIMUS will review for completeness and screen all cases for final eligibility determination and the county will complete the eligibility determination for all children up to 250% FPL.  Children under 150% FPL (no-cost Medi-Cal) will be provided ongoing case maintenance by the county and children between 150% and 250% will be referred to MAXIMUS for ongoing case maintenance and premium collections.

Change in Eligibility Determinations

Current Eligibilities

Future Eligibilities

Changes in Reimbursements

Currently, out-of-network providers receive adequate reimbursements for providing emergency care to HFP enrollees while in-network providers receive HFP rates. Under Medi-Cal, out-of-network provider receive Medi-Cal rates for providing emergency care to Medi-Cal enrollees and in-network providers receive their contracted rates. This transition could pose issues for those who currently receive adequate reimbursements for providing emergency care to HFP enrollees.

Benefits to the Transition

Unified Family Coverage

Children will no longer have to transition between programs when the family income fluctuates. From 2009-2010, 42% of HFP children were eligible for Medi-Cal at some point over the previous three years.

No Wrong Door

Families can apply at a county, by mail or online.

Reduced Cost-Sharing

Children in families with incomes below 150% FPL will no longer pay premiums or co-payments. Families between 100 and 150% FPL currently pay monthly premiums between $4 and $14 and co-payments between $5 and $15 for services.

Expanded Benefits

Children will receive retroactive coverage for 3 months prior to their application, access to free vaccines, and those under 21 have access to the EPSDT program, which may also deem them eligible for the full range of Medi-Cal Specialty Mental Health Services.

Significant Plan and Provider Continuity

Most children will be able to remain with their existing plan. Data shows that 78% of HFP children are enrolled in a plan that participates in both Medi-Cal and HFP and 84% of providers contract with the plan for both HFP and Medi-Cal programs.

More Stable Plan Choices

HFP commercial health plan participants have been declining.

Simplified Contracting

With the 84% overlap of HFP and Medi-Cal providers, this will eliminate the need to manage two different contracts (one with DHCS and one with MRMIB).

Other benefits include: Consolidating Health Care Entitlement Programs, Simplifying Administration of Two Major Public Coverage Programs, Improving Plan Accountability and Monitoring, Achieving General Fund Savings, Aligning with More Consumer Friendly and Seamless Coverage System in 2014, Serves as Early Building Block for Successful Implementation of ACA.

Thank you all for helping make yesterday’s conference an overwhelming success! We are honored to have an amazing network of people dedicated to improving California’s delivery system and expanding coverage to the state’s uninsured. A special thank you to our wonderful speakers and to the volunteers and staff who worked tirelessly to make the day possible.

To informally review some of the key points made by conference speakers, check out the twitter hashtag #itup2012. We were lucky to have a number of attendees contributing to the twitter feed throughout the day.

You may access same-day handouts here. Additional conference materials, including speaker presentations, will be made available in the near future (a password may be required for access).

We look forward to seeing you all at our regional and issue workgroups over the next year. If you have any questions, concerns or feedback about the conference, please e-mail info@itup.org.

Today’s ITUP conference will be live tweeted by staff and attendees on www.twitter.com. Look out for the hashtag “itup2012,” or follow us as at @itup. The conference begins promptly at 8:30am and ends around 4:30pm. Click here to see the agenda.

Feel free to contact me at ashley@itup.org if you have any questions.

The Kids Coverage Coalition is engaging various stakeholders (especially consumer advocates) to begin thinking about the role assisters will play in 2014.  Due to the complexity of the Exchange and the target to enroll uninsured individuals in 2014,

Who are Navigators?

ACA established a Navigator program to help explain, educate, assist and successfully enroll consumers into QHPs within the Exchange. A Navigator is defined as an entity that assists consumers with Exchange enrollment. Their duties may include public education, distributing fair and impartial information, assisting in Exchange enrollment, providing culturally and linguistically appropriate information, and providing general health insurance consumer assistance. Specific criteria for navigators are still being developed by HHS.

ACA states that any private or public entity that is selected as a Navigator may receive a Navigator grant. To be eligible, this entity must either have existing relationships with individuals who qualify for the Exchange or must be able to readily form these relationships. Funding for Navigator grantees must come from fees assessed on QHPs and not from federal funding.

Progress on California’s “Assister” Program

According to United Way, On December 27, 2011, California’s Exchange Board released a Request for Proposals (RFP) for “Communications Support for the Outreach and education Campaign Plan and Assisters Program.” The RFP states that “assisters” can include Navigators and individuals/entities who already assist with coverage enrollment (i.e. agents, brokers, representatives of providers, community-based organization, county eligibility workers and many others). The RFP also contemplates the development of a compensation plan. Applications were due to the board by January 31. Another goal of this solicitation is to assist in preparing the apply for the Level II grant, a more robust grant than the Level I one which will fund the Exchange’s operation through the end of January 2014.

