Last Tuesday’s Health Care California conference gave us a chance to pause and reflect on ACA implementation efforts to date—and where we need to go as a state—before the fun begins again with the next open enrollment season in November. If there was a general sentiment across the panel presentations it was simply that California has done well to this point, having slashed the number of uninsured in half and probably slowed the growth in premium costs, also by about half; but now comes the harder part, including the work on reducing health care costs. Many suggested that if we don’t get a handle on costs, the gains of health reform could be erased, and additional agenda items could not be addressed, from tackling longstanding issues like timely access to care, to covering the remaining uninsured.
There was only one session devoted to consumer angles in reform and featuring Health Access’ Anthony Wright–it’s worth highlighting if only to remind our colleagues in the policy community that if we want health reform 2.0 to be successful, consumers will need to be at the heart of the most critical initiatives in care delivery. One example, touched on by several panelists, is patient-centered medical homes, an important mechanism for coordinating care for people with chronic conditions. Medical homes work best when patients and families are fully engaged in their design and execution.
Financial Impacts of the Affordable Care Act in California (Opening Panel)
Those looking for weeds on the cost issue got plenty. Covered California’s robust enrollment gives the plans and Covered CA officials a better grasp of the risk we are facing in the new marketplace, says David Panush of Covered California, and this should give us a jump start on managing that risk.
There are no quick fixes for the cost issues, said several panelists—and it’s not the lack of regulatory mechanisms that’s to blame for rising health care costs, says Micah Weinberg of Bay Area Council, and this is why we need to double down on getting better value from all of our medical spending.
Consumer Panel: “Who’s Helped, Who’s Hurt” by the ACA in CA
That California is no longer on the list of states with high uninsured numbers is reason enough to celebrate, says Carla Saporta of the Greenlining Institute. And noting that California is a majority minority state, people of color have even more reasons to celebrate. But there are still huge gaps, for example it took way too long to adopt the materials in the now 13 threshold language standard for Covered CA language access. The early enrollment surge leaves us with many in the system have not used before so need to focus on helping people better utilize the system.
That so many enrolled in spite of the barriers to enrollment reminds us of the need for reform, said Anthony Wright of Health Access, and the need to do better in the next round. We need everyone in the system–enrolled and getting good access to care—so that it works better for all of us. He pointed out the decisions by California to improve upon the ACA, such as making Covered California an active purchaser with the authority to negotiate rates and other important details with insurers. To reap the rewards from our active purchasing approach, including better management of costs, consumers should really weigh their new options. Though automatic renewal will be critical for some consumers and for marketplace stability overall, consumers in position to do so should make a point of SHOPPING AROUND. It’s a lot to ask of consumers—and advocates may be in the best position to help consumers get more engaged at these levels.
Lunch Keynote: Diana S. Dooley, HHS CA Secretary
The focus on enrollment to this point has made sense, said Dooley. But we need to start shifting attention to the other legs of the stool: cost containment and delivery system reform. With eight counties set to pilot coordinated care initiatives for ‘duals’ (individuals dually eligible for Medicare and Medi-Cal), and the state’s SIM (State Innovation Model) grant poised to begin in January if funded, we are moving into the next exciting stage of reform. We will know we are successful when consumers become healthier as a result of these and related initiatives to lower costs and improve quality of care.
Featuring “accountable care communities for health,” California’s SIM proposal is about the health of the population, Dooley said. “It asks all of us to think differently not just about health care but about health and how our community is configured to support health and reduce disparities: How can we live differently, in ways that keep us well? If, as Let’s Get Healthy California Task Force Co-Chair Don Berwick tells us, 30% of care provided is unnecessary or actually harmful—but how do you go after that safely? And with so many new people in California’s care delivery system, we know we cannot provide care the way we did in the past.
Medi-Cal Panel: looking for sunshine, beyond the enrollment backlog
Cathy Senderling-McDonald of the County Welfare Directors Association is, borrowing a football metaphor, still looking for sunshine, having trouble seeing past the Medi-Cal enrollment backlog, down to 250,000, and the pent up demand for care introduced by so many new enrollees in a time of great uncertainty about access to providers. Add to that the renewal challenges—made somewhat easier by full passage of SB18.
And supposing we do find our ‘steady state’ for these challenges, access to health care is just one factor in people being healthy…what about housing, family support—it will be important to get at these angles as we dig deeper into reform.
With responsibility for risk shifting in an already shifting landscape for care delivery as the MediCal managed care plans delegate risk to the RBOs (risk bearing provider groups), the group with the most to lose right now are the Medi-Cal enrollees, said Francisco Silva of the California Medical Association. In an even more chilling reminder of the work we have cut out for us, half of the enrollees in plans facing financial solvency issues or corrective action plans are Medi-Cal beneficiaries.
But given that Medi-Cal enrollees and individuals with subsidized make up more than one-third of covered lives in the state means that this population should have clout, real buying power—and with that growing influence in the way care is delivered and paid for in the golden state.
The Politics and Problems: Where do we go from here?
The concluding political panel touched on several hot button topics, including the role of government and the increasing vulnerability of Medi-Cal as it covers more and more Californians. This group of 12 million and counting makes up a massive voting block, says Richard Figueroa of California Endowment. “What will it take for this group to start demanding ‘hands off my Medi-Cal!” And as time goes on lawmakers will not be able to continue ignoring the remaining uninsured.
Echoing Diana Dooley, Bruce Bronzan sees coverage as the first critical step in implementation, but the ACA includes numerous provisions and tools to tackle the remaining challenges (discussed over the course of the day): care coordination, shared medical information, and re-aligning incentives, to name just a few examples.