Thankful for a Year of Progress on Health Care

Many Californians are thankful for this year’s progress on implementing health reform and improving our health system through new coverage expansions and patient protections. In particular, California will soon open up Medi-Cal to enroll all children regardless of immigration status, capping a year of progress toward a more inclusive health care system.

The Affordable Care Act was a historic step forward, and California has made remarkable progress on implementation, with the fifth highest drop in uninsured residents.  But just as important, California has used the law as a jumping off point for a more inclusive, accessible, and affordable health care system.

This last year California enacted several patient protection bills addressing unfair out-of-pocket costs. The signed legislation—some of it the strongest in the nation—will help prevent out-of-network bills due to inaccurate provider directories, huge cost-sharing for specialty drugs, double deductibles in family plans, as well as extend protections against “junk insurance” to those covered by large employers.

  • SB 137 (Hernandez) will require updated, standardized, and accurate provider directories.  Co-sponsored by California Pan-Ethnic Health Network, Consumers Union, and Health Access California (see separate SB137 fact sheet), SB 137 will address the common insurance industry practice of posting inaccurate, out-of-date, and misleading provider directories.
  • AB 339 (Gordon) will require insurers to cover medically necessary prescription drugs and limit cost-sharing on specialty drugs and other needed medications. The bill ensures coverage for drugs for which there is no therapeutic equivalent; prohibits placing most or all of the drugs to treat a condition on the highest cost tiers of a formulary; requires formularies to be based on clinical guidelines and peer-reviewed scientific evidence; places monthly cap on specialty drug cost sharing; and more (see separate AB339 fact sheet).
  • AB 1305 (Bonta) would ensure an individual patient does not face higher out-of-pocket costs just because they are in family plans, closing a potential loophole in the out-of-pocket maximum protections in the Affordable Care Act (see separate AB1305 fact sheet). The bill would ensure that the $6,600 maximum out-of-pocket cost cap applies to individuals in family plans, not just individual plans.
  • AB 248 (Roger Hernández) will extend consumer protections to ensure large employers do not offer “junk insurance” that does not cover basic benefits. Federal and state law already hold insurance sold to small employers and individuals to a basic standard (60% actuarial value), but under current law insurers are free to sell large employers “junk” plans. When large employers offer such subminimum plans, employees are stuck with thousands of dollars in out-of-pocket costs. If an employee accepts that coverage, even if it is subminimum coverage, the employee is automatically ineligible for premium subsidies through Covered California (see separate AB 248 fact sheet).

These bills close loopholes in Obamacare and address lingering issues, and in fact use the new law as a platform for improved patient protections.

COVERAGE EXPANSION: Due in part to the aggressive outreach and enrollment efforts, California also made historic progress in reducing the number of uninsured, with the fifth largest reduction of the uninsured rate in the nation and millions covered—but we still have an above-average uninsured rate, with more to do.

Along with restoration in the state budget of some key public health programs, California took another significant step this year with the confirmation to cover all income-eligible adults in Medi-Cal with “deferred action” immigration status, and the commitment to extend Medi-Cal cover all children up to 266% of the poverty level regardless of immigration status—another expansion that we must work together to successfully launch this May.

And we will continue the fight for health for all, either at the state level through SB10(Lara), or through various county efforts, building on recent progress in Sacramento, Contra Costa, Monterey, and the CMSP consortium of 35 counties.

REVENUES: Finally, we successfully worked for a new Medicaid waiver that provide new incentive and resources to transform the delivery system, to provide better integration of health and human services, and to have a more inclusive and smarter safety-net.

We also made progress on new revenues to support investments in our health system, through ballot measures and a special legislative session. Building on these efforts, we enter 2016 with a full agenda.

See our 2015 Year in Review for details.


Covered CA Board Meeting November 19, 2015: Highlights for Consumer Advocates

This week’s Covered California Board meeting, the last for 2015, focused on the Covered CA bus tour and related OE3 campaigns; early results from Open Enrollment 3 or OE3; how the Section 1332 waiver (an option within the Affordable Care Act to waive certain ACA provisions to demonstrate a new principle or model at the state level for how to achieve the same goals but through different means) stakeholder process will work and parameters for proposals; and the certification process and priorities for 2017 Qualified Health Plans (QHPs).

Covered CA Bus Tour and Related OE3 Campaigns

As noted by Covered CA director Peter Lee in his opening remarks, Covered CA’s marketing and advertising strategies are heavily guided by research and analytics—and OE3 is no different.

