Recent Budget Subcommittee Hearings on DMHC and DHCS

The Assembly and Senate budget subcommittees recently held hearings on the budgets for the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS). You can read the agendas for the Senate Budget Subcommittee #3 on March 19 and in Asm. Budget Subcommittee #1 for more details about these proposals.

Department of Managed Health Care

DMHC’s budget was heard in Senate Budget Subcommittee #3 on March 19 and in Asm. Budget Subcommittee #1 a few days later on March 23. DMHC’s mission is to regulate, and provide quality-of-care and fiscal oversight for health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Health Access supported DMHC’s budget change proposals for additional staff and resources for the following work, and both committees left these items open (did not take a vote) in order to collect more information.

  • Federal Mental Health Parity: DMHC requested staff positions to address workload associated with conducting medical surveys of the 45 health plans that need to comply with the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA requires health plans that offer mental health benefits to do so in a manner comparable to medical and surgical (medical) benefits. Assessing whether health plans are in compliance with MHPAEA involves reviewing health plans’ processes and justifications for classifying benefits into classifications (inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; and emergency care), determine parity for financial requirement (e.g., deductibles, copays, coinsurance); quantitative treatment limitations (e.g. number of visits, days of treatment) and non-quantitative treatment limitations.
  • Additional Enrollment in the Individual Market: DMHC helps California consumers resolve problems with their health plans and works to provide a stable and financially solvent managed care system. The ACA and California law requires health plans offering coverage in the individual market to accept every individual that applies for that coverage. Last year, DMHC estimated that 90 percent of all new enrollees in individual market plans would be under the jurisdiction of DMHC while the other ten percent would be under jurisdiction of the CA Department of Insurance (CDI). It turns out that DMHC has jurisdiction over approximately 98 percent of the enrollees in Covered California individual market plans. DMHC is requesting additional staff positions to address the increased workload resulting from the revised projected increase in enrollment in the individual market.
  • Large Group Claims Data (SB 1182, Leno, 2014): Last year, Health Access supported Senator Leno’s SB 1182, which requires health plans and insurers to provide de-identified claims data to a large group purchaser. The bill increases transparency by making information available to large group purchasers that helps them understand what is driving their premiums, better negotiate rates, and help efforts to improve the health of employees through disease management programs. DMHC is requesting staff positions to implement the bill.
  • Dental Plans Medical Loss Ratio (AB 1962, 2014): Last year, Health Access also supported AB 1962, which requires dental health plans to report their dental loss ratio to DMHC. Getting information about how much health plans spend on administration vs. actual care will help consumers understand the value of their dental plans. The data collected under AB 1962 will also help the Legislature to establish a dental medical loss ratio after 2018.

Department of Health Care Services (DHCS)

The Senate Budget Subcommittee #3 heard the DHCS budget on March 19. (Assembly Budget Subcommittee #1 heard DHCS’ budget on February 23, and you can read the Health Access blog post on that hearing here.) DHCS operates a number of programs that health care services to eligible individuals, namely Medi-Cal. Medi-Cal coordinates and directs the delivery of health care services to approximately 12 million individuals, including low-income families, seniors and persons with disabilities, children in families with low-incomes or in foster care, pregnant women, low-income people with specific diseases, and childless adults up to 138 percent of the federal poverty level.

  • Medi-Cal Estimates and Caseload: The Governor’s budget assumes total annual Medi–Cal caseload of 12.2 million for 2015–16. This is a 2 percent increase over the revised caseload estimate of 12 million for 2014–15. Health Access agreed with the Legislative Analyst Office‘s (LAO) that actual caseload information, not estimates, would help the Committee make better decisions. DHCS has begun posting monthly caseload data on its website. We believe the Administration’s estimates are too high because they don’t fully account for people leaving Medi-Cal for other coverage and IT difficulties in getting more accurate data. Health Access reiterated its support for using monthly caseload data, and the department will provided updated numbers in the Governor’s May Revise.Health Access also supported the committee staff’s recommendation to adopt placeholder trailer bill language to eliminate nonemergency emergency room copay in Medi-Cal. The copay has never been implemented because the state has not received approval from the federal Centers for Medicare and Medicaid. We believe the copay unnecessarily imposes additional costs on low-income people who need health care. Studies have shown that the copay does not affect ER use.
  • CalHEERS Oversight: CalHEERS is the IT system that supports the single, streamlined application process for Medi-Cal and Covered California. CalHEERS has had a number of problems, resulting in key populations not being able to access the coverage they need. For example, under the ACA, former foster youth qualify for Medi-Cal coverage until age 26 regardless of their income. This law has been in effect since January 1, 2014 but has not been programmed accurately into CalHEERS, resulting in enrollment delays, enrollment in the wrong affordability program, or denial of Medi-Cal for former foster youth. Consumer advocates continue to be concerned about the lack of transparency and stakeholder engagement in setting the policies and priorities for CalHEERS, contrary to the requirements of AB 1296 (Bonilla, 2011). Specifically, stakeholders have received limited updates regarding CalHEERS changes but have not had an opportunity to give input on those priorities. Health Access echoed the concerns raised by WCLP and other consumer advocates and urged the subcommittee to maintain oversight over this issue.

