A California Resolution to the Primary Debate on the Future of Health Reform

Blog post written by Anthony Wright, Executive Director of Health Access California

Since Health Access does not endorse candidates, I have refrained from commenting on the Presidential primary debates. There has been little to analyze on the Republican side, given the minimal substance on health policy, besides the standard talking points about the repeal of Obamacare.

On the Democratic side, the health care debate has been more interesting. Secretary of State Hillary Clinton has embraced the Affordable Care Act and outlined a series of proposals to not just defend it but “build on it” for increased affordability, expanded access and improved quality.

While Senator Bernie Sanders voted for and supported the Affordable Care Act, he strongly advocates for a broader revamp of our health system to create “a Medicare-for-all health care system.”

As opposed to re-litigating whether the Affordable Care Act should have been enacted in the first place, this debate on the Democratic side has been useful to begin the crucial national discussion of what should be the next steps to improve the health care system. But too often the debate, or the descriptions of it, have been stuck in pre-existing primary fight frames about incrementalism vs. revolutionary change, progressivism vs. pragmatism, broad visions vs. detailed plans, inside vs. outside–as if these concepts are necessarily opposed to each other and policy change doesn’t require some interplay between these forces. As an organization that has been involved in making real policy change that improves the lives, and health, of Californians, we know that progress requires both broad visions and detailed plans, the inside play and the outside action, and a balancing of progressive objectives with pragmatic realities. These are not either/or, making progress requires both.

While I admire both candidates, I wish they had engaged this debate a bit more constructively. Senator Sanders talks about single-payer no differently from ten years ago, as if the Affordable Care Act never passed, as if there was not just policy progress but political lessons that have been learned from the country’s decade-long grand debate on health reform. He is right to put forward a grand vision where health care is a right for all Americans, but missed an opportunity to provide not just technical and fiscal details but to lay out a strategy of how we could transition to such a system from the world we are today–both politically and policy-wise. And while Senator Clinton was right to focus on concrete, specific steps that could provide tangible and immediate benefit to consumers, she never connected her various proposals into a broader vision of quality, affordable health care for all Americans, and was too quick to dismiss single-payer as politically unrealistic. While undoubtedly true in the short term, certainly with a Republican Congress, our political vision should not be restrained by what is possible in the moment–and indeed it is the job of our political leaders to stretch the boundaries of the debate. If nothing else, she would be good if she could be clear in responding to how her agenda is any more realistic with a Republican Congress-if there is a strategy on key issues, like how hard would it be for any member to vote against additional affordability in the form of tax credits, or to point to a growing bipartisan angst on prescription drug prices.

As the primary fight winds down, there is an opportunity. Recognizing he is likely not to win the nomination, Senator Sanders seems to be focusing on influencing the party platform and its positions, including the endorsement of Medicare-for-all single payer. In addition, I agree with Jonathan Cohn of the Huffington Post, that Sanders could have an important voice on health policy in coming years, advocating for “the most successful and popular elements” that “lay the groundwork” to that goal.

What are those elements? Cohn suggests having the government negotiate on prescription drug prices, and in particular the adoption of a true “public option” that would compete with the private plans. But there is a broader agenda than just the public option, which was a rallying point that we actively organized in support of during the effort to pass the ACA.

Supporting “single payer” has become shorthand for some advocates for a range of different improvements and reforms, and politically and policy-wise it is better to spell out those goals specifically. When folks support Medicare for All, they usually are seeking a health system that is more universal, progressively financed, cost-effective, streamlined and efficient, comprehensive, and prevention-oriented. Those are goals we can make progress toward that provide policy and political momentum for additional reform. A single-payer financing system that help facilitate those goals, but it’s not the only way, and the details matter–for example, it’s technically possible to have a single-payer system that is based on regressive taxation or unaffordable cost-sharing. And making progress on specific goals are not just tangible victories that would help people, but would provide momentum and policy progress toward additional reform.

