Families USA Health Action 2015 Conference: Insights for California

Last week several Health Access staff joined with 27 other advocates from across California at Health Action 2015 (#HA20), Families USA’s 20th annual conference.  In terms of content, #HA20 struck a delicate balance between pushing ahead with “health reform 2.0” (health system transformation, health equity, and more) and the continuing work of basic health reform implementation, especially in those states that didn’t do the Medicaid expansion.

Thanks to the tweets running throughout the 3-day conference, and to Families USAs handy blog summaries of the proceedings, those who could not attend (or who found their attention wandering…) can virtually re-live the 3-day event.  More than any other I’ve attended, this conference exemplified the use of social media to stimulate buzz around the events. (We helped: Health Access came out in the top 10 list of viral influencers.)

Rather than duplicate Families’ conference summary, we bring you insights for California—insights you can use for the work at hand.

Health Care System Transformation

Who doesn’t want better care? For “system transformation” to work, people need practical options for accessing care in the right settings—coverage serves this critical structural function.  In other words, you can’t improve a system, if so many people are not in it.

But States like California that are making good progress on enrollment are right to ask: how can we sustain these coverage expansions? If you wanted, you could spend the entire conference in the often murky wonklands of “Health Reform 2.0.”–but these issues got their own track. But Families USA gets credit that most presenters stayed accessible without losing too much of the nuances of this critical and sometimes obscure work.

“If we care about expanding access, we must deal with the related issues of rising costs, of suboptimal quality, and prevention,” says plenary speaker Reed Tuckson, a trail blazer in health equity and community prevention strategies.  In another plenary we learned the clock is ticking on this work: Demographic changes related to the aging of the baby boomers and increasing diversity of the U.S. population add to the case to minimize waste and inefficiency in health care delivery systems. “The strength of this country rests with immigrants, as it always has,” says plenary speaker Paul Taylor. If we may finish his fine sentence:” and even more so if they have coverage.”

Speaking of waste and excess spending…keynote speaker Senator Elizabeth Warren noted, “We already brought health insurance to 10 million more people [3 million in California!), yet our total health spending is less than if we’d done nothing at all.” But guess who’s still making obscene amounts of money? The blockbuster drug industry, of course. Sen. Warren gave us a sneak preview of a new bill to be introduced this week, the “Medical Innovation Act,” that would create a fund (“swear jar”) that major drug companies must pay into when they commit fraud and need to settle lawsuits brought by the federal government. That fund would be dedicated to restoring the much diminished budget of the National Institutes of Health.

Health Equity Woven Throughout Conference Sessions

As noted by closing plenary speaker John McDonough, this was the first conference to feature equity and disparities in most, if not all, of the plenaries and workshops—rather than confined to a separate track. Place matters—but how many of us know about communities like Camden New Jersey that have found tools from community organizing to involve patients’ families in efforts to make care accountable in very practical ways to patients’ needs. Another plenary speaker, Senator Sherrod Brown (D-OH) also reminded us of how health status and longevity is connected to zip code.

If anyone knows where health equity work is headed—and where the opportunity lies to eliminate health inequalities, it is Health Action regular Dr. Brian Smedley. Most of the focus areas recommended by Dr. Smedley, will resonate for California advocates, particularly those working on the Medi-Cal waiver renewal and the state budget process: expanding health professions training programs, improving cultural competence, expanding community health centers, addressing low Medicaid reimbursement rates, and linking social determinants of health to prevention efforts. “It’s hard to eat better and exercise when community conditions don’t support those behaviors,” said Dr. Smedley.

California Not Alone on Several Critical Issues

  •  Provider Access: California‘s insurance markets and Medi-Cal have their access challenges—and this is why, even as I write, Health Access is sponsoring legislation to establish standards for provider directories (learn more about our efforts and lessons for other states in the slides from Beth Capell’s well attended workshop). It was gratifying (and not) to learn that California is NOT ALONE in facing such challenges.
  • Simplifying Choices on Exchanges: Several state-based exchanges and the federally facilitated marketplace, healthcare.gov, are learning the hard way that it’s possible to give too many choices in the new marketplace for insurance. Over 120,000 enrollees in Covered California picked a bronze product, even though they were eligible for a silver Cost Sharing Reduction product—with copays of less than $10 for a doctor visit and much better cost sharing generally. These Californians make less than $30,000 a year and yet bought a product with a deductible of $5,000—when they were eligible to buy something with a deductible as low as $75. California is on the path to simplifying plan choices (learn more here), but we have a ways to go.
  • Key Health Programs at Stake in the Federal Budget. With both houses of Congress controlled by Republicans, the need to re-authorize CHIP, fully fund Medicaid, and maintain and enhance other vital health reform initiatives cannot be overstated. Bruce Lesley of First Focus reminded us that the ACA was designed to sit on top of CHIP and Medicaid. If CHIP disappeared or was re-configured in harmful ways (for example by dropping the “ICHIA” option for states to cover immigrants kids and parents without having to wait 5 years), states could see shortfalls and/or out-of-pocket costs for kids could become unmanageable.

