Medi-Cal and Medicare Turn 50–With Much To Celebrate & Room for Improvement

As we celebrate how much help Americans have gotten from Medicare and Medicaid after 50 years, including the many improvements to both programs from the Affordable Care Act, we are reminded of the work left to do. In particular, we need to close the gaps in both programs to cover the remaining uninsured. Building on the success of Medicaid, Medicare, and the ACA, California can make more progress toward the goal of health for all with bills like SB4 and SB10, while strengthening the health care system on which we all rely.

Medi-Cal’s Central Role in California

Covering more than 12 million Californians, nearly one-third of the state population, Medi-Cal is a critical pillar of California’s health care system.  Thanks to the Affordable Care Act, Medi-Cal is no longer a collection of programs for specific populations, but a broad-based safety net for all Californians with low and moderate incomes.  It helps people get back on their feet, providing financial security for families and a gateway to cost-effective health care that is free or very low cost.

Medi-Cal also has the potential to demonstrate better ways to deliver care while reducing racial and ethnic disparities.

Hallmarks of Medi-Cal’s Success

  • Working Families, Seniors, People with Disabilities—and now Working Adults. For most of its 50 years, Medi-Cal provided free coverage for low-income moms, kids, seniors and people with disabilities. Now with the Affordable Care Act, Medi-Cal also covers low-income adults without children under age 18. And it now covers almost half of California’s children.
  • Early Medi-Cal Expansion. California was one of the few states to expand Medi-Cal early, drawing down federal matching funds to serve nearly 700,000 Californians in the county-run Low-Income Health Programs (LIHP). The LIHPs provided care in the context of a medical home and preparing patients to auto-enroll in coverage.
  • Immigrant InclusionCalifornia has extended affordable health care coverage to a broader group of legally residing immigrants than what is required by federal law. California’s Medi-Cal program also includes persons residing under the color of law (PRUCOL), including those eligible for DACA (Deferred Action for Childhood Arrivals)—and now covering all California children regardless of immigration status.
  • Express Lane Eligibility. To help facilitate enrollment California identified over 600,000 adults and 150,000 children served in the CalFRESH food assistance program and made it easy for them to enroll in Medi-Cal.

Medi-Cal Turns 50…With Room to Improve

Even after 50 years, Medi-Cal is not without its challenges—for consumers and for the health care system as a whole…

  • Access to care: Medi-Cal enrollees have more difficulty seeing the doctor, especially specialists, than other Californians with job-based coverage.[i] Efforts are underway to address this problem, through better oversight of the adequacy of networks and provider directories, increased provider reimbursement rates, and improved complaint processes.
  • Managed care transition. Medi-Cal has shifted most of its consumers into managed care, shifting from a payer of claims in a fee-for-service system to contracts with managed care plans that include incentives to coordinate care effectively and requirements for adequate networks and timely access to care.
  • Restoration of medically necessary services. The final 2015-16 budget does not restore benefits eliminated in 2009, including acupuncture, audiology, chiropractic, incontinence creams & washes, optician/optical labs, podiatry & speech therapy—services that allow beneficiaries to live or work with dignity in the community.
  • California’s waiver or proposed Medicaid reforms envision a stronger safety net of health and human services for beneficiaries (“whole person care”) and the remaining uninsured.
  • #Health4All: The ACA explicitly excludes undocumented immigrants from financial help for coverage. California recently expanded state-only Medi-Cal to include kids and many of the most populous California counties serve undocumented adults in their safety nets, but too many do not. Yet, undocumented Californians are key members of our community and economy. California should build on its tradition of immigrant inclusion and fund coverage for all low-income undocumented adults (SB 10) in Medi-Cal.
  • Streamlined enrollment process. Two years into full implementation of the Affordable Care Act, the enrollment process still does not work as well as it should and particularly for those with limited English proficiency or households with mixed immigration status.

Medicare and California

California has more Medicare beneficiaries—5.6 million—than any other state and therefore more at stake in the Affordable Care Act’s many provisions to generate billions of dollars in savings for Medicare while improving care and safety for patients.[ii]