We have also joined our colleagues at the California LGBT Health and Human Services Network and Equality California to press for the inclusion of optional questions regarding sexual orientation and gender identity (SOGI) demographic data on the Medi-Cal/Covered California application. Because of the ACA’s prohibition on discrimination, as well as the emphasis on affordability, many LGBT individuals and families can get Medi-Cal or private health insurance for the first time. LGBT people face many health disparities, which are reflected in higher rates of breast cancer, tobacco use, drug and alcohol abuse, violence, and suicide, as well as worse mental health outcomes. These disparities are due at least in part to a long history of being discriminated against by medical providers and denied medically necessary care, as well as inability to access health insurance. Collecting data about SOGI is a critical part of addressing these health disparities and help us evaluate whether the investments we’ve made in outreach and enrollment in LGBT communities are working. At the hearing, DHCS publicly committed to working toward making this a reality. You can read the CA LGBT HHS Network’s letter on collecting SOGI data here.

  • Dental Services in Medi-Cal: The Committee heard testimony about a recent California State Auditor (CSA) audit of the Denti-Cal Program, which found that some counties may not have enough providers to meet the dental needs of children in the program. The utilization rate for Medi-Cal dental services by children is low relative to national averages and to the rates of other states. CSA stated a primary reason for low dental provider participation is California’s low reimbursement rates for these services. The federal CMS has directed California to improve access to dental care for children, and DHCS proposes to accomplish this by targeting the use of mobile dentistry vans in Alpine, Amador, and Calaveras counties and increasing outreach to families with children aged 0-3 who haven’t seen a dentist in the last year.

DHCS has also proposed to require local Child Health and Disability Prevention programs and providers to refer all Medi-Cal eligible children participating in the program to a dentist beginning at age one instead of at age three. Health Access supports this proposal because it makes California responsive to direction from CMS for the state to improve the rate at which young children receive dental services. This proposal was supported by consumer advocates and dental providers.

  • Medi-Cal Provider Rates and Access: The Governor’s Budget continues the AB 97 Medi-Cal payment reductions, which is estimated to save $550M. Consumer advocates, providers and their associations, and others were on-hand to express their concern that the existing Medi-Cal rates, payment reductions, and rate freezes have negatively impacted Medi-Cal enrollee’s ability to access Medi-Cal services. There was testimony that rates are too low to cover the cost of providing services to Medi-Cal patients. Health Access supported restoring the AB 97 rate cut to improve access to Medi-Cal.
  • Medi-Cal Annual Open Enrollment: DHCS is proposing trailer bill language that would lock some Medi-Cal beneficiaries (those under family and child aid codes) into their managed care plans for a full year and only allow them to change plans during a mandatory open enrollment period. Health Access opposes this proposal because it limits consumer choice and access–while health plans can continue to change their providers mid-year.
  • Elimination of COLA for County Eligibility Administration: The Governor’s proposed budget includes a budget trailer bill proposal to permanently eliminate the annual cost-of-living (COLA) adjustment for reimbursements to counties for administering Medi-Cal eligibility. The State is in the midst of crafting a new reimbursement methodology, but the new methodology is not yet in place. Until then, Health Access, along with the County Welfare Directors Association (CWDA), believes it’s premature to eliminate the COLA. The Legislature and Governor currently have the ability to suspend the COLA on an annual basis, which is what has been done the past several years. In the meantime, counties are getting supplemental funding from the state for the increased workload as a result of ACA implementation.

Happy 5th Birthday, Affordable Care Act—LA Celebrates, Highlights Work Still Left to Do

This blog entry was written by Nancy Gomez, Health Access’ Southern California Program Director

On Monday March 23rd Health Access gathered with key partners, health care consumers, and elected officials in Los Angeles to celebrate the 5th Anniversary of the Affordable Care Act. Approximately 70 people enjoyed the celebration and press conference (and, let’s not forget, cake).photo2_LASpeakers included:

