Small-Business Exchanges Draw Few Insurers

Obamacare’s new insurance marketplaces for small businesses, which have already stumbled before getting out of the gate, are facing another pressing question just months before millions can sign up for benefits: What happens if insurers don’t show up to sell?

Early looks at insurance offerings on the Obamacare exchanges show that insurers aren’t exactly signing up in droves to sell on the new Small Business Health Option Program exchanges. In some states, just one insurer has signed up for the SHOP exchanges, which are supposed to foster competition and make it easier for small businesses to purchase coverage. The SHOP exchanges exist alongside the exchanges for individuals, which have gotten more attention in preparation for the health law’s rollout.

Continue Reading The Obama administration is still trying to recruit insurers to states where there’s been little interest in exchanges. But some health law advocates believe administration health officials have put a greater emphasis on standing up the individual exchanges, where they hope premium tax credits will be a big draw for millions to sign up for coverage next year.

In many cases, they also see little incentive for SHOP exchanges in 2014. A limited tax credit for small businesses available only in the SHOP exchanges has so far received less interest than expected, and a key feature providing employees with more freedom to pick their health plan has been delayed in most states.

“I think the SHOP exchanges are basically a 2015 issue, but we will see how they work out in the states that are doing them, and they might turn out to be a bigger factor going forward,” said Tim Jost, a Washington and Lee University law professor and supporter of the health law.

That’s the hope in Washington state. Just one insurer will sell exchange plans to small businesses in 2014, even as nine signed up for the state’s individual exchange. So the Washington exchange is scaling back the SHOP rollout, making the program available in only some counties in the first year.

Exchange officials in the state insist that they were ready for a full SHOP launch in the first year, but they said insurers, facing limited time to prepare for these new markets, focused on scooping up customers in the individual market, which the exchange had projected would account for 98 percent of enrollment in 2014.

“While we were disappointed overall this first year, it was just tough for [insurers] from a timing standpoint to get everything geared up and ready to roll for Oct. 1,” said Michael Marchand, director of communications for the exchange. Already, several insurers have indicated their interest in joining the SHOP exchange for 2015, he said.

Just one insurer has also signed up to sell coverage in North Carolina’s federal-run small-business exchange in 2014, prompting concern from advocates in the state.

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Insurers See Way To Dodge Federal Healthcare Law Next Year

A new fight is brewing over health insurance companies letting millions of Americans renew their current coverage for another year — and thereby avoid changes under the federal healthcare law.

That may offer a short-term benefit for certain consumers and shield some of those individual policyholders from potentially steep rate increases. But critics say this maneuver could undermine government efforts to remake the insurance market next year and keep premiums affordable overall.

At issue is a little-known loophole in President Obama's landmark legislation that enables health insurers to extend existing policies for nearly all of 2014. This runs contrary to the widespread belief that all health insurance must immediately comply with new federal rules starting Jan. 1, when most provisions of the law take effect.

"Insurers are onto this, and the big question is how many will try to game the system," said Timothy Stoltzfus Jost, a law professor and health policy expert at Washington and Lee University.

Some of the nation's biggest health insurers are looking to take advantage of this delay, and Arkansas officials are encouraging companies to do this by resetting customers' renewal dates for the end of December. There's also concern that some insurers and agents could rush to sell more individual policies before year-end so they could be extended in 2014.

Some policy experts are expressing concern about this practice for fear that insurers will focus on renewing younger and healthier policyholders and hold them out of the broader insurance pool next year. Their absence could leave a sicker and older population in new government insurance exchanges, driving up medical costs and premiums there.

"This could undermine the Affordable Care Act, and it opens the door for exacerbating potential rate shock in the exchanges," said Christine Monahan, a senior analyst at Georgetown University's Health Policy Institute. "The health insurers can cherry-pick some healthy people and it raises prices for everyone else."

This issue could affect some of the 15 million people nationwide who purchase their own coverage and millions more of the uninsured who are expected to join government exchanges next year. It would not pertain to the 150 million Americans who get health benefits through their employers.

Many health insurers are still mulling over their options on how to handle these individual renewals.

"Some carriers will require everyone to switch plans Jan. 1, and other carriers will allow customers to stay on their existing plan as long as possible," said Bob Hurley, senior vice president of carrier relations at online site eHealthInsurance. "We are trying to nail this down with the carriers. I think it would be better for consumers to have that choice to carry their policy forward."

