Some states reconsider closing high-risk health insurance pools

About half of the 35 states operating insurance pools for high-risk residents had planned to close the pools after the Affordable Care Act’s insurance exchanges opened, but some of those states are considering extending their programs in light of ongoing problems with the exchanges. The move would temporarily keep some people with serious illnesses out of the new insurance exchanges, but it could also destabilize the market as insurers set premiums for 2015 in the spring. The Wall Street Journal (tiered subscription model)

ACA Implementation in California

The Affordable Care Act has already made a difference for millions of Californians who have new consumer protections — from removing lifetime limits and arbitrary caps on coverage to mandating coverage of preventative services without co-payments or cost sharing, according to Health Access. Hundreds of thousands of Californians have new financial help to afford care, including seniors on Medicare getting prescription drugs and small businesses getting tax credit s to continue to offer coverage to their workers.

The most recent 2013 estimates are that over one million Californians have been able to get coverage through new options provided under the Affordable Care Act. Over 21,000 Californians who were denied coverage by insurers due to their health status now have coverage through California’s ACA-funded Pre-existing Condition Insurance Program (PCIP). PCIP had 16,000 enrolled on July 31, 2012. Over 435,000 young California adults up to age 26 have coverage through their parent’s health plan under the ACA and state conforming legislation. Over 615,500 Californians in 53 counties have new coverage through Low-Income Health Programs (LIHPs) – the most expansive early expansion of coverage under the Affordable Care Act in the country.

Other provisions that have helped more people are the small employer tax credit, the early retiree reinsurance program, the financial relief and savings for the state budget, and the prevention of additional state cuts to eligibility and enrollment.

About 8,978,000 insured Californians gained new consumer protections. The over two million Californians who buy coverage as an individual now have the security that insurers are no longer permitted to rescind coverage, especially after the patient gets sick. Some ACA provisions provide direct financial assistance to allow patients and policyholders, seniors and small businesses, to get relief when paying premiums.
Health Access says the following efforts have helped consumers afford the cost of health care:
• No-Cost Preventative Care: 6,181,000 Californians now have preventative care without cost sharing, so there is no financial barrier between them are these screenings and services.
 Rebates: $73,905,280 in rebates were issued to the policyholders of 1,877,186 Californians because their insurance companies did not spend enough of their premium dollars on giving health care, under the ACA’s medical loss ratio provision.
• Rate Oversight: Over 1,507,532 Californians saved over $175.2 million as a result of the rate review process when Anthem, Blue Shield, and Aetna rate hikes that were retracted, rolled back, or withdrawn.
• Prescription Drug Help in Medicare: 319,429 California seniors and people with disabilities saved $453.8 million in prescription drug cost, under the ACA provision that begins the process to close the Medica re prescription drug donut hole.
• Small Business Tax Credit: In the 2011 tax year, over 375,000 California small businesses (70% of the total) were eligible for the tax credit to help pay for the cost of coverage of their 2,442,900 California workers. The average credit is $752 per worker. The average credit is $1,000 per worker for the 158,000 businesses that are eligible for the maximum assistance.

Other benefits include state budget savings yielded in the recent Medicaid waiver, which helped prevent further budget cuts. This list doesn’t include the millions of dollars in federal grants to enhance public health and prevention efforts, to build capacity in community clinics, to set up Covered California, and to improve consumer assistance programs — all of which have an economic impact as well.

Here are some specific examples of California’s leadership:
1. California was the first state to establish an insurance marketplace — Covered California. Covered California will also standardize benefit packages so consumers can make apples-to-apples comparisons.
2. The California Legislature passed laws requiring new essential benefits standards for coverage that will go into place in 2014. In addition, California mandated maternity coverage as a basic benefit 18 months early, in July 2012. It revived a benefit that most insurers were no longer giving in the individual insurance market.
3. With bipartisan authorship, California created the biggest pre-existing Condition Insurance Program in the country, a new option for over 16,000 Californians who were denied for private plans due to their health status. (The next highest state has around 10,000 enrollees.) PCIP became a victim of its own success, this month closing to new enrollees until 2014, when such denials will not be allowed. (MRMIP, the more limited state high-risk pool, will remain an option through 2013.)
4. California quickly implemented the ACA provision that banned denials for children with pre-existing conditions starting early in 2010. When insurers balked, state law made it clear that insurers who refused to offer policies to children would be barred from covering adults as well — bringing the major insurers back into the market. The state law also went further than federal law, to limit what children with pre-existing conditions can be charged to no more than twice any other child for the same policy.
5. California has been one of only five states to expand coverage early. The state has been the leader, using federal matching funds so that over 500,000 Californians are now getting coverage in county-run low-income health programs. (This total is more than 20 times the other states with early Medicaid expansions.) These enrollees will be shifted to full Medicaid coverage on January 2014.)

The major coverage expansions of the ACA will begin January 2014. California can cut the number of uninsured by half or even two-thirds, and provide more security for those with coverage. The Medicaid program will be expanded to cover virtually everyone around or below the poverty level, and affordable private coverage will be available for everyone who doesn’t get it through an employer. Models developed by the University of California project that, in five years, 1.2 million to 1.6 million Californians will enroll in Medi-Cal; and another 1.8 to 2.1 million will enroll in subsidized coverage in the Exchange. If done correctly, it will be the biggest expansion of coverage since the creation of Medicare and Medicaid in the 1960s. For more information, visit

Republicans Introduce Pre-Existing Plan Bill

House Republicans introduced a bill to shift additional funds into the Pre-Existing Conditions Insurance Plan to open it to new enrollees and extend funding through the end of the year. The Pre-Existing Conditions Insurance Plan was supposed to cover 375,000 enrollees. However, with only 110,000 enrolled, the administration was forced to close the program because of a lack of funds. The Helping Sick Americans Now Act would move funds from the Public Health and Prevention Fund into PCIP to keep the program open through the end of the calendar year.

H.R. 1549, The Helping Sick Americans Now Act, was introduced by Representatives Joe Pitts (PA) chairman of the Energy and Commerce Health Subcommittee, Michael Burgess, M.D. (TX), vice chair of the Health Subcommittee, and Ann Wagner (MO). Rep. Joe Pitts said, “Five weeks ago, House Republicans asked the President to move additional funds into the Pre-Existing Conditions Insurance Plan…Since the White House hasn’t answered our appeal, we’ve introduced legislation that would ensure that Americans with pre-existing conditions can once again have access to this program. “The Administration’s lack of a willingness to set sensible priorities has required us to introduce this legislation to provide immediate coverage for these individuals and ensure no American with a difficult medical diagnosis is told “tough luck” because the President failed to act,” said Rep. Burgess. “The legislation that will help dismantle the Public Health Slush Fund and help those with preexisting conditions get access to care through the high risk pools,” said Rep. Ann Wagner.

On April 3, the Health Subcommittee held a hearing to investigate the suspension of enrollment in PCIP. Susan Zurface, a 42-year old mother of two, testified about her struggle with leukemia and how being barred from the program has made it virtually impossible to get affordable health coverage. Testimony and video of this hearing is available here:

Last Updated 08/10/2022

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