Familiarity with the ACA and Covered CA has vastly improved in recent years—and this is true across communities of color, suggesting that more targeted marketing efforts are paying off.  Though Covered CA has spent millions on ads, the fact is that news coverage still has the bigger payoff.

One reason for this year’s emphasis on the availability of premium subsidies is the discouraging finding that awareness of the penalty for not carrying insurance (84%) is quite a bit stronger than awareness of financial help (64%). This is important because the premium subsidies really are the #1 reason to purchase coverage.

Ad campaigns have also focused on the new dental benefit available through Covered—for its own sake but also as a new hook to drive traffic to Covered CA. About 15% are signing up for dental coverage. California is about average in the percentage of adults who have visited a dentist in the last year (67%, based on 2012 data).

All told, Covered CA has 590 storefronts—thanks to consumer advocates for making a case for these. We were right—that people really value face-to-face interaction in their enrollment process.

Recent improvements to the Shop and Compare tool, specifically around transparency of final costs to the consumer are paying off.

The Covered CA bus tour, stopping in 42 communities, focused on spotlighting iconic buildings around the state and use of the “Enroll Now” spotlight has helped drive consumers to the enrollment website.

Early Results from Open Enrollment 3 or OE3

Though data are tentative, 34,000 Californians have enrolled thus far—about 2,000 a day. Noting that so many wait to the last minute, the real test of effectiveness will be the first two weeks of December for the Jan. 1 effective date and the last weeks in January for the final Jan. 31 deadline.

Even Lee will admit there is room for improvement on call center wait times, especially for the Certified Application Counselors and agents, who have faced waits up to an hour. From October to November the wait time for the regular line has doubled to 4 minutes. Efforts are underway to do more rollover calls.

Section 1332 Waiver Stakeholder Process and Guidelines

Lee shared the guidelines and a few cautions about the Section 1332 waiver opportunity. First, the general guidelines:

  • It cannot add to the federal deficit
  • It requires state legislation
  • It has a 5 year timeframe (learn more here)

One key question is whether a 1332 waiver is required to make the improvements California seeks. So much of what Covered CA is doing, especially as an active purchaser, is actually independent of any Section 1332 waiver. And because of that, we have tremendous latitude and flexibility to do as we see fit to address state priorities for reform.

With that background, those contemplating a Section 1332 waiver should ask…

  • How the proposal will address CC mission: to increase the number of insured Californians, improve health care quality, lower costs, and reduce health disparities through an innovative, competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value.
  • Does it achieve cost savings? It should not add liabilities to the state general fund.

The stakeholder process will run from Jan-April 2016 with next steps to be decided in the summer.

Public comments on Section 1332 waiver angles touched on general themes of lingering affordability issues despite subsidies; the need to address churning and difficulties with the transition from Medi-Cal to Covered CA, and of course Health4All adults, specifically the proposal (now part of SB 10-Lara) to allow adults and others not eligible for Medi-Cal to purchase coverage through Covered CA with their own money. Beth Capell, speaking for Health Access, asks the Board and stakeholders to be mindful of tight legislative timeframes–that if a stakeholder process really goes through June, and without a Covered California board meeting in July, it would be too late to get a bill passed to submit a waiver this year.

Certification Process and Priorities for 2017 Qualified Health Plans

The discussion on plan designs for 2017 was more of a preview of items for full discussion in January 2016 with final Board action by February. For the year 2017 we can anticipate substantive changes on plan designs and triple aim (or quadruple aim) goals on cost, quality, better care, and equity. Much of the legwork for these changes has been done in the Quality Subcommittee of the Quality and Plan Management Advisory Committee-see their Powerpoint presentations for helpful background.

Looking ahead to 2017, the general expectation is for plans to emphasize preventive care; strategies to control costs; and benefit changes that align with value and improve outcomes. They should also offer a range of meaningful choices for consumers along with strategies to retain members.

For CPEHN (California Pan-Ethnic Health Network), Health Access, and many other advocates the 2017 plan designs present an unprecedented opportunity for Covered CA to use its contracting power to reduce disparities. This starts with the QHPs collecting all the necessary data to establish benchmarks and show reduction in disparities over time. Over time transparency mechanisms like the Shop and Compare tool should display comparative data on how plans are doing to address disparities.

