Archive | State Health Exchanges

Finding health plans that include the doctors you want

Many consumers shopping for coverage through Covered California have trouble finding policies that include the doctors and hospitals they’re accustomed to seeing.

  • To make insurance affordable, insurers are seeking to control costs in part by limiting the number of doctors and hospitals included in their networks.

Shopping for doctors is never easy. This year, the state’s new health exchange seems to be making it tougher than ever.

  • Most of the insurance companies on the exchange are offering provider networks that are far narrower than those sold on the market today. Blue Shield is offering a network through its exchange plans that represents roughly 37% of its full network.

Many consumers who currently have insurance and are shopping for a new plan through Covered California are finding it difficult to locate policies that include the doctors and hospitals they’re accustomed to seeing.

Covered California issued a report last week saying that more than 58,000 physicians were available through the exchange’s plans, compared with the 63,000 to 72,000 physicians in the state’s largest commercial networks.  But how that plays out for consumers probably depends on the specific plan they choose.

  • In many cases, even doctors themselves are unsure of their status in the new plans. Insurers have a long history of inaccurate and outdated provider listings, which the law does nothing to fix. And the provider lists found on Covered California have themselves been riddled with errors.

*Modified from a LATimes.com article

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Insurers limiting doctors, hospitals in health insurance market

The doctor can’t see you now. Insurers in California’s new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.

  •  To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state’s new health insurance market opening Oct. 1.

New data reveal the extent of those cuts in California, a crucial test bed for the federal healthcare law. These diminished medical networks are fueling growing concerns that many patients will still struggle to get care despite the nation’s biggest healthcare expansion in half a century.

  • Consumers could see long wait times, a scarcity of specialists and loss of a longtime doctor. “These narrow networks won’t work because they cut off access for patients,” said Dr. Richard Baker, executive director of the Urban Health Institute at Charles Drew University of Medicine and Science in Los Angeles. “We don’t want this to become a roadblock.”

To see the challenges awaiting some consumers, consider Woodland Hills-based insurer Health Net Inc. Across Southern California the company has the lowest rates, with monthly premiums as much as $100 cheaper than the closest competitor in some cases.

  • Health Net also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data.

In Los Angeles County, for instance, Health Net customers in the state exchange would be limited to 2,316 primary-care doctors and specialists. That’s less than a third of the doctors Health Net offers to workers on employer plans.

In San Diego, there are only 204 primary-care doctors to serve Health Net patients.

  • Other major insurers have pared their list of medical providers too, but not to Health Net’s degree. Statewide, Blue Shield of California says exchange customers will be restricted to about 50% of its regular physician network.

In response, California officials have been pressing Health Net and other insurers to add more doctors since companies filed their initial rosters in May. The state exchange, Covered California, says it will monitor enrollment closely once it begins next month and it’s prepared to step in if problems arise.

“Our interest is in assuring everyone enrolled in a plan has ready access to the clinicians they need,” said Peter Lee, executive director of Covered California. “That means if a plan can’t serve patients, we’ll close it down from taking new enrollment. That is in some ways the nuclear option.”

In recent months, the top priority for state officials and insurers has been affordable premiums. A smaller panel of doctors and hospitals generally yields lower rates because insurers can negotiate better discounts with providers who receive more patients.

  • The California Medical Assn., which represents more than 37,000 doctors statewide, thinks the state is underestimating the difficulties ahead. Based on its research, the organization is skeptical of the state’s claim that its health plans will cover about 80% of all California physicians. Other doctors worry about the effect on certain Latino and African American communities that have been historically underserved.

But some health policy experts say that medical costs will continue to escalate if patients can’t see their doctor regularly and get the follow-up care they need for chronic conditions such as diabetes. Similar concerns over patient access have surfaced in other states such as Maine and Wisconsin.

  • “We are nervous about these narrow networks,” said Donald Crane, chief executive of the California Assn. of Physician Groups. “It was all about price. But at what cost in terms of quality and access? Is this contrary to the purpose of the Affordable Care Act?”

The federal law requires exchange plans to include enough providers so that services are available “without unreasonable delay.” Likewise, state law sets various requirements for “network adequacy” so patients have enough doctors and hospitals nearby.