  • Joan Pirkle Smith, Health Access California Board Chair (and event MC) kicked off the celebration with an overview of Health Access’ just published ACA 5th Anniversary Report. The report, a collaboration involving many coalition and community partners, describes implementation, impacts, and needed improvements going forward.
  • LA Supervisor Mark Ridley Thomas spoke of the accomplishments of the ACA nationally, statewide, and countywide, including the continued efforts of My Health LA, the LA County program that has already enrolled over 75,000 people including the undocumented. He also addressed the need to address access issues and disparities that still remain and that disproportionately impact immigrant and under-served communities.
  • Celinda Milagros Vazquez, Planned Parenthood LA’s VP of Public Affairs, described the many benefits of the ACA for women, in particular reproductive rights, and highlighted the work of community Promotoras (community health workers).
  • Spike Dolomite Ward, a health care consumer, shared her personal story of going uninsured simply because she was self employed, only to find herself at a loss hearing the news from her doctor: Stage 4 breast cancer. The ACA “saved my life,” she shared, because she was able to enroll in the PCIP (Pre-Existing Condition Insurance Program) which ultimately provided her with the life-saving treatment she needed before Covered California first opened for enrollment in October of 2013.
  • Dr. Rishi Manchanda of the National Physicians Alliance spoke about being able to provide care to previously uninsured patients and highlighted the new consumer protections, no-cost preventive care, and other positive changes of the ACA. He also underscored the need to expand Medi-Cal for the undocumented population.
  • Gustavo Herrera, California Director of the Young Invincibles, outlined the successes of the ACA for people 18 to 32, the affordability options, and current advocacy priorities for the Young Invincibles.
  • Astrid Campos, Campaign Manager for the Children’s Partnership, touched on the ACA’s many benefits and coverage options for children and the work that still needs to be done to ensure 100% coverage for ALL children in California.
  • Riana King, Health Care Consumer (Young Invincibles), shared her personal story of being diagnosed and treated for her Crohn’s disease and her deep appreciation to the ACA for allowing her to remain covered under her parent’s insurance plan, which made it possible for her to have the surgery she desperately needed and the lifelong treatment she will require.
  • California Immigrant Policy Center Executive Director Reshma Shamasunder, described the benefits of the ACA for communities of color and the work that still needs to be done in terms of SB4 (#Health4All) and and the need to provide care for the underserved and under-represented.

The event also included an awards ceremony recognizing the role of the state’s elected officials in the state’s success to date on the ACA. Each of the following state leaders were honored with “Health Care Champion Award” plaques:

  • Members of Congress:  Adam Schiff, Judy Chu, and Karen Bass
  • Senators:  Ricardo Lara, Ed Hernández, Holly Mitchell
  • Assemblymember:  Jimmy Gomez

Many of our friends and partners participated in the planning of the event including:

  • Planned Parenthood Los Angeles
  • Children’s Defense Fund, California Chapter
  • Children Now
  • California Partnership
  • Children’s Partnership
  • California Immigrant Policy Center
  • Young Invincibles

photo1_LAevent

Thank you again to all who joined our celebration and pledged to continue their advocacy and support around SB4 and securing coverage for all.

Please see photos of our event here: https://www.facebook.com/rblwcuz/media_set?set=a.10206477330519928&type=1

Some of the press coverage included:

5-Year Anniversary of Affordable Care Act: A New Report

Leading up to the 5th anniversary of the Affordable Care Act on Monday, March 23rd, Health Access California released a new report describing implementation, impacts, and needed improvements going forward.  The “power of coalition” to form a consensus for bold and far reaching reforms–is reflected in the report itself, which features substantive contributions from groups serving children and youth, ethnic minorities, immigrants, the uninsured and under-insured, workers, and county-based eligibility workers along with stories of California consumers who are directly benefting from the law. California provides a bright example of what a state can do to not only embrace the law but take it further to address priorities for the state.

Solid Results on Key ACA Benchmarks

As the report shows, the state went further than the law required on most ACA Exchange provisions and set up Covered California as an active purchaser with the power to negotiate lower rates for consumers. As a result…

  • More than 60% of people previously uninsured in California now have coverage, and premium rates are growing at half the rate before the ACA went into effect.
  • Over four million Californians are now covered in new options through Medi-Cal and Covered California, and millions more have new consumer protections and more financial security.

Improving on the ACA to Address State Priorities

Instead of repeal or replace or questionable Medicaid waivers, California has taken advantage of the considerable flexibility within the ACA itself to innovate and address specific priorities for the state and its diverse communities. Specific improvements made by California policymakers include:

  • leveraging the exchange’s bargaining power to promote value for the consumer;
  • standardizing plan choices for consumers;
  • keeping insurers accountable by additional transparency on premium rates;
  • simplifying eligibility and enrollment through “express lane” eligibility and hospital presumptive eligibility;
  • expanding Medicaid early through Low-Income Health Programs;
  • including certain immigrants in public programs through state-funded Medi-Cal; and (at least in certain counties) providing safety net care and coverage options for the undocumented and remaining uninsured.
  • Dedicating significant resources to targeting and making headway in enrolling groups with high rates of uninsurance, including communities of color and LGBT Californians.

Lots More To Do!

The agenda for consumer advocates moving forward include care and coverage for the remaining uninsured, including the undocumented, further health system reforms to lower costs and improve quality, and a focus on health equity, not only by maximizing enrollment for communities of color but through prevention and population health initiatives and efforts to address the social determinants of health. In addition, Health Access California is sponsoring five bills this year in the California legislature to help consumers by preventing with surprise or unfair out-of-pocket costs.

The Bottom Line

The report highlights five years of solid results, but that work is not finished until everyone has quality, affordable coverage, and care that allow all Californians–no matter their income they make, language they speak or where they come from–to enjoy longer and healthier lives.

The history of health reform & your new 1095A form

Further reflections from my Peter Harbage memorial comments,

Or, How I learned to live with the individual mandate

If the debate about health reform has been electric, the debate around the “individual mandate” was the lightening rod, with all the zigs and zags of an electric bolt. Just as millions are filing their taxes, with a new tax form 1095A showing the new subsidies to afford coverage they received under the Affordable Care Act over the course of 2014, and others filing taxes realize they now are paying a penalty for being uninsured, it was noteworthy to look back at this policy, especially as we remember one of the early evangelists of the mandate.