Other Issues: Continuing Issues with the Transition from Medi-Cal to Covered CA

As noted in comment letters to the Board by Western Center and Health Consumer Alliance among others, the transition of Medi-Cal enrollees into Covered CA is still shaky at best. Consumers do not yet have the ability to transfer from Medi-Cal to Covered CA plans without a gap in coverage, which contradicts the ACA goals for the continuum of coverage, says Cori Racela of NHELP-CA.  A key challenge in that transition from Medi-Cal to Covered CA, says Elizabeth Landsberg of Western Center on Law and Poverty, is you don’t have coverage until you pick a plan and pay your premium premium—this is not clear to enrollees in many circumstances. Covered CA should look for ways to simplify the process for these folks.

Coming Up Next for Covered CA

  • November 23 is the deadline for comments on the vision benefit RFP (find details here).
  • December 15, 2015 is the enrollment deadline for coverage effective Jan. 1.
  • There will be no December Board meeting, though December 17 will be held open in case there is a need for Board action. Advisory Groups will continue meeting, even in December.
  • January-April, 2016: Section 1332 waiver stakeholder process.

Blue Shield Tries To Back Out Of $140 Million Commitment to California Communities

When nonprofit insurer Blue Shield California made a $1.2 billion bid to acquire Care1st, a Medi-Cal managed care plan serving 500,000 Southern California patients, it agreed to conditions set forth by DMHC (Department of Managed Health Care), including a commitment to increase its investment in the state’s safety net by an additional $140 million over 10 years. But this week Blue Shield disavowed this commitment, stating that it sees the $14 million requirement as a “floor” for its annual giving to the safety net.

Given the nonprofit insurer’s usual giving levels of about $35 million a year, Health Access California has raised concerns with DMHC that the insurer might actually do less for the safety net if its interpretation of the conditions is allowed to stand.  DMHC Director Shelly Rouillard seems to share some of our concerns. In a letter dated November 12, 2015 Rouillard reiterated her expectation, expressed during the negotiations process, that “Blue Shield would increase its overall charitable contributions to improve healthcare delivery in California (learn more in today’s LA Times).”

Health Access, the statewide health care consumer advocacy coalition, is directly urging Blue Shield of California, to abide by its historic nonprofit mission and contribute an additional $14 million/year for 10 years to its charitable foundation for safety-net funding—as was clearly expected when state regulators approved their acquisition of Care1st.

Earlier this year when Blue Shield of CA moved to acquire Care1st, it came under intense scrutiny for excessive $4 billion surpluses and for denying the charitable obligations that would ordinarily apply to those and other assets. Last July Health Access California and other consumer advocacy organizations sought strong conditions on the merger to address its potential negative impacts. The DMHC did impose some but not all of the undertakings (activities to meet charitable obligations) sought, including a commitment of $200 million for specific projects and goals to help reassure that this merger was in the public interest, including $140 million over 10 years to the Blue Shield of California Foundation to improve the state’s safety-net.

More recently further issues have been raised around the insurer’s inaccurate provider directories, unreasonable rate increases, and other practices not consistent with the behavior expected of a nonprofit insurer.

This week’s events raise serious questions about whether BlueShield is exploiting loopholes on other merger conditions or other consumer protections, prompting Health Access to seek stronger and more airtight conditions for the even-bigger mergers coming up for approval in the next few months.

Fifth Circuit Appeals Court Ruling on President Obama’s Executive Order on Immigration: What It Means for #Health4All in California

Last Monday the U.S. Fifth Circuit Court of Appeals voted 2-1 to block President Obama’s 2014 executive order on immigration, dealing a major setback to efforts to shield an estimated five million immigrants living in the U.S. from deportation (learn more here). Issued in November 2014, the President’s executive order would have allowed millions of immigrants to apply for work authorization and protection from deportation. From the immigration enforcement perspective, it would have allowed the Administration to prioritize enforcement of current law—such as it is. Ironically, the Obama administration has processed more deportations, about 400,000 per year, than any other president in history (learn more here). In February of 2015 a Texas district court issued a preliminary injunction, bringing implementation of the executive order to a halt.

The health coverage intersection in California came the following June, in the final state budget where the Brown Administration reaffirmed California’s policy of including income-eligible California adults with “deferred action” immigration, such as those who may benefit under President Obama’s administrative relief, in state-funded full-scope Medi-Cal. The state budget also includes coverage of kids regardless of immigration status—with additional implementation direction passed in SB4.