  • The differences in network size are noticeable across Southern California. Health Net has 920 physicians in Orange County, compared with more than 2,500 for Blue Shield, according to company data.

Health Net has fewer than 800 doctors in San Diego County, while nearly 3,000 physicians are available in an Anthem Blue Cross plan.

  • In addition to doctors, some big-name hospitals may be left out. A spokesman for Cedars-Sinai Medical Center said the hospital has received many calls from patients who were worried about keeping their access to the hospital and its affiliated doctors in the new health plans next year.

*Modified from a LATimes.com article

 

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Uh oh: 7 in 10 Doctors Boycotting California’s Obamacare Exchange

 Another glaring example of why the ‘if you like your doctor, you can keep your doctor’ mantra President Obama and other ACA enthusiasts touted is simply false: An estimated seven out of every 10 physicians in deep-blue California are rebelling against the state’s Obamacare health insurance exchange and won’t participate, the head of the state’s largest medical association said.

  • “It doesn’t surprise me that there’s a high rate of nonparticipation,” said Dr. Richard Thorp, president of the California Medical Association. Thorp has been a primary care doctor for 38 years in a small town 90 miles north of Sacramento. The CMA represents 38,000 of the roughly 104,000 doctors in California.
  • He called the exchange’s doctors list a “shell game” because “the vast majority” of his doctors are not participating. Why? Because when asking physicians to participate in the exchange, the memorandum of understanding failed to provide reimbursement rates. As expected, few physicians were willing to blindly agree to participate without knowing what the rates would be.
  • “We need some recognition that we’re doing a service to the community. But we can’t do it for free. And we can’t do it at a loss. No other business would do that,” he said.
  • California offers one of the lowest government reimbursement rates in the country — 30 percent lower than federal Medicare payments. And reimbursement rates for some procedures are even lower.
  • In other states, Medicaid pays doctors $76 for return-office visits. But in California, Medi-Cal’s reimbursement is $24, according to Dr. Theodore M. Mazer, a San Diego ear, nose and throat doctor. In other states, doctors receive between $500 to $700 to perform a tonsillectomy. In California, they get $160, Mazer added.
  • Only in September did insurance companies disclose that their rates would be pegged to California’s Medi-Cal plan. That’s driven many doctors to just say no.
  • Who would have guessed? Physicians, like I’m sure most working adults, would rather not be paid a fraction of what their services are worth, so are choosing not to participate. This in turn means the pool of doctors available to patients will be smaller. And worse yet, they’re currently being led to believe that more doctors are participating than actually are.
  •  “Some physicians have been put in the network and they were included basically without their permission,” Lisa Folberg said. She is a CMA’s vice president of medical and regulatory Policy. “They may be listed as actually participating, but not of their own volition,” said Donald Waters, executive director of the Alameda-Contra Costa Medical Association.
  • Waters’ group represents 3,100 doctors in the East Bay area that includes Oakland, with an estimated 200,000 uninsured individuals.    “This is a dirty little secret that is not really talked about as they promote Covered California,” Waters said.
  • All of the changes and uncertainty in the health care industry are also, not surprisingly, leading many doctors to consider retiring early. “I just turned 55, and a lot of us are kind of going, ‘Maybe there’s something else we can do in the last 10 years,’ because this is just getting too onerous to keep on going,” said Dr. Theodore M. Mazer, the Washington Examiner reported.
  • Once again, enrollment does not mean access to care. “[T]here aren’t enough doctors to take the low rates of Medicaid,” said Alex Briscoe, health director for Alameda County Health Care Services Agency, the Washington Examiner reported. “There aren’t enough primary care physicians, period.

Modified from a Townhall.com and a Washington Examiner article

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Up to 35K ObamaCare Applications Still Not Entered in California

California residents who have signed up for health insurance on the state’s exchange to make sure they are covered on Jan.1 could still find themselves uninsured in the new year by no fault of their own. 