This past Sunday I was honored to speak at the memorial of Peter Harbage, a health care policy consultant and friend. In both an earlier blog post, media quotes, and my remarks on Sunday, I made reference to the strange and surreal journey of the individual mandate, from a proposed partisan conservative concept to thwart health reform to a centrist compromise to a law supported by liberals.

Among his many other contributions to the world of health reform and health policy, Peter Harbage was an early evangelist for the notion of the individual mandate—and in that role helped shape the Affordable Care Act as it is benefitting millions today.

The individual mandate was first proposed in 1993 by Republican Senators as an alternative to the health care reform championed by the Clinton Administration. A related idea, the creation of “exchanges” to foster a market of coverage was the subject of a Heritage Foundation paper.

But when Massachusetts policymakers, faced with the loss of federal Medicaid funds and a looming health reform ballot by advocates, passed a health reform that had elements befitting a Republican Governor and a Democratic legislature.

The individual mandate was then seen as the conservative Republican way to do health reform, with the focus of “individual responsibility.” Liberals focused mostly on expanding public programs, from Medicaid for children and parents, all the way to Medicare for everyone: a single payer system.

But the inclusion of the individual mandate in the Massachusetts reform, with the endorsement of GOP Governor Mitt Romney and Democratic Senator and icon Ted Kennedy, moved it into the policy conversation.

In California, Governor Schwarzenegger made the individual mandate the centerpiece of his health reform push in 2007, as it reflected his brand of Republicanism.

Prior to this, consumer and community groups, and progressives in general, were skeptical of the individual mandate–in fact, Health Access California opposed prior mandate proposals in the state legislature. (Even today, this opposition was warranted, given the proposals’ flaws. And those flaws did color our thinking, leading one paper of mine to be entitled, “Individual Mandate: Unwanted, Unworkable, Unwise”),  It wasn’t that individual should contribute to the cost of coverage–they did so in the old system, and they would under a public program expansion or single-payer system through taxes. The issue was that such proposals seemed to blame the victim, and put the burden of the problem of uninsurance on the individual, rather than the employer who doesn’t provide health coverage to its employees; the insurer who overcharges or who denies for pre-existing condition; or on a state government that restricts Medicaid or any other financial help for coverage to the poorest of the poor, and even leaves out many of those who need help.

What was notable about the Massachusetts plan, and Schwarzenegger’s effort in California, was that the mandate was bundled as “shared responsibility” with other proposals that progressive reformers thought were essential–requirements on insurers and employers, guarantees on affordability, etc. For example, here in California, Schwarzenegger included many of these steps. Additional negotiation with the Democratic Assembly brought it further, but not far enough for some. It eventually died in the California Senate with opposition from the right and left.

Peter was one of the main consultants working with the Schwarzenegger Administration on its effort, working with the New America Foundation.

That same year, Peter continued as the senior advisor on health care to Senator John Edwards for his run for Presidencies, and in that role helped craft, in 2007-8, the first comprehensive health reform proposal by a major presidential candidate in a generation. Since the failure of the President Bill Clinton in 1993, Democrats generally did not put forward broad health reform proposals, favoring specific proposals like an HMO Patients’ Bill of Right or expansion of children’s coverage. Some minor candidates endorsed single-payer, but neither the candidates nor the proposal had significant traction.

So it was a really big deal for Senator Edwards, a serious candidate as the former vice-presidential nominee of the Democratic party, to spell out a plan that would get close to universal care. Other candidates might have laid out broad principles, or had a more piecemeal approach. Having a comprehensive plan certainly was not a given: Senator Clinton had her health care reform credibility (or baggage, depending on your viewpoint) from her past efforts, and may not have seen an advantage. Senator Obama had a good history on health care in the state legislature, but his initial speeches and comments were cautious.

Columnist Paul Krugman praised the proposal in a op-ed called “Edwards Gets It Right”: “At first glance, the Edwards health care plan looks similar to several other proposals out there, including one recently unveiled by Arnold Schwarzenegger in California. But a closer look reveals extra features in the Edwards plan that take it a lot closer to what the country really needs.” And he noted that it prodded the other major candidates as well: “This is a smart, serious proposal. It addresses both the problem of the uninsured and the waste and inefficiency of our fragmented insurance system. And every candidate should be pressed to come up with something comparable. Yes, that includes Barack Obama and Hillary Clinton.” Krugman called out the candidates, including the one who would be President. By having Senator Edwards propose this comprehensive plan, it prompted and gave political space for Senator Clinton and Senator Obama to follow suit with similar proposals–which they did.

With Peter’s urging and crafting, Senator Edwards included the individual mandate in his plan, and suddenly, the individual mandate became a conservative idea, to a benchmark of universality. The candidate staking out the left flank was calling for an individual mandate–and all the other policy changes that logically flow from it–if you want to ensure that people must have coverage, suddenly you have to heavily regulate and negotiate with insurers, to stop denials for pre-existing conditions, and to set standards for coverage, and to subsidize it for the many who can’t afford it. If you subsidize it, you have to define what kind of coverage you are talking about, in terms of benefits and cost-sharing. You have to ensure employers just don’t dump coverage, so you need some requirement on them. At the end of the day, the mandate was much more an expectation of government ensuring access and affordability, than on individuals who generally already need coverage in today’s modern world of expensive medicine where one emergency can otherwise mean financial ruin.