Beyond the public option, another idea would be for Clinton to adopt a goal that would be an element of a single-payer system that progressives support–that no American should have to pay more than a percentage of their income to get basic health insurance, based on a progressive sliding scale. Through the subsidies available in the exchanges, the Affordable Care Act took a dramatic step toward this goal away from the previous regressive individual market, where what you paid was based on how old and sick you were. But the ACA’s guarantees of affordability have exceptions and caveats and despite the best efforts of many, the tax subsidies were never sufficient to provide coverage as affordable as most employer coverage. Senator Clinton has already proposed increasing the subsidies and tax credits available under the ACA to provide better affordability–it wouldn’t be too far a stretch to be able to make that broad guarantee that has been the hallmark of Senator Sanders’ proposals, and that is clear and understandable as a political rallying cry and policy goal. 

In their debate about universality, one key question is how to include undocumented immigrants–a question that arises in designing a single-payer system or in each of the multiple programs that exist today. In an early debate, both Senators Clinton and Sanders endorsed the ability of immigrants being able to buy coverage in the exchanges with their own money–something California is seeking to do through SB10(Lara) and a 1332 waiver. Senator Clinton has supported allowing states to go further with immigrant inclusivity, including with 1332 waivers–but perhaps she could detail how these state efforts build toward a truly universal health system, and how that helps the health system be stronger for everyone.

Senator Clinton could also follow the California’s example by encouraging the federal and state exchanges to be active purchasers, bargaining for the best value and driving standard benefits and improved quality. The principle of increasing the bargaining power is core to single-payer proposals, but was also an essential part of the law creating Covered California that was signed by Republican Governor Schwarzenegger, and has been part of the California policy landscape for years at CALPERS and Healthy Families and Medi-Cal under Administrations of both parties. This greater negotiating leverage helps provide more oversight over the insurance industry overall as well as reducing the cost of coverage with the potential for improving health outcomes and reducing health disparities.

Similarly, using the federal government’s bargaining power to take action on prescription drug costs is likely an area of policy agreement between the two Democratic candidates. Beyond the specific policy proposals, it also would be an important test case for politicians to stand up to a big-money industry, an industry that has not been afraid to spend obscene amounts of money to get its way.

In her position papers, Senator Clinton has also identified issues about capping the cost-sharing for specialty drugs, mirroring California’s law AB339 sponsored by Health Access California. She could broaden that, as both she and Senator Sanders have talked about out-of-pocket costs broadly, from deductibles to co-pays. She could outline not just specific proposals but some general goals on unfair out-of-pocket costs–ones that could likely get bipartisan support, like our state effort has this year against surprise out-of-network medical bills.

Each of these elements by itself may not be the “political revolution” that Senator Sanders seeks. But each of them could become major fights with key parts of the health industry–whether insurers, drug companies, or providers–that provides the “what side are you on” clarity that has provided the spark of Sanders’ message. And together, these efforts would dramatically improve the health system and bring us closer to the vision. Opponents might say that the ACA and these efforts to implement and improve it are a “slippery slope” to single-payer, but I think that metaphor is reverse. Rather, advocates are scaling a mountain–we have made progress up the mountain, and we are that much closer to the peak, but let’s be clear-eyed that the air is thinner, the angles steeper. As with climbing a mountain, we need to be strategic and smart as we make additional steps up toward an improved health system.

#Health4All Continues to Gain Momentum

Last Tuesday, the Assembly Health Committee voted on SB 10 (Lara), which expands health care coverage to all Californians, regardless of immigration status, by authorizing the state to apply for a federal waiver that would allow undocumented immigrants to buy coverage through Covered California using their own money.

Consumer and immigrant advocates showed their strong support for SB 10, testifying in support of this important bill and submitting letters of support. Advocates have been working for expanding access to quality, affordable health care coverage to all Californians, regardless of immigrant status. SB 10 now heads to the Assembly Appropriations Committee.

Health4All Conference and Lobby Day
Join Health4All’s Conference & Lobby Day on May 15-16. The conference will take place at Sacramento State on Sunday, May 1. Monday, May 16. the march will start at 10 am at Embassy Suites and end on the north steps at the Capitol for the rally. Register today!

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Consumer Advocates Raise Concerns About Aetna-Humana Mega-Merger at CDI Hearing

On April 27, the California Department of Insurance held a hearing on the proposed merger of Aetna and Humana. This hearing takes place after a public meeting held by the Department of Managed Health Care (DMHC) in January.

