“Medicare for All,” the political dream of extending federal health program for the elderly and disabled to all Americans, still gets the headlines. But here in the nation’s most populous state, it is Medicaid—or Medi-Cal, as the federal health program for the poor is called in California—that comes closest to providing a universal safety net. Medi-Cal deserves more attention now because its no-or-low-cost health services provide a vital backstop in this time of pandemic and freefalling employment, and because it holds possibilities that have yet to be realized.

Medi-Cal spending, which comes mostly from federal funds, has grown rapidly over the past decade. And this past week, even as the governor and legislature agreed on a state budget with plenty of cuts, Medi-Cal kept on growing. Overall spending on Medi-Cal is budgeted for a 12 percent increase in 2020-21, to more than $110 billion. This increase covers surging enrollment—the governor’s office has estimated an additional 2 million people will join Medi-Cal this year after losing jobs or insurance.

Medi-Cal now is the most important anti-poverty program in a state with persistently high poverty rates. An estimated 14.5 million Californians—more than one-third of us—will be on Medi-Cal by summer’s end, double the number in 2010. Medi-Cal has been woven into the fabric of our lives, from infancy to near-death. Roughly half of California children are on Medi-Cal. So are some two-thirds of our nursing home residents. And if the current economic collapse becomes a long-term depression, millions more Californians will end up depending on Medi-Cal for our healthcare, too.

Medi-Cal’s rapid expansion into a safety net for all Californians represents triumph, trouble—and opportunity.

The triumph belongs to the Affordable Care Act, also known as Obamacare. Before that law passed in 2010, Medicaid, originally an after-thought in the 1965 federal law that established Medicare, covered only certain categories of poor adults—like parents with children, or people with certain conditions. But Obamacare funds states to open Medicaid eligibility to virtually all low-income adults under 138 percent of the poverty line—about $17,600 for an individual, or $36,000 for a family of four. No state embraced Obamacare’s Medicaid expansion more fiercely than California, which even covered income-eligible children and young adults (up to age 26) who had been excluded from the federal program due to their immigration status.

This expansion, combined with the establishment of exchanges for purchasing insurance, got results: the percentage of uninsured Californians dropped from 18 percent to 7 percent over the last decade. The impact of this shift is visible in poorer places like the San Joaquin Valley, where Medi-Cal expansion, and the money it brought into healthcare, produced a surge of new clinics and health facilities. (Staffing such places, however, remains a challenge.)

But that expansion caused trouble—the program struggled to keep up with the needs of all the new enrollees. While millions now may be protected from financial ruin if they get sick because Medi-Cal is paying the bills, Medi-Cal does not guarantee them high-quality healthcare.

The obstacles lie in the way care is disbursed. In California, more than 80 percent of people on Medi-Cal are enrolled in managed care organizations, which are paid by the state to provide enrollees with care. And managed care is not performing as well as it should. A 2019 report on Medi-Cal managed care plans found that the quality of their care declined or stayed flat on most measures between 2009 and 2018, according to the California Health Care Foundation. The same study showed declines in two-thirds of measures involving healthcare for children.

Improving quality is difficult because Medi-Cal mirrors the complexity of the state. Though Medi-Cal is a federal program overseen by the state, the managed care plans operate at the county level. Depending upon the county they live in, Californians on Medi-Cal are offered different plans from different entities. Some counties have just one publicly managed plan; other counties have the “two-plan” model, with a public and a commercial option; and other counties, notably San Diego, offer multiple commercial choices.

So if you’re on Medi-Cal, your experience varies depending on your plan and where you live. You’re more likely to get the care you need in Yolo County, which has just one plan, the well-regarded Partnership Health Plan, than next door in Sacramento County, which has a confusing array of commercial plans. Health plan management can differ widely within regions. In Southern California, Orange County’s CalOptima is still associated with scandals in the past decade. But Inland Empire Health Plan, serving Riverside and San Bernardino counties, is considered a model.

These Medi-Cal challenges represent an opportunity. Before the pandemic hit, 2020 looked like the year the state was going to improve the program. Health advocates were pushing to raise the state’s standards for the Medi-Cal managed care plans, so that they would have to show continuous improvement in the health outcomes of their customers. Children’s advocates were working to make Medi-Cal better for kids.

And earlier this year, the governor was pursuing a highly ambitious set of proposals called CalAIM (for California Advancing and Innovating Medi-Cal). The proposals involved using Medi-Cal more broadly to help the most vulnerable Californians—particularly people who are homeless and those caught up in the justice system—with their most difficult challenges, from mental health to housing. At the same time, CalAIM proposed to simplify the complex Medi-Cal program, with the goal of producing better health outcomes for more people.

But now, with the state’s health bureaucracy consumed by COVID, CalAIM is on hold. So is a proposed expansion of Medi-Cal to cover senior citizens who are undocumented.