Covered California Board Meeting Highlights

Covered California had its first board meeting of the year on January 15. Diana Dooley, Secretary of the state’s Health and Human Services Agency, was re-elected board chair. Dooley has held this role since Covered California was formed four years ago.

2015 Enrollment Update
Executive Director Peter Lee gave an update on Covered California’s 2015 open enrollment efforts. As of January 12, over 228,000 new enrollees have selected a health plan. Of those enrolled, nearly 9 out of 10 people are eligible for a subsidy, which highlights how the Affordable Care Act has made healthcare more affordable and accessible. Also, 28 percent of enrollees are Latino, 19 percent are Asian, and 3 percent are African-American.

Covered California has determined that another 300,000 people who are eligible for a subsidy but have not picked a plan and completed the enrollment process. Half of that group is Latino, 11 percent are Asian, and 6 percent are African-American. Lee said these numbers demonstrate the success of Covered California’s marketing and outreach efforts in these communities. They also highlight the fact that consumers need help understanding their options so they can pick the best plan for themselves. Covered California service representatives have begun calling people who’ve started the process to help them get enrolled into a plan. We hope a total of 1.7 million Californians (up from 1.2 million) will ultimately enroll before February 15.

Covered California has made progress but there is still more to do to assure that those who are eligible get coverage, particularly in the Latino, African-American and Asian Pacific Islander Communities. We offered comments at the meeting that focused on the need for the following:

  • Notification and transition of people between Covered California and Medi-Cal: Health Access echoed Western Center on Law and Poverty’s call for the need for a better process to notify individuals who are being transitioned into Medi-Cal because they no longer qualify for a subsidy. This is particularly important because there will always be people going back and forth between the two programs, and a smoother transition will ensure folks get continuity of care and don’t fall through the cracks.
  • Health Plan Call Center Metrics: Health Access also pressed the need for more information about call center metrics, particularly information about health plan call centers. There have been reports of people having significant problems reaching health plans and having this data will help us to address any challenges there.
  • LGBTQ Demographic Data:  Advocates repeated our requests for demographic data regarding sexual orientation and gender identity that should be on the Covered California application and in CalHEERS. Having this data will help us to assess and evaluate application and program enrollment data to see if LGBTQ individuals are adequately represented and tailor outreach strategies for this community. In addition, this data will help us to identify health disparities, just as we already do by region and other demographic categories such as gender identity and language spoken.

Covered California Adopts Policies Allowing New Entrants in Regions with Limited Consumer Choice

Covered California adopted policies on recertifying existing plans and laying out rules for how plans new to Covered California could participate in the exchange. Plans that have been in operation before Covered California was launched, but haven’t participated in the Exchange, can participate in the state’s 5 regions out of 19 regions where there are fewer than three health plan choices. These regions cover predominantly rural counties in Northern California and on the Central Coast. Health Access and other consumer advocates support Covered California’s efforts to give consumers more choice for plans, particularly in counties with only one or two plans available.

Health Access Asks Covered California to Close Loophole Allowing Sub-Minimum Value Plans in the Large Group Market

Health Access, along with the California Labor Federation, asked the board and staff to close a loophole in ACA regulations that allows employers to provide sub-minimum value coverage in the large group market by requiring any plan that participates in Covered California to offer minimum essential coverage in its large group products. The ACA’s employer responsibility requirements, which are foundational and critical to success of the ACA, go into effect this year.

Because of the loophole, at least one large carrier is encouraging low-wage, high turnover employers to offer “skinny” plans that offer very limited coverage. The exploitation of this loophole has several pernicious results for consumers that must be avoided. First, if an employee accepts sub-minimum coverage from their employer, they cannot enroll in Covered California and can’t take advantage of subsidies. If they get sick, they will be stuck with very high bills. Second, some of these low-wage workers will end up on Medi-Cal as a result of being offered sub-standard coverage. Health Access asked Covered California to come back to this issue at a later board meeting and amend its contracts consistent with these consumer concerns.

You can read the letter Health Access and the California Labor Federation wrote to Covered California here.

2016 Health Benefit Designs – More Work to Be Done on Specialty Drugs

Covered California also approved health benefit designs for 2016, with the caveat that further changes are needed for specialty drug designs. Health Access has asked Covered California, along with the state’s regulators, to ensure that health plan drug benefits do not discriminate on the basis of disease or health conditions, which is illegal under the ACA.

Health plans place so-called specialty drugs, which drugs designed to treat a specific chronic health condition, such as rheumatoid arthritis, AIDS, and Hepatitis C, into the highest cost tier of pharmacy benefits, which have high cost-sharing requirements that are out of reach for most consumers. When health plans apply high cost-sharing requirements to these drugs (without regard to clinical evidence, medical necessity, or reasonable medical management) while requiring lower, fixed cost-sharing requirements for other drugs, they force patients who suffer from certain diseases to pay much more than other patients.

In light of recent federal guidance that makes these practices illegal under the ACA’s anti-discrimination provisions, Covered California needs to ensure that benefit designs for the 2016 plan year comply with the law. Covered California is convening a workgroup consisting of regulators, health plans, and consumer advocates to review the specialty drug designs to insure consumer access to pharmacy treatment for chronic conditions. Health Access plans will be actively involved in this process to ensure that consumers are protected from discrimination in health care.