This hearing comes on the heels of a Senate Health Committee hearing this month on SB 932 (Hernandez), a bill that ensures that mergers and consolidations in California’s health care marketplace do not have a negative impact on cost, quality, and access to care for California consumers. Currently, two of four major health insurance mergers have been finalized by the state of California; Blue Shield of California acquired Care1st last year and Centene’s proposal to acquire Health Net was approved with conditions by state regulators in March. The Aetna-Humana merger is one of two mergers still pending, along with Anthem-Cigna. Other hospital and health mergers have also taken place, including the Daughters of Charity Health System purchase by an investment firm in 2015.

Tam Ma, Health Access California’s Policy Counsel, provided comment on behalf of California consumers, raising questions about Aetna’s track record in California and if they should be allowed to have even greater market share. Specifically, she made the case that to ensure that this merger—and others— is in the public interest, insurers should not be allowed to get bigger unless they commit to getting better, sharing skepticism about whether bigger is actually better for consumers.

Lack of Consumer Protections a Concern

In her testimony, Tam Ma focused on Aetna’s track record in California’s commercial market and its lack of respect for California law as well as basic consumer protections.

  • Routine Medical Survey: Through DMHC’s most recent Routine Medical Survey, Aetna was found to have three major deficiencies, of which one had still not been corrected three years later. Although Aetna reported they have corrected this deficiency, it is disappointing it took them 3 years to do something as basic as posting information about consumer rights on its website.
  • Enforcement actions:  Aetna has been the subject of numerous enforcement actions by DMHC, most of which stem from its poor handling of patient grievances, from which it has had 45 violations since 2011. Aetna has accumulated over $100,000 in fines in the last year alone and in 2014 was fined $200,000 for failing to process claims and provider disputes in a timely manner.
  • Unreasonable rate increases: Aetna has proceeded with 7 rate increases that both DMHC and CDI have found to be unreasonable. As a result, small businesses had to pay more than they should have for care. Should this merger be approved, it must be conditioned on the promise that Aetna will not continue to engage in price gouging.
  • Reducing Market Competition: According to an analysis by Cattaneo and Stroud, the Aetna-Humana merger is likely to reduce competition in the Medicare market in eight California counties, including Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego and Ventura. These are among the most populous counties in California and are home to 24 million consumers, 60% of the state’s population.

Consumers Union, CALPIRG and the Greenlining Institute raised similar issues and questions as Health Access, including concerns about unreasonable rate increases, skepticism about passing savings along to consumers, concerns with low consumer satisfaction scores and unease with Aetna’s lack of attention to diversity and health disparities.

Consumers Union predicts that the $1.25 billion in synergies is more likely to go to increased profits than to reduced premiums or improved service. They also made the case that Aetna’s claim that market turbulence forced it to adopt steep rate increases despite the regulators’ misgivings, but changes in the marketplace have affected all the plans while Aetna stands out for resisting transparency and failing to provide relevant information to the regulators. Further, with increased market power from a merger, there is no reason to believe that the larger company would improve its responsiveness to regulators or sensitivity to consumer rate burdens. Therefore, Aetna’s extreme history of resistance around rate review should be factored into this deal, if this merger is approved at all. Lastly, Consumers Union made that case that consumers need assurances that the newly combined plan will lift up consumer interests and improve their lot rather than leaving consumers carrying the weight of this deal.

CALPIRG reinforced the issue of Aetna going ahead with charging rates deemed unreasonable by state regulators, and reviewed findings of a study they recently published. Aetna had one of the worst track records on this issue–many other insurer were more likely to roll back or retract a rate hike found unreasonable by a regulator.

The anti-competitive effects of this merger, coupled with Aetna’s poor track record, make it likely that quality will continue to go down while prices continue to go up for consumers. Consumer advocates pressed that it is unlikely that Aetna will pass along efficiencies and cost savings to consumers and other purchasers if they have repeatedly pursued unreasonable rate increases.