The nation's largest health insurer, UnitedHealth Group Inc. of Minnetonka, Minn., said, "We are currently looking at the best way to serve our customers' best interests while continuing to comply with the Affordable Care Act going into 2014."

WellPoint Inc., the Indianapolis insurance giant that runs Blue Cross plans in California and 13 other states, said its renewal practices will vary by state. In California, the company said its Anthem Blue Cross unit may allow individual policyholders to renew through March 31.

Kaiser Permanente, a major nonprofit health plan based in Oakland, said it doesn't plan to renew policies beyond Jan. 1 in California and most of the other states where it sells coverage.

Richard Kern and his wife, a retired couple in Los Angeles, say they would welcome the flexibility to keep their individual policy from Aetna Inc. for another year amid so much uncertainty over next year's rates.

"We don't even know what the prices and alternatives are under Obamacare," Kern said. "We are waiting for the other shoe to drop."

If an insurer offers this option, it would then be up to consumers to decide whether they want to renew an existing policy into 2014. The length of any renewal may depend on what month their annual plan year begins.

Many lower-income people will qualify for federal premium subsidies, which will be available only when purchasing new coverage available in state- or federal-run insurance exchanges. It would make financial sense to take advantage of that government aid. Individuals earning less than $46,000 or families below $94,000 annually would be eligible for subsidies.

However, many people who are middle income or above could face significantly higher premiums next year with no subsidies. Those premium increases are tied to federal requirements that insurers accept all applicants regardless of their medical condition and the inclusion of more comprehensive benefits.

Renewing an older policy could mean forgoing some of those richer benefits and new limits on out-of-pocket medical expenses.

Last week, California officials estimated that premiums may rise 30% on average for about 1.3 million existing policyholders primarily because of those changes in the federal law. Insurers have warned that some customers could see their premiums double depending on their age and other factors.

Citing that threat of higher rates, Arkansas officials issued a bulletin to insurers last month describing how they could extend individual policies until Dec. 30, 2013, and then renew them for another year.

These health plans "would not be required to comply with the [Affordable Care Act] market reforms until 12/31/2014," according to the Arkansas bulletin.

"For those folks who don't qualify for subsidies, this is a consumer-friendly thing because the premium rates for 2014 will be substantially higher," said Dan Honey, deputy commissioner of compliance for the Arkansas Insurance Department. "You will be exposed to rate shock."

Other states may oppose that approach, further underscoring the uneven implementation of the federal healthcare law across the country. Oregon Insurance Commissioner Louis Savage said these renewals could be problematic and his office issued a rule barring any extension beyond March 31, 2014.

"We want to get as many people as possible into the exchange," Savage said. "I think having renewals go deep into 2014 is counterproductive to the goals of the federal healthcare law."

In California, state lawmakers are working on legislation that could address this renewal issue and other details about how individual policies comply with the federal overhaul.

These questions over renewals are separate from "grandfathered" health policies that existed before the federal law passed in March 2010. Those plans don't have to meet all the requirements of the healthcare law as long as insurers or employers don't make significant changes to them.

chad.terhune@latimes.com

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Virginia Lawmakers Agree: Banning Insurers From Covering Abortion Hurts Low-Income Women

This week, Virginia became the 21st state to restrict coverage for abortion services in the health insurance marketplaces set up under Obamacare. Over the past several years, that’s become an increasingly common tactic to restrict abortion access, as anti-choice lawmakers rush to prevent insurers from being able to cover the cost of the legal medical procedure.

Even though the measure banning abortion coverage — which was an amendment that Gov. Bob McDonnell (R) tacked onto a broader General Assembly bill — ultimately passed the legislature, it still sparked a debate that cut across party lines. Republican and Democratic lawmakers both suggested that preventing women from using their insurance coverage to pay for abortion services is ultimately a class issue, a point confirmed by women’s health advocates:

But members of both parties agree that the measure’s biggest impact will likely fall along class lines, landing hardest on some of the people the federal health-care overhaul was designed to help: working women who barely get by on their incomes.

“Those people that can afford insurance outside of the exchanges will be able to buy whatever they want. People that can’t afford to buy outside of the exchange will have to buy policies that don’t cover these procedures,” said Sen. John C. Watkins (R-Powhatan), who sponsored the bill but opposed the amendment by Gov. Robert F. McDonnell (R). “It just sets up a class situation, in my mind.” [...]