Gov. Brown’s budget clarification also provides a case in point for the Fifth Circuit Court’s dissenting argument by Justice Carolyn King: The President’s DAPA Memo provides only guidelines—it does not confer any actual benefits to the immigrants, as justices on the prevailing side have claimed. King is right, and this is why states like California that recognize the value of extending health services to the entire community, have had to make special policy provisions and allocate separate state-only funding to extend affordable coverage to immigrants. This is our choice—that only a few states have made, and the President’s Executive Order, even if it withstands the court challenges, does not change this.

Looking for the Silver Lining While Continuing the Momentum on Health4All

As noted by Marielena Hincapié of the National Immigration Law Center, If there is any silver lining to Monday’s appeals court decision it is simply that this issue will very likely go to the Supreme Court in the current October-June cycle—all it takes is four justices to put the case on the docket.

If the Supreme Court rules in the Administration’s favor, the Administration would have only a few months to implement the executive order.  California, however, should be ready to move ahead with state-funded Medi-Cal eligibility for the DAPA adults.

That, in turn, would get us closer to the statewide goal of #Health4All. It would make expansion–and the expense–of a full Medi-Cal expansion to all who are income-eligible relatively smaller. Next year’s SB 10 (Lara) would seek that, as well as a Section 1332 waiver from the federal government to allow immigrants from households above the Medi-Cal eligibility threshold to purchase coverage through Covered CA.

All of these things will take time—longer than any human being should have to wait for decent health care.  This is where the counties come back into the picture and where their role should be expanded. Earlier this year, Sacramento, Contra Costa, and Monterey counties, along with the County Medical Services Program serving 35 small and rural counties, all started new pilot programs extending primary and other levels of care to their undocumented residents, while Los Angeles and Santa Clara and other augmented what they offered. From these counties we hope to glean important lessons for the broader campaign for #Health4All.

This is to say, and if we may echo Hincapié: “the power of our movement [for #Health4All and more] is greater than the sum of any anti-immigrant decision.”

Obamacare in the Ballot Box: Quick Take on Kentucky Governor’s Race from California

Heading into last Tuesday’s mid-term election, there was plenty at stake for the future of health reform (HBO’s John Oliver tried to warn us), particularly in states that have refused or have yet to decide whether to implement the optional Medicaid expansion—or had decided, like Kentucky, to opt in, not because the political winds were blowing in that direction, but thanks to Governor Steve Beshear’s bold executive order.

In view of Kentucky’s many successes on the ACA—the second largest drop in uninsured residents, a robust state-based exchange, and its distinction as the only southeastern state to opt in to Medicaid expansion—Tea Party Republican Matt Bevin’s gubernatorial win last Tuesday on an anti-Obamacare, anti-Medicaid expansion platform came as something of a shock, if not a wake-up call for what may be at stake for Obamacare in 2016.

In a recent Health Affairs blog, David Jones provides helpful perspective on the Bevin victory—it will likely embolden and fan the flames of the anti-Obamacare candidates, no doubt, but these candidates will be hard pressed to take away affordable benefits from the millions of Americans who would otherwise find themselves uninsured today.

We don’t want to downplay what is at stake for Affordable Care Act in 2016. Nor, like Jones, do we want to rush to judgment on the significance of Bevin’s victory. But we would rather “fan the sparks of hope” for the future of the ACA from across the nation.

Looking ahead to 2016, we see even in the battleground states, polling shows likely voters agreeing the ACA is here to stay and preferring candidates who are prepared to improve on, rather than scrap the law.

For states like California that are taking Obamacare as far as it can go or using it as a jumping off point for additional reforms, there is a story to tell on the national stage.

Evidence suggests that “active purchaser” or stronger authority over rates translates to lower premiums and slower growth in rates from one year to the next. And now California is taking that authority further to re-align incentives for higher quality, cost-effective care in time for the 2017 plan designs. If successful, such efforts will go to the heart of the issues Obamacare’s most vitriolic opponents care about most, or so they say: bending the cost curve. Why would you expand Medicaid, say leaders in Utah and Alabama, for example, when the program is so broken? And so we find these states up to their ears in delivery system reforms or Medicaid waivers of questionable intent, but with little to show for such efforts to date.