The Greenlining Institute focused its concerns on Aetna’s lack of attention to supporting diversity and addressing health disparities, arguing that Aetna must acknowledge the need for greater diversity at all levels of their business, especially among executive and board-level management. They questioned Aetna’s commitment to its own “Racial & Ethnic Equality” initiative considering only 14 percent of executive positions and 15 percent of its board of directors are people of color. Additionally, only 31 percent of Aetna’s employees are people of color. Aetna cannot adequately meet the needs of Californians unless they reflect the populations that they serve.

Further, Greenlining urged Aetna to provide concrete assurances that they will train, recruit, and hire a diverse workforce that reflects California and build its supplier diversity network with small, minority-owned businesses, which are a key engine of economic development for communities of color. However, from 2013-2014, Aetna took a significant step backwards by decreasing its investments in diverse suppliers by over $1.1 million, resulting in an overall decrease from 0.77% diverse spending in 2013 to 0.07% in 2014. Additionally, Aetna ceased its partnerships with African-American small businesses and also terminated its contracts with Women Business Enterprises. Even more disappointing, Aetna did not partner with any Disabled Veteran Business Enterprises, LGBT Business Enterprises, or Multi-Certified Business Enterprises in 2013 or 2014. Given that California represents the largest market for diverse businesses, this record is embarrassing and unacceptable.

Greenlining also focused their comments on Aetna’s need to invest significant resources towards upstream, preventive health improvements in underserved communities. For example, they must focus investments towards vital community health resources such as affordable housing, environmental improvements, jobs and workforce development, grants to community-based organizations, and other strategies that target the root cause of poor health. If this merger proceeds without a clear commitment to improving health and economic outcomes for communities of color, then California will continue to suffer from systemic barriers that have led to such blatant health and wealth disparities.

The Community Reinvestment Coalition made complementary comments, particularly on the issue of how Aetna invests in California, and whether it uses the COIN program to target investments.

Health Access and other consumer advocates concluded by urging state regulators and policymakers to conduct a thorough assessment of Aetna’s track record on consumer protections and unreasonable rate increases, along with recommendations for conditions that must be included for this merger to bring any benefit to consumers.

If you or your organization would like to submit comments about this merger or the larger questions at stake concerning mergers in general, you have until Friday, April 29, 5:00 pm to submit your comments to mergercomments@insurance.ca.gov.

Legislative Priorities Clear Deadlines

As the April 22 policy deadline approached, all of Health Access’ priority bills made it over the finish line. Last week, the legislative committees voted on two important bills that will increase transparency in our health care system.

Transparency for Prescription Drug Costs

Prescription drugs are the health service most commonly used by consumers and contribute to soaring out-of-pocket costs. AB 2436 (Hernandez), heard in the Assembly Health Committee on Tuesday, seeks to increase transparency in drug prices by giving consumers more information about the cost of their prescription drugs and how much they will have to pay. In committee, the bill was amended to remove a provision that would also require the drug company to disclose the cost of the same drug in Canada, Germany and Mexico, which typically have lower prescription drug costs than the US–it now focuses on providing consumers with more information about how much they have to pay for their medications, and what health plans pay for those drugs.

Shining a Light on Mega Mergers and Anti-Competitive Practices

As mega-mergers sweep the health care industry in California and across the nation, consumer and patient advocates are urging policymakers to put consumers over companies.  On Wednesday, SB 932 (Hernandez) was heard in the Senate Health Committee and requires health industry mergers to be scrutinized by state regulators to ensure that they are in the interest of consumers. It also requires regulators to hold public hearings on mergers, which provides consumer advocates opportunities to offer comment and feedback on these deals. Health Access and other consumer and patient advocates support the measure and have long called for more scrutiny as state regulators examine these deals. The bill also prohibits health providers such as hospitals from engaging in anti-competitive behavior in their contract negotiations with payors.

Both AB 2436 and SB 932 will be considered by the Appropriations Committee. For sample letters of support, click here.

Health4All – 1332 Waiver Gains Momentum

This Tuesday, the Assembly Health Committee will be voting on SB 10 (Lara), which expands health care coverage to all Californians, regardless of immigration status, by authorizing the state to apply for a federal waiver that would allow undocumented immigrants to buy coverage through Covered California using their own money. Consumer and immigrant advocates support expanding access to quality, affordable health care coverage to all Californians, regardless of immigrant status–our health system is stronger when everyone is included. For sample letter of support, click here.