See Health Access’ letter to California regulators regarding specialty drug benefit design here.

Changes to Navigator Payment Policy

Covered California awarded nearly $17M in grants to community organizations across the state to help educate consumers about the benefits of coverage, helping them compare and shop for plans, and helping them enroll. Organizations receiving navigator grants are expected meet enrollment goals in order to receive their payment. Navigators have played a critical role in reaching culturally and linguistically diverse communities across the state.

Covered California and its navigator grantees have been met with some unanticipated challenges through the enrollment process. The Covered California Board adopted some changes to its Navigator Payment Policy to allow count assisted applications through plan selection towards enrollment goals and for consideration of organizations’ efforts to implement their campaign strategy. These changes will help Navigator grantees receive payment for their important work in getting Californians enrolled.

Health Access Priorities for California’s Waiver Renewal

Health Access is pleased to present a new white paper, Medi-Cal Reform 2.0: Health Access Priorities for California’s Next Medicaid Waiver, as a discussion draft. We invite all stakeholders, especially our allied consumer and community advocates, to look it over and submit any comments to jhilman@health-access.org. In your feedback, please indicate whether we can include your comments on a moderated discussion board.

With much deliberation and engagement of expertise from across the state, the Medi-Cal waiver renewal stakeholder process is in full swing. What comes out of these barrage of meetings will be important for the next critical phase: preparation of the draft application by the Department of Health Care Services (which administers Medi-Cal and oversees waiver initiatives) with additional opportunities for consumer advocates and others to weigh in.

The state hopes to submit its initial application sometime in late February or early March of this year. After that we expect vigorous back-and-forth negotiation with CMS on the different points of the proposal, in particular the financing assumptions behind the state’s waiver request.

In multiple workgroups (Health Access California served on three of them, joined by other allies like California Pan-Ethnic Health Network, SEIU, Congress of California Seniors, Western Center on Law and Poverty, and others), DHCS put forward concepts in an attempt to formulate a rough consensus on their major waiver ‘asks.’ In the world of waivers (watch for highlights in a coming blog), it’s expected that states will ask for as much flexibility as possible in terms of how federal Medi-Cal financing should be used to meet the state’s ambitious Medi-Cal and health system reform goals. The goal is a renewed waiver to begin as soon as the current waiver expires in late October of this year.

From the Executive Summary…

The coming renewal of California’s section 1115 Research and Demonstration Medicaid waiver and Delivery System Reform Incentive Program (DSRIP) presents a critical opportunity to build on the state’s success in implementing health reform and to tackle longstanding issues in the state’s health care safety net.

Health Access seeks a new “Bridge to Reform 2.0” Medicaid waiver (and DSRIP 2.0) which supports our safety net; improves care and provides a medical home for Medi-Cal enrollees and the remaining uninsured; and moves California toward the “quadruple aim” of better care, better health, lower cost and reduced disparities, through both delivery system reform and population health approaches that integrate health care with other human services and community supports. Health Access supports the following vision and goals for Medi-Cal Reform 2.0:

  • ENSURING A SAFETY NET THAT SURVIVES AND THRIVES FOR THE NEWLY EXPANDED MEDI-CAL PROGRAM AND REMAINING UNINSURED
    Past waivers have focused on yielding needed resources for public hospitals and the safety-net, and this priority is as urgent as ever. In light of California’s success with Medi-Cal enrollment, the safety net needs the capacity to address the pent-up demand for care presented by new Medi-Cal enrollees, even as it continues to serve the remaining uninsured. A critical part of the Bridge to Reform waiver, the DSRIP program brings additional resources to the safety net with funding levels tied to outcomes on delivery system reforms designed to make the safety net more efficient and effective so they can serve millions more.
  • CONNECTING ALL CALIFORNIANS WITH A MEDICAL HOME THAT STARTS WITH COORDINATED PRIMARY CARE
    Our health care system works better when everyone—both Medi-Cal enrollees and the remaining uninsured—has access to coordinated care in a primary care setting. President Obama recently gave relief from deportation to hundreds of thousands of California immigrants. To help California provide comprehensive managed care for the remaining uninsured (and others the state may determine eligible over the course of the waiver), the federal government should share savings with the state from reduced utilization of emergency care and related services financed through Restricted-Scope Medi-Cal. A complementary goal would be to restructure the Disproportionate Share Hospital (DSH) and Safety Net Care Pool funding to provide more comprehensive primary and preventive care to the remaining uninsured.
  • PROVIDING INCENTIVES FOR SPECIFIC, PRIORITIZED DELIVERY SYSTEM REFORMS AND POPULATION HEALTH GOALS
    The Medi-Cal Reform 2.0 waiver should embrace the ‘quadruple aim’ and keep the patient at the center of efforts to improve care, reduce costs, improve health and reduce disparities. A major source of financing for the safety-net, and the health system as a whole, a Medi-Cal waiver should provide health care delivery systems with sufficient resources and direction to focus on patient-centered goals—using a shared savings structure, and through related payment, transparency, and policy mechanisms. DSRIP 2.0 should prioritize key health goals already vetted from the Let’s Get Healthy California Task Force report. Such changes should protect consumers and our health system, as they improve care, outcomes, and equity. Patients benefit from care transformations when their social circumstances—transportation needs, access to healthy food, decent housing and safe neighborhoods—are taken into account. DSRIP initiatives, too, need to build on proven medical home models and stretch beyond clinical walls to engage the community supports and resources to improve outcomes for patients, starting with Medi-Cal enrollees and the remaining uninsured. Finally, building on stakeholder consensus (not to mention CMS expectations) that DSRIP 2.0 should have a stronger emphasis on measurable outcomes, all metrics and analytics tied to clinical and population health outcomes should be stratified by race/ethnicity, primary language, income, gender, sexual orientation, and gender identity.  Likewise, transparency and reporting mechanisms like dashboards should be accountable and accessible to the communities with the most to gain from delivery system reforms.
  • INTEGRATING HEALTH CARE WITH OTHER HUMAN SERVICES THROUGH WHOLE PERSON CARE
    The premise of ”whole person care” is that health care is most effective when it engages services and supports across the silos of health, housing, corrections, and more. At a minimum such “horizontal integration” innovations should include integration of physical health with behavioral health, (mental health and substance abuse); ‘whole person’ care for those most in need, including those post-incarceration and those with seriously behavioral health issues; and coordination of long term services and supports for seniors and persons with disabilities as well as the “dual-eligibles” (those enrolled in Medicare and Medi-Cal). Counties should have additional incentives to develop innovative connections between health care and housing, health care and corrections, and other population health approaches.

