Source: Washington Post

Large businesses expect to pay between 4 and 5 percent more for health-care benefits for their employees in 2015 after making adjustments to their plans, according to employer surveys conducted this summer.

Few employers plan to stop providing benefits with the advent of federal health insurance mandates, as some once feared, but a third say they are considering cutting or reducing subsidies for employee family members, and the data suggest that employees are paying more each year in out-of-pocket health care expenses.

The figures come from separate electronic surveys given to thousands of mid- to large-size firms across the country by Towers Watson, the National Business Group on Health and PriceWaterhouseCoopers, consulting groups that engage with businesses on health insurance issues.

Bracing themselves for an excise tax on high-cost plans coming in 2018 under the Affordable Care Act, 81 percent of employers surveyed by Towers Watson said they plan to moderately or significantly alter health-care benefits to reduce their costs.

The excise tax will be levied on companies offering annual benefits that exceed $10,200 for individuals or $27,500 for families. For any costs above those amounts, businesses would be taxed 40 percent on the difference. Nearly three quarters of the businesses interviewed by Towers Watson said they are concerned they will be subject to the excise tax.

To lower their tax bill, many companies are looking to cut their premiums by raising deductibles. Many also are making greater use of health-care savings accounts.

“My takeaway from the employer surveys is that this trend is accelerating,” said Paul Fronstin of the nonprofit Employee Benefits Research Institute.

The National Business Group on Health finds 81 percent of employers offering insurance plans that include higher deductibles and an annual health savings account. The savings account allows employees to deposit money tax-free, and employers often deposit a set amount of money into these accounts at the beginning of the year.

“These plans have been around for more than a decade, but there is no doubt that the excise tax is out there, and employers want to do something now. Which is why we’re seeing greater interest in these types of plans,” Fronstin said.

Others see these changes as less of a result of the Affordable Care Act and more a response to the steadily increasing costs of health care. The expected increase of 4 to 5 percent from 2014 to 2015 is no greater than in previous years, but the continued pressure on businesses has forced a wave of cost-sharing innovation, giving employees what the industry calls more “consumer-directed” choices to make between the quality of care and the cost.

“I think this in many ways has very little to do with the Affordable Care Act,” said Gail Wilensky, a senior fellow at Project Hope, a health-care advocacy and services group. “It started 10 to 12 years ago, and is being used by employers to try to get their employees to react in what they see as a more responsible way.”

Experts say there is no evidence that consumer-directed plans necessarily increase what employees pay out of pocket, emphasizing that such costs depend on a range of details specific to the insurance plan.

“The question is whether it will get people to get better care, or whether they will put off care and end up having to get more expensive care,” Wilenski said.

Surveys by Towers Watson and the National Business Group on Health suggest out-of-pocket costs paid by employees are increasing. According to their data, average annual out-of-pocket costs have jumped more than 40 percent just in the past three years, from $1,890 per employee in 2011 to $2,649 in 2014. Over the same period, employees’ share of total expenses, which includes both monthly premiums and out-of-pocket expenses, has increased from 34.3 percent to just over 37 percent.

And experts point out that even costs absorbed by employers are felt by employees in other ways.

“Even if the increase is only a few percentage points, the health-care costs are crowding out other portions of the pie. It puts a squeeze on pay increases, it puts a squeeze on retirement contributions,” said Steve Nyce, a researcher in charge of surveys at Towers Watson.

“The challenge is not only premium increases, but also out-of-pocket expenses, where increasingly people have to pay more at the point of care.”

Even those shying away from high-deductible plans are finding other ways to give employees incentive to purchase cheaper care. Almost three quarters of employers interviewed by Towers Watson said they are adding some form of consumer initiative, such as pricing transparency tools, second-opinion services or claims assistance programs.

It also appears that employers are moving away from providing family coverage. A third of employers interviewed by Towers Watson have already cut subsidies for spouses, are planning to do so in 2015, or are considering such changes. Subsidy reductions are becoming even more common when spouses have insurance available through their own employer: 26 percent said they are considering surcharging or fully excluding spouses if coverage is available elsewhere, and another 37 percent already have this policy in place or plan to implement it in 2015.

The survey by Towers Watson found that nearly one in four employers considers private exchanges to be a viable alternative for 2016. Private exchanges are online platforms, typically operated by brokers or insurers, that allow employees to shop for plans directly and customize more expensive add-ons, such as dental or hospitalization benefits, presumably giving the employee some control over the real cost of an insurance plan. (Towers Watson operates its own private exchange).

By contrast, employers had very little confidence in public exchanges in their first year in operation; 77 percent said they are “not at all confident public exchanges will provide a viable alternative” for their employees. While it is clear that employers want to reduce or restructure benefits packages, most, 99.5 percent, said they have no plans to direct employees to public exchanges.

Businesses are also planning a range of changes to the ways employees can access health care. One third of employers interviewed by Towers Watson plan to expand telemedicine provisions, in which patients conduct routine health check-ups over the phone. A quarter of employers consulted by NBGH currently include so-called “narrow networks,” in which employer insurance plans will only support treatment at facilities that have been determined “high-value” by independent monitors who have measured the cost of care against the quality provided.

“This goes back to the idea of getting better value for the dollar spent,” said Randy Abbott, a senior consultant at Towers Watson. “At present, there is no correlation between cost and quality for doctors. The narrower networks are designed to evaluate providers based on quality of care and quality of outcomes, all compared to a competitive price.”

The Towers Watson survey, which came out on Aug. 20, projects that costs will increase 4 percent in 2015, factoring in likely employer adjustments. Surveys conducted by the National Business Group on Health and PriceWaterhouseCoopers placed the number slightly higher, reporting 5 percent and 4.8 percent, respectively

New York Times by Andrew Pollack –

August 14, 2014:

It may be the biggest thing in diaper rash treatment, a custom-made product to soothe a baby’s bottom at the eye-popping price of $1,600.

This is no Desitin or Balmex, or any other brand found in stores. This cream is blended to order in a pharmacist’s lab.

Does it work better than the common treatments? There is little evidence either way. But the sky-high prices commanded by such compounded medicines are drawing the ire of health insurance companies that must pick up the bill. They say the industry is profiteering at their expense.

Compounded medicines are the Savile Row suits of the pharmacy, made to order when common treatments will not suffice. Pharmacists say it is the doctors who decide what to prescribe. But many pharmacies have standard formulations and some promise six-figure incomes to sales representatives who call on doctors.

Besides the $1,600 ointment to treat diaper rash, there was the $8,500 cream to reduce scarring and the $2,300 salve to relieve pain recently billed to Catamaran, a pharmacy benefits manager. Alarmed that its spending on compounded drugs has quintupled in just two years, Catamaran has begun to review such claims more carefully.

Pharmacy benefit managers owned by UnitedHealth and Blue Cross and Blue Shield plans are also reining in spending on compounded drugs, as are insurers like Harvard Pilgrim and various state workers’ compensation plans.

Express Scripts, the largest pharmacy benefits manager, has said it will stop paying for more than 1,000 ingredients used in compounding, cutting spending by its health plan clients on such medicines by 95 percent. It said such spending had grown to $171 million in the first quarter of this year from $28 million in the first quarter of 2012.

“There are absolutely situations where compounded medicines are appropriate,” but other cases in which the products are “unsafe and overly expensive,” said Dr. Sumit Dutta, chief medical officer at Catamaran, which is based in Schaumburg, Ill. “If you remove the profit motive, what is the base-line appropriate use of these products?”

Exhibit No. 1 for those who contend that profiteering is at least part of the reason for the proliferation of compound medicines is the indictment in June in Southern California of 15 doctors, chiropractors, pharmacists and financial brokers, including a major donor to President Obama. They are charged with engaging in a kickback scheme that billed workers’ compensation for millions of dollars in such medicines and led to the death of a baby exposed to a compounded pain cream his mother was using.

But the compounding industry is fighting back.

