By the end of December 2013, slightly more than 45,000 people in San Diego County had enrolled in a private health insurance plan through Covered California, about 2,000 more than the goal of enrolling 43,000 by the end of March.
According to the state’s most recent enrollment statistics, San Diego has already surpassed its target, reaching 105% of its goal by the end of December. Statewide, California has met 86% of the statewide target it hopes to meet by the end of open enrollment March 31. Of the more than 500,000 Californians who enrolled in a new health plan via the state’s exchange, 9% are based in San Diego, a part of the state representing 8.3% of the state’s total population.
By contrast, Los Angeles — which has enrolled more people than any other county in the state (132,000 by Dec. 31, 2013) — so far has reached just 74% of its open enrollment goal; another 45,000 residents will need to enroll to meet the county’s intended target.
Fresno and San Bernardino counties are showing the poorest performance in the state, having met 47% and 45% of enrollment goals respectively.
The Greater Bay Area is leading state enrollment benchmarks, having so far signed up nearly 117,000 people, well surpassing its base projection of roughly 89,000 enrollees and reaching 130% of its initial enrollment projection by the end of December 2013.
According to exchange officials, another 125,000 Californians purchased health insurance policies during the first half of January, several weeks after the latest numbers were officially released. However, information about where the additional enrollees live is not yet available.
Providers and insurers in the area are optimistic about the enrollment numbers.
Scripps Health reported an uptick in patients as a result of the law. “We are beginning to see an influx of Covered California patients at our practice locations,” said Janice Collins, senior director of public and community relations with Scripps Health.
Sharp HealthCare, which has long been a major presence in San Diego but is new to the individual health insurance market, is optimistic about how enrollment is progressing. Enrollment numbers in Sharp HealthCare plans have increased from around 4,100 on Dec. 31, 2013, to 5,821 by the end of January.
“This is especially gratifying since we are new to the individual market,” said John Cihomsky, vice president of public relations and communications with Sharp HealthCare. “We anticipate continued growth as we move closer to the March 31 deadline,” he said.
Although the numbers show progress in reducing the number of uninsured in the southern-most county of the state, more education is needed, said Brian Mast, vice president of communications for eHealthinsurance.com.
“While the state exchange has enrolled over 45,000, the total number of uninsured in this county alone is estimated to be over 380,000,” Mast said.
More education is needed about options available to consumers through Covered California, as well as directly from insurers or through insurance brokers, Mast said.
The San Diego Difference
San Diego’s enrollment patterns in many ways reflect the trends seen across the country. For example, in San Diego — as elsewhere — the majority of new enrollees who qualify for a tax subsidy selected a silver-level plan. In San Diego, 64% purchased a silver plan. Among those purchasing coverage through the federal exchange, Healthcare.gov, 60% opted for the silver plan.
“That’s what we’ve been expecting,” said Caroline Pearson, vice president at Avalere Health and head of the Washington D.C.-based advisory firm’s health reform practice. “People who are getting cost-sharing reductions, which are folks at 100% of poverty up to 250% of poverty, have a strong incentive to buy a silver plan with lower copays,” she said. Cost-sharing subsidies — which lower a person’s out-of-pocket expenses, such as deductibles and copayments — are only available to those who purchase silver plans.
Those with incomes between 200% and 400% of poverty level are also eligible for premium subsidies. “Those premium subsidies are pegged to a silver plan but people still have the option to buy down to bronze coverage,” Pearson said.
Through the federal exchange, 20% selected a bronze-level plan. In San Diego, such plans were more popular with those not eligible for subsidies; 38% of residents without financial assistance from the government selected a bronze plan.
In San Diego, 84% of the 45,000 people who bought insurance through Covered California qualified for a subsidy. Of those who bought coverage through the federal exchange, 79% enrolled in a plan using financial assistance.
But that may be where the similarities end, particularly when comparing San Diego’s performance against other regions of California.
One example: While Health Net has captured just 16% of overall enrollment throughout the state, in San Diego, it’s the market leader among those purchasing subsidized health plans — 29% of new enrollees selected a Health Net policy. Health Net is a close second on the unsubsidized side of the market with 25% of new enrollees. Blue Shield of California captured 30% of unsubsidized enrollees in San Diego.
San Diego’s Unique Characteristics
San Diego’s geography coupled with the price of the plans being offered by Health Net — particularly its HMO product — are two likely causes for its leading role, experts say.
“We don’t have the competitive nature of some of the other markets,” explained Linda Keller, executive vice president of consulting and account management with Intercare Solutions, a San Diego-based insurance brokerage.
Aside from Kaiser Permanente, the San Diego market is dominated by two health care provider groups — Scripps Health and Sharp HealthCare. Both are included in Health Net plans’ provider networks. Sharp HealthCare, however, is participating in more plans being sold in the area, including Health Net’s HMO plans. Scripps Health is included only by Health Net’s PPO bronze plan.
“In San Diego people are likely to say, well, Sharp is in all of [the plans] so I’m going to make my choice based on price. If Health Net’s got the lowest price then that’s the choice I’m going to make,” Keller said.
Lack of provider competition in the area combined with geography is influencing consumers’ choice of health plans, according to Keller. “San Diego is a unique market in that we’re surrounded by the ocean and Pendleton (a Marine Corps base north of San Diego) and the desert and Mexico, so you don’t really go outside of San Diego to get care,” she said.
Trade Offs Between Cost and Access
Craig Gussin, principle of San Diego-based Auerbach & Gussin Insurance and Financial Services, said many consumers will face limited access to providers. Most of the plans being sold through Covered California have limited their provider networks in an effort to hold down premium costs.
Health Net’s HMO provider network “is a tailored network and has about 800 PCPs and specialists,” said Brad Kieffer, a spokesperson for Health Net. By contrast, the company’s PPO network has more than 5,000 providers.
Its HMO network is considerably more popular than the PPO plan at this point, Kieffer said. Experts say that’s based on its highly competitive price.
“I just worked with a family of three … and looked at silver plans for them,” Gussin said. “HealthNet was $144 per months and the next closest plan was $272.”
Gussin is concerned about the longer-term effect of the narrow networks.
“My prediction is in the next three months when they realize they can’t see their doctors, you’re going to have a major upheaval,” he said, referring to consumers enrolling in the lowest-cost plans, which also have the most-limited networks.
As the end of the open enrollment period approaches, experts say more attention will inevitably be paid to consumers’ satisfaction with the plans they’ve purchased. How all the changes play out in San Diego over the next months and year will no doubt be felt in the market and influence open enrollment for the 2015 benefit year.
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