And that is why although the individual mandate has Republican roots, it is disingenuous to call it a Republican proposal. The Democrats, in adopting it and making it workable, also made it their own. They set standards and subsidies for coverage. You could see it in the comments of the Republican Senators like Chuck Grassley and others that Senator Max Baucus was attempting to bring along in negotiations during the summer of 2009–they like the idea of individual responsibility, but then got cold feet when they recognized the implications of what that would mean would also have to be changed. Few Republicans shared the ideological flexibility (or inconsistency) of Mitt Romney and Arnold Schwarzenegger–who to their credit, followed the logic of their policy, at least to a point.

The focus of the policy went from a mandate on individuals to get the coverage they want and need anyway, and more a mandate on government to guarantee that  such coverage is available, affordable, adequate, and administratively simple.

In a world without Peter’s influence, perhaps Senator Edwards doesn’t offer a such a comprehensive proposal, and that the Senators Clinton and Obama don’t either. Or they offer such varied and different ideas that there isn’t the consensus in the Democratic Party that allows the eventual President Obama to move a proposal through Congress. Having the progressive candidate endorse the individual mandate was a key moment in having progressives adopt it as a plank–so much so it was only a small deal when President Obama included it in his proposal, even if it wasn’t in his proposal as a candidate.

Health reform wasn’t won in the 2007-08 campaign, but the opportunity could have been lost without many factors coming together. Peter Harbage was one of many people who made health reform his life’s work, and together history was made, and millions now benefit from coverage. I was happy to help spotlight the specific and tangible way he helped thread the needle to put the United State on the path to reform.

And it gives an opportunity to remark about the evolution of a health policy idea, one that people are seeing evidence now as they see the subsidies or penalties on their tax filings. The policy’s dramatic story continued through contentious Congressional debates and even threatening to undo the entire project at the Supreme Court, being upheld by a narrow 5-4 vote. The rest, as they say, is history.

New Report Shows Post-ACA Enrollment in County Indigent Programs

HEALTH ACCESS UPDATE:
Thursday, March 12, 2015

NEW STUDY REVEALS DRAMATIC DIFFERENCES IN ELIGIBILITY & ENROLLMENT FOR COUNTY INDIGENT CARE PROGRAMS; SHOWS POST-ACA NEED TO REFOCUS SAFETY-NET TO BETTER SERVE THE REMAINING UNINSURED

* Counties Vary Widely: On Income, 43 Counties Provide Care Up To 200% of Federal Poverty Level; Six are Below, Nine Are Above That Medium Threshold; Twelve Run Public Hospital Systems; Only Ten Report Providing Services to Undocumented Immigrant Californians.

* New Health Access Report Shows Counties Successfully Enrolled Most In Their Indigent Care Programs in ACA. Counties With Broad Eligibility Showed Continued Need; Those With Restricted Eligibility Had Few If Any Enrollees.

* Momentum For the Remaining Uninsured, as My Health LA Now Covers 81,000 Californians, and Many Counties Currently Discussing Reforming Their Indigent Care Programs. As an Example, Sacramento County Starting to Discuss Restoring Care for Undocumented Immigrants at Workshop on March 18th

 

A new report released today by Health Access California, the statewide health care consumer advocacy coalition, shows the major impact of the Affordable Care Act on California’s safety-net programs, as well as dramatic differences by the counties in both their eligibility levels by income and immigration status, and especially in their enrollment. The study puts a spotlight both on counties that are refocusing their programs to serve the remaining uninsured including undocumented immigrants, and on counties starting to have that conversation.

The survey shows that the Affordable Care Act expanded coverage to many of those with limited care options through county indigent care programs. The survey also shows there is still a need for a safety-net that survives and thrives, as tens of thousands of Californians who remain uninsured are still using these services in each county with expanded eligibility. Howvever, many counties with restrictive eligibility requirements have few if any people getting care through their programs, and thus need to re-adjust their programs. Community and health advocates are urging counties and the state to reorient their safety-net programs to serve the need that continues to this day.

The survey of all 58 counties’ indigent care programs, a follow-up from an earlier November 2013 Health Access report, shows the impact of the dramatic expansion of health care coverage under the Affordable Care Act. In late fall of 2014, Health Access conducted a survey of California county health departments, asking about eligibility and enrollment in programs for the medically indigent. The survey found that:

** California counties continue to be dramatically different in how they care for the “medically indigent,” both in term of how they provide care, who is eligible due to income and immigration status, and other factors.

o Forty-three counties serve residents at twice the federal poverty level; six counties have income limits below that; nine counties have income levels above that.

o Only ten counties provide services beyond emergency care to the undocumented.

** The 2014 implementation of the Affordable Care Act significantly reduced the number of Californians in every county indigent care program in the state, as counties successfully enrolled their patients in Medi-Cal and Covered California.