“Millions of people benefit from compounding,” said Jay McEniry, executive director of a coalition formed hastily in June to fight the cuts by Express Scripts and others. “For the most part, people who take compounded medications have no alternatives.”

The coalition is called Patients and Physicians for Rx Access, though it was started mainly by compounding pharmacists.

Compounding, which dates from the ancient days of medicine, involves a pharmacist making medicines for a patient who cannot be helped by mass-manufactured drugs. For instance, patients might need a special formulation because they are allergic to an ingredient in a commercial product, or a liquid formulation if they cannot swallow pills.

But compounding has grown well beyond that, and has gotten black eyes in the process. Two years ago, about 750 people were sickened and 64 of them died from injections of a fungus-tainted steroid made by the New England Compounding Center, a company that was essentially mass manufacturing.

Congress last year passed legislation to improve federal oversight of compounding, particularly such large operations.

The new controversy centers on medicines that are not injected, mainly topical creams to treat pain and scarring. People in the compounding business say that spending on such drugs is growing because doctors are turning away from the maligned painkillers known as oral opioids out of concern about abuse. A cream delivers relief more directly to painful joints or muscles, with less entering the bloodstream to cause side effects.

They also say the cost of ingredients has risen because of increased regulatory scrutiny of overseas chemical manufacturers. Even so, they say, compounded drugs account for less than 1 percent of pharmaceutical spending. Another factor appears to be a change in an industry standard for how such medicines are billed, which took effect in 2012.

Before that, pharmacists submitted claims listing just the main ingredient, usually with some markup. Under the new system, each ingredient is listed, with its cost.

This is something pharmacy benefit managers wanted. But they now say that compounders, knowing they can bill for each ingredient, have begun adding more of them.

While creams typically contain about four ingredients, the $8,500 scar cream contained 13 ingredients, and the $2,300 pain cream had 18 ingredients, according to Catamaran. The $1,600 diaper rash ointment had only two ingredients, one an organic floral extract.

Pharmacy benefit managers say there is scant evidence that these combinations of ingredients are safe or any more effective than conventional drugs approved by the Food and Drug Administration, like Voltaren Gel, a topical pain treatment with only one active ingredient that costs about $50 a tube. Compounded drugs do not require F.D.A. approval.

Some states are acting to control spending on compounded drugs in workers’ compensation, said Brian Allen, vice president for government affairs at Progressive Medical/PMSI, a workers’ comp pharmacy benefit manager. California passed a law in 2011 and Ohio has set a limit of $600 per prescription. Georgia is looking at a limit of three ingredients per prescription.

But some say abuses continue and point to the indictments issued in June by a grand jury in Orange County, Calif. They center on Kareem Ahmed, a million-dollar donor to President Obama’s re-election campaign.

According to a 2012 profile of Mr. Ahmed in Talking Points Memo, his company, Landmark Medical Management in Ontario, Calif., buys accounts receivable from doctors and other health care providers treating workers’ compensation cases. The doctors and pharmacists get less than the face value of the claims, but do not have to wait months for processing. Landmark profits when the claim is eventually paid.

But the indictments said the purchase of accounts receivable was really a disguised kickback to doctors and chiropractors to induce them to prescribe compounded creams that Mr. Ahmed had formulated “based on the profitability of the ingredients.”

The indictments also named 10 doctors or chiropractors, two pharmacists and two Landmark employees.

Priscilla Lujan of Los Angeles applied one of those creams to her knee for a workplace injury and then prepared a bottle for her 5-month-old son, according to her lawyer, Shawn J. McCann. She allowed the baby to bounce on her knees and suck her fingers.

The next day, the boy, Andrew Gallegos, was dead, from what the coroner’s office called “multiple drug intoxication” with “extremely high and lethal” levels of some of the pain cream ingredients in his blood.

Benjamin N. Gluck, a lawyer for Mr. Ahmed, said, “Mr. Ahmed and Landmark complied with all applicable laws at all times and we expect to be fully vindicated.”

