Despite nearly 9-in-10 enrollees through California’s state-run public exchange receiving a subsidy to help pay for their insurance, almost half say it is difficult to afford the monthly premium.

According to a report by The Henry J. Kaiser Family Foundation, 44% of Covered California enrollees reported difficulty in paying their monthly premium, versus a quarter of adults with other types of private coverage. “It is clear that assistance is looking like it is not enough,” says Melissa Majerol, a policy analyst at Kaiser in Washington.

While this survey, funded by the Blue Shield of California Foundation, only looked at California, Majerol points out California has a higher cost of living, so that is one possibility to explain the difficulties.

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“Unfortunately, it has been the hard reality for Californians for many years that the basic cost of housing, food and transportation” takes up a higher percentage of income than many areas of the country, says Covered California spokesperson James Scullary. “It is no surprise that adding health insurance puts a strain on families. We know we need to change the underlying [cause] of health care being expensive.”

To overcome these challenges, the state and exchange are negotiating 2016 rates with health plans. As an active purchaser, the exchange secured a 4.2% weighted average increase for 2015, lower than the double-digit increases of the past, Scullary says.

The exchange is also working to lower consumers’ out-of-pocket expenses. On May 21, California became the first state to approve a cap on specialty drug costs, such as those to treat HIV and AIDS. The exchange has also made changes to standard benefit designs to reduce out-of-pocket expenses at the point of care, including adding lab tests and rehab to a co-pay and not applying those costs toward a deductible.

Since the majority of Covered California enrollees (62%) chose a silver plan, often they faced large pass-through costs with deductibles as high as $10,000. Under the new plan, almost all doctor visits and prescriptions are covered by a co-pay, Scullary says.

Getting appointments

Some of those newly insured also report difficulties with getting appointments. Those with coverage through Covered California or Medi-Cal were more likely than those with other private coverage to say a provider would not see them due to coverage. Thirteen percent of adults with Covered California and 8% of adults with Medi-Cal said a provider would not take them, compared to 3% of adults with private coverage, the Kaiser study found.

Further, larger numbers of the newly insured continue to visit emergency rooms versus doctor’s offices, which is a costly place to go to get primary care,” says Michael Lujan, co-founder and chief strategy officer at Limelight Health in San Francisco.

“They don’t know how to use coverage, they know what they know,” Lujan, who is the incoming president of the California Association of Health Underwriters, adds.

Sometimes, a provider won’t accept new patients or is no longer in-network. Lujan says this too is being worked on. A bill in the California Senate would mandate standardization around how often provider networks are updated to ensure information is accurate and not displaying doctors who are retired or even deceased, as it does now.

Brokers

Part of the way to overcome these challenges and to reach the remaining uninsured is through brokers, who play a “very, very important role,” Kaiser’s Majerol says. “Now that large sums of people have signed up, that will be the next step of [reaching] the remaining uninsured.”

Lujan adds that brokers are progressively doing more in California. In year one open enrollment, he says, there were barriers between brokers and getting access to community events, when agents and navigators were not allowed in the same place, or able to share resources or compensation.

In year two, there were able to gather at events. And in year three, they are opening storefronts “that look like community centers,” he says.

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Insurance agents are crucial to the success of the Affordable Care Act in California, says Scullary, the exchange spokesperson. “There is no doubt they are well rooted in the community. They are trusted individuals. These are people in your neighborhood,” he says. “They’ve been invaluable when it comes to helping people get the coverage they need.”

During the second open enrollment, the most used enrollments in exchanges (43%) were through a certified agent. “There is no question agents play[ed] a vital role,” Scullary says, “especially in communities where they speak the common language [of] consumers.”

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