For those less familiar with Medi-Cal and waivers, this paper starts with a quick background of the waiver process and the results and lessons learned from the last waiver, before detailing how the new waiver can meet these four general goals.

Will the AG Let For-Profit Prime Takeover the Daughters of Charity Health System?

Last week, Health Access joined hundreds of allies, community organizations, elected officials and labor to oppose the sale of 6 hospitals operated by the non-profit Daughters of Charity Health System to the for-profit Prime Healthcare, Inc. California law requires the Attorney General’s (AG) review and consent for any sale or transfer of a health care facility owned or operated by a nonprofit corporation whose assets are held in public trust. The AG held public meetings at each hospital every day this week and has until early-February to either approve or deny the proposed sale. The AG may also approve the sale with additional conditions (for details see the AG’s web page for nonprofit hospital transactions). These meetings have garnered a lot of attention from print, television, and radio media.

Health Access is opposed to this deal because Prime Healthcare’s commitment to keeping the hospitals open and maintaining hospital services is conditional and limited. In addition, these hospitals have had nonprofit charitable status, and we have questions about whether the valuation of their assets is accurate, particularly in light of changes brought on by the Affordable Care Act. Health Access is also concerned about assertions about Prime and its troubling history. A copy of our opposition letter, which describes all the concerns raised by Health Access, is available here.

Nancy Gomez, our Southern California Program Director testified in opposition to the sale at Monday’s meeting at St. Francis Hospital in Lynwood, CA. The meeting began with a 10-minute presentation from Dr. Prem Reddy, owner of Prime Healthcare, Inc. detailing the terms of the sale and the merits of his company. The leadership of the Daughters of Charity echoed his sentiments. After that, a steady stream of opposition and supporters took to the podium.

Health Access offered testimony summarizing our opposition to the sale to a four-member panel of the Attorney General’s Office. The hearing started at 10:00 AM and continued past 5:30 PM. There were 250 individuals slated to offer testimony in addition to individuals who signed up to speak, and each was limited to a two minute time limit. Prior to the meeting, a rally and press conference was held. Over 400 people were in attendance at the rally.

Tam Ma, Health Access’ new Policy Counsel, testified in opposition at the public meetings held at St. Vincent’s Hospital in Los Angeles on Tuesday and O’Connor Hospital in San Jose on Wednesday. These meetings followed a similar format to Monday’s meeting, with representatives from Prime and Daughters of Charity making statements before community members weighed-in. Tam was quoted in in the San Jose Mercury News.

The following are some of the many news stories that have been written about the AG’s hearings and the proposed sale of these non-profit hospitals.

Full #CABudget Analysis and Update

HEALTH ACCESS UPDATE: Friday, January 9, 2015
GOVERNOR’S BUDGET CONTINUES HEALTH REFORM…AND RECESSION-ERA HEALTH AND HUMAN SERVICE CUTS AS WELL

*        2015-16 budget allows for higher enrollment in Medi-Cal to 12.2 million Californians, a $94.6 billion overall program including federal dollars ($18.6 billion in state general fund dollars).

        Governor Brown’s budget continues the health and human services cuts made in the depths of the recession, with no significant restorations to public health programs, Medi-Cal health benefits, or Medicaid provider reimbursement rates.

