A Look Back at the Dozen Years of Implementing & Improving the Affordable Care Act, and More in CA
The last decade+ in California was built on two major events, which shaped the years ahead:
- The re-emergence of a major budget crisis in California in 2009. That year, major budget cuts triggered 10% provider rate cuts, and the elimination of dental and other benefits in Medi-Cal—benefits that took ten years to be restored.
- The passage and enactment of the Patient Protection and Affordable Care Act in 2010, with leadership from President Obama, and many California Congressional leaders (including Speaker Nancy Pelosi, key committee chairs Waxman, Miller, and Stark, and many others). Since then, California’s actions to implement and improve upon the ACA has lead to cutting the uninsured rate in half, the biggest reduction of all 50 states.
Here is a timeline of health reform in California since the passage of the ACA in 2010:
California passes key bills to adopt many of the consumer protections in the Affordable Care Act, including:
- AB 1602 (Perez) & SB 900 (Alquist) establish first-in-the-nation post-reform Health Benefits Exchange.
- SB 1163 (Leno) institutes rate review in California.
- AB 2244 (Feuer) ensures access & affordability for coverage for children with pre-existing conditions.
- AB 2345 (De La Torre) requires coverage of preventive services; AB 2470 (De La Torre) prevents rescissions.
- AB 342 (Price) allows young people to stay on parents’ coverage until age 26.
- SB51 (Alquist) requires medical loss ratio and outlaws annual and lifetime limits.
Also: AB 1503 (Lieu) bill passes to protect uninsured from ER doctor overcharges.
Governor Jerry Brown elected. California voters also approve Prop. 25, to pass state budgets by a simple majority, rather than 66% ending the years of late budgets and brinksmanship.
While dealing with another massive budget deficit, newly elected Governor Brown continues California implementation of health reform, with bills on improving consumer assistance SB 922 (Monning), streamlining eligibility and enrollment AB 1296 (Bonilla), and instituting the medical loss ratio SB 51 (Alquist).
California passes SB 222 (Evans/Alquist) and AB 210 (Hernandez), a long-sought mandate to require maternity coverage in all plans, 18 months earlier than required under the federal law’s essential benefit protections.
Governor Brown signs more bills implementing the Affordable Care Act, including ones setting standards for essential health benefits, AB 1453 (Monning) & SB 951 (Hernandez), the new rules for small group coverage AB 1083 (Monning), and new notice for coverage options during life changes AB 792 (Bonilla).
Over 50 counties start Low-Income Health Programs (LIHPs), enrolling over 550,000 Californians—most of the early Medicaid expansions nationally.
Prop. 30, an upper income tax increase, passes, which along with previous steep budget cuts and a recovering economy, promises to end a decade of budget deficits and crises.
President Obama re-elected, with Democrats gaining seats in the U.S. House & Senate, continuing implementation of the Affordable Care Act, which is upheld by the Supreme Court.
In special legislative session, California officially implements and improves upon the ACA’s major planks, including instituting individual insurance market reforms such as the ban on pre-existing conditions AB1x2 (Pan) & SB1x2 (Hernandez), and the Medi-Cal expansion, AB1x1 (Perez) & SB1x1 (Hernandez/Steinberg).
Adult dental benefits partially restored in the state budget.
California begins its implementation of the ACA, launching coverage through Covered California and the Medi-Cal expansion; new consumer protections and market rules also take effect. Millions of Californians gain coverage.
Through SB 964 (Hernandez), California requires annual surveys of health plan network adequacy and timely access.
Governor Jerry Brown is re-elected.
California takes steps to #Health4All, the effort to include undocumented immigrants in our health system:
- Expansion of Medi-Cal coverage for all children regardless of immigration status, SB 4 (Lara)/AB 75.
- Sought a waiver to open up Covered California, SB 10 (Lara)
- Multiple counties expand eligibility for safety-net services, growing from 9 to 47 counties, including Sacramento, Contra Costa, Monterey, and CMSP.
The Legislature passes new protections against unfair health care costs, sponsored by Health Access, including:
- Protections against surprise medical bills, AB 72 (Bonta, Wood, et. al.)
- Caps on extreme prescription drug cost-sharing, AB 339 (Gordon)
- Prohibition on “junk” employer-based coverage, AB 2088 (R. Hernandez)
- Requirement on accurate & updated provider directories, SB 137 (Ed Hernandez)
- Notice of unreasonable rate increases and opportunity to shop around, SB 908 (Ed Hernandez).
Improvements in Medi-Cal include a new “Medi-Cal 2020” waiver, a revamped MCO tax, and key investments, including the limiting of estate recovery.
In special session, the Legislature passes the strongest tobacco control package in a generation, raising the smoking age to 21 and regulating e-cigarettes.
California voters support new revenues by wide margins, including Prop. 55 (upper-income tax extension) and Prop. 56 (tobacco tax).
Donald Trump is elected President.
