California Before 10 Years of the ACA

Especially given all that is going on in our health system, it is time to stop re-litigating a health law signed ten years ago, especially one that has shown so much proven success. California is proof of how much our health system has transformed. Prior to the Affordable Care Act, California was the national poster child for the need for health care reform in 2010:

  • SKY HIGH UNINSURED RATE: California had the highest number of uninsured of any state, and the 7th highest uninsured rate in the nation. If Southern California were its own state, it would have rivaled Texas for number one. Los Angeles could claim to be Ground Zero for the health care crisis in America. The Census data counted over 7 million uninsured; The California Health Interview Survey counted 8.2 million in 2009, 24.3% of the state’s population under 65, and nearly a third of those over 18.
  • BRUTAL BUDGET CUTS: In the middle of a recession and economic crisis in 2009, the situation was only getting worse. California had a massive budget deficit of tens of billions of dollars, and Governor Schwarzenegger was proposing cutting the Medi-Cal program by hundreds of thousands of people and—at one point eliminating the entire Healthy Families program that covered one million children. While those eligibility cuts were not undertaken, the Legislature did pass significant cuts to Medi-Cal, including eliminating ten medically necessary benefits, from dental to vision to podiatry and speech therapy, many of which were not restored for a decade.
  • BUYER BEWARE: California was the home of an individual insurance market known as the “wild West,” with minimal standards or patient protections for many health insurance products. Hundreds of thousands of Californians had junk coverage that didn’t cover basic benefits. Many others were denied for pre-existing conditions, not just for cancer or AIDS but hay fever, a college knee injury, or postpartum depression. California became the battleground over “rescissions,” where insurers would retroactively cancel the coverage of premium-paying policyholders who filed claims. Insurers would have whole departments to review the questionnaires of those who filed claims, and could leave patients without coverage at exactly the time they needed it. A series of articles by Lisa Girion in the LA Times spotlighted this issues across the nation.
  • RATE INCREASES: Most memorable was a February 5, 2010 story by Duke Helfand in the LA Times, spotlighting a 39% rate increase by Anthem Blue Cross of California. President Obama spotlighted the story continuously, to make the case for health reform. The story is credited with reviving the interest in passing the ACA after the special election to fill Senator Ted Kennedy’s seat went to Republican Scott Brown. At the time, California did not have rate review: many plans could raise rates at any time, multiple times a year, without filing much less review by regulators.

We can’t go back. We can’t undo the progress we’ve made since those dark days.

California attempted several efforts at health reform for decades prior to the ACA, including ballot measures: Prop 166 in 1992, with an employer requirement to offer coverage, and Prop 186 in 1994, with a single-payer proposal, that both were defeated soundly. In 2002, the state, prompted by a bill by then-state Senator Hilda Solis, commissioned a Health Care Options Project, where academics put forward different ideas for reforming the health system and expanding coverage. Some of those papers became legislation, including another single-payer proposal by Senator Kuehl, and an employer mandate by Senate President Burton, which passed and signed into law in 2003. Fast food restaurants and retailers put the measure up for referendum, Prop 72, where the measure got 48.2% percent of the vote—not enough to pass, but enough to continue the conversation. This lead to local efforts like Healthy San Francisco, and to other state legislative efforts, such as single-payer, employer mandates, Medi-Cal expansion, or a hybrid approach that included individual insurance market reforms, affordability assistance subsidies, individual mandate, and other components that would eventually be found in the Affordable Care Act.

These multiple efforts faltered without the federal framework and financing of the ACA. If the ACA is undone by a court case or an election, our health system will revert back to the bad old days, and without the resources to rebuild. If we keep it in tact, the ACA provides a foundation for future reforms and improvements.such

We have always acknowledged that the ACA isn’t perfect. When Health Access produced a 2010 fact sheet of the top ten benefits of the bill, the other side of the sheet included a full list of issues and improvements we were seeking. Those issues such as greater affordability, immigrant inclusivity, and greater oversight of the industry on health costs, continue to be the issues we work on now, ten years later. You never fail until you give up.

The ACA not only helped the millions of people of people who gained coverage and consumer protections, but it gave us momentum for additional state steps, and hopefully can be a platform for the next great reform. Perhaps the biggest contribution was that the ACA showed that progress was possible. We fought the corrosive cynicism that leads people to disengage. Because the ACA passed, presidential candidates are debating what should be the next, bigger reform. And we look forward to that discussion and action in the next decade.