*         Budget includes policy changes to: impose an open enrollment period to change Medi-Cal managed care plans; enroll those in limited-benefit health programs in comprehensive coverage; broaden the managed care plan (MCO) tax to help fund a restoration of a previous cut to in-home supportive services; renew California’s Medicaid waiver; and review the Coordinated Care Initiative.

*        The budget proposal does not change current and longstanding California policy that those newly eligible are covered under President Obama’s order to extend “deferred action” immigration status, but it isn’t officially in the budget–nor are other efforts to finish the job and cover the remaining uninsured.

        Issues not included but that will be explored in budget hearings or through bills, including  proposals to cover California’s remaining uninsured regardless of immigration status (SB4 by Sen. Lara), and to limit Medi-Cal estate recovery (SB33 by Sen. Hernandez), which discourages patients from enrollment and potentially risking losing the family home. 

 

Earlier today, Governor Jerry Brown released his proposed budget for the 2015-16 fiscal year. His $113.3 billion budget (state general fund dollars), reflects a 1.7% increase from the current budget, and includes $47.2 billion for elementary and secondary education, $14.1 billion in higher education, $24.1 billion in health, $7.8 billion in human services, and $10.2 billion in corrections.

The Governor’s budget continues California’s current commitments on health care and health reform, but also continues the cuts to public health programs and Medi-Cal rates and benefits made during the recession, and doesn’t make the investments needed to reduce barriers to coverage, increase access for Medi-Cal patients, or cover the remaining uninsured.

DISCUSSION ON POVERTY: Governor Brown called for “self discipline and real prudence” with the budget, and that it wasn’t time for “exuberant overkill.” Prompted in part by advocates from the HHS Network, including Health Access California and other allies around the state, arguing that a state budget shouldn’t just pay down the wall of debt but also break down the wall of poverty, many of the questions at the Governor’s press conference addressed the issue of income inequality. Perhaps in anticipation, a section of the budget summary was titled “Addressing Poverty and Income Inequality.” In response to questions, Governor Brown referenced presidential efforts including Roosevelt’s “forgotten Americans” and Johnson’s War on Poverty, the book The Other America, and the Kerner Commission report. “This is part of America, the structure of modern individualism, capitalism, stratification,” said the Governor.  “It’s there. California does more than most states to mitigate that.” He referenced that the problems are “part local, part global,” and noted the challenges of addressing the issue even by state or national policies. “These are all issues that have been around for a long time, and I think we are doing a good job in California. Comparatively, we are doing more than other states, and we will continue to do as much as we can,” Brown added.

He cited his mayoralty in Oakland, and his time in Calcutta, India: “I’ve been in contact with low-income people of many persuasions… I think I do have a sensitivity of people’s difficulties in life.” said Brown. “Just in two years, we added two million people to health care, and now it’s “now what’s next?” He continually cited the Medi-Cal expansion, alongside the school Local Control Funding Formula, and other state efforts to address poverty.

On health care and Medi-Cal specifically, the Governor made reference to the Medi-Cal expansion: “That’s a 50% increase. That’s 4 million people. That’s real money going to real people. Theses are people who are not rich. They are not middle class. They are low-income people. Having this health security is a comfort, is decent, and is going to improve the quality of their lives. One of the biggest causes of bankruptcy are medical bills. So when we spend all this money, and it’s billions–when you add up what the federal, state and local governments pay, it’s over $90 billion.”

MEDI-CAL: The Governor’s budget continues health reform and the Medi-Cal expansion, with no major restorations. The Budget assumes the Medi-Cal caseload will increase approximately 2.1 percent from 2014‑15 to 2015‑16 (from 11.9 million to 12.2 million), after the big jump in the previous year largely because of the continued implementation of federal health care reform. The Governor’s Medi-Cal 2015-16 budget reflects a $94.6 billion overall program, mostly federally funded with just $18.6 billion contributed from the state general fund.

With regard to the Medi-Cal expansion, $14.3 billion would come from the federal government to pay for 100% of the newly eligible under the Affordable Care Act. In contrast, just under $1 billion ($943.2 million) is the state costs of paying for those previously eligible but newly enrolled–which in turn is matched by additional federal dollars.

IMMIGRANT HEALTH CARE: The budget does not make any eligibility changes to Medi-Cal, including to California’s longstanding history in covering immigrant populations in Medi-Cal otherwise excluded from federal programs. The budget references the President’s recent executive order on immigration, citing that “these individuals may be recognized as having Permanent Residence Under Color of Law statdue to their deferred action status…This status potentially qualifies individuals for state-funded full-scope Medi-Cal… At this time there is a great deal of uncertainty about the scope, timeing and effect of these actions. Consequently, the budget does not assuem any higher costs from these individuals, but covering eligible immigrants under these programs could cost hundreds of millions of dollars annually.” So the expectation is that Californians impacted by the President’ action who meet the income requirements will be covered, but more work is needed to fnish the job to cover those that the President’s executive authority couldn’t assist.

When asked directly about the #Health4All proposal to cover all of the remaining uninsured, including the undocumented, the Governor didn’t reject it outright but simply said “There’s not a lot of money left in the budget. It’s very tight.” This proposal, SB4 (Lara), will be a major emphasis for health, immigrant and community advocates this yaer.

