California’s health exchange may require its health plans to pay sales commissions to insurance agents to keep insurers from shunning the sickest and costliest patients.

Covered California is working on a proposal that would force the plans to pay commissions effective next year, said Executive Director Peter Lee. The proposed rules could apply to regular and special enrollment periods, and would leave the specific commission amount or percentage up to insurers, he said.

Regulators in other states have warned insurers about altering commissions in a way that discriminates against higher-cost consumers, but Lee said Covered California may be the first exchange to adopt specific rules.

Hundreds of thousands of people lose subsidies under the health law, or even their policies, when they get tangled in a web of paperwork problems involving income, citizenship and taxes. Some are dealing with serious illnesses like cancer. Advocates fear the problems, if left unresolved, could undermine the nation’s historic gains in health insurance.

Coverage disruptions due to complex paperwork requirements seem commonplace in the health law’s system of subsidized private insurance, which currently covers about 12.7 million people.

The government says about 470,000 people had coverage terminated through Sept. 30 last year because of unresolved documentation issues involving citizenship and immigration. During the same time, more than 1 million households had their financial assistance “adjusted” because of income discrepancies. Advocates say “adjusted” usually means the subsidies get eliminated.

After most health insurers racked up financial losses on Affordable Care Act plans in 2014, many companies’ results for last year worsened, creating heavy pressure to improve performance this year.

An analysis of filings by not-for-profit Blue Cross and Blue Shield insurers—among the biggest players in the law’s exchanges for buying individual insurance—shows the challenge facing the industry as it seeks a turnaround in the individual business. They paid out more for health care in the first three quarters of 2015 than they took in from premiums on their individual plans.

On Wednesday, Humana Inc. became the latest of the big publicly traded companies to flag problems, saying its losses on individual plans deepened last year. Humana included in its 2015 results $176 million in losses it expects to incur on such plans in 2016.

Democratic candidate Bernie Sanders recently released his health-care plan: a government-run single-payer system for the U.S., similar to what many European countries have. Criticism of the plan has so far focused on its lack of political feasibility, but there is an even more important reason to be wary: Accounting for costs and tax increases, it would reduce labor supply by 11.6 million. In a struggling economy, with tepid wage growth, hurting employment should be the last thing on any politician’s agenda.

The plan truly promises everything under the sun. Not only will everyone be able to get any medical treatment needed — with no cost at the point of service — but the plan won’t require a terribly high tax increase.

For all the damage that ObamaCare has done, it has also led to an awakening among Americans about the inadequacies and costs of a government-centered health care system. This awakening has created an enormous opportunity for conservatives. But making the most of that opportunity will require being clear about what is wrong with ObamaCare, why it needs to be replaced, and what a replacement must involve.

Unfortunately, while many 2016 presidential candidates have backed the “repeal” part of the “repeal and replace” equation, few have addressed how they would start over.

They would do well to follow the advice of The Heritage Foundation. The think tank’s soon-to-be-released policy handbook for candidates, Solutions 2016, lays out the “then what” reforms candidates should be talking about:

  • Remove regulatory and policy obstacles that discourage choice and competition.
  • Encourage personal ownership of health care by reforming the tax treatment of health care.
  • Transform health care coverage for low-income Americans by reforming Medicaid as a true safety net and glide path out of poverty.
  • Modernize Medicare program to meet the demographic, fiscal, and structural challenges that threaten to bankrupt the system.

With the results now in from the Affordable Care Act’s third open enrollment period, it’s getting increasingly difficult to sugarcoat the extremely low numbers of enrollees relative to original projections. The 12.7 million people who signed up for an exchange plan amounts to just half as many enrollees as was projected by government and private sector research organizations when the ACA passed.

The Rand Corporation predicted 27 million, the Centers for Medicare and Medicaid Servicespredicted 24.8 million, the Urban Institute predicted 23.1 million, and the Congressional Budget Office predicted 21 million.

N.C. Insurance Commissioner Wayne Goodwin this week became the latest public official to warn of the harms wreaked by the Affordable Care Act, saying the federal insurance law has destabilized the state’s insurance market and now threatens to leave some residents without options for health insurance.

Goodwin expressed his concerns in a letter sent Tuesday to Sylvia Burwell, secretary of the U.S. Department of Health and Human Services, as a follow-up to a personal conversation he had with the Obama administration official in November. Goodwin, a Democrat up for re-election this year, warned that the ACA is driving up insurance costs, reducing consumer options and generating unsustainable financial losses for the insurers, with the potential risk that insurers will withdraw from the state altogether.

Stung by losses under the federal health law, major insurers are seeking to sharply limit how policies are sold to individuals in ways that consumer advocates say seem to discriminate against the sickest and could hold down future enrollment.

In recent days Anthem, Aetna and Cigna, all among the top five health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents.