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Tour Urges Health Care; Officials Say Residents Need To Get Coverage

VENTURA COUNTY STAR

Health insurance consumers worry about skinny networks of doctors, money they may need to pull out of their pockets, and rising tax penalties faced by the uninsured.
Covered California Executive Director Peter V. Lee said they should focus more on a patient from the Pomona area. He underwent emergency heart surgery and then obtained coverage through the 2-year-old Covered California marketplace created to cover the previously uninsured.
"The big penalty," Lee said of people bypassing insurance, "is you're rolling the dice that you won't walk out of the ER with a $40,000 debt."

Lee and other Covered California officials came Tuesday to Ventura, to Clinicas del Camino Real, to push enrollment for 2016 coverage.

Enrollment in plans sold through Covered California just began and runs to Jan. 31.

They chose Clinicas to be part of their across-the-state bus tour because the countywide clinic system provides 19 counselors who help people enroll in Covered California plans. The system also provides care for people in a coordinated-care approach praised by Lee.

Created via the Affordable Care Act, Covered California covers more than 1.3 million residents across the state, with about 90 percent meeting income levels that qualify them for subsidies to reduce premiums. Between 295,000 and 450,000 people are expected to join plans for next year.

In Ventura County, 32,900 people were enrolled at the end of June. Nearly 30,000 received subsidies.

Premiums are increasing a little more than 4 percent next year in the three-county region that includes Ventura County. For people in bronze plans, deductibles are rising from the current rate of $5,000 for a single person to $6,000.

"Sometimes they're surprised at how expensive it can be," said Catherine Pedrosa, outreach education specialist for the United Way of Ventura County, noting that co-pays decrease under the higher-premium plans.

Lee said many people in plans outside the bronze tier will face little, if any, deductible for much of their care.

Although premiums are rising, many of the people who receive subsidies will end up paying less next year, he said.

Other people worry about access to doctors. A study released earlier this year concluded 75 percent of the physician networks in California's Affordable Care Act plans are narrow. That means 25 percent or fewer doctors in a region are covered.

"California is in real trouble when it comes to new enrollees seeing doctors when they need them," said Carmen Balber, executive director of the Consumer Watchdog advocacy group.

Lee called such studies "thinly done" and said access to care in Covered California is the same as in other private insurance systems.

"These are 'health care in America' issues," he said of the size of physician networks.

Availability of doctors in Ventura County will increase because UnitedHealthcare has been added to the list of insurers, Lee said. Anthem Blue Cross, Blue Shield and Kaiser Permanente also offer Covered California plans in the county.

Balber said it's particularly difficult for people to find out whether their specialists are covered.

"There's no guide for consumers to be able to tell how many specialists, how many cardiologists in their area, are available," she said.

The California Department of Managed Health Care announced Tuesday it was fining Blue Shield and Anthem Blue Cross for inaccurate directories in 2014 designed to show which doctors were covered in Covered California plans.

Lee called the announcement old news. He said insurers have made big strides in improving their directories since 2014.

Covered California also plans to offer a consolidated directory of doctors, he said, suggesting the change could happen in the next year.

Dr. Richard Declusin, a heart and lung surgeon in Oxnard, is not in any Covered California networks and doesn't plan to be in the future.

"Reimbursement to physicians is exceedingly low," he said of the payments provided by the insurers who sell plans through Covered California. "It's lower than our expenses."

Lee said 80 percent of California's doctors are included in a Covered California plan. He defended the system's network of specialists but said primary-care doctors on the front-line of treatment are the priority.

The health care model of compensating specialists far more than primary-care doctors is backward, he said. Covered California pushes insurers to offer financial rewards to primary-care doctors who meet certain standards.

Lee addressed rising tax penalties faced by people who don't obtain insurance. He noted some people are exempt if the cost of insurance overwhelms their budgets.

But he also said the penalties are a way for the uninsured to contribute to costs of care that otherwise are shouldered by all taxpayers.

"It's all of our burden," he said.