He said the prosecution’s legal theory was “defective and has never been accepted by any court.” He added that selling accounts receivable, a practice known as factoring, was “a common and completely legitimate business practice” that was “especially necessary in the medical field because insurance companies make it so difficult, time-consuming and expensive for providers to collect on their bills.”

Los Angeles Times by Soumya Karlamangla –

July 29, 2014:

Nearly 60% of Californians without health insurance before Obamacare sign-ups began last year now have a medical plan, but the remaining uninsured will present a challenge in the second round of enrollments beginning this fall, according to a new study.

A Kaiser Family Foundation survey examining the state’s progress under the federal medical care overhaul said more than 80% of those still uninsured hadn’t had coverage in two or more years, including 37% who reported never having coverage before.

Foundation Chief Executive and President Drew Altman said though large numbers of Californians gained insurance during the first open enrollment period, “expanding coverage gets harder from here.”

The biggest reported barrier to signing up was cost, even though nearly two-thirds of those who remained without coverage were eligible for either Medi-Cal or subsidies through the state-sponsored marketplace, the survey found.

Mollyann Brodie, the foundation’s senior vice president, said researchers are observing a disconnect between what people expect insurance will cost and the price of plans actually available.

She said that in the next enrollment period, which begins Nov. 15, outreach needs to be “even more targeted and more intense to convince this group of Californians that they can actually get health insurance.”

The federal Affordable Care Act required nearly everyone to have health insurance starting in 2014. In California, people with qualifying incomes can receive subsidies to get discounted plan rates through the state’s health insurance exchange, Covered California. The state’s low-income health plan, MediCal, has also been expanded to include more people.

Erika Malady, 33, looked into signing up for health insurance last year but decided against it.

A single mother living in Santa Fe Springs, Malady said that when she browsed through the available plans offered through Covered California, the monthly premiums were about $120 a month. She said she couldn’t afford that on her annual salary of about $35,000 a year.

“It’s too expensive,” she said.

The study found that 42% of those who were uninsured before Obamacare sign-ups remained without insurance after. Twenty-four percent of those were eligible for subsidies through the exchange, and 39% were eligible for Medi-Cal, the survey found.

More than 70% of those who remained uninsured said health coverage was something they felt they needed.

Malady said she wants health insurance and now worries about having to pay a penalty and not having a safety net if she becomes ill. She says she’ll try to find an affordable plan when open enrollment opens again later this year.

“I’m not going to hold my breath,” she said.

Many survey respondents who signed up for insurance said it made them feel more financially secure. But 46% of the newly insured also said paying their monthly bill was at least somewhat difficult.

Total enrollment in Covered California private health plans is approximately 1.2 million. The exchange estimates that number will reach 1.7 million by the end of the next enrollment period.

A large share of those still uninsured — approximately 30% — are undocumented immigrants, who aren’t eligible to sign up for insurance through the state exchange or Medi-Cal, the survey found.

Nearly 20% of the remaining uninsured said they didn’t sign up because they’ve either been too busy or don’t know how. Brodie said that points to a continuing need for trained people who can help explain the process.

“It’s hard, it’s complicated, it’s serious, it’s scary,” she said. “This is not the same as just going to buy your groceries.”

Brodie said despite the attention given to the state exchange websites, many enrollees needed more personalized assistance.

Though open enrollment for Covered California won’t begin again until November, qualifying patients with special circumstances, such as losing employer-provided insurance or moving, can apply now for coverage. Signups for Medi-Cal coverage for lower-income residents continues year-round.

Insurance Journal by Alex Wayne and Shannon Pettypiece –

July 31, 2014:

Even as Obamacare continues to be attacked by foes and challenged in court, hospital chains and insurers are making more money, more patients using emergency rooms are paying for their care, and the country as a whole is enjoying slower growth in its healthcare spending.

HCA Holdings Inc., the largest for-profit hospital chain, yesterday raised its forecast and reported a 6.6 percent drop in uninsured patients at its 165 hospitals, a reduction that grows to 48 percent in four states that expanded Medicaid, a top initiative of the Patient Protection and Affordable Care Act. WellPoint Inc., which made the biggest commitment of any publicly traded insurer to the Obamacare markets, raised its guidance today after handily beating analyst estimates for the quarter on rising membership linked to the overhaul.