** Counties with broad eligibility requirements are seeing strong continued need for their safety-net programs, with tens of thousands people enrolled in some counties. Some are adapting and augmenting their programs to be more comprehensive, focusing on primary and preventive care.

o Beyond programs like Healthy San Francisco and Alameda’s HealthPAC, the new My Health LA program launched in September 2014 and is already serving 81,000 Angelenos.

** Counties with restrictive eligibility requirements, especially those that exclude the undocumented, are finding few if anyone left in their indigent care programs—but not because there is not need.

** While some counties adjusted benefits, most counties generally did not change eligibility for their programs in the last two years, opting for a “wait and see” approach after both the ACA implementation and the state’s reallocation of some safety-net funds.

o Fresno was the main county that actively considered, and in fact voted on, rolling back eligibility significantly, but it is in the process of establishing a reformulated program, including for the undocumented.

o Other counties and advocates are looking to refocus and reform their programs to better meet community needs and the remaining uninsured including the undocumented.

o For example, Sacramento, one of three counties to stop serving the undocumented in 2009 (the others being Yolo and Contra Costa), is having a conversation, at a workshop on March 18th, about options for restoring such services, and in what form.

Based on this survey, Health Access recommendations urge counties to re-orient their programs to better serve the remaining uninsured, as many counties are starting to plan their 2015-16 budgets, which are set to start in July 2015. The President’s executive order on immigration also will spur these policy conversations, as immigrants with this expanded “deferred action” status become eligible for both state Medi-Cal or these county programs, depending on income.

With the Affordable Care Act successful enrolling many Californians, some counties are consdering reorienting their indigent care programs to meet the new needs of the remaining uninsured. Many community groups are working in many counties to make sure all Californians have basic access to the primary and preventive care they need. Much like the county Low-Income Health Programs were a bridge to health reform and the Medi-Cal expansion, these county efforts can ultimately be a bridge to a statewide solution, where all Californians can be covered regardless of immigration status.

For more information, read the report on the Health Access website at: http://www.health-access.org/images/pdfs/CountySafetyNetReportSurveyResults3-12-15.pdf 

Senate Budget Subcommittee #3 Hearing on CHHS Programs

The Senate Budget Subcommittee on Health and Human Services held its first hearing of the year on March 5, 2015. Programs within the California Health and Human Services Agency (CHHS) were on the committee’s agenda. The Senate Budget Subcommittee #3’s hearing agendas can be found here.

Office of Systems Integration – CalHEERS Oversight
First on the agenda for CHHS programs was the Office of Systems Integration, which manages the CalHEERS (California Healthcare Eligibility, Enrollment, and Retention System), an IT system that supports the application process for insurance affordability programs (Medi-Cal and Covered California). It is jointly sponsored by DHCS and Covered CA.

CalHEERS has had a number of problems, resulting in key populations not being able to access the coverage they need. For example, under the ACA, former foster youth qualify for Medi-Cal coverage until age 26 regardless of their income. This law has been in effect since January 1, 2014 but has not been programmed accurately into CalHEERS, resulting in enrollment delays, enrollment in the wrong affordability program, or denial of Medi-Cal for former foster youth. Similar issues arise with the Medi-Cal Access Program (formerly known as Access for Infants and Mothers – AIM).

Our colleagues at Western Center on Law and Poverty testified about the lack of transparency and stakeholder engagement in setting the policies and priorities for CalHEERS, contrary to the requirements of AB 1296 (Bonilla, 2011). Specifically, stakeholders have received limited updates regarding CalHEERS changes but have not had an opportunity to give input on those priorities. Health Access echoed the concerns raised by WCLP and other consumer advocates and urged the subcommittee to maintain oversight over this issue.

Senator Holly Mitchell, Chair of the Budget Subcommittee, expects further conversations on CalHEERS at the March 19 hearing, when the DHCS programs and budget will be on the agenda. The subcommittee held this item open for further discussion and information gathering.

Office of the Patient Advocate
Beth Abbott, former Director of Administrative Advocacy at Health Access and new Director of the Office of the Patient Advocate (OPA), was “pleased as punch” to present her office’s budget change proposal to the committee.

Last year, the OPA was revamped and its responsibilities include producing health care quality report cards with clinical performance and patient experience data for the state’s largest health plans and over 200 affiliated medical groups; compiling and reporting on how state health consumer assistance call centers are (or are not) helping patients, from the Department of Managed Health Care, Department of Insurance, Department of Health Care Services, and Covered California; and the development of model protocols for these call center agencies.

OPA has requested $206,000 in 2015-16 and $182,000 ongoing to support the implementation of the Complaint Data Reporting Project. Health Access testified in strong support of OPA’s funding request. Health Access has a long history of working to strengthen consumer assistance hotlines to help Californians navigate the system, exercise their rights, and make informed health care choices. We have sponsored and supported legislation to revamp the OPA and give it the new responsibility of collecting, tracking and reporting on data from state health consumer assistance agencies. Having this information will help the state know whether its call centers are (or are not) helping patients. We also expressed our hope that OPA will, in the future, include reporting on call center metrics such as call wait times and dropped calls because call center performance is an important element of consumer complaint handling. Our colleagues at Western Center on Law and Poverty, CPEHN, and Congress of California Seniors also spoke in support. The Subcommittee held this item open for additional discussion.