For updates on these important bills, be sure to follow our Facebook page or sign-up for our e-advocate list!

New Staff Joins Health Access Team

In the last several months we have welcomed four new teammates to the Health Access team, including two organizers in the last week! Learn more about the entire Health Access team here.

Jose Tapia joined Health Access in late 2015 as our new Administrative & Legislative Assistant. José received his BA in Political Science from the University of California, Los Angeles (UCLA). He is a native to Los Angeles and has previously worked as an intern with several Congressional offices in Southern California. Thanks in part to his diverse upbringing, José has a strong commitment to ensure all Americans have access to quality and affordable health care. Prior to coming along to Health Access, José worked with Doctors for America in Washington, D.C.

Bethany Snyder joined Health Access in December 2015 as our new Director of Communications. Bethany has over 15 years’ experience in health care advocacy, communications and public affairs. She is an expert in managing strategic communications, leading successful advocacy initiatives, designing innovative outreach programs and running high-profile campaigns. Having worked for various health care organizations, Bethany has a passion for expanding health care access and ensuring the sweeping changes to our health care system benefit those most in need.

Aurora Garcia joined Health Access as our Southern CA Community Organizer, this month. Aurora has over six years of experience working in the nonprofit sector, which began with working with The Council of Mexican Federations where she fundraised for programs designed to help the Latino community. With a greater desire to organize, she began working as the CA Outreach Coordinator for Young Invincibles advocating on issues impacting young adults and in 2014, Aurora transitioned to California Partnership as the Los Angeles Organizer and Coordinator where she worked on advocacy and training on the state budget and its impact on low income communities.

Yasmin Peled also joined Health Access this month as our Northern CA Community Organizer. Yasmin received her BS in Molecular, Cell and Developmental Biology from the University of California, Santa Cruz (UCSC). While studying at UCSC, Yasmin got her start in health care advocacy running a mobile health care clinic for the homeless and under-served in Santa Cruz County. Prior to joining Health Access, Yasmin worked with Families USA in Washington, D.C., with a focus on health equity issues.

Patient-Protection Bills Moving Forward in Legislature

With the legislative session in full-swing, Health Access California’s bills are moving full steam ahead!

Last week, SB 908 and SB 1135 both passed the Senate Health Committee. SB 1135 (Monning) helps consumers know there are time limits on how long they have to wait to get health care appointments and who to complain to if they have problems with their health plan. Among other provisions, the legislation would put the state regulator’s complaint number on the insurance card. SB 908 (Hernandez) gives consumers and purchasers the information they need to decide if they want to stay with a health plan that has an unreasonable rate increase. Both of these measures now move to the Senate Appropriations Committee.

This week, the Senate Health Committee passed SB 997 (Lara), which allows low-income, undocumented children currently covered by Kaiser Permanente to remain with Kaiser, if they chose to, while enrolling in full-scope Medi-Cal coverage. It is now goes to the Senate Appropriations Committee as well.

Two measures addressing transparency in prescription drug prices are also gaining traction. SB 1010 (Hernandez) would require insurers and health plans to provide detailed, publicly available information on prescription drug costs for large employers and state purchasers, such as CalPERS, the Medi-Cal program, Corrections, and the Department of General Services. It passed the Senate Health Committee this week and now goes to the Senate Appropriations Committee.

Another bill addressing drug prices, AB 2436 (Hernandez), will be heard in the Assembly Health Committee next week. This bill gives consumers more information about the cost of their prescription drugs, how much they will have to pay, what their health plan pays for the drug, and also the cost of the same drug in Canada, Germany and Mexico.

For more information about all of Health Access’ sponsored legislation, click here. To track all health care bills that impact California consumers, check out our Bill Tracking Matrix. An updated version is posted every Monday morning.

Want to take action to ensure these bills become law? Click here to learn how! 

Covered California Board Addresses 1332 Waiver, Quality Requirements, Special Enrollment Verification and other Hot Topics

This blog was written by Kate Burch

On April 7, 2016, the Covered California Board addressed several hot topics at their April meeting. You can find a recording of the board meeting, links to the presentations, and links to all of the proposed regulations, attachments, etc. here.