Taxpayers too may be benefiting from the law approved in 2010. Medicare spending rose by just $1 per beneficiary in 2013, the fourth year in a row that saw a slowdown, the government reported yesterday.

“Obamacare’s turned out to be quite good for healthcare companies,” said Les Funtleyder, a portfolio manager at Esquared asset management, in a telephone interview.

LifePoint Hospitals Inc., another for-profit chain, also raises its forecast yesterday while the largest insurer, UnitedHealth Group Inc., said earlier this month it added 635,000 people to its Medicaid plans and was expanding into two dozen Obamacare exchanges in 2015, from five this year.

Early Life

Still, it’s early in the life of the law, which just began enrolling Americans into insurance plans last year. Longer term, questions remain on whether the slowdown seen recently in health-care costs can be definitively tied to Obamacare or whether it was the result of a slow recovery from the 2008-2009 recession.

At the same time, investors will be watching to see if WellPoint’s bet on Obamacare pays off, a question largely turning on how healthy the new customers are and whether their medical costs are largely covered by premiums.

Other hurdles remain, as well. Americans’ opinions on the measure may be too hardened for Democrats to see much political benefit this year, or to fight off changes to the act in the future, said Robert Blendon, a professor of health policy at the Harvard School of Public Health.

Recent polls indicate that more Americans remain opposed to the healthcare law than support it, although that includes people who think it isn’t liberal enough.

‘Trend Lines’

“In the election campaign Democrats are going to really make a good case that things are not as bad people said, and in fact they’re getting better,” Blendon said in a telephone interview. “If you watch the trend lines, there’s a significant share of people who feel over the long term this isn’t going to work out well and they’re not affected by daily news.”

Costs are a top concern, as insurers and state regulators decide premiums for 2015. If rates rise too much in the future, people who don’t receive U.S. subsidies to help with the bill may drop coverage, undercutting the act’s intent to have everyone insured.

Californians who bought individual insurance plans saw rate increases this year of 22 percent to 88 percent, Dave Jones, the state’s insurance commissioner, reported yesterday.

“For those whose incomes were low enough, there were premium subsidies under the Affordable Care Act,” Jones said in a statement. “But for Californians whose incomes were not low enough, there was likely a major rate increase.”

8 Million Enrollees

About 8 million Americans signed up for private plans offered through the health law’s insurance exchanges by April, and another 6 million were added to Medicaid, the state-federal program for low-income people, according to the Obama administration.

The proportion of the U.S. population without insurance has fallen 3.7 percentage points to 13.4 percent since the end of the 2013, according to Gallup Inc., the lowest rate since the firm began surveys of coverage in 2008.

“We’re now halfway through the first year of expanded coverage under the Affordable Care Act and, so far, our experience has been very positive,” William Carpenter, LifePoint’s chairman and chief executive officer, said in a July 25 conference call. The company operates 100 hospitals, according to data compiled by Bloomberg.
$13 Million Gain

The law contributed as much as $13 million to LifePoint’s earnings in the second quarter, about 40 percent more than the company had expected, he said. People paying bills themselves, a proxy for the uninsured, represented just 4.8 percent of admissions, down from 7.1 percent a year earlier.

Jennifer Lynch, an analyst at BMO Capital Markets Corp. in New York, raised earnings estimates for the company on July 28.

“Benefiting from Obamacare,” Lynch said in a succinct explanation to clients.

HCA hospitals have likewise seen “fairly noticeable reductions in our uninsured volume,” Milton Johnson, the company’s chairman and CEO, told analysts yesterday on a conference call. “We believe we are well positioned to succeed in the health-care reform marketplace.”

About 40 percent of customers with plans from the law’s insurance exchanges previously had no coverage, Bill Rutherford, HCA’s chief financial officer, said on the call. There were 5,500 people with exchange plans admitted to HCA hospitals in the second quarter, and 19,000 visited the company’s emergency departments.