  • As many as 35,000 of the health insurance applications faxed in to Covered California, the state’s insurance exchange, have yet to be fully entered into the system, according to Sam Smith, president of the California Association of Health Underwriters, and the clock is ticking. In order to be covered by Jan. 1, Smith says California applications need to be fully processed by Dec. 23 and premium checks need to be postmarked by Dec. 31.
  • FOXBusiness.com learned on Thursday that the ObamaCare exchange in the Golden State is scrambling to get faxed applications into the system and none of the applications have been submitted to insurance carriers. “These people who think they were covered may be in for a holiday surprise,” says Smith. 
  • He says Covered California had been instructing brokers and agents to fax in applications from the first day the exchange opened on Oct. 1 because the website was not yet fully functional. If insurance companies haven’t received the applications, they can’t process them and fully enroll the individuals. And with so little time left, Smith is skeptical that verification and payment for premiums can be fully completed by the deadline.  

Mismanagement Leads to Major Logjam

  • Smith says it is standard practice in the insurance industry for scanned applications to be uploaded into databases automatically. After it’s scanned, brokers verify the information is correct before final submission.
  • At Covered California, however, the paper application differs from the online application – meaning that all faxed-in applications need to be manually entered into the database. This process, which can take up to two hours per application, has created a tremendous logjam for the state exchange, which Smith says has received anywhere from 23,000 to 35,000 applications by fax.
  • “The person that’s looking at this application and inputting the data has to be putting the information in by hand, and the [questions] are not in the same order as the data screen so you have to go back and forth, back and forth, which causes errors and adds time,” says Smith.
  • “They don’t have the manpower – now they’re telling us they won’t have the manpower.” Covered California is now asking brokers for their help—but it may be too late.
  • Smith says Covered California’s plan is to upload some of the basic information for each application, save it, and then send an online request to the broker who submitted the application. At that point, the broker can accept the request and fill out the application themselves – assuming they have the two hours necessary to finish the process.
  • If the enrollment process isn’t fully completed and the check isn’t postmarked by Dec, 31, coverage cannot begin on Jan. 1, says Smith. He is highly skeptical that brokers will be able to shepherd this process fully by the deadline.
  • Smith says the whole process could have been avoided if the website’s contractor had followed industry protocol regarding the applications, or had Covered California come forward with the truth and reached out to brokers for help earlier this fall.
  • “It’s a management issue. We may not like it, but the truth is our friend,” says Smith.

*Modified from a FoxBusiness.com article

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California votes against extending canceled health policies

Spurning President Obama’s plan for canceled policies, California’s health insurance exchange voted against any extension for about 1 million policyholders in the state. The five-member board of the exchange voted unanimously to keep its current requirement that insurers terminate most individual policies Dec. 31 because they don’t meet all the requirements of the Affordable Care Act.

  • The decision ends a weeklong drama over what would happen for policyholders who will lose their existing coverage at year-end and face finding replacement insurance that may cost them substantially more in many instances. Covered California, the state exchange, considered allowing renewals into 2014 as Obama proposed or a short-term extension through March to give people more time to shop.
  • But state leaders ultimately rejected those options. They expressed concerns about further confusing consumers and worried that widespread renewals could keep too many healthy customers out of the broader risk pool that will shape future rates.
  • “We know this transition is difficult and some people will be hurt,” said Covered California board member Susan Kennedy. “But delaying the transition won’t solve a single problem.”
  • Covered California said 79,891 people have enrolled in private health plans through Tuesday. The state has outperformed the troubled federal exchange, which has struggled with an error-prone website and meager enrollment.

Modified from a latimes.com article

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Small Group Health Insurance “Cancellations”––The Next Shoe to Drop But a More Complicated One

Obamacare is impacting the small group insurance market in many of the same ways as the individual health insurance market.

While employers with less than 50 workers don’t have to provide coverage, if they do they are required to comply with the same essential benefit mandates, age rating changes, and pre-existing condition reforms the individual market faces.

THIS MEANS ESSENTIALLY ALL SMALL GROUP POLICIES CANNOT CONTINUE AS THEY ARE––THEY HAVE TO BE DISONTINUED.