High Cost Drug Proposal
The Governor’s budget includes $300M set aside to pay for new breakthrough drugs, such as those used to treat Hepatitis C. The budget does not allocate this funding to specific departments at this time. Individuals enrolled in Medi-Cal, the AIDS Drug Assistance Program (ADAP), patients in state hospitals, and inmates in state prisons are among those who may potentially be treated with the new Hepatitis C drugs. The Administration is convening a workgroup to address the state’s approach regarding high-cost drug utilization policies and payment structures. Right now, the workgroup only includes state departments and county representatives.

Health Access and other consumer advocates urged the inclusion of consumer and patient advocates in the workgroup. Advocates also requested that this process look at all high-cost drugs and not just those for Hepatitis C. Concerns about access and affordability will apply to all high-cost drugs coming to market.

Health Access will continue providing updates about the budget subcommittee process throughout the spring.

New Covered California Announcements

Governor Jerry Brown today appointed Genoveva Islas and Marty Morgenstern to the Covered California board, replacing Susan Kennedy and Kim Belshe, who are attending their last meeting today. One last vacancy, after the departure of Dr. Bob Ross, in awaiting an appointment by the California Senate.

While neither appointee has huge background in health insurance per se, the new board members bring real-world experience representing California consumers, workers, families and communities, which will be important when negotiating with the insurers on getting better value. Viva Islas has deep experience working with Central Valley families, with a focus on public health and prevention. Former Labor Secretary Marty Morgenstern fully understands the issues of front-line workers, both coping with cost-sharing and also as labor has negotiated for health benefits. After this crucial first four years getting Covered California up and running, and many Californians enrolled, the next challenge for these new board members is to really use the bargaining power of Covered California to improve our coverage and ultimately our health.

Covered California also released more detailed enrollment data coming out of a second open enrollment period. The data is in this Powerpoint:

There were 495,073 new enrollees thru Feb 22; 944,000 renewals, (and also 779,000 new enrollees in Medi-Cal). We are pleased that hundreds of thousands more Californians are enrolled, to benefit those families directly with health and financial security, but for the state’s health system on which we all rely. With a bigger, broader, and younger enrollment pool, this positions Covered California to negotiate for better rates for next year.

In the second open enrollment period, we saw more Latino and younger enrollees: 37% Latino (as compared to 31% in the first open enrollment); 21% for ages 26-34 (17% in the first open enrollment). It’s good that Covered California has reached further into Latino communities, but there’s more to do. Enrolling those who are left will take more focus and creativity, as well as on-the-ground outreach and assistance. We need to focus on better connecting Californians to coverage when they are in the middle of life changes, from job changes, moves, family events, etc.

We’ll have an update from the full board meeting later.

King v. Burwell Oral Arguments THIS WEEK: A view from California

This Wednesday the Supreme Court will hear oral arguments on King v. Burwell, a case that contests the subsidies available in the 36 states that have federally facilitated marketplaces or FFMs. The case is based on an hyper-literal, politically motivated mis-reading of Section 1311 of the ACA, which says that subsidies are available to people “enrolled through an Exchange established by the State under 1311.″ At stake is nothing less than affordable coverage for 8 million Americans (See Kaiser Family Foundation’s helpful overview of King v. Burwell here).

Again, no matter how it gets decided in June, King v. Burwell will have no impact in California—end of story. But it is fair to say that an adverse decision will create two health care Americas — one that provides peace of mind for its residents (California) and another that will put families right back where they started: at risk of ‎not receiving the health care they need.

States like California that are implementing the ACA in good faith are already demonstrating that the ‎law effectively increases health coverage, aids the long-term effort to lower costs, and creates helpful competition — something that could be achieved elsewhere if only a state had the will to implement the statute effectively.

Californians should feel secure with the coverage and financial assistance they get from Covered California, and should take advantage of the extended open enrollment period through April 30th to sign up. Even the political fallout and reaction from a politically-motivated decision against Obamacare is highly unlikely to impact California. If the court does take away subsidies for millions of Americans, a simple Congressional clarification of a few words could restore the subsidies. Even with the many in Congress who oppose Obamacare, it’s impossible to imagine President Obama, or even Congressional Democrat leaders Nancy Pelosi of California or Harry Reid of Nevada–both states with state-run exchanges–agreeing to attack or compromise that undermines coverage and access to care in their home states.

Covered California, a state-based exchange marketplace, has bent over backwards to promote the subsidies, with the result that 89% of Covered CA enrollees are using them–compared to 87% nationwide. It bears noting that communities of color are particularly benefitting from the premium subsidies and that they will be disproportionately impacted by an adverse decision in the federal marketplace states.

In California we fully understand that without the subsidies, young and healthy people would not enroll, leaving older and sicker consumers behind in the risk pool and thus driving up premium costs. From here the marketplaces would spin into a “death spiral”—and it’s game over for the ACA, at least in the FFM states.