If even in the worst possible scenario, Kentucky’s reforms come unraveled under a Bevin administration, California will be here to show how Obamacare can be a jumping off point for reforms addressing access, quality, and cost. Instead of resting on the laurels of our own favorable polling on the ACA, we should bring the full story of California’s success forward in 2016.

DHCS & CMS Agree to Medi-Cal 2020 Waiver Framework!

This past Saturday (Halloween), the California Department of Health Care Services announced it had reached a new “conceptual agreement” with the federal Centers for Medicaid and Medicare Services (CMS) on the general framework of “Medi-Cal 2020,” the renewal of the 2010-2015 Medi-Cal waiver.


  • With details to be specified in the coming months, the framework is likely to spur innovation in California counties with respect to delivery system reforms, care for the uninsured, and “whole person care” or integration of health care services with other human services.
  • The current five-year “Bridge to Reform” waiver, which expired on Halloween, is extended through December 31, 2015. Once the new waiver is finalized, it would start in January 2016, and consumer groups should be ready to work with counties to improve care and build on innovative models of health care delivery for the remaining uninsured.
  • The conceptual framework has huge potential to improve care for millions currently on Medi-Cal and to expand access to cost-effective primary care for the remaining uninsured.
  • It will be up to the individual counties to maximize these opportunities for their remaining uninsured—or they could lose safety net care pool dollars.

A waiver is a formal request by a state to the Secretary of Health and Human Services to waive specific Medicaid program requirements to test new ways to deliver care. Since the 1990s, California has made extensive use of waivers to further state health reform goals or more recently, to implement worthwhile reforms—like the Medicaid expansion—ahead of schedule.

The new Medicaid waiver would provide at least $6.2 billion in new funds and likely more over the next five years to California, as well as a framework to encourage innovation in health delivery, dental care, safety-net services for the remaining uninsured, and integration with other human services—“whole person care.”

Though the scale and financing are significantly scaled back from the state’s original renewal application, the new waiver would infuse new resources and provide new flexibility and accountability for improved care for many Californians, including Medi-Cal beneficiaries and the remaining uninsured.

The following key waiver provisions are supported by the conceptual agreement:

  1. Innovative delivery system reforms based at the county-operated public hospitals get green light, though the time frame is limited to one year with the option to renew for another one to three years, depending on findings from a planned independent assessment of uncompensated care. The current waiver had a DSRIP (Delivery System Reform Incentive Payment Program, a federal pay for-performance quality improvement initiative. California’s DSRIP program, the first in the nation, has strengthened care delivery throughout 21 public health care systems, extending quality, coordinated care more accessible and efficient to more patients, with positive results. The DSRIP program has a new acronym: PRIME (Public Hospital Redesign and Incentives in Medi-Cal).
  2. Global payment for county-based safety net programs. Counties will have fresh incentives to re-direct their Disproportionate Share Hospital (DSH, for five years) and at least one year of Safety Net Care Pool (SNCP) dollars ($236 million in federal funds) to innovative approaches to care for their uninsured residents, with flexibility on how they use those dollars both inside and outside the hospital setting—see recent examples. Like a lump sum payment, the global payment, a first in the nation approach, will give counties that have yet to set up indigent care programs all the incentives they need to push ahead. These payments will incentivize cost-effective primary care and discourage expensive hospital-based care—a win-win for counties and uninsured patients alike.
  3. Whole Person Care ($1.5 billion over 5 years). Many of the highest risk patients, for example homeless people or people leaving incarceration, cannot benefit from care without additional supports like housing services or food assistance. It’s one thing to diagnose a homeless patient with diabetes—but that patient won’t get very far in following the prescribed treatment without a roof over their head or the ability to find affordable, nutritious foods.  Under the whole person care pilot provision, counties can engage other social services and supports to help their patients fully benefit from care.
  4. A Dental Transformation Incentive Program ($750 million over 5 years). Under this initiative, the state would have fresh incentives to improve dental care in Medi-Cal using the limited DSHP (Designated State Health Program) dollars still available for California.

Through the waiver negotiation process, concerns about current Medi-Cal beneficiaries’ access to care were raised. The conceptual agreement thus includes an independent assessment of access to care and network adequacy for those enrolled in Medi-Cal managed care plans. Health Access welcomes this assessment and believes it will complement current efforts to ensure timely access to care statewide.

