The Very Best (Unsung) Achievement of the ACA in California

From our colleague Elizabeth Abbott, director of administrative advocacy for Health Access, reporting from the Medicaid Stakeholders Advisory Committee last Friday: 

All of us have spent considerable time following the progress of establishing the state-based exchange in California, from its marketing and outreach efforts, plan contracting, negotiating rates, consumer protections, and the set-up of the exchange’s infrastructure.  The ACA envisioned that the individual market would no longer underwrite consumers (price their insurance coverage or access to it at all) based on their health status, or offer products resembling “junk insurance.”  We have compared California’s insurance marketplace to the Wild, Wild West to a remarkable degree.  The Exchange has been referred to as “the bright, shiny, new object” that it has captured everyone’s attention.   Health Access too is  applauding their efforts and success (and providing criticism where appropriate.)

However, we could easily argue that an equally significant achievement (maybe even better!) is the Medicaid Expansion under the ACA. Last year, the Governor and the Legislature accepted the provision of the ACA that permits the state to expand our program for low-income Californians.  It provides a streamlined process that differ from the pre-ACA rules which had certain limitations on who could qualify based on specific categories of benefits. And maybe even the best part is that the federal government picks up the entire cost for this expansion of Medi-Cal for the first three years!  As a result of this expansion, the Department of Health Care Services (DHCS) estimates that before the end of 2014, they will have more than 10 million consumers enrolled in Medi-Cal, up from their pre-ACA enrollment of 7-8 million.

How did they do it?  At the urging of Health Access and many of our allies, California took an aggressive approach of preparing for the start of the ACA and organizing the transition of eligible people into Medi-Cal “to be ready to go on Day 1.”  The following are specific actions undertaken by the state in one of the most active efforts of any state in the country to find and sign-up eligible Californians. (Unbelievably, some states decided not to take any advantage of this provision of the ACA, which left thousands, even hundreds of thousands of people uninsured through public or private programs in those states.)  The numbers shown in parenthesis after the specific action shown below are the number of consumers so far added to the Medi-Cal program under each provision:

  • CA entered into an agreement with the federal government to expand the counties’ Low Income Health Programs (LIHPs) as part of a waiver of strict Medi-Cal rules to enroll people in the county health program and then convert them to Medi-Cal effective January 1, 2014.  (+652,000)
  • CA ran a computer cross-check to find any people who were already qualified for food stamps (the Cal-Fresh or SNAP program) who did not have health insurance, identified over 600,000 adults and 150,000 children, and contacted them to see if they wanted to enroll in Medi-Cal.  If these already qualified low income beneficiaries elected the health coverage, they could sign-up using a simplified and expedited process.  (+65,000 so far)
  • CA collaborated with our exchange to make sure people who called Covered CA who appeared to be eligible for Medi-Cal under the new ACA rules were referred immediately to their county of residence to determine eligibility and be signed up.  (+877,000)
  • CA expedited state systems processing for people who applied for Medi-Cal in the counties to be enrolled in the program quickly and easily.  (+106,000)

These are only the interim numbers of newly eligible people and undoubtedly will increase as 2014 progresses.  The Department of Health Care Services, the agency that administers the Medi-Cal program [and many other services], is also incorporating new, streamlined and/or expanded benefits for mental health and substance use to better serve consumers.  They are also undertaking pilot programs for Dual Eligibles (people entitled to Medicare and Medi-Cal) to move them into coordinated care programs with the stated objective of achieving better health outcomes and reducing costs.  This is based on an increasing recognition that consumers with unmet behavioral health needs complicate the delivery of services and greatly increase costs.

This level of change includes adding new beneficiaries, expanding services offered, and modifying the methodology of delivering that care is a huge shift for the state.  It is essential that all stakeholders stay focused on these processes—and outcomes—to assure that the desired results are achieved.   DHCS has for several years convened a Stakeholders’ Advisory Group to advise the department regarding all aspects of this change—and to give them their perspective from their work in the field.  This Stakeholders Advisory Group has assumed even more importance.  The last meeting of that Advisory Group took place last Friday before a public audience, and the department got an earful from health plans, providers, counties, doctors, hospitals, and consumer advocates regarding what they thought was working—and what was not.  Our Executive Director, Anthony Wright, and senior leadership of other consumer organizations regularly participate in these stakeholders’ meetings.

We should remember that we all have a stake in the outcome of these changes, whether we have health insurance or not.  We urge you too to stay engaged in this process.