In this pullback you can see the shadow of political reality: Medi-Cal, as part of a federal program, remains vulnerable to the national partisan struggle over healthcare. Congressional Republicans still seek cuts in Medicaid, and the Trump administration remains committed to overturning Obamacare through legal challenges and regulatory changes. What’s more, if Congress doesn’t produce more aid for California, it could force future cuts in payments to Medi-Cal providers.

Nevertheless, the program seems poised to keep growing because the need is so great. Payments to managed care plans should be tied to measures of access, quality of care, and patient outcomes. And California must train more and better healthcare workers if quality is going to improve. Medi-Cal is such a big part of California healthcare that improvements to the program could benefit the whole system.

Starting today, Californians—especially those of you who get health insurance from your employers—should demand that the state do better by Medi-Cal. Because the way the world is going, you’ll need Medi-Cal before you know it.

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Desert Healthcare District ACA campaign manager Samantha Prior, who works on enrollment in the Coachella Valley, said that in the first open enrollment period, large community events did not work well. So this time around, they’re going out to apartment complexes, community centers, mobile home parks, and hospitals to inform people of their options.

A lack of public transportation was an issue in the Desert Healthcare District, but other parts of the Inland Empire had other problems to contend with. Inland Empire Economic Partnership president and CEO Paul Granillo said it’s important to remember that Riverside and San Bernardino counties have a combined population of 4.3 million people. If the Inland Empire were a state, it would be the 26th largest in the country (just 70,000 people shy of Kentucky). It’s a mix of urban centers (Ontario, San Bernardino, Riverside) and more rural areas like Temecula and the High Desert. “If you’re going to paint your house, you’ve got to measure it and figure out how much paint you need,” said Granillo. “With the ACA and other initiatives, there’s always a failure to take into account the size and complexity of the region.”

Julie Marquis, senior editor at Kaiser Health News and the panel’s moderator, said the region’s diversity is part of this complexity: The Inland Empire’s population is close to 50 percent Latino, 7 percent African-American, and has a growing Asian population as well. What, she asked, is the healthcare literacy of these groups?

Granillo said that it’s impossible to lump these groups together. There are 2 million Latinos in the region (the fourth-largest concentration in the nation) for instance, and just 18 percent of them are newly arrived. There are also generational divides. An older generation went to work at the steel mill and received insurance on their first day on the job. “You didn’t have to worry about it,” he said. “It was part of the package. That has changed.”

Marci Aguirre, director of community outreach for the Inland Empire Health Plan, which serves low-income patients on Medi-Cal, said the region’s undocumented and newly arrived immigrants have faced a particular set of challenges. Language was a barrier—particularly because Spanish-speaking enrollers were extremely scarce in the first open enrollment period. Another barrier was fear and confusion over who was eligible in mixed-status families with documented children and undocumented parents. She said that a number of people who lacked green cards or even documentation (under deferred action, for instance) were eligible to enroll but didn’t know it.

Marquis asked the panelists if the region’s healthcare infrastructure is keeping up with the growing insured population.

Granillo said that keeping up with the region’s growth—as well as the growing poverty rate—is a challenge, period. “We are under-doctored and under-nursed and under-hospitaled,” he said.

Aguirre said that the Inland Empire Health Plan has been growing its network of doctors and healthcare providers since before the ACA was implemented. “We don’t turn doctors away who want to be part of the network,” she said. The plan recruits, too: They’re offering grants to doctors to move their practices, or a portion of their practices, to the region.

Medi-Cal, said Marquis, is not popular among physicians because it doesn’t pay very much. How do you entice doctors to serve low-income patients?

Aguirre said that the Inland Empire Health Plan pays physicians in high-need specialties above the Medi-Cal rate when necessary. And Prior said that the Federally Qualified Health Clinics in her district get reimbursed slightly above Medi-Cal rates as well. This is a statewide issue and not unique to the Inland Empire, said Aguirre.

The region is also trying to create a pipeline of homegrown doctors through UC Riverside’s new medical school. There are a number of new loan forgiveness and tuition reimbursement programs for doctors who stay local for a certain period of time after graduating, said Aguirre.

A key element of the ACA is shifting the burden of healthcare from high-cost emergency room visits to preventative care. Marquis asked the panelists to talk about the demand for such services from people with chronic conditions that are prevalent in the region, like asthma.

Prior and Aguirre both said that educating people on the resources available to them is hugely important. Prior said that homeless people now qualify for free preventative care, and her district has been trying to spread the word about this increased access.

Aguirre said that a new program that offers home visits to families who visit to the emergency room frequently for non-emergencies has been very successful. People don’t realize they have options beyond their primary care physician or the emergency room—from urgent care to a 24-hour nurse care line. Even offering advice as simple as writing down your questions for the doctor before going into an appointment can help people learn more about their health issues.

In the question-and-answer session, an audience member asked the panel how they get past the complexity of the ACA to educate regular people.

Prior said that partnerships with neighborhood groups and nonprofits have been key. These groups are already in schools, in churches, in community centers; they’re holding events in the evenings and putting out information in the newsletters people already receive.