Cianti Stewart-Reid, executive director of Planned Parenthood Advocates of Virginia, said that the only real effect of the amendment would be to limit access for women who make too much money to qualify for Medicaid but not enough to purchase their insurance on the private market.

“What it means is that women — by and large low-income but working women in Virginia — won’t have access to abortion,” Stewart-Reid said.

Abortion access is, of course, an incredibly important class issue. Of all the women who have abortions in the United States, 42 percent fall below the federal poverty line — partly because low-income women often still struggle to access affordable and reliable contraception. And when women are denied the opportunity to have a legal abortion, that greatly increases their risk of falling into poverty.

And the restrictions that state lawmakers pile on top of women seeking to have an abortion often hit low-income women the hardest. For example, 24-hour waiting periods — which force women to make multiple trips to a clinic — ultimately mean women are paying the costs for the additional transportation, the additional childcare, and the additional lost income during the time off of work. On top of the hundreds of dollars that an abortion procedure can cost out-of-pocket, that quickly adds up to be too much for poor women who are already struggling to pay the bills.

Virginia lawmakers were correct to identify the class dynamics exacerbated by unnecessary restrictions on abortion coverage. Unfortunately for the women in the state, however, their anti-abortion governor is expected to sign the legislation into law.

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Insurers See Way To Dodge Federal Healthcare Law Next Year

A new fight is brewing over health insurance companies letting millions of Americans renew their current coverage for another year — and thereby avoid changes under the federal healthcare law.

That may offer a short-term benefit for certain consumers and shield some of those individual policyholders from potentially steep rate increases. But critics say this maneuver could undermine government efforts to remake the insurance market next year and keep premiums affordable overall.

At issue is a little-known loophole in President Obama's landmark legislation that enables health insurers to extend existing policies for nearly all of 2014. This runs contrary to the widespread belief that all health insurance must immediately comply with new federal rules starting Jan. 1, when most provisions of the law take effect.

"Insurers are onto this, and the big question is how many will try to game the system," said Timothy Stoltzfus Jost, a law professor and health policy expert at Washington and Lee University.

Some of the nation's biggest health insurers are looking to take advantage of this delay, and Arkansas officials are encouraging companies to do this by resetting customers' renewal dates for the end of December. There's also concern that some insurers and agents could rush to sell more individual policies before year-end so they could be extended in 2014.

Some policy experts are expressing concern about this practice for fear that insurers will focus on renewing younger and healthier policyholders and hold them out of the broader insurance pool next year. Their absence could leave a sicker and older population in new government insurance exchanges, driving up medical costs and premiums there.

"This could undermine the Affordable Care Act, and it opens the door for exacerbating potential rate shock in the exchanges," said Christine Monahan, a senior analyst at Georgetown University's Health Policy Institute. "The health insurers can cherry-pick some healthy people and it raises prices for everyone else."

This issue could affect some of the 15 million people nationwide who purchase their own coverage and millions more of the uninsured who are expected to join government exchanges next year. It would not pertain to the 150 million Americans who get health benefits through their employers.

Many health insurers are still mulling over their options on how to handle these individual renewals.

"Some carriers will require everyone to switch plans Jan. 1, and other carriers will allow customers to stay on their existing plan as long as possible," said Bob Hurley, senior vice president of carrier relations at online site eHealthInsurance. "We are trying to nail this down with the carriers. I think it would be better for consumers to have that choice to carry their policy forward."

The nation's largest health insurer, UnitedHealth Group Inc. of Minnetonka, Minn., said, "We are currently looking at the best way to serve our customers' best interests while continuing to comply with the Affordable Care Act going into 2014."

WellPoint Inc., the Indianapolis insurance giant that runs Blue Cross plans in California and 13 other states, said its renewal practices will vary by state. In California, the company said its Anthem Blue Cross unit may allow individual policyholders to renew through March 31.

Kaiser Permanente, a major nonprofit health plan based in Oakland, said it doesn't plan to renew policies beyond Jan. 1 in California and most of the other states where it sells coverage.

Richard Kern and his wife, a retired couple in Los Angeles, say they would welcome the flexibility to keep their individual policy from Aetna Inc. for another year amid so much uncertainty over next year's rates.