1332 Waiver Report

Stakeholders and experts have been very involved in working with Covered California over the last three months to develop the ideas and possibilities for a 1332 waiver, which allows states to make certain changes to their implementation of the ACA as long as they meet key goals on coverage, affordability and more. The Covered California staff considered the many proposals that were put forward and presented an analysis of some of the possibilities to include in a 1332 waiver.

The Covered California staff report cleared the way for a waiver to allow undocumented immigrants to purchase insurance through the marketplace, with their own money. The analysis by staff shows that the proposal to expand access to undocumented immigrants meets all of the federal guidelines for a 1332 waiver and would not be overly burdensome for Covered California to implement. Developing a targeted waiver proposal and fleshing out the details will require significant time and Covered California is “ready and willing,” as Peter Lee said, to embark on that process if the legislature decides to move forward with a 1332 waiver.

It’s now up to the legislature to move a 1332 waiver forward and up to advocates to keep pushing the issue at the state and federal level to make equal access to Covered California a reality.

In addition to the proposal to include undocumented immigrants, Covered California staff looked at other proposals for 1332 waiver topics. The staff report strongly supports a phased approach to the 1332 waiver, with only a narrow, focused waiver feasible this year, and with broader changes possible in future years when there’s more time for analysis and development of proposals. Details of their analysis are available here. You can also read a previous blog post here.

Model Contract and Benefit Design for 2017 – 2019

The Covered California Board adopted the proposed model contract and benefit design for plan years 2017-2019.

There were no changes to the medical benefit design that was presented in February. There were minor changes clarifying aspects of pediatric dental benefits that are included in QHPs. For the optional stand-alone family dental plans, changes removed outdated codes, standardized some cost sharing, and standardized the exclusion of adult tooth whitening, implants, and adult orthodontia.

The model Qualified Health Plan Issuer Contract includes changes that makes it more clear what Covered California expects from the plans in the way of improving both the delivery and quality of care provided to consumers. Changes include language that will help ensure that subsidy-eligible individuals are guided to purchase insurance through Covered California so they are able to get help paying for insurance; policies that should help ensure that insurance agents have no incentive to guide consumers toward particular plans or metal tiers; clarification of the appeals process and timelines for sending important notifications to consumers; and groundbreaking quality requirements and performance standards, along with a pilot period to implement them.

Quality and Delivery System Reform

When Covered California presented their proposed model contract at the February board meeting, it included innovations to move toward achieving higher quality health care and lower costs. The presentation at April’s board meeting included changes to the now infamous “Attachment 7” based on stakeholder feedback. Covered California’s board has said that putting consumers first means putting high expectations on the plans they contract with. They’re raising the bar on the plans they contract with to drive the effort to serve consumers well, to ensure that care is delivered more effectively and people are getting the right care at the right time.

Covered California’s model contract seeks to adopt payment strategies that reward value. They want patient-centered benefit design that will encouraging patients to get primary care and encourage plans to move towards integrated, coordinated care. While the requirements around quality improvement are in line with the federal requirement that any health plan that has participated in a Marketplace for two consecutive years implement and report on a Quality Improvement Strategy, Covered California’s approach to “track, trend, and improve” over time goes well beyond what is required in the federal marketplace and will greatly benefit California consumers. Some of details include:

  • All plans will have to assign a primary care clinician to enrollees within 30 days of enrollment if the enrollee hasn’t selected one on their own.
  • There won’t be any deductibles for primary care or specialty visits in silver, gold, and platinum metal tiers for the individual market.
  • Plans have to incentivize patient-centered medical homes and integrated health care models.
  • Payment reform will reward hospital outcomes and results; plans must exclude outlier hospitals (or justify keeping them in-network) starting in 2019.
  • In an effort to start reducing health disparities, plans must improve collection of self-identified racial/ethnic information; and must track, trend, and improve over time care related to diabetes, asthma, hypertension, and depression.
  • To better engage people in making the best choices for their health care, plans with more than 100,000 member must create tools enabling consumers to compare costs and quality when choosing a provider. Smaller plans have to have other options for members to understand costs.
  • Health plans also need to promote consumer access to and use of their personal health record.
  • While most of the performance standards will be measured based on Covered California enrollees only, plans must report disparities reduction across all their lines of business.