  • The first small group renewals are now occurring––the January 1 renewals that typically have to be delivered during the month of November under state law.
  • Many employers are facing significant changes in order to comply with Obamacare and therefore price increases. The biggest rate increases are generally going to those employers with the youngest groups the most impacted by the new “age compression” rules.
  • Does this mean these small employers’ coverage has been outright cancelled and they will now send their workers to the exchanges?  No, at least not anytime soon. But that does not mean that lots of these small employers aren’t angry and confused.
  • Some small groups, but only a very few, benefit from the grandfather rules if their plan was in place in March 2010 and they haven’t made any but the slightest changes. Like the individual market that comes under the same grandfather rules, the Obama administration made those regulations so stringent almost no one is grandfathered.
  • Perhaps the most common means by which small groups are avoiding the big increases, at least for the first year, is through the early renewal strategy. Most states and health plans have allowed employers to change their renewal date to late in 2013 thereby allowing them to keep the old health plans for about another year. But this is a stay of execution, not a solution. Their old plans are toast when they next renew.
  • If the small employer doesn’t have access to the early renewal strategy, then they must face higher premium costs immediately. To offset these higher costs, at least in part, small employers are doing what they have always done––increasing deductibles and co-pays to try to keep the premiums close to what they were. This is also what the employers who used the early renewal strategy will have to consider come the end of 2014.

Will the small employer, faced with these increases, abandon their health plans and send their workers to the exchanges? Since so many have gotten that early renewal one-year stay of execution, we really won’t know that for a while.

The number of small employers offering health benefits was already on a years long steady and this certainly can’t help. But with all of that said, the simplistic, “Small employers are better off dropping coverage and sending them to the exchange,” is just too simplistic.

Let’s say an employer pays $7,000 a year toward the average worker’s health insurance benefit––typical in the small market. Let’s further say the employer could just give the worker that money in a pay raise and send them to the exchange.

First, the employer can’t just give them a payroll raise of $7,000. Increasing their wages has payroll tax and benefit cost implications––Social Security and Medicare taxes, workers compensation premiums, fringe benefit costs tied to payroll, vacation pay, and so on. That $7,000 would need to be reduced to about $6,000 to offset the employers payroll costs before it could go to the worker (and an employer with more than 50 workers would also be subject to the $2,000 fine for not providing health benefits and the “raise” would have to be further reduced).

Now the worker has $6,000 to take to the exchange. But wait, health insurance bought by an individual is not income tax preferenced––the worker has to pay state, federal, and payroll taxes of their own on this “raise.” Even if the worker is only in a 20% marginal bracket, this means the $6,000 just melted to about $5,000.

So the worker ends up with $5,000 to take to the exchange––about $400 a month. A higher income worker in a higher tax bracket might end up with only $4,000 net of taxes with which to buy insurance.

How does the worker fare with $5,000 to spend in the exchange? Remember the lower your income the higher the subsidies. If the worker has a very low income, they do very well––maybe even make a lot of money. If they are lower middle-income, they do OK. If they are middle to upper income they lose.

Who wins under this scheme? The lowest paid and least skilled workers. Who loses? The highest paid and most skilled, and presumably sought after workers. This strategy suddenly doesn’t look so smart if competing for skilled workers is what worries the employer.

It gets more problematic. The health insurance exchange subsidies are tied to family income, not what an employer pays their workers. An employee making $50,000 with a family could win under this scheme by being eligible for lots of subsidy. But if another $50,000 worker has a spouse also working and the household income is now $80,000 or $90,000 a year they would be disqualified for all or most of the federal health insurance subsidies.

So, this $50,000 worker does OK and that one has to pay most if not the full cost of health insurance out of their pocket.

It gets even more complicated. Employers often contribute more for family coverage and give single workers less because their coverage costs less. So, how do they pass out the raise when and if health benefits are terminated? Does a single worker get paid less for doing the same job going forward?

Just ditching the employer’s health insurance plan can be more attractive to businesses that are filled with low-income and unskilled workers. But any business that relies on even a few skilled and key employees will likely find this simplistic, The, “Just dump the insurance, give them a raise, and send them to the exchange,” idea has more holes than Swiss cheese.

They will use the early renewal strategy when they can to buy themselves a year. Then they will likely increase employee premiums and deductibles to keep the wolf from the door for maybe another year. But Obamacare caps out-of-pocket costs and employers will quickly bump up against that in a year or two.