"We don't even know what the prices and alternatives are under Obamacare," Kern said. "We are waiting for the other shoe to drop."

If an insurer offers this option, it would then be up to consumers to decide whether they want to renew an existing policy into 2014. The length of any renewal may depend on what month their annual plan year begins.

Many lower-income people will qualify for federal premium subsidies, which will be available only when purchasing new coverage available in state- or federal-run insurance exchanges. It would make financial sense to take advantage of that government aid. Individuals earning less than $46,000 or families below $94,000 annually would be eligible for subsidies.

However, many people who are middle income or above could face significantly higher premiums next year with no subsidies. Those premium increases are tied to federal requirements that insurers accept all applicants regardless of their medical condition and the inclusion of more comprehensive benefits.

Renewing an older policy could mean forgoing some of those richer benefits and new limits on out-of-pocket medical expenses.

Last week, California officials estimated that premiums may rise 30% on average for about 1.3 million existing policyholders primarily because of those changes in the federal law. Insurers have warned that some customers could see their premiums double depending on their age and other factors.

Citing that threat of higher rates, Arkansas officials issued a bulletin to insurers last month describing how they could extend individual policies until Dec. 30, 2013, and then renew them for another year.

These health plans "would not be required to comply with the [Affordable Care Act] market reforms until 12/31/2014," according to the Arkansas bulletin.

"For those folks who don't qualify for subsidies, this is a consumer-friendly thing because the premium rates for 2014 will be substantially higher," said Dan Honey, deputy commissioner of compliance for the Arkansas Insurance Department. "You will be exposed to rate shock."

Other states may oppose that approach, further underscoring the uneven implementation of the federal healthcare law across the country. Oregon Insurance Commissioner Louis Savage said these renewals could be problematic and his office issued a rule barring any extension beyond March 31, 2014.

"We want to get as many people as possible into the exchange," Savage said. "I think having renewals go deep into 2014 is counterproductive to the goals of the federal healthcare law."

In California, state lawmakers are working on legislation that could address this renewal issue and other details about how individual policies comply with the federal overhaul.

These questions over renewals are separate from "grandfathered" health policies that existed before the federal law passed in March 2010. Those plans don't have to meet all the requirements of the healthcare law as long as insurers or employers don't make significant changes to them.

chad.terhune@latimes.com

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Insurers Limit Doctors, Hospitals In State-Run Exchange Plans

California's health insurance rates for a new state-run marketplace came in lower than expected this week, but one downside for many consumers will be far fewer doctors and hospitals to choose from.

People who want UCLA Medical Center and its doctors in their health plan network next year, for instance, may have only one choice in California's exchange: Anthem Blue Cross. Another major insurer in the state-run market, Blue Shield of California, said its exchange customers will be restricted to 36% of its regular physician network statewide.

And Cedars-Sinai Medical Center, one of Southern California's most prestigious and expensive hospitals, said it's not included in any exchange plans at the moment.

Those types of exclusive arrangements, increasingly tight networks and outright exclusions are becoming more common as insurers and government officials search for ways to hold down rising medical costs.

The vast majority of Californians get their health coverage through their employers and won't be immediately affected by these limitations in the state-run market. But private companies are pursuing similar changes to shave costs. More employers have been adopting these narrower networks and the government's overhaul of the individual insurance market is accelerating the trend.

Some consumer advocates express concern that insurers will go too far and deprive patients of meaningful choices. State officials sought to blunt that criticism this week, pointing out that the 13 health insurers selected will offer access to about 80% of California's practicing physicians and hospitals.

"If we want to keep costs down, something has to give," said Betsy Imholz, special projects director for Consumers Union. "At first blush, it seems like Covered California has negotiated some good deals, but in any given community we will see how this network issue plays out."

Covered California, the state agency implementing the federal healthcare law, said these trade-offs are necessary in many cases to keep premiums reasonable for California's families. Officials said they took steps to ensure that health plans offer an adequate number of quality medical providers and have measures in place for expanding their networks in the event that more people than expected sign up.

More than 5 million Californians are expected to be eligible for coverage in the exchange, and about half of them could qualify for federal premium subsidies.

Details on these insurance networks aren't known yet as insurers and providers wrap up their contracts and await regulators' review in the coming weeks. It's possible some medical groups and hospitals could be added.

