Sunday, November 17, 2013

Q: Where is Obamacare Working? A: Covered California and Medi-Cal, and the Health Care Team Must Keep Leading

                                      As seen in Sierra Sacramento Valley Medicine Vol. 64 / No. 6 - Nov/Dec 2013  

The Final Countdown to
a Covered California

By Adam Dougherty, MS IV

THE CLOSING MONTHS OF 2013 bring a slew
of activity in the implementation of the
Affordable Care Act in California, and it is
impressive to see just how far the state has come
since the law was passed. While there have been
some unfortunate delays announced from the
feds, the main pillars of the law remain intact.
Notable delays include the postponement of the
annual and lifetime caps on out-of-pocket
insurance costs to 2015, and deferral of the rule
requiring large companies to provide
comprehensive coverage to full-time employees.
The following are what’s happening with the big
pillars, which go live beginning in 2014.

The Mandate
The controversial individual mandate will go
into effect on New Year’s Day, where most
individuals will be required to have insurance
coverage or will pay a penalty on their taxes that
year if they don’t. In 2014, the penalty equals 1
percent of income or $95 (whichever is greater),
and in 2016 phases up to 2.5 percent of income
or $695. Groups exempt from this mandate
include individuals who would have to pay
more than 8 percent of their income for
insurance, undocumented immigrants, and
Native Americans.

The Exchange
For those with incomes above 138 percent
of the Federal Poverty Level (FPL), the state’s
health insurance exchange called Covered
California is expected to provide competitive
insurance rates in a regulated market, while tax
subsidies will help make coverage affordable for
individuals and families up to 400 percent FPL.
The exchange began pre-enrollment on October
1st, and will officially go live on the first of the
year. The $80 million Covered California media
blitz is in full swing, and Exchange officials hope
to enroll over 70 percent of the 2.4 million
Californians who are eligible for subsidies over
the next year.

California is moving full steam ahead to
expand Medi-Cal to every individual under 138
percent FPL or roughly a salary of $16,000 per
year for an individual and $27,000 for a family
of three. This equates to 1.4 million newly
eligible Californians, adding to the ranks of
today’s 8 million Medi-Cal beneficiaries. Here is
what that looks like:

Counties have been working feverishly to
bring many of these individuals into the
temporary Low Income Health Plans (LIHPs),
commonly known as the “Bridge to Health Care
Reform.” Over 615,000 Californians have
already enrolled in county LIHP programs since
2011, and nearly all will transfer automatically
to Medi-Cal on January 1st. Today, nearly 12,000
Sacramentans are benefitting from this program.

It’s not all good news for Sacramento
County, though, as the state plans to claw back
$9 million next year from the County health
budget since these traditionally county-financed,
low-income individuals will transition to statefinanced
coverage (even though expenditures
will remain, as the county will still be
responsible for care to those who remain
uninsured). County officials are devising how
best to streamline existing programs as any cuts
to benefits seem to be off the table.

While the expansion will have far-reaching
benefits for the health of the newly insured,
coverage does not simply equate to access.
California still has the lowest Medicaid spending
per enrollee in the nation, and the second
lowest share of physicians accepting new
Medicaid patients at 57 percent. More so, the 10
percent Medi-Cal rate cut proposed in the
Governor’s budget was indeed upheld in the
courts and is now actively being implemented.

Nevertheless, 150 primary care services in
Medi-Cal will still see a boost in payment to
Medicare level in 2013-2014, thanks to the ACA,
equating to a 136 percent increase in
reimbursement on average. It is imperative that
these services are taken full advantage of over
the next year, and significant effort be put in to
extend them past 2014, in order to bolster
primary care networks and adequately meet the
pent-up need for the newly insured. While
reimbursement is the most immediate priority,
the state and committed, forward thinking
stakeholders must buy in to more organized and
integrated payment and delivery models that
improve efficiency while reducing barriers to
care or risk further provider network

Public Awareness
Much of the public continues to remain in
the dark on most of these developments, and
often become more skeptical when they do hear
about it. A recent Kaiser Family Foundation
study conducted in August exemplifies this
phenomenon, where individuals were asked
who they would trust getting information from
vs. actual exposure:

The health care team tops the list of trusted
sources, yet only one-fifth of individuals have
received any information from a doctor or
nurse. While the entire political spectrum is,
indeed, represented in the medical profession,
this peer-reviewed fact should be emphasized:
Insurance coverage reduces mortality, improves
quality of life, and enhances productivity.

The reality is that many eligible individuals
will still lack coverage by the end of the decade
because they can’t afford it, they can’t properly
navigate the system, or have encountered any
number of barriers to outreach. Whatever our
preferred ideology, it would behoove all our
patients to benefit from these reforms, and as
stewards of health, we should be expected to
guide them.

Leading the way in this regard are the
California Academy of Family Physicians, the
California Chapter of the American College of
Physicians, the California Academy of Physician
Assistants and the Osteopathic Physicians and
Surgeons of California, whose partnership was
awarded an $865,000 grant from Covered
California to develop educational programs for
physicians and materials for patients in order to
increase the number of Californians with health
care coverage.