This part of the model contract to improve quality and equity was hailed as transformative and groundbreaking, supported by advocates, and even by industry, which appreciated the extra time to craft what they called more workable guidelines.

Special Enrollment Verification

All consumers can sign up to purchase health insurance during open enrollment, but if they want to sign up outside of open enrollment they need to have a qualifying special event in their life. This can include a change in family size, a change in income, moving, divorce, losing employer-sponsored coverage and a number of other events. Covered California’s current policy is to rely on self-attestation; consumers say what their special life circumstance is when signing up during the special enrollment period, electronically sign that it is true under threat of penalty, and they are able to enroll. Health plans have expressed concern that people who sign up during special enrollment cost them more money than people who sign up during open enrollment, and imply that consumers are trying to game the system by only signing up once they get sick, rather than doing the right thing and signing up during open enrollment.

Covered California staff presented a Special Enrollment Policy for discussion, with the intention of voting on it at the next board meeting. Covered California’s guiding principles for special enrollment are that only people who have a qualifying life event should sign up during special enrollment; people should not be delayed in getting coverage because of the verification process; documentation should be verified prior to coverage taking effect so consumers will not end up cancelled retroactively; and electronic verification should be utilized as much as possible.

Covered California staff would like to continue with self-attestation for 2016 and engage in a random sampling verification process. Covered California would require that a random sample of people enrolling during the Special Enrollment Period provide documentation to prove the qualifying life event that they attested to. If Covered California can’t verify the qualifying life event, the individual will be ineligible to enroll during the Special Enrollment Period.

Language on the application will more strongly explain consumers’ financial liability for incorrectly attesting to a qualifying life event and will require that consumers acknowledge that they might be asked to verify their qualifying life event.

In 2017, Covered California seeks to phase in electronic verification of documents whenever possible, and implement collection or verification methods for events that can’t be verified electronically. Covered California has not explained how they will address situations where documentation does not exist, or is not available within 60 days of a qualifying life event. Examples include someone fired from a low-wage job where there isn’t any formal letter of termination, or someone who has a baby and doesn’t receive a birth certificate for several months. Another example is a young adult who moved from renting a room in a group home and didn’t have a previous utility bill in their name.

Consumer advocates raised these grave concerns about the lack of such documentation, and sought more evidence (than the only anecdotal stories that the insurers have provided publicly) that some consumers were actually gaming the system, rather than not having documentation. Stakeholders and the Covered California staff agreed to continue working on the issue.

Individual Eligibility and Enrollment Regulations Readoption

In addition to the changes to Special Enrollment policy, the proposed Individual Eligibility and Enrollment Regulations include removing inapplicable definitions, amending regulations to comply with the recent federal regulations, and updating language to include Qualified Dental Plans. The Covered California Board will vote on the Individual Eligibility and Enrollment Regulations at the next board meeting.

SHOP Appeals Regulations

The Board voted to authorize Covered California staff to file a permanent rule-making package with the Office of Administrative Law. There are minor changes to ensure compliance with federal regulations and some additional appeals requirements.

Certified Application Counselor Program

The Board voted to amend the Certified Application Counselor regulations so that Covered California will continue paying for the fingerprinting and background checks for Certified Application Counselors. Prior to this vote, Covered California was scheduled to stop covering those costs at the end of June 2016. With the change, Covered California and the Board acknowledge the value of the unpaid Certified Application Counselors, including the almost 12,000 enrollments they were responsible for during the third open enrollment period. Continuing to cover the costs of fingerprinting and background checks will enable many community organizations and health care clinics to keep helping their clients with Covered California enrollment and utilization.

#Health4All 1332 Waiver Greenlighted by Covered California

A new Covered California report gave a green light to pursuing a federal waiver that will allow all Californians, regardless of immigration status, to be able to buy coverage with their own money through Covered California. Currently, undocumented immigrants are barred from using the state marketplace under the ACA even when using their own money and instead must go directly to a broker or health plan to purchase health insurance.