Funtleyder said the hospital chains’ reports may also reflect an improving economy, allowing more people to seek care that they postponed during the recession.

More Quarters

“We may need to see a couple more quarters to parse out who’s going and why,” he said. “If it’s the individually insured who didn’t have insurance going to the hospital, it’s Obamacare. If it’s everybody, it’s probably the economy.”

UnitedHealth, the largest for-profit insurer, said on July 17 it would offer plans in as many as two dozen exchanges in 2015, from five this year. The company also added 635,000 people to its Medicaid plans, growth that Gail Boudreaux, the CEO of United Healthcare, the company’s insurance division, called “tremendous” in a conference call with analysts.
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Kaiser Health News by Michael Ollove –

July 25, 2014:

For the 8 million people who persevered through all the software trapdoors in the new health insurance exchanges and managed to sign up for coverage in 2014, their policies will probably automatically renew come November when open enrollment begins.

Seems like good news after all the headaches consumers endured after the program’s launch last year. Except that renewing the same policy may not be the best choice. Many may end up paying far more than they need to and with policies that don’t best fit their individual circumstances.

“(Automatic re-enrollment) could conceivably mean people will pay more in premiums unless they proactively take steps to comparison shop,” said Jenna Stento, a senior manager at Avalere Health, a health care research and consulting firm.

If you made a good choice last year, what could be so wrong about re-upping with the same plan?

Turns out plenty, particularly for those among the 87 percent of enrollees in health insurance exchange plans who received a federal subsidy to help pay for premiums. Understanding why that’s a problem isn’t easy, the result of complicated quirks in the Affordable Care Act, which established the exchanges in the first place.

Premiums Up 8 Percent

Overall, premiums on the exchanges in 2015 may be a bit higher for most people, at least according to one analysis of proposed plans and rates in nine states. Avalere found that the average premiums for Silver plans will climb an average of 8 percent. (There are four grades of plans offered, starting with Bronze plans with the cheapest premiums, but higher deductibles and co-pays, and moving up to Silver, Gold and Platinum.)

The Obama Administration announced last month that consumers who bought their policies on the federal exchange would have them automatically renewed, as well as the amount of their subsidies. It will be up to each state exchange whether to offer a similar automatic renewal. People whose level of income has changed would need to enroll again since it would affect the amount of their subsidies.

But consumers who automatically re-up with the plan they already have could face steep and unexpected premiums and out-of-pocket costs, particularly if they received a federal subsidy.

Changing Benchmark Plans

Here’s why. The subsidy people receive is pegged to the second-lowest priced Silver plan, the so-called “benchmark plan,” meaning that the amount of a subsidy any individual receives no matter which plan he or she selects, is based on how much they would receive if they picked that benchmark plan.

In a hypothetical example Avalere provides, “Sue,” a Maryland resident, enrolled in the 2014 benchmark Silver plan in her region – offered by CareFirst Blue Cross — which had a monthly premium of $214. Based on her income, Sue’s contribution toward her monthly premium was set at $58, so she qualified for a monthly federal subsidy of $156 to make up the difference. If Sue had chosen a plan with a higher premium, her federal subsidy would have remained fixed at $156 and she would have had to pay more out of her own pocket.

However, in 2015, according to Avalere’s analysis of early rate filings, CareFirst Blue Cross will no longer be the second lowest Silver plan in Sue’s region but the ninth lowest out of 18 Silver plans, meaning that it will lose its status as the benchmark plan. CareFirst’s new monthly premium is $267. The new benchmark Silver plan (the Silver plan with the second lowest premium) will be the Kaiser Foundation Health Plan with a monthly premium of $231.

Sue’s contribution remains the same, but she will now qualify for a higher federal subsidy of $173 to make up the difference between her ability to pay $58 per month and the higher $231 monthly premium of the new benchmark.

If she automatically re-enrolls with CareFirst, however, she will have to cough up another $36 a month. By doing nothing, her out-of-pocket contribution will rise by 62 percent.