Health Net Inc., another exchange option in Southern California, said it expects to seek state approval to use its existing network, which includes both UCLA and Cedars-Sinai, for one of its exchange plans.

Once all those decisions are finalized by early July, Covered California said it will help consumers find out online whether particular doctors and hospitals are in a health plan's network. Enrollment in the exchange opens Oct. 1 for policies that take effect in January, when most Americans must have health insurance or pay a penalty.

"When people come to choose their plan, we will have a directory so they can make sure Dr. Ramirez is in these three plans, for instance," said Peter Lee, executive director of Covered California. "Consumers care about that information."

Meanwhile, some insurance agents said it's hard to judge these proposed prices in the state exchange without knowing what's on the menu in terms of available providers.

"Trying to determine whether these rates are low or high without knowing the provider networks is like trying to tell the value of a car when you can only see the tires — you don't know if you are looking at a Ferrari or a Yugo," said Bruce Jugan, an insurance agent in Montebello and president of Benefitscafe.com, which sells health insurance to individuals and businesses.

Paul Markovich, chief executive of Blue Shield, said renegotiating with hospitals and physician groups for lower reimbursements was a key factor for insurers in holding down rates. Medical providers are sometimes willing to accept lower payments in return for higher patient volume from these narrow networks.

Markovich said premiums for Blue Shield's existing individual policyholders will rise 13% next year on average for coverage under exchange plans.

That marked an improvement from earlier predictions of even bigger rate hikes. The state issued a report in March that estimated premiums for many consumers could go up 30%, on average.

Premiums are generally rising to reflect the federal law's requirements for richer benefits and guaranteed coverage regardless of people's medical history.

"The physicians and hospitals that signed up for our network have agreed to accept lower reimbursement specifically to make the exchange more affordable," Markovich said.

Blue Shield's exchange network in the Los Angeles area doesn't include UCLA or Cedars-Sinai. Instead, it features hospitals such as Keck Hospital of USC, Long Beach Memorial and St. John's Health Center. Blue Shield said its statewide network for exchange policies will include about 24,000 physicians, compared with 66,000 doctors in its full preferred provider organization roster.

In Los Angeles County, state officials expect 1.6 million people to be eligible for coverage in the exchange. Premiums will vary based on a person's age, location and level of coverage.

For instance, in the north Los Angeles County region, the rates for a 40-year-old purchasing a Silver plan range from $222 a month for Health Net to $294 a month for Kaiser Permanente. There will still be other individual policies for sale outside those offered through Covered California, but federal subsidies can be used only inside the exchange.

Health Net sees growing acceptance of these narrower networks. The Woodland Hills insurer said enrollment among employers in California, Arizona and Oregon in those smaller networks has grown 37% in the last year.

chad.terhune@latimes.com

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Health Insurers Decline on Proposed Medicare Advantage Cuts

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Doctors, Insurers Trade Blame on Out-of-Network Fees

Just over a year ago, Angel Gonzalez, 36, awoke with searing chest pain at 2 a.m. A friend drove him to the closest emergency room.

Though he was living on $18,000 a year as a graduate student, Mr. Gonzalez had good insurance and the hospital, St. Charles in Port Jefferson, N.Y., was in his network. But the surgeon who came in to remove Mr. Gonzalez's gallbladder that Sunday night was not.

He billed Mr. Gonzalez $30,000, and an assistant billed an additional $30,000. Mr. Gonzalez's policy covered out-of-network providers, but at a rate it considered appropriate: $2,000. "I was on the hook for more than I made in a year," Mr. Gonzalez said.

A health-insurance industry report to be released on Friday highlights the exorbitant fees charged by some doctors to out-of-network patients like Mr. Gonzalez. The report, by America's Health Insurance Plans, or AHIP, contrasts some of the highest bills charged by non-network providers in 30 states with Medicare rates for the same services. Some of the charges, the insurers assert, are 30, 40 or nearly 100 times greater than Medicare rates.

Insurers hope to spotlight a vexing problem that they say the Affordable Care Act does little to address. "When you're out of network, it's a blank check," said Karen Ignagni, president and chief executive of AHIP. "The consumer is vulnerable to 'anything goes.' "

"Unless we deal with cost, we won't have affordability," she added. "And unless we have affordability, we won't have people participating" under the Affordable Care Act.