Details Missing From the Conceptual Agreement, Including Any Focus on Equity

A conceptual agreement is just that—a high-level overview of mostly technical areas of the waiver like the various payment methodologies that will be tested over the course of the waiver. The CMS 10/31 letter touches on the metrics for analyzing the success of payment methodologies on triple aim goals (improved quality, lower costs, and better health outcomes)—but no mention of equity or health disparities. Health Access and other advocates will continue to pursue that, since in most of the waiver advisory group discussions, health equity emerged as a core objective for the waiver renewal.

The time between now and December 31 will be used to hammer out the waiver renewal details (“Special Terms and Conditions”), on how these programs will be structured and overseen. Advocates will be looking to make sure the details work to meet the overall goals, including about how Medi-Cal 2020 will be used to reduce health care disparities. For example, payment methodologies can be tied to progress in collecting race and ethnicity and primary language data and making meaningful use of these data to support triple aim goals and better integration and coordination of care for diverse populations with complex health care needs. As noted in the CMS October 31 letter, the PRIME evaluation program will include a broad set of metrics—those metrics should include all measures needed to reduce disparities.

All of these details will need to be addressed by the end of the year. For further details see the October 31 letter from CMS to DHCS officials.  

Health Access is excited that this framework will spur further innovation in counties across the state, on health care delivery, on safety-net services for the remaining uninsured, and on integrating health with other human services.  Community groups have been working with their counties on revamping and improving their safety-net systems, and the conceptual agreement will take those efforts to the next level.  Once the waiver renewal is finalized by year-end, we expect to see an explosion of exciting activity at the county level to improve health care once the details are hammered out.

Next Steps

  • Keep your eyes on the prize: last week a small group of health care consumer advocacy groups sent a letter to CMS outlining the “must-haves’ in the waiver renewal with justifications for California’s full request.
  • Take a minute to thank DHCS Director Jennifer Kent and Medi-Cal Director Mari Cantwell for their dogged persistence on key waiver provisions. This has not been easy!
  • It is our understanding that the waiver stakeholder advisory committees, will be called together again, whether separately or as a block, at least once before the December 31 deadline, to discuss the final terms of the waiver renewal. Watch our blog or your email inbox for details on that process.

Covered California Open Enrollment Started Sunday!

Yesterday marked the official start of Covered CA open enrollment, which will run through January 31, 2016. For coverage effective January 1, people must enroll by December 31, 2015. As always, Medi-Cal enrollment is open year-round and individuals experiencing any life transitions (losing a job or moving, among many qualifying events for Special Enrollment) may enroll anytime, even after January 31, 2016.

For health care advocates and other consumer groups, it’s worth clicking around the much improved Covered CA website to explore the various tools available to maximize enrollment and target those eligible but not yet enrolled. Here are a few highlights:

  •  The Shop and Compare Tool is more useful than ever—showing options for plans by county with estimates of consumer out-of-pocket spending for each along with summary information about plan quality.
  • A Preview Plans tool helps applicants pick the right plan based on what is important to them, for example how often they think they will visit the doctor or how many prescription drugs they will need. Once you input your personal information and preferences, you will see the plan options with links to provider directories for each plan. Those shopping for a better plan are encouraged to visit their plan’s website to look up whether their preferred provider is still in network. Knowing that timely access and network adequacy are works in progress, Health Access encourages consumer advocates and navigators to check out these tools with an eye on their accuracy as policy improvements are made.
  • Find Local Help: Folks can get free help with the enrollment process by phone (and the many languages spoken at the call center) or from a navigator or certified application counselor in their area. This is important because we know that the remaining uninsured and long-term uninsured will likely need more help with information and guidance in picking a plan and understanding the value and details of health insurance. The navigators and enrollment assisters are specifically trained to help these consumers sort through these important issues.
  • All Covered CA pages are translated in Spanish and other threshold languages. See these links at the top right of each page.
  • Pay first month’s premium online to “close the deal.” After going through the application process and selecting the right plan, it’s nice to be able to finish the process by paying the first month’s premium online. More insurers than ever are making this possible this year. This “effectuates” (fancy talk for making it real) enrollment, setting the on-boarding process in motion.
  • Using your plan: This year Covered CA is rightly focusing on helping consumers make the most of their health insurance to live healthier lives. Tools and information to make the most of your plan.