THE CONTINUED CUTS: This budget leaves in place cuts made during the recession, including one that the Legislature sought to restore in last year’s budget. This includes:

* Key public health programs (last year, the final budget restored the Black Infant Health Program but not a dozen other programs that both prevention and treatment efforts);

* Medi-Cal benefits that were cut in 2009 (two years ago, dental coverage was partially restored but other benefits from podiatry to psychology to audiology to vision services remain largely uncovered for adults on Medi-Cal);

* Medi-Cal provider rates–rates that are among the lowest in the nation and that make access to doctors, specialists and other providers harder for some of the 12 million Californians with Medi-Cal coverage. (The 2011 budget cut provider rates by 10%. The Governor’s budget does include $130 million to fund for exemptions to provider rate cuts that were approved last year, for high-cost drugs, certain speciality physician services, and other particular services.)

Advocates argue that restoring and investing in Medi-Cal, as the Legislature proposed last year, would improve access to care, and bring in enhanced federal matching funds into our health system and economy.

KEY HEALTH POLICY DECISIONS INCLUDED: The budget does include some specific budget-related adjustments based on policy decisions made last year to reflect the county administration workload in enrolling new Medi-Cal recipients ($78 million), and in including behavioral health treatment for autism ($151 million). The budget also proposes policy changes like:

* Requiring those in limited benefit programs to seek enrollment in full coverage programs–a goal consumer advocates support, with the caveat that those programs should continue for folks not eligible for comprehensive coverage or they should include wrap around services when such comprehensive coverage doesn’t provide those services.

* Imposing an open enrollment in Medi-Cal, which would restrict access and limit choice for those eligible for Medi-Cal.

* Revamping/broadening the managed care organization tax that currently funds Medi-Cal to meet federal guidelines and support a restoration for in-home supportive services.

* Seeking ways to improve participation in the Coordinated Care Initiative for those seniors and people with disabilities in both Medi-Cal and Medicare.

* Pursuing a renewed five-year Medicaid waiver to “support ACA implementation, drive significant delivery system transformation, and provide long-term fiscal stability of the Medi-Cal program.” There are multiple workgroups currently meeting to craft this proposal to the federal government.

ISSUES NOT INCLUDED: There were key health budget policy issues raised by the Legislature last year that were not addressed by this budget, from the budget restorations for provider rates to the effort to cover the remaining uninsured, this year reflected in Senator Lara’s SB4.

The budget also does not remove the current estate recovery policy that discourages patients from signing up for Medi-Cal coverage. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be done in the budget instead. Advocates will vigorously pursue this change, including this year in Senator Hernandez’ SB33, so some Californians don’t fear that their loved ones lose the family home as a result of signing up for coverage.

Initial Reaction to the Governor’s #CABudget

Earlier today, Governor Jerry Brown released his proposed budget for the 2015-16 state budget, which continues California’s commitments on health care and health reform, but also continues the cuts made during the recession, and doesn’t make the investments needed to reduce barriers to coverage, increase access for Medi-Cal patients, or cover the remaining uninsured.

HEALTH BUDGET OVERALL: While the Governor’s budget continues California’s efforts on health reform, we are disappointed the budget proposal also continues the recession-era cuts to health and human services. California’s comeback depends on not just paying down the wall of debt but breaking down the wall of poverty. California has made dramatic progress under the Affordable Care Act to expand coverage with mostly federal funds, and we need this new budget to continue that momentum, by removing barriers to coverage, ensuring those covered in Medi-Cal get access to care, and extending coverage to the remaining uninsured.

IMMIGRANT HEALTH CARE: California should be proud of our long history in Medi-Cal of covering immigrant populations otherwise excluded from federal programs, and this budget neglected to affirm that policy for those under the President’s order, not to mention the rest of the remaining uninsured. For the benefit of the health system we all rely on, we will push this year to ensure access to coverage for all Californians, regardless of immigration status. Immigrants are a vital part of our community and economy and should be fully included in our health system.

THE CONTINUED CUTS; The California comeback hasn’t included many families still struggling, and should extend to the health and human programs that were cut in the recent recession. This budget leaves in place cuts to key public health programs, Medi-Cal benefits, and provider rates–rates that are the lowest in the nation and that make access to doctors, specialists and other providers harder for some of the 12 million Californians with Medi-Cal coverage. Restoring and investing in Medi-Cal, as the Legislature proposed last year, would improve access to care, and bring in enhanced federal matching funds into our health system and economy. We should remember that the surplus was created in part out of $15 billion in cuts to health and human services–cuts that continue today and into the future. Ultimately, the level of services for California should not be set at the level of resources available during the worse recession since the Great Depression.

KEY HEALTH POLICY DECISIONS: The budget does include some specific budget-related adjustments based on policy decisions made last year to reflect the county administration workload in enrolling new Medi-Cal recipients ($48 million), and in including behavioral health treatment for autism ($89 million). The budget also proposes policy changes like:

* Requiring those in limited benefit programs to seek enrollment in full coverage programs–a goal consumer advocates support, but want to be sure that those programs continue for folks not eligible for comprehensive coverage or for when such comprehensive coverage doesn’t provide those services.