The staff recommendation was to consider a focused, limited waiver this year, and begin to consider more sweeping changes for future years. The proposal to allow immigrants to enroll in Covered California was identified as a focused proposal that did not violate any of the proposed federal guardrails. “The ball in now in the legislature’s court,” said Peter Lee, saying that Covered California “stood ready and willing” to help develop and implement the waiver if that is what the Legislature choose to do. Enabling legislation will need to be passed by the Legislature and signed by Governor Brown to submit the 1332 waiver to the federal government. Health Access California and other consumer and immigrant groups have been advocating for allowing undocumented immigrants to buy unsubsidized health plans through Covered California through a 1332 waiver as well as through SB 10 (Lara).

Health Access testified that moving forward with this waiver is not just an important symbolic step toward inclusion but will also provide practical benefit and additional access for thousands of Californians.

Several other advocates made similar points, stating that allowing undocumented immigrants to buy health insurance through Covered California removes a counterproductive exclusion in the federal law. This exclusion discourages a crucial part of our economy and society from taking responsibility for their health and finances by purchasing coverage and sends an unfortunate signal to many more. Soon, many California families with mixed immigration status will be able to buy coverage together easily, even if some family members are eligible for subsidies and others are not.

Consumer and immigrant advocates look forward to working with Covered California to ensure all Californians are covered. This change will allow undocumented Californians to purchase coverage using their own money, which will benefit not just these families but the health system as a whole. It strengthens the health system on which we all rely when health care coverage is accessible for all Californians, regardless of immigration status.

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Wonkery for Your Week

We wanted to spotlight two of the recent Health Wonk Reviews, a biweekly compendium of the best from the health policy blogosphere.

Last week, Charles Gaba at ACAsignups.net (the best place to track Obamacare enrollment nationally) had a very California-heavy edition, with posts about Covered California’s quality initiatives, our death-with-dignity law, and our post about anti-tobacco activity. Also directly relevant to the current debate in the California legislature is a post from Louise Norris at Colorado Health Insurance Insider about the recent Florida legislation against surprise medical bills.

The previous edition, David Williams at Health Business Blog featured our post on health plan mergers.

Expect a new edition later this week by Jaan Sidorov at The Population Health Blog.

Increasing the Minimum Wage Is Good for Our Health!

Today the California legislature is taking historic votes to raise the state’s minimum wage to $15, phased in over the next few years. While the economic benefits of providing workers with more income are clear, increasing the minimum wage also has positive health effects.

Increasing the minimum wage improves low income workers’ health by increasing the likelihood that an employee is insured, either through their employer or through Covered California. Low income workers are far more likely to be uninsured, either because they are not offered coverage on the job or because they decline coverage because it is unaffordable. At $15 an hour, 77% of employees will accept employer sponsored coverage.

In addition to providing the needed income to afford health insurance premiums, an increase in wages allows employees to afford the co-pays for critical health care services, like doctors’ visits and prescription drugs. As employers have increased deductibles and other cost-sharing arrangements, low-income consumers are even less able to afford to obtain care, even if they have coverage. An increase in the minimum wage provides additional income to afford critical and life-saving health services.

Numerous academic studies have established that being poor is bad for your health and that the social determinants of health are responsible for the health inequities in our society. The social determinants of health are aspects of the environment in which you live. Through research, we know that access to healthy foods, clean air, a safe place to play and exercise, and other environmental circumstances impact health status. The broad academic literature on social determinants of health makes clear that improving the minimum wage will improve the health status of Californians.

Increasing the minimum wage will also improve the state’s budget. As the minimum wage increases, we estimate that General Fund spending on Medi-Cal will decline by $700 million-$800 million annually. Some working adults will shift from traditional Medi-Cal which is funded 50/50 state/federal to the Medi-Cal expansion population for which the federal government will pay 95% of the cost. Others will choose to accept employer coverage which they will be able to afford; and still other working adults will enroll in Covered California where subsidies are funded by the federal government, not the state General Fund.

Health Access applauds the Governor and the Legislature for taking this bold step to increase the minimum wage and improve the financial and health status for millions of Californians.