Framing the Opportunity and the Message for Open Enrollment 2015-16

  • Subsidies are available to make coverage affordable! In terms of messaging, we want to echo and elaborate on Covered CA’s own emphasis on publicizing the availability of subsidies—not just for the premiums but also or cost sharing assistance. Recent surveys show that people actually know more about the tax penalty for not having coverage, than about the tax subsidies available to help families afford coverage in the first place. Organizations should use the open enrollment period to educate Californians about the many positive benefits that are available to low- and moderate-income families. To this end, Health Access would welcome stories illustrating how the subsidies have helped individual consumers afford and keep coverage or how this coverage has helped them take charge of their health and enjoy financial security and peace of mind.
  • Coverage is not an end in itself, but a tool for keeping healthy or managing any chronic conditions. Getting enrolled is a critical first step—but that is only the beginning. Across the nation, insurance marketplaces are rightly focusing on how consumers can best use their coverage to stay well.

In this vein, it crucial to know your rights and the importance of using complaint processes (among other examples) for situations where the promise of what coverage is supposed to deliver falls short. Here are a few examples:

  • Is the drug formulary (list of approved drugs in a given plan) restrictive or does it place specialty drugs on the highest cost tiers of the plan? A few months back Covered CA effectively barred this practice—but for some consumers the out-of-pocket expenses for high cost medications may still be too high. We want to hear about these situations so that we can continue adjusting the policy as needed.
  • Is the provider directory accurate? With passage of SB 137 (E. Hernandez) Accurate Provider Directories in the 2015 legislative session, these expectations will be higher. But it will take time to fully implement this new law. In the meantime, Health Access wants details about any difficulties with provider directories (share a story here).
  • To appeal enrollment determinations, Covered CA has a complaint page. And for complaints against Covered CA itself (nobody’s perfect), people should complete the Covered CA complaint form.

The Bottom Line On Covered CA Open Enrollment

Covered California continues to offer four transformative benefits to consumers:

  • No denials for pre-existing conditions
  • Financial help to better afford coverage and limit out-of-pocket obligations
  • Standardizing benefits for easy comparison and security in coverage
  • The bargaining power of a big group rather than an individual all alone at the mercy of the market. As an “active purchaser” exchange, California has been able to keep premiums low from one year to the next.

And there are more reasons to make the most of Covered CA open enrollment  2015-2016. By the most recent census, California showed the fifth-largest drop in the percentage of uninsured–but our state is still above average in our uninsured rate. Despite the significant progress made, we need this third open enrollment period to bring more Californians the benefit of coverage—starting with financial security and timely access to care.

Elections Matter: Kentucky and Virginia May Decide Medicaid Expansion on Tuesday

The health care for hundreds of thousands of Americans is on the ballot on Tuesday in Virginia and Kentucky. Comedian John Oliver reminds us of this stark fact in his HBO show Last Week Tonight, where he details the “Medicaid Gap” and how state legislative races could allow Virginia to expand coverage… and how a Republican taking over control of the Governor’s mansion in Kentucky could reverse the progress in the state which had the most successful drop in the number of uninsured.

The clip is worth watching, as are the results on Tuesday evening:

HHS Proposed Regulations Barring Discrimination on Basis of Sex, Gender, Gender Identity, Race and National Origin, Disability, and Age Need Work: Deadline to Comment is November 9, 2015

Last month the federal Department of Health and Human Services (HHS) released a proposed rule implementing Section 1557 of the Affordable Care Act, which extends civil rights protections under Title VI, Title IX, the Age Discrimination Act, and the Americans with Disabilities Act (ADA), among others, to health programs that receive any federal funds.  No matter whether a given state operates its own exchange or if it is part of the federal marketplace, Section 1557 will apply to all health plans and the providers with whom they contract in every state—and it will apply to employer-based plans so long as that plan has insurance products serving populations that receive any federal funds, including Medicaid (Medi-Cal in CA) and premium tax subsidies. In short, Section 1557 should apply to virtually all plans and providers in California.

Longstanding California anti-discrimination law, the Unruh Civil Rights Act, already applies to plans and providers but the proposed federal protections add several important layers of protections.