GOP control of the White House and Congress threatens the progress made and the coverage provided for millions under Medicaid, Medicare, and the Affordable Care Act. Yet after multiple attempts at ACA repeal and Medicaid cuts and caps, these core health programs largely survive the year due to massive resistance, including in California.
California continues to see a reduction in the uninsured to 7%, despite federal administrative attacks on the ACA, due to state counter-actions by Covered California and the Legislature, such as AB 156 (Wood) on a full three-month open enrollment, and SB 133 (Hernandez) to ensure patients continuity of care when insurers withdraw from a market.
Dental and vision coverage in Medi-Cal are fully restored in the state budget, along with provide rate supplements from tobacco tax funds.
California passed landmark legislation on prescription drug price transparency, SB 17 (Hernandez).
California continued to take action to stop sabotage of the ACA, with legislation to ban junk coverage, including substandard “short term” plans, AB 910 (Hernandez) and limited association health plans, AB 1375 (Hernandez).
California placed greater oversight on the industry, including:
- Stronger review of health plan mergers, AB 595 (Wood).
- Ensuring the $250 cap on co-pays, AB 1021 (Weiner).
- Ensuring 80% of premiums are spent on patient care, AB 2499 (Arambula).
- Regulating pharmaceutical benefit managers (PBMs), AB 315 (Wood).
2018 elections change the health policy landscape:
- Federally, Californians vote out 7 members of Congress that voted for ACA repeal—half of the state’s Republican caucus. The election of California’s Nancy Pelosi to Speaker ends the threat of Congressional attacks on the ACA and Medicaid.
- Governor Gavin Newsom is elected.
California took first-in-the-nation steps to expand coverage, access and affordability, including:
- New state subsidies to provide additional affordability assistance in Covered California, both for lower-income and middle-class consumers beyond the ACA threshold of four times the poverty level.
- Medi-Cal expansions for all income-eligible young adults, regardless of immigration status.
- Other improvements in Medi-Cal to restore benefits, keep seniors and people with disabilities covered; improved quality standards and integration efforts, and increase screening for adverse childhood events led by a new Surgeon General.
California took steps to further control costs, include
- Expanding and enhancing rate review of health premiums for large purchasers, AB 731 (Kalra).
- Efforts to lower prescription drug pricing, including protections against “pay for delay” policies through AB 824 (Wood), and the starting of Medi-Cal Rx and a state prescription drug purchasing pool.
- A settlement with Sutter Health prohibiting future anti-competitive contracting and pricing practices.
A global pandemic necessitated a broad range of state and federal public health responses, such as new efforts to for no-cost testing and treatment for COVID-19 through private coverage and Medi-Cal, including for the uninsured and underinsured. During this public health emergency, the ACA’s coverage expansions became an essential safety-net to keep Californians covered, even as many lost employer-based coverage. California implemented its additional affordability assistance in Covered California and the Medi-Cal expansions for all income-eligible young adults, regardless of immigration status, and rejected budget pressure to roll back benefits.
The federal “No Surprises Act” passes, providing a comprehensive national solution to surprise medical bills from doctors and hospitals, largely based on California’s AB 72 from 2016.
State legislative advances included the introduction of “CalAIM” reforms and recontracting in Medi-Cal, and:
- Authorizing the state to contract to manufacture generic drugs, under a “Cal Rx” label, SB 852 (Pan)
- Expanding “mental health parity” and the treatments that insurers must cover, SB 855 (Wiener)
With the swearing in of President Joe Biden and Vice President Kamala Harris, and later former CA Attorney General Xavier Becerra as HHS Secretary, a new pandemic response begins, including the American Rescue Plan, which created new federal subsidies in 2021 and 2022 to provide additional financial help, so nobody of any income has to spend more than 8.5% of the income on premiums in Covered California.
At the state level, Governor Newsom and the Legislature agreed to expand Medi-Cal for all income-eligible older adults 50 years old or more, regardless of immigration status, (Arambula, Durazo)
- Other improvements in Medi-Cal included improved benefits for pregnant people and eliminating the “asset test” that restricting eligibility for seniors and people with disabilities.
- Other efforts include requiring insurers to help patients track their out-of-pocket spending (SB 368 Limon), to improve timely access to mental health (SB 221 Weiner), and allow individuals to put their dependents on their coverage (AB 570 Santiago).
Governor Newsom proposes to fully remove the exclusion of Medi-Cal based on immigration status, extending coverage to another 700,000 Californians. Other budget investments proposed include:
- A commitment to build on federal funds to reduce cost-sharing in Covered California.
- The elimination of premiums in Medi-Cal for over 500,000 children and others.
- The creation of an Office of Health Care Affordability to set enforceable cost growth targets.
California takes steps to hold health plans accountable for improved quality and equity, as a purchaser and regulator:
- At Medi-Cal, a once-in-a-generation reprocurement process established a new contract for all managed care plans with higher expectations for transparency, benefits, quality standards, and coordination.
- At Covered California, a new model contract was adopted to require improvements in four key areas, with accountability that could result in penalties or removal.
- At the Department of Managed Health Care, new regulations are in process would require quality and equity standards for commercial health plans.