Among the fees on the report's list are a $6,205 outpatient office visit to a doctor in Massachusetts for which Medicare would have paid $152; a $12,000 bill for examining a tissue specimen in New York for which Medicare would have paid $128; and a $48,983 surgeon's fee for a total hip replacement in New Jersey that Medicare would have reimbursed at $1,543. Many of the highest billers were in New York, Texas, Florida and New Jersey.

Elisabeth R. Benjamin, co-founder of the Health Care for All New York coalition, who is often at odds with the insurance industry, said that "is one area we totally agree on." She continued, "Out-of-network billing is just out of control."

Even when out-of-network fees are compared with average commercial insurance reimbursements, which are usually greater than Medicare, she said, "It's pretty outrageous."

Doctors say the report is skewed because it focuses on a few dozen cases of overcharging that are not representative of their billing. In response to the insurers' report, the American Medical Association noted on Thursday that a recent analysis found that doctors' services account for just 16 percent of health care costs.

"There are outliers in every profession, in every business," said Dr. Andrew Y. Kleinman, a plastic surgeon who is vice president of the Medical Society of the State of New York.

Dr. Kleinman also noted that insurers had effectively shifted the costs of out-of-network care onto patients by changing reimbursement formulas. Instead of the rates commercial insurers usually pay doctors, insurers increasingly are basing their out-of-network payments on Medicare rates, usually far lower.

A growing number of high-end, flexible health plans offer policies that cover outside providers at, for example, 140 percent of Medicare. "They're selling you an insurance product you can't use," Dr. Kleinman said. "You're buying an insurance policy where the out-of-network benefit is worthless."

The industry's own report suggests that using Medicare rates as a benchmark will lead to patients' picking up much more of the cost for out-of-network care, whether they carefully select a specialist or, as in the case of Mr. Gonzalez and many others, have no choice in the matter.

Had Mr. Gonzalez been 65 or older, Medicare would have paid only $958 for the surgery. The average commercial price is $12,292, according to FAIR Health, an independent nonprofit group that tracks information on health care costs.

But Mr. Gonzalez's health plan, United Healthcare, determined the fee should be $1,273, of which the company paid $838. Mr. Gonzalez filed appeals, which were rejected. He then contacted Community Health Advocates at the Community Service Society of New York for help, and the group's caseworkers negotiated with the surgeon on his behalf.

After months of wrangling, the surgeon agreed to accept a significantly reduced payment: $340.

Consumer advocates and health insurance executives are calling for greater transparency in health care pricing, including upfront disclosure of prices of medical procedures and services.

"The health care industry can give you an estimate, just like any other industry," said Carrie H. Colla, an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, noting that the Dartmouth-Hitchcock Medical Center has a patient price estimator online.

"It's just not current practice right now," Dr. Colla said. "Sometimes a doctor won't even know. The patient really has to push for it."

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Insurers' 2014 Hikes Already Taking Toll

If you work for a small business, your next health insurance premium may give you sticker shock.

Many of the small-business and individual insurance policies are working the health reform law’s 2014 fees into their 2013 bills, contributing to double-digit premium increases for some people.

Continue Reading All those new consumer benefits packed into the health reform law — birth control without a co-pay, free preventive care and limits on when insurers can turn down a customer — had to be paid for somehow.

So the law’s drafters included a new tax on health insurers, starting at $8 billion in 2014 and increasing to $14 billion within four years, to help meet the new expenses. And insurers in 2014 will also have to pay a “reinsurance contribution” to cushion health plans that end up with a lot of sick customers under new rules requiring them to cover people with pre-existing conditions.

Some health insurance companies are getting a jump-start, passing on those 2014 fees to consumers in policies that start in 2013.

While insurance rates have been going up for years — and not all of the new increases can be pinned to the health law — the hikes will certainly give more fuel to Obamacare critics.

(PHOTOS: 10 alarmist quotes on health law ruling)

Insurers say they have no choice but to increase premiums to cover those costs. But it’s hitting pocketbooks sooner than some people expected, and that’s causing controversy.

Everyone, even many of the law’s supporters, admit premiums are going to go up under the health law — although many people will get subsidies to help pay for coverage. Many of the costs — and the priciest benefits — were pushed beyond the 2012 election to 2014. But if the public revolts when they see 10 percent,15 percent or 20 percent rate hikes, already shaky support for the health law could suffer.

That means there’s a lot at stake for insurance companies and the law’s supporters when consumers see their health insurance bills.