* Imposing an open enrollment in Medi-Cal, which would restrict access and limit choice for those eligible for Medi-Cal

* Revamping/broadening the managed care organization tax that currently funds Medi-Cal to meet federal guidelines and support a restoration for in-home supportive services.

* Seeking ways to improve participation in the Coordinated Care Initiative for those seniors and people with disabilities in both Medi-Cal and Medicare.

* Pursuing a renewed five-year Medicaid waiver to “support ACA implementation, drive significant delivery system transformation, and provide long-term fiscal stability of the Medi-Cal program.”

There are key health budget policy issues not addressed by this budget:

* It’s disappointing the budget does not remove the estate recovery provision that complicates enrollment and discourages patients for signing up for Medi-Cal coverage. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be done in the budget instead. We will vigorously pursue this change, so some Californians don’t fear that their loved ones lose the family home as a result of signing up for coverage.

* Our biggest priority is taking the momentum of the Affordable Care Act, and the President’s recent executive actions, to ensure coverage for all Californians, regardless of immigration status–which would yield positive benefits for the health system we all rely on. California has been a leader in including immigrants in our society and investing in our future–the next and most vital step is in health care.

Preview of Governor’s #CABudget

On Friday, Governor Jerry Brown will release his proposed budget for the 2015-16 state budget, which has major implications for California’s health care system. The health care budget expected to have high estimates due to Medi-Cal expansion and strong enrollment, but also include some key policy decisions Health Access is closely monitoring.

BUILDING ON PROGRESS? California has made dramatic progress under the Affordable Care Act to expand coverage, and the question under this new budget is whether we continue that momentum or not. Can we remove barriers to coverage, ensure those covered in Medi-Cal get access to care, and extend coverage to the remaining uninsured?

For example, enrollment estimates expected to include those newly eligible under President Obama’s order to extend “deferred action” immigration status–people excluded from federal Medicaid but not state-only Medi-Cal. California should be proud of our long history and policy of covering immigrant populations excluded from federal programs, and that policy should be reaffirmed and extended in this year’s budget. Immigrants are a vital part of our community and economy and should be fully included in our health system.

WILL CUTS CONTINUE?: The big question is whether the California comeback extends to the health and human programs so many Californians rely on, or whether the Governor proposes to continue the cuts made in the recent recession. Public health programs, Medi-Cal benefits, and provider rates were all proposed for restoration in the Legislature last year, and should be considered again by legislators if the Governor doesn’t himself. With many more Californians covered under Medi-Cal now, we should restore cuts to Medi-Cal providers, to bring in enhanced federal matching funds, and to ensure millions of Californian have better access to the doctors and specialists they need. California has reduced the wall of debt but needs to do more to dismantle the wall of poverty in our state. We should remember that the surplus was created in part out of $15 billion in cuts to health and human services–cuts that continue today and into the future. Ultimately, the level of services for California should not be set at the level of resources available during the worse recession since the Great Depression.

KEY HEALTH POLICY DECISIONS: Bills from last year highlight budget debates that are coming this year. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be done in the budget instead. We will vigorously pursue this change, so some Californians don’t fear that their loved ones lose the family home as a result of signing up for coverage. (This year’s version of that bill is SB33 by Sen. Hernandez.)

Our biggest priority is SB4 by Sen. Lara, taking the momentum of the Affordable Care Act, and the President’s recent executive actions, to ensure coverage for all Californians, regardless of immigration status–which would yield positive benefits for the health system we all rely on. California has been a leader in including immigrants in our society and investing in our future–the next and most vital step is in health care.

We look forward to the Governor’s announcement at 10am, and for HHS Secretary Dooley’s budget debrief call at 2pm:

Date:  Friday, January 9, 2015
Time:  2 p.m. Pacific Time*
Call-In Number:  (888) 658-8648
Passcode Phrase:  CHHS Budget

Senate Committees Announced

Senate President Pro Tem Kevin Deleon announced the makeup of various committee today:

Of particular note for health advocates, Health Committee will be:
Hernandez (Chair), Nguyen (Vice Chair), Hall, Mitchell, Monning, Nielsen, Pan, Roth, and Wolk.

Budget Subcommittee on Health and Human Services #3 is Mitchell, Monning, and Stone.

More to come!

Inauguration Day!

Inauguration day in Sacramento always brings the possibility and excitement of the new–even if it is when key political leaders get re-elected. Both Governor Jerry Brown and Insurance Commissioner Dave Jones invoked health care and the Affordable Care Act, and their comments are worthy of mentioning.

Governor Jerry Brown began his historic fourth term with an inaugural address that cited the progress made in the last four years in a range of areas, from the economy and the budget to education and health care. On health reform, he stated: 

“Two years ago California embraced the Affordable Care Act, dramatically increasing its health insurance coverage under the Medi-Cal program. The state will enroll 12.2 million people during this new budget year, a more than 50 percent increase. Providing the security of health coverage to so many Californians who need it is the right thing to do. But it isn’t free. Although the federal government will temporarily foot much of the bill, new state costs – now and more so in the future – will run into the billions.”

