Insure the Uninsured Project Conference: Highlights

This year’s ITUP gathering, fittingly dedicated to Peter Harbage, featured many key insights and “take homes” for advocates. Rather than lament the absence of consumer voices from any of the plenary and workshop sessions, here’s our report with comment and reflection on most of the sessions in italics.

Actionable News from Covered California

Covered California Director Peter Lee announced that 474,000 Californians have newly enrolled in coverage in the second open enrollment period that ended Sunday–and expressed confidence that Covered California would meet the 500,000 target when stragglers are brought in and the final numbers are tallied. But just to be sure and to compensate for the long wait times to get help enrolling by phone (800-300-1506), open enrollment has been extended through Sunday, February 22, 2015 for those who are already “in line.”

  • With his staff and state officials, Peter Lee is considering a proposal to allow a SEP (Special Enrollment Period, i.e. outside the open enrollment season) for individuals facing fines when they file their taxes. Given the challenges of enrolling and educating the community about their new options, not to mention the advantages of having the largest possible risk pool, Covered California should adopt this proposal. California law permits a special enrollment period if the feds publish notice of “any other events” listed in title 45 Section 155.420 (d)—which says “a qualified individual demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.” So if the feds decide that tax season (at least this year) is an “exceptional circumstance” (because it is the first year of the penalty presumably) then Covered California may say it as well. We should learn more about these efforts at the next Covered CA Board Meeting on March 5.
  • Since Covered CA is planning for higher enrollment through the special enrollment opportunities around life-changes than in the next open enrollment, we should do more to ensure such life changes have clear paths to enrollment.
  • On average 94% of consumers decided to keep their current plan. This may or may not be a good thing. If Covered CA had better transparency tools to compare plans on cost and quality, for example, consumers might be a bit more choosy about their plans from one year to the next.
  • We rather liked hearing about Covered CA plans for the coming year to go quite a bit further as an “active purchaser” exchange, to “lean in,” as Lee likes to say, and contract with clinical analytics vendor (Truven) to compare plans on clinical outcomes and find answers to burning questions like: what difference does it make to get care in a medical home? How do network designs affect care and outcomes? This direction for Covered CA builds on our early successes with standardized benefit design. We see many critical opportunities in the use of analytics to address disparities and improve equity. Right now plans and providers are all over the map in terms of who is collecting what data on disparities, as we learned in the EHR(Electronic Health Records) session later in the afternoon; but by recent estimates only about 10% are making meaningful use of these data. We cannot think of a more meaningful use for the data than to guide Covered CA’s decisions as an “active purchaser”  and its emerging efforts to bring better value plans to consumers, plans that are equipped to serve diverse communities.  

Public Payer Session on Remaining Uninsured
It’s always a treat to hear from forward-thinking counties like Alameda, Los Angeles, and San Francisco on what they are doing for the remaining uninsured in their communities—and the many lessons from this work for state-level campaigns like SB4 or the Medi-Cal waiver.

* Mitch Katz, MD (Director, LA Department of Health Care Services) framed hot-button issues like reimbursement rates (they are way too low to ensure access to cost effective, well-coordinated care, especially for those who need it most and this problem can be addressed in the budget process, outside the waiver) and the Medi-Cal waiver renewal in ways that challenge all of us to ask harder questions and want more from these areas of policy. Katz is right to ask, do we really need a Medicaid waiver to do the things contemplated thus far in the state’s waiver renewal? Section 1115 “research and demonstration” waivers should be about pushing the envelope to build on what’s working to cover and care for the remaining uninsured. It was also gratifying to hear that MyHealth LA enrollment is already past 81,000 with space to cover 146,000. In this case, it’s the county providing a model really for the nation.

* Alameda County’s director Alex Briscoe echoes Katz’s call for higher reimbursement rates emphasizing their importance for attracting enough physicians to serve the Medi-Cal population. Briscoe’s visionary talk closed with a show stopper: “The only way to really control costs in Medicaid is to have fewer poor people.” That’s exactly right—and a timely reminder that health reform 2.0 should work to lift people out of poverty, addressing the social determinants of health and poverty (and where you live, what sort of access to educational opportunity do you have, etc.).

Healthy San Francisco (HSF) is once again digging new ground on affordability issues, this time honing in on the 4,500 (25%) of the county’s estimated 18,000 remaining uninsured who, were it not for the high cost of living in SF, would be eligible for Medi-Cal or Covered CA. With funding provided by California Health Care Foundation, HSF is doing a feasibility study on ways they might leverage SF’s own employer responsibility ordinance to subsidize premiums in Covered California for some of this group, says Deputy Director Colleen Chawla. Even with all the financial assistance provided in the Affordable Care Act, we know many Californians need more help–and are committed to working on this, especially in this high cost-of-living state.

View from DC

Speaking (via Skype) of costs, Neera Tanden of the DC-based Center for American Progress touched on mounting voter anxieties about the “middle-class squeeze” and as part of that, the cost of care–which is puzzling in that health care spending and costs are actually on the descent. The problem, she points out, is that the benefits of lower expenditures have gone to all (stakeholders) except the consumers. We agree that as we seek additional payment and delivery system reform, the “shared savings” mantra should extend to consumers: How will consumers benefit from these changes—maybe by reinvesting some of the savings in better access or care for the remaining uninsured?

The view from the beltway is that California leads the nation on ACA implementation. Where Tanden sees opportunity for California and the small handful of states that have active purchaser exchanges is in the Section 1332 super waiver option build into the ACA—might this be a mechanism for a state-level approach to a public plan option? We’re still cogitating on this idea—and starting to think also of the county initiatives (described above) as a precursor to a public plan option or something like it. 

Representative Xavier Becerra also spoke, congratulating California for its leadership in implementing the Affordable Care Act and getting millions enrolled. His talk turned to the judiciary, talking about the politicization of Supreme Court from Bush v. Gore to the NFIB v. Sebelius case that narrowly upheld the ACA but allowed states to reject the Medicaid expansion. He also touched on the current threat of King v. Burwell, which threatens to take away subsidies for those in federally-run exchanges–based on a theory of Congressional intent that was understood by nobody. He also referred to the recent Texas ruling on President Obama’s executive order on immigration. Becerra expressed confidence that the injunction was temporary, and that the President’s policy would prevail in the end–but thought the credibility of the judiciary was being tested.

Closing Plenary: Future of Reform and Lessons from Massachusetts for CA

In its payment and delivery system reform legislation (phase 2 of its 2006 state-based reforms), codified in Chapter 224, Massachusetts took a number of bold steps to rein in its spending on health care, from its starting point as the highest spending state (learn more here). The foundation and mechanism for compliance with cost growth benchmarks is the state’s Health Policy Commission. Starting this year, if a provider entity does not meet minimum cost growth benchmarks they can be fined $500K and must submit to a performance improvement process. As California refines or develops new payment incentives for providers to redesign care, the state can draw important lessons from Massachusetts experience: that payment structures and incentives need to be adjusted to reflect the disproportionate risk that certain providers (i.e. safety net and county providers) are taking on by virtue of the communities they serve. Massachusetts is still paying for early mistakes in this area, says Thomas Traylor of the Boston Medical Center, and we do well to learn from these mistakes as we design our own payment incentives.