What’s Positive in the Proposed Rule: Highlights

  • The rule’s new protections against sex discrimination apply to gender identity. Section 1557 is designed to protect women and LGBT individuals from discrimination not only in the health coverage they receive (this is handled in another ACA section) but also in the health care services they receive. Though the language in the rule needs to be strengthened around sexual orientation protections. The rule does, however, strengthen existing California law related to health care for transgender persons.
  • Insurance policies may not categorically exclude coverage for care related to gender transition, and access to facilities must be consistent with gender identity—the GLMA (Health Professionals Advancing LGBT Equality) applauds these provisions.
  • The rule specifies requirements for accessibility and effective communication with persons with disabilities and enhanced language assistance for people with limited English proficiency (LEP), though California’s laws on the latter are actually stronger (see also CPEHN’s overview of language assistance policies in California). Of course, there is always room for improvement on these issues—see CPEHN’s proposed improvements on these provisions of the rule.
  • The proposed rule specifies that individuals may seek legal remedies for any discrimination under Section 1557—a private right of action. This is important because we know that laws and regulations, no matter how well designed, are not always enforced properly, and that therefore setting legal precedence will be helpful. To this end, Harvard Law School’s Center for Health Law and Policy Innovation (CHLPI) is launching a litigation initiative—for details contact

What’s Missing or Weak in the Proposed Rule

  • Discriminatory benefit design: The rule falls short in defining discriminatory practices in plan benefit design and formulary tiers as it relates to people with chronic conditions who rely on prescription medications and other healthcare treatments. Federal regulations should go at least this far, says the AIDS Institute. AB 339 (Assemblymember Gordon) Prescription Drug Cost Sharing, sponsored by Health Access and supported by a broad range of consumer groups was signed into law last month by Governor Brown. AB 339 will require insurers and health plans to cap cost sharing for prescription drugs at $250 per month per prescription in most plans (or $500 in Bronze plans); cover medically necessary prescription drugs; prohibit placement of most or all drugs to treat a specific condition on the highest cost tiers of a formulary; requires formularies to be based on clinical guidelines and peer-reviewed scientific evidence as well as cost (learn more in our fact sheet).
  • Scope of protections based on disability. While HIV is protected as a disability, other conditions that may be disabling like rheumatoid arthritis and Hepatitis C are not protected under the proposed rule.
  • Sexual orientation protections. While the proposed rule’s long introduction states that “as a matter of policy, we support banning discrimination in health programs and activities not only on the bases identified previously, but also on the basis of sexual orientation”, the text of the proposed regulations never mentions sexual orientation. Gender identity, sex stereotyping, and “on the basis of sex” are all defined, but none of those definitions explicitly includes sexual orientation.

Tools for Participating in the Comment Period

The comments are due by November 9, 2015.

Angles for Comments

Health Access agrees with other consumer and community advocates that these issues related to benefit design have a discriminatory impact in practice, but the proposed rule falls short in addressing them:

  • Failure on the part of health plans and exchanges to include adequate information on the cost of covered medications, though existing California law, SB 1052 (Torres) of 2014, still being implemented, already requires health plans to include information on cost sharing in standardized information on formularies.
  • Due to the conflicting legal decisions about whether sexual orientation is protected by existing prohibitions on sex discrimination, Health Access recommends that the definition of “on the basis of sex” also include sexual orientation.

HHS is also asking specifically for comments on whether Section 1557 should include an exemption for religious organizations. Health Access strongly opposes exemptions that would allow discrimination based on religious views, particularly in view of the long history of both religious discrimination and discrimination by health care providers against LGBT individuals and families.

We look forward to working with partners on this crucial issue.

UCLA Forum tonight: Is Merger Mania Healthy?

“Is Merger Mania Healthy?”

The Affordable Care Act (ACA) has inspired many providers to consolidate and major payers have now joined this trend. Anthem has announced that it is merging with Cigna, and Aetna announced it is merging with Humana. If these mega mergers are approved by the government, the health insurance industry will consolidate the top five payers into just three companies, each with annual revenue over $100 billion. Providers, regulators, and consumer advocates are concerned that the payer consolidation will limit the negotiating power of private and government health programs. In this Health Forum, our speakers will present the provider, consumer, and government perspective on whether merger mania is healthy.

Our executive director Anthony Wright is one of the speakers tonight at the UCLA Jonathan and Karin Fielding School of Public Health, as part o

When: Wednesday, October 28, 6:00-8:00pm PDT

6:00-6:30pm: Coffee and Reception

6:30-7:15pm: Panel Presentations

7:15-8:00pm: Question and Answer Session

Where: Neuroscience Research Building Auditorium, UCLA

635 Charles E. Young Drive South, Los Angeles

Online: To join the livestream on October 28, please click HERE. Please note that the program begins at 6:30pm PDT.