Some of the key points in the RFP include plans for:

• The design and development of a comprehensive Assisters Program Plan (including identifying training curriculum requirements) in order to conduct enrollment, outreach and education efforts for promoting state affordable health insurance programs;
• The development and design of an Assisters Program that will provide support for enrollment, retention and use of coverage; and
• The development of the Assisters Program’s functions will be uniquely distinctive compared to the design and development of statewide outreach and education campaigns.

Progress in Other States

According to the Georgetown University Health Policy Institute’s Center for Children and Families, 11 states have established Exchange legislation or executive orders and 29 have received Exchange establishment grants. California is further along than any other state in thinking about Navigators. Two other states, New York and Maryland, have also begun working on Navigator programs. Maryland has commissioned two reports (Manatt and Hilltop) to provide recommendations to inform future legislation. Findings indicate that there should be separate navigator and broker roles in both the individual and small business Exchange (SHOP). The New York Health Foundation commissioned a comprehensive report through their establishment grant, which is slated to be released April 2012.

Other states that are worth tracking include Washington, Rhode Island (long-standing success with CBO enrollment counselors for Medicaid/CHIP) and Massachusetts (strong contractual relationships with CBOs and providers).

The Kids Coverage Coalition will be releasing their final draft of their report, “Scope of the Navigator Role,” in the next few months.

The Exchange, in partnership with with the Department of Health Care Services, Department of Managed Health Care, Department of Insurance, and the Managed Risk Medical Insurance Board, submitted comments on the recent federal Essential Health Benefits bulletin. The comments are a result of discussions with stakeholders, an assessment of potential benchmark plans in California, and comments that were submitted to the Board.

Read the comments here.

Medi-Cal

Budget Proposal Includes Steep Cuts to HHS

Unsurprisingly, this year’s budget proposal is a continuation of a years-long trend that cuts deeply into critical HHS programs. Despite the state’s improving fiscal condition, slow economic growth and lower-than-anticipated General Fund revenues were cited as reasons for the major cuts and adjustments. Key proposed changes include a major reduction in IHSS services, a large expansion in managed care for seniors, individuals in rural areas, and long-term care beneficiaries. In addition, many of the state’s programs are proposed to be consolidated within DHCS, including Healthy Families, ADAP, mental health, substance abuse, and others. Significant trigger cuts will take effect in the event that it does not pass and General Fund revenues fail to meet expectations; none of these cuts, however, will directly affect HHS programs/departments. Read more here.

Judge Tentatively Blocks Medi-Cal Cuts

In October 2011, CMS approved the state’s plan to reduce certain Medi-Cal payments by 10%. State officials have projected that the cuts will save $623 million. On Monday, U.S. District Court Judge Christina Snyder tentatively blocked a 10% cut to Medi-Cal reimbursement rates, saying the cuts could cause irreparable harm. Read more here.

Integrating California’s Safety Net

Dr. Annette Gardner, PhD of UCSF recently looked at 5 different county safety net systems in California to determine their progress in integration leading up to 2014. At a UCSF briefing in Oakland on December 13, 2011, representatives from the 5 county systems came together to review the findings and share, in person, successes and challenges within their counties. Dr. Gardner selected five disparate counties that are very involved in implementing services and systems to create seamless health care safety nets. Counties vary based on type of delivery system, community, participation in the 2005 Coverage Initiatives, and geographic location. Counties selected were San Mateo, San Diego, Contra Costa, Humboldt and San Joaquin. Read the findings here.

§1115 Waiver

New ITUP Report on County Progress

The §1115 Waiver provides a bridge to implementation of the Affordable Care Act of 2010 (ACA). The projected value to the state and counties is more than $10 billion in federal match over the next five years. This briefing paper describes the evolution from our current system to the new system outlined in the ACA, and the waiver’s crucial role in facilitating this transition.

DHCS Releases Draft Behavioral Health Needs Assessment

Today, the Department of Health Care Services (DHCS) released their draft Waiver Behavioral Health Services Needs Assessment. The Needs Assessment will be funded by the California Endowment and the Substance Use and Mental Health Services Administration. Read more here.

Dual Eligibles

Medi-Cal Procurement Office Posts Final RFS for Duals Demonstrations

California is one of 15 states that has been awarded a federal contract to develop new models of coordinated care for people eligible for both Medicare and Mediciad (Medi-Cal), also known as dual eligibles. California has about 1.15 million dual eligibles. Dual eligibles tend to have many chronic health conditions and rely on services from numerous providers. The Duals Demonstration will involve models through which one entity is coordinating care for the total needs of a person – medical and social. Currently, only a small portion of California’s dual eligibles are enrolled in organized care systems. On December 22, 2011, the draft request for solutions for duals demonstrations was released. More than 50 individuals and organizations submitted comments. You can access the final RFS here. Read more from DHCS.