The Governor is correct that expanding coverage under the Affordable Care Act was the right thing to do–in a state that took full advantage of the new opportunities under the Affordable Care Act, over 3.5 million Californians got newly covered under the new options and benefits in just the first year. Not only did California cut its uninsured rate in half in 2014—a dramatic reduction for a problem that some had considered insolvable, but we made major improvements and instituted new protections in the health care system for all Californians, not just the newly insured.

However, the Governor overstated the state costs of expanding coverage, which are minor in context and given the benefit. In fact, the federal government will pick up much of the bill permanently, not just temporarily. All subsidies in Covered California are financed through the federal Affordable Care Act, with no state participation. In Medi-Cal, the federal government is covering 100% of the cost of the newly eligible for the next two years–but even in 2020 and beyond, that share will be go down to 90% permanently. While there is a cost, the benefits are big: the Affordable Care Act is a boon, not a burden, to the state’s health system, economy, and budget.

We appreciate the Governor’s partnership in making the Affordable Care Act work, and the work that has been done and is left to do in health reform will be as big a part of his legacy as his visionary focus on infrastructure and climate change. The work ahead must include making it easier to sign up for coverage, and ensuring consumer protections that patients have access to the care they need when they need it. Finally, California can and should continue and extend its history and policy of covering immigrants excluded from federal health programs. The Governor cited key steps he has already taken to include immigrants into the fabric of California life, recognizing that immigrants are essential parts of our economy and society–we need to take the next step, to include immigrants in our health system as well.

Insurance Commissioner Dave Jones started his speech after being sworn in with some humor about the many television ads against Prop 45, joking that his travel schedule was going around the state looking over doctor’s shoulders interfering with their medical decisions. He then outlined some broad goals out of his immediate jurisdiction but of interest: education, income inequality, and climate change.

In his role as Insurance Commissioner, her cited his four goals as: 1) earthquake preparation; 2) consumer protection; 3) fostering a vibrant insurance market, and 4) implementing the Affordable Care Act. On that fourth one, he highlighted the work to date, stating he worked with Covered California and other state departments (including DMHC which regulates much more of the health insurance market), but he promised to be an “independent regulator,” not afraid to disagree with other leaders on health reform if he felt it was right.

Four years ago, he started his term by signing emergency regulations on health reform, and this time was no different–he announced new regulations on provider directors and network adequacy, which we will comment on in a separate post. But he clearly wanted to project that he would continue to be active in this arena.

New Health Laws and Fresh Opportunities for the New Year

The New Year 2015 brings fresh opportunity to deliver on the promise of health reform and affordable coverage and care, with several new laws going into effect today.

SB964 (Provider Network Adequacy (Hernandez) addresses the issue of narrow networks and whether enrollees in health plans (including but not limited to those in Covered CA and Medi-Cal) have adequate access to care.  With more and more Californians signing up for coverage in this second open enrollment season, this law, which requires the Department of Managed Health Care (DMHC) to provide stronger oversight of network adequacy, was long overdue.

Of course passing the law was only the first step. The action now moves to the regulatory front, starting with a substantive stakeholder process at the Department of Managed Health Care. Health Access and other bill sponsors will also look to Covered California to set stronger standards for network adequacy and timely access in their model contracts for 2016 qualified health plans, leaning on the state marketplace’s role as an “active purchaser.”

SB1276 Hospital Fair Pricing: Low-income Californians (<350 % of poverty) faced with a hospital bill will be eligible for a “reasonable payment plan,” meaning their payments will be capped at 10 percent of income after living expenses are taken into account. This law, updating a 2006 Hospital Fair Pricing law, goes to the heart of a sobering reality, that even after the implementation of the Affordable Care Act, for all of its positive impacts and results in the Golden State, there will be too many Californians without affordable coverage options.

Plenty of Californians still find themselves on hospital bill away from financial crisis. For example, Under the ACA workers whose out-of-pocket premium costs consume more than 8% of income qualify for subsidies in Covered California. But a federal interpretation of the law states that if single employee coverage consumes <8% of income but family coverage consumes more than 8%, then subsidies are unavailable for the family—leaving some spouses and children without an affordable coverage option. Too many immigrants are left out of the ACA’s guarantees of affordability and will therefore benefit from the new hospital fair pricing standards. And speaking of immigrants…

Maximizing the Impact of President’s Executive Order on Immigration for immigrant families’ health care access. The President’s executive order expands those eligible for deferred action status, keeping many immigrant families in tact and safe from deportation. While the exclusion from federal ACA benefits stands, immigrants with “deferred action” status who are at or below the poverty level will be able to get Medi-Cal coverage under existing state law–including the California residents, mostly parents, provided relief under the President’s order.

But given that only a fraction of DACA-eligible youth have enrolled in state-funded Medi-Cal, the pressure is on to minimize barriers to enrollment for these families and to create the assurances that enrollment and coverage will not pose any risk of deportation. It’s a formidable undertaking: but we can’t think of anything more worthwhile as a step toward truly universal coverage in the Golden State.

May we work for a healthier California in the new year!