Heading into Wednesday, we can take comfort in the amicus briefs filed on the case—most strongly support Burwell and the current disposition of subsidies in FFM states. The best we’ve seen argues that none of the FFM states had notice that their decisions to delegate marketplace operations to the federal government would have any impact on the availability of subsidies for their residents (see more on the amicus briefs).

Any adverse decision would have no leg to stand on, least of all any notion that FFM states could somehow turn their ships around overnight and become state-based exchanges. It took years of painstaking effort (and upwards of $1 billion in planning grants for California) to craft the consensus for a robust, state-based exchange. It is therefore not reasonable to expect FFM states to scramble to assemble their own exchanges. By the time they sort out the politics or funding of this, it will be too late for their marketplaces and the consumers in those states will pay the price.

In fact, given how groundless and outlandish the case is (if you can stomach the details from Mother Jones Magazine, click here), we can do this case justice by stepping up outreach and enrollment efforts all across the land, not just for the SEPs but for anyone still needing to enroll.

Since California has a state-based exchange, subsidies are not at risk here—not at all.

  • If you are receiving a subsidy now, you can rest easy.
  • If you work with individuals who are using a subsidy, please get the word out: they, too, have nothing to fear.
  • If you are providing outreach or enrollment assistance, DO NOT LET THE KING V. BURWELL CASE DISTRACT FROM THE WORK AT HAND. Remember that Covered California has introduced a new special enrollment category for people who recently learned about the tax penalty for being uninsured—we’re guessing that’s a lot of people who could get covered through April 30.

Beyond that plenty of folks are eligible for a SEP (Special Enrollment Period), especially the Young Immortals who are the most likely to experience a qualifying life event.

To follow the King v. Burwell hearing on Wednesday, March 4: 

Andy Hyman

Today we mourn Andrew Hyman, a smart and strategic leader whose behind-the-scenes work led to numerous health reforms and improvements to our nation’s health and health care, a lead program officer at the country’s largest health philanthropy, and a friend to Health Access California and dozens of state-based consumer advocates.

His colleagues at The Robert Wood Johnson Foundation have highlighted many fitting testimonials to Andy from a who’s who of the health policy world, comments that give you a sense of his work, in philanthropy and previously at the Department of Health and Human Services.

I remember getting to know Andy over a decade ago at health policy conferences in DC, where early on he had a thrillingly realistic sense of how health reform could be advanced–what combination of state reforms and momentum, election results and political forces, policy developments and trends, and specific vote-counting in the Senate could combine to yield expanded coverage. His vision embraced not just policy but being mindful of politics; not just research and education but the crucial role of organizing and advocacy, not just elites but movements, and not just federal but state-based work. He helped establish and champion the Consumer Voices for Coverage program at Robert Wood Johnson, which provided support for Health Access and other groups working on California health reforms working in coalition as Its’ Our Healthcare! and Having Our Say, as well as other consumer advocacy coalitions in other states. These state-based efforts that he helped support built critical infrastructure for winning health reform nationally soon afterwards.

AndyHyman

Rather than declare victory, he worked to support state-based implementation of Affordable Care Act–both the needs of the state policymakers, and of the advocates that shape the environment in which they work. It’s hard to think of too many other people who can credibly claim to have been a part of the success in as many states as Andy could–even if he would never have sought such credit. He will be missed by health reformers and advocates in DC and throughout the country, and unknowingly by many who never knew his name but felt his impact.

He was always approachable and affable: On a trip back East, I offered to meet him at his office in New Jersey, but he arranged to meet more conveniently for me in New York. Last September, he expressed worries about second open enrollment period, and wanted to be comforted by the report on the ground in California. He asked me for critiques of what he and his foundation colleagues were doing, and actually wanted the answer–even though he knew them already. Even when California wasn’t a grantee in recent rounds of funding, Andy continued to be a source of support and strategy–sending an E-mail appreciating a snide quote of mine in Politico, talking about emerging issues for funders and policymakers, offering concern and advice about balancing work and family life. As I wrote a state advocate colleague this morning, I’ll very much miss him and my twice annual conversations with him. The last few were poignant if not profound, so I’ll always remember them.

My colleague Judi Hilman, who worked with him when in her previous job in Utah, had her own remembrances:

I got to work with Andy when I was running Utah’s health policy shop, Utah Health Policy Project, and I (and my friends back in Utah) will always be grateful for his willingness to bring us and other red states to the Consumer Voice for Coverage table. No matter how difficult it was to implement the ACA in our states, Andy kept our eyes on the prize and in his gentle way he reminded us that we should never compromise our vision for reform, even if we had to take twisted paths to get there.

I will certainly miss Andy’s commitment to bipartisanship—even after so many in the reform community seemed to give up.  On his own, Andy reached out to red state Governors like Utah’s Herbert to help them find a voice or a role in the process—one day, in fact I bumped in to him on the street in Salt Lake after his meeting with Herbert’s staff.  It didn’t take much schutzpah for me to invite him to come to our coalition strategy conference later that day. He showed up, of course, and offered thoughtful and provocative reflection. Andy’s memory will help me and so many of us keep that slow drumbeat going for real reform, in blue and even in red states.