*Modified from a Health Care Policy and Marketplace Review article

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Why Obama Can’t Just Uncancel All Those Insurance Plans

President Obama’s plan to reverse himself and let millions of people keep their health policies—the ones that insurance companies cancelled because don’t meet the Affordable Care Act’s standards—is something like an attempt to unscramble an omelet.

Among the problems:

  • State insurance commissioners are not enthusiastic. They’re the people who are actually in charge of approving the plans and rates that private insurers offer in each state. The regulators association threw tepid water on the plan in a statement Thursday, saying the decision “threatens to undermine the new market, and may lead to higher premiums and market disruptions in 2014 and beyond.” These officials can nix the idea at the state level, as Washington state’s regulator already has, according to the New York Times.
  • The feeling isn’t unanimous: California’s insurance commissioner, who already pushed some health plans to extend policies because they didn’t give customers the notice required by law, favors extending policies. But other state laws make doing so messy. In Florida, too, the commissioner supports the plan.
  • Insurers are also wary. The industry had a cool response to the reversal. Even if insurers want to extend the old policies, and their regulators agree, it’s not clear that there’s enough time. Will doctors and hospitals accept the resurrected plans? Rates and plans are normally filed for approval months ahead of time. “The complexity of trying to uncancel millions of canceled individual policies with only six weeks left in the year is staggering,” Citigroup  analyst Carl McDonald wrote, Bloomberg News reports.
  • Extending old plans changes the risk pool next year. The people in the individual market whose plans were cancelled have already passed medical underwriting—the insurance industry’s practice, banned from next year on, of denying coverage to people for being sick or having other preexisting conditions. That means they’re generally a healthier bunch than those entering the exchanges next year. The idea that some of these folks would have to pay more for more robust plans was baked into the law—their premiums will help subsidize coverage for sicker people whom insurers can no longer turn away. That’s why regulators, actuaries, and insurers are warning that the change could destabilize the market next year and drive up premiums for everyone else.
  • Even if it works, the fix is not a fix—it’s a delay. Obama didn’t say he’d let people keep their old, noncompliant health plans indefinitely. Year-long policies that start through Oct. 1, 2014, will be considered OK, and the administration is “assessing whether to extend it beyond the specified time frame,” according to the administration’s letter to insurance commissioners. But whenever the administration does start enforcing that piece of the law, people are going to get another round of cancellation letters from their insurance company. If they don’t have comparable choices on the exchanges, they’ll get angry all over again.

*Modified from a BusinessWeek.com article

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Poll: 78% of Uninsured Not Interested in ObamaCare

A new Gallup poll brings more terrible news for President Obama and his signature health plan, showing that only 22% of uninsured Americans intend to buy insurance through the ObamaCare exchanges. The worse news is that you can bet that the 22% who do intend to sign up are made up of the oldest and sickest among the uninsured. Meanwhile, the 78% who are uninterested in being insured are likely the youngest and healthiest.

  • This means a sicker and older pool of enrollees, which means higher premiums for a couple hundred million Americans who were perfectly satisfied with what they had–that is, before President Obama, Democrats, and the media decided what was best for us.
  • One of the major selling points for using ObamaCare to disrupt our health care system (that polls showed up to 80% of Americans were satisfied with) was to insure the uninsured. But according to this poll, only a very small minority of that small minority is even interested in obtaining insurance. Even more troubling is the realization that a month ago, that number was double; a full 44% of the uninsured said they would purchase insurance though the exchanges.
  • Over the course of a month, however, the reality of ObamaCare scared off half of that 44%. The high cost of premiums, the high deductibles customers have to pay regardless of any tax subsidy, and the unforgivable bungling of the rollout only discouraged those who we blew up a perfectly good health care system to help.
  • When you look at the nearly 4 million Americans who have already had their insurance cancelled, the low enrollment numbers we have seen so far, and combine that with the website problems, sticker shock, and overall disgust, it is not out inconceivable to speculate that by this time next year, ObamaCare will have caused the number of uninsured in America to increase.

*Modified from a BigGovernment.com article

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Dave Jones says California customers should be allowed to keep health plans

California Insurance Commissioner Dave Jones said he’s taken steps Thursday to allow more than 1 million residents with terminating insurance plans to keep them through next year. Jones said he’s asked Covered California to release insurers offering plans on the exchange from the requirement to cancel policies that don’t comply with the health care overhaul.

  • Jones has said repeatedly that he disagreed with the state exchange’s decision not to allow those plans to continue once the federal law took full effect.. Neither California nor federal law requires insurers to cancel non-compliant plans by Dec. 31. Jones noted that California insurers are not canceling small business customers — “and I think that also is unfair,” he said.
  • “I’ve asked Covered California to take this action immediately so that health insurers are free then from this contract provision and can follow the president’s request, and my request, that they allow their existing customers to renew their policies into 2014,” Jones, a staunch supporter of the federal health law, said in a conference call from San Francisco.
  • In California, an estimated 1.1 million people have received cancellation notices informing them that their plans were out of compliance with the federal health care overhaul. Jones had foreshadowed his decision by negotiating temporary reprieves for about 225,000 customers with two large insurers – Blue Shield of California and Anthem Blue Cross of California
  • “It’s very clear to everybody who has been following this issue the federal government told people in California and throughout the United States they can stay in their existing plans,” Jones said. “These are individuals and families who did exactly what we’ve been urging them for years to do, which is to purchase health insurance … So, clearly there was a commitment made to them and I think it’s important, collectively, that commitment be upheld.”
  • A Covered California spokesman, Roy Kennedy, said in a statement the exchange was assessing the impact and analyzing its options on how it will incorporate the modification into existing policy. He said the exchange is aware of the “urgent need for clarity around this segment of policy and is working closely with health plans, regulators, and policymakers to quickly determine how the president’s new guidance will be fulfilled for Californians.”
  • Other states operating their own insurance marketplaces, including Washington and Oregon, are rebuffing Obama’s invitation to extend the canceled policies. Obama has come under increasing pressure from congressional Democrats to delay the cancellations in light of the administration’s problematic launch of its online web portal for three dozen states.
  • “We will not be allowing insurance companies to extend their policies,” Washington Insurance Commissioner Mike Kreidler said in a prepared statement. “I believe this is in the best interest of the health insurance market in Washington.” Oregon Insurance Commissioner Laura Cali has said there were too many logistical difficulties to justify an extension.

*Modified for a sacbee.com article

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California insurance chief criticizes exchange for cancellations

California Insurance Commissioner Dave Jones says the state health exchange “made a bad decision” by requiring its participating insurers to cancel coverage by Dec. 31 for hundreds of thousands of consumers. “I don’t think it was necessary,” Jones said in an interview. “I think people should be given the opportunity to stay in their current plans for another year.”

  • Tuesday, Jones discussed a settlement with Blue Shield of California that will buy some more time for about 80,000 policyholders whose policies are being terminated. The San Francisco insurer agreed to let those policyholders extend their current coverage until March 31 to resolve regulators’ claims it didn’t give customers ample warning about the changes.
  • “This is important because it will allow people with current plans more time to shop and it resolves a defect we discovered,” Jones said. But Blue Shield said the changing deadlines may confuse customers and lead some people to pay a deductible twice in one year after they enroll in a new plan for 2014.
  • The issue of cancellations for about 900,000 individual policyholders in California and several million nationwide has sparked intense criticism of President Obama’s healthcare law. In recent weeks, insurance companies across the country have notified policyholders that their existing coverage will expire because it doesn’t meet all the standards of the Affordable Care Act.
  • In previous interviews, Peter Lee, executive director of Covered California, has defended the exchange’s requirement for health plans to end current policies by Dec. 31. He says consumers will benefit in the long run from having more people in the larger risk pool, which will influence future rates.
  • Lee and others had worried about insurers cherry-picking their healthier customers and renewing them for another year through most of 2014, as permitted under the healthcare law.
  • Jones said he isn’t sure those fears were warranted. “I’m not convinced it would have been fatal to the risk pool,” said Jones, a Democrat who has strongly backed the implementation of the healthcare law. “The Dec. 31 cutoff for individual policies in California didn’t have to happen.”

*Modified from a LA Times article

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