In another example, “Dave” enrolled in the benchmark Silver plan in Washington state, Group Health Cooperative, which had a monthly premium of $281. He received a federal subsidy of $85 each month, leaving him with a monthly out-of-pocket bill of $196.

In 2015, BridgeSpan Health will replace Group Health as the benchmark plan in Dave’s area, with a premium of $263 a month. Because of that lower premium, Dave will be entitled to only a $67 a month federal subsidy, leaving him again with a $196 monthly out-of-pocket expense if he switched to BridgeSpan. But if Dave sticks with Group Health, which hiked its premiums to $313, he will have to pay $246 each month out of his own pocket, a nearly $600 increase compared to last year.

This is not a theoretical wrinkle. Of the nine states whose 2015 premiums Avalere examined (Connecticut, Indiana, Maryland, Maine, Oregon, Rhode Island, Vermont, Virginia and Washington), all but Vermont appear headed for a new benchmark plan when open enrollment commences. Consumers who live in six of these states may have an unpleasant surprise when they see their bills if they let their policies automatically renew.

In Rhode Island and Virginia, the opposite may be true. Last year’s benchmark plans are expected to become the lowest price Silver plans, instead of the second lowest. Consumers renewing the 2014 benchmark plans in those two states could actually see their out-of-pocket premium costs decrease in 2015.

“There could be significant financial value to take a look at the site and see if there might be more affordable options for you, given the changes since last year,” Steno said.

Website Tools

As re-enrollment approaches, numerous health care advocacy organizations, including Easter Seals, the March of Dimes, the Livestrong Foundation, the National Alliance on Mental Illness, and many others have urged the U.S. Department of Health and Human Services, which operates the federal health exchange, and the states that run their own exchanges to develop tools on their websites that will help consumers identify the plans that best fit their particular circumstances, not only in terms or premium costs, but also their actual usage.

In the first year, all exchanges showed the differences in premiums of the various health care plans as well as their differing cost-sharing formulas. Cost-sharing refers to deductibles, copays and co-insurance. (Copays are a fixed amount you pay for a particular medical service, such as $40 per primary care visit; co-insurance is a percentage that you have to pay for each service, such as 20 percent of a hospitalization.)

The lower the premiums, the higher the cost-sharing burdens on patients. As a result, cost-sharing formulas can result in the difference of thousands of dollars between one plan and the next, depending on an individual’s or family’s specific health care needs.

Those with chronic conditions, for example, who need many doctor visits in the course of a year, would do best to enroll in a higher premium plan with lower co-pays for individual visits. Relatively healthy people, on the other hand, would likely come out ahead by enrolling in a lower premium plan with higher co-pays.

That is why health advocates want all the exchanges to offer calculating tools that would enable customers to plug in information on their actual health care usage from the previous year to get an idea of how much they would be likely to spend in each plan in the year ahead.

“Our goal is that every state website will have the information to help you understand your real out-of-pocket costs,” said Marc Boutin, president of the National Health Council, which offered its own calculating tool for customers during the last enrollment.

But with all the computer mishaps in the first enrollment year, neither the 36 federal nor 15 state exchanges had such a tool in the first year. Colorado tried in the first year, but consumers found the tool confusing and the exchange disabled it, said Adele Work, director of product implementation for Connect for Health Colorado. Consultants are working on a replacement, she said, but it may not be available in time for November. It’s not clear which, if any, other states will have such a tool in place either.

Exchanges also did poorly in providing two other categories of information of great interest to consumers. Many exchange websites were unable to offer up-to-date lists of the medical providers who were in each network plan. And very few exchanges – Colorado and Nevada were exceptions – could tell consumers which medications each health plan covered, information that could make a difference of thousands of dollars.

Because of last year’s disastrous roll-out, most exchanges will have modest ambitions for the second enrollment period. Offering consumers a smooth enrollment experience is the goal of most exchanges. But a smooth experience won’t necessarily be enough to guarantee landing the best policy.