Evaluating Various Enrollment Options

DHS is preparing a demonstration proposal to the Centers for Medicare & Medicaid Services (CMS) to require Medicare beneficiaries who are also eligible for Medi-Cal to enroll in Medi-Cal MCOs. One goal of California’s demonstration project is to bring multiple kinds of care — behavioral health, social support, medical care and long-term coverage — under one administrative umbrella. One of the key decisions the state faces is how to orchestrate that movement. At a basic level, there are two options — either beneficiaries choose or the state assigns. However, under either option — or a combination of both options — there are dozens of details and circumstances that make the issue much more complex than a simple “either-or” decision. California Healthline recently asked policymakers and stakeholders to consider the pros and cons of various enrollment options — voluntary, mandatory, passive, active, opt-in, opt-out. Read more here.

California Health Benefit Exchange

Summary of the First January Board Meeting

The Exchange Board’s January 17 meeting was focused on the release of the IT solicitation, communications support for outreach, and health plan management and delivery systems improvement. During the open comment period (December 20-December 30, 2011), 1,343 stakeholder comments from 36 organizations were received regarding the draft RFP for an IT vendor. Comments included compliments on various aspects of the solicitation, corrections needed (i.e. verbiage, references), clarification requests (i.e. processes) and policy issues (i.e. other program functions). As a result of the comments, additional statements were added to various sections (see specific additions in this presentation). Read more about the January Board meeting here. The Board’s second January meeting focused on EHBs (see next article).

California Assesses Potential Benchmark Plans for Essential Health Benefits

On December 16, 2011, DHHS released a bulletin on EHBs regarding the regulatory approach they may use to define EHBs under Section 1302 of the Affordable Care Act. The bulletin proposed that EHBs be defined on a state-by-state basis using a benchmark approach. The Exchange Board contracted with a vendor, Milliman, to analyze and compare the health services covered by the 10 benchmark plans in California. Milliman determined that all potential benchmark plans are comprehensive, though pediatric dental and vision services and habilitative services are not typically covered in potential benchmark plans. Read more here. In addition, HHS recently released a list of the largest three small group products by state.

ITUP Workgroup Recommendations

In 2011, ITUP hosted two issue workgroups on the Exchange and 25 regional workgroups on various health policy topics throughout California’s nine regions. Workgroups brought together policy makers, counties, health plans, employers, unions, community groups, providers, advocates, and other public and private stakeholders throughout the state. ITUP has prepared a brief that summarizes participant thoughts and recommendations regarding the creation of the California Health Benefit Exchange. Overall, participants feel that aggressive outreach, a level playing field, continuity of coverage, program simplification and cultural/linguistic appropriateness are some of the keys to a successful Exchange.

Pre-Existing Condition Insurance Plan

California’s PCIP Ranks #1 in Enrollment

As of November 30, 2011, 4,907 Californians had enrolled in PCIP. California ranks higher than the other top states, including Pennsylvania (4,379), Texas (3, 644), Florida (3,285). According to the Business Journal, California’s PCIP enrollment reached 6,307 by Jan. 12, and an additional 467 individuals will be covered starting Feb. 1. Read more here.

Employers

Workers Experience Rises in Health Care Costs and Loss of Coverage

According to a recent California HealthCare Foundation report, workers at a quarter of California businesses saw their health benefits diminish while their copayments, deductibles, and premium shares increased in 2011. More than a third of employers are considering shifting more premium costs to workers next year. Other key findings from the report include: since 2002, family premiums rose 153%, more than five times the 29% increase in California’s inflation rate; the proportion of California employers offering coverage declined from 73% to 63% in the last two years; and workers at small firms with a deductible of $1,000 or more increased to 27% from just 7% in 2006.

Data

Rise in US Spending Reaches Historic Lows

January’s issue of Health Affairs reports that US health care spending reached historically low growth rates in 2009 and 2010.  According to analysts at CMS, the low rate of growth reflects lower utilization in health care than in previous years. Health care spending only grew 3.9% in 2010, which is just 0.1 percentage point faster than 2009.  Health spending as a share of the overall economy remained at 17.9% of the gross domestic product (GDP) as the economy rebounded and GDP grew 4.2%. This share has risen over time from 5.2% in 1960 to 17.9% in 2010. CMS attributed the low rate to the recession. Due to high unemployment, continued loss of private coverage, and increased out-of-pocket costs, many individuals chose to forgo care or seek less costly alternatives. Read more here.

Slower Moving States Have More to Gain from ACA

A new issue brief by Urban assesses state implementation progress and looks at expected benefits, dividing states according to their progress implementing Exchanges.   It also includes new state-level estimates of the coverage effects of the ACA. The study shows that slower moving states have a higher baseline uninsurance rate, on average, and would be likely to see the largest declines (i.e., most improvement) in their uninsurance rates and receive the most benefits.