The law’s backers have a history of using steep rate increases to garner public support for health reform — and against insurers. One turning point that helped the law’s passage was when Democrats blasted a 39 percent rate increase requested by Anthem Blue Cross in California in early 2010.

Now, insurers are being proactive, arguing the health law is driving the increase in prices.

“There’s a massive new health insurance tax that starts in 2014,” said Robert Zirkelbach, a spokesman for industry group America’s Health Insurance Plans. “For policies that are sold in 2013 and extend into next year, there’s going to be taxes imposed. … As a result, like all taxes, they will be reflected in premiums charged.”

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Health Insurers Raise Some Rates by Double Digits

Particularly vulnerable to the high rates are small businesses and people who do not have employer-provided insurance and must buy it on their own.

In California, Aetna is proposing rate increases of as much as 22 percent, Anthem Blue Cross 26 percent and Blue Shield of California 20 percent for some of those policy holders, according to the insurers’ filings with the state for 2013. These rate requests are all the more striking after a 39 percent rise sought by Anthem Blue Cross in 2010 helped give impetus to the law, known as the Affordable Care Act, which was passed the same year and will not be fully in effect until 2014.

 In other states, like Florida and Ohio, insurers have been able to raise rates by at least 20 percent for some policy holders. The rate increases can amount to several hundred dollars a month.

The proposed increases compare with about 4 percent for families with employer-based policies.

Under the health care law, regulators are now required to review any request for a rate increase of 10 percent or more; the requests are posted on a federal Web site, healthcare.gov, along with regulators’ evaluations.

The review process not only reveals the sharp disparity in the rates themselves, it also demonstrates the striking difference between places like New York, one of the 37 states where legislatures have given regulators some authority to deny or roll back rates deemed excessive, and California, which is among the states that do not have that ability.

New York, for example, recently used its sweeping powers to hold rate increases for 2013 in the individual and small group markets to under 10 percent. California can review rate requests for technical errors but cannot deny rate increases.

The double-digit requests in some states are being made despite evidence that overall health care costs appear to have slowed in recent years, increasing in the single digits annually as many people put off treatment because of the weak economy. PricewaterhouseCoopers estimates that costs may increase just 7.5 percent next year, well below the rate increases being sought by some insurers. But the companies counter that medical costs for some policy holders are rising much faster than the average, suggesting they are in a sicker population. Federal regulators contend that premiums would be higher still without the law, which also sets limits on profits and administrative costs and provides for rebates if insurers exceed those limits.

Critics, like Dave Jones, the California insurance commissioner and one of two health plan regulators in that state, said that without a federal provision giving all regulators the ability to deny excessive rate increases, some insurance companies can raise rates as much as they did before the law was enacted.

“This is business as usual,” Mr. Jones said. “It’s a huge loophole in the Affordable Care Act,” he said.

While Mr. Jones has not yet weighed in on the insurers’ most recent requests, he is pushing for a state law that will give him that authority. Without legislative action, the state can only question the basis for the high rates, sometimes resulting in the insurer withdrawing or modifying the proposed rate increase.

The California insurers say they have no choice but to raise premiums if their underlying medical costs have increased. “We need these rates to even come reasonably close to covering the expenses of this population,” said Tom Epstein, a spokesman for Blue Shield of California. The insurer is requesting a range of increases, which average about 12 percent for 2013.

Although rates paid by employers are more closely tracked than rates for individuals and small businesses, policy experts say the law has probably kept at least some rates lower than they otherwise would have been.

“There’s no question that review of rates makes a difference, that it results in lower rates paid by consumers and small businesses,” said Larry Levitt, an executive at the Kaiser Family Foundation, which estimated in an October report that rate review was responsible for lowering premiums for one out of every five filings.

Federal officials say the law has resulted in significant savings. “The health care law includes new tools to hold insurers accountable for premium hikes and give rebates to consumers,” said Brian Cook, a spokesman for Medicare, which is helping to oversee the insurance reforms.

“Insurers have already paid $1.1 billion in rebates, and rate review programs have helped save consumers an additional $1 billion in lower premiums,” he said. If insurers collect premiums and do not spend at least 80 cents out of every dollar on care for their customers, the law requires them to refund the excess.

As a result of the review process, federal officials say, rates were reduced, on average, by nearly three percentage points, according to a report issued last September.

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