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I grew up in Grand Terrace in San Bernardino County and have been working since I was 16 years old, often in customer service jobs. I’ve had my ups and downs at work and in life, particularly since the big recession hit. I moved back in with my parents, who live in Riverside, in 2010. But I never much worried about health insurance. I’m still young–I’m 30–and I’ve never been seriously ill or injured. I don’t have a wife or kids.

But in the last couple years, my chronic childhood asthma has returned with the vengeance. It’s a terrible feeling. My lungs get inflamed and constricted, and my breathing becomes labored. When I lost that job, I took some solace in the fact that my timing might be good. Obamacare would be starting soon, with sign-ups in the fall of 2013.

That didn’t mean I was stoked about the idea. I’m a libertarian, and I’m not a fan of President Obama in general, or his health plan. But I needed the care. So I went to the Covered California website, which I’d learned about from TV ads.

I found the website a little bit confusing, but I eventually figured out how to sign up for a Bronze plan. That is the cheapest kind of plan, though Bronze plans often have high deductibles. I thought I was done, but I wasn’t. Months went by and I never received a confirmation from Covered California. I wondered what had happened.

The answer came in the mail. Covered California sent me a letter saying that I wasn’t eligible to sign up for one of their plans–I didn’t make enough money. That rejection surprised me; I didn’t know that your income could be too low. But it’s true that I didn’t have a lot of money. My unemployment payments, which I hadn’t included on the form, had run out. My only income at that time was from a part-time gig playing guitar at my church.

Instead, the letter (and subsequent rejection letters) would inform me, I was eligible for Medi-Cal, California’s version of Medicaid, the federal program to cover the poor. I wasn’t happy about this, but I had no choice: I needed some coverage because of my potentially life-threatening condition. So I had to go to another website and apply for Medi-Cal, and received a package in return asking me to pick a plan within Medi-Cal. But before I could choose, I was automatically put on the Inland Empire Health Plan.

The hard part was trying to get health care with my Medi-Cal plan. Making an appointment to see a doctor who could renew my prescription for asthma drugs and inhaler was incredibly difficult. The only appointment at first was two months out. Then, the day before, the doctor’s office called to cancel. I rescheduled again for another month or so out—and the clerk called again to cancel.

At that point, I got very persistent and demanded an appointment immediately. I told them I wasn’t taking no for an answer. I knew that if I had nothing to stop an asthma attack, I could die. I had been borrowing the inhalers of a couple of friends to get by and they might not be around the next time an attack came on.

Eventually, after many calls (and after another patient canceled, creating an opening), I got an appointment at the regional health center in Riverside, just off Indiana Avenue, not far from where I live. The doctors there would take my IEHP coverage. It was an eye-opening experience. The place was jammed, and people were waiting for hours for a doctor. It took me three hours to get seen by a doctor, even though I was an easy case. My asthma didn’t need to be diagnosed, and all I really needed was an inhaler.

The outcome, however, was less than optimal. I had previously used a ProAir inhaler, which uses the drug albuterol sulfate, which has been very effective in controlling my asthma. But under the new health plan, they switched me to a different inhaler with a drug, Ventolin, that doesn’t give me the same strong relief. (It doesn’t help that the Ventolin cartridge is twice as big). I only learned about the switch at my local CVS pharmacy when I tried to fill the prescription. When I asked about the switch, I was told that I didn’t have a choice. Ventolin was what IHEP covered.

I’m not sure what I’d do if I had to continue on the Medi-Cal health plan with IHEP. The good news is: I don’t have to. I just got a full-time job and soon will be eligible for benefits again. I’m thankful I won’t have to be one of people in line again, waiting hours to be seen, mired in red tape, and worried about taking my next breath.

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Have these promises been kept? And has one of the most highly touted promises of this sweeping healthcare reform—that it would give consumers more choices—been fulfilled? The answers to both these questions are complicated, said a panel of industry insiders at an event co-presented by The California Wellness Foundation at the University of California Center Sacramento. As the second open enrollment period begins, people in the Sacramento region have more access to healthcare and in some ways more options than ever before, the panelists agreed. But the ACA is not an unqualified success.

Garry Maisel, the CEO of Western Health Advantage, a regional HMO based in Sacramento, said that the ACA has benefited people with preexisting conditions unequivocally. They went “from no access to guaranteed access” to healthcare, he said. But other consumers saw their choices limited by Obamacare. A number of large insurance plans—UnitedHealth, Signa, and Aetna—opted not to participate in the state-run market. There are now fewer choices in benefit designs—not as many different deductibles and co-pay structures—than there were in the past. And, a number of insurance plans joined California’s exchange but narrowed their networks of providers.

Western Health is not one of them, said Maisel. If you buy insurance with Western Health through Covered California, you get access to their full network of healthcare providers. That network was considered narrow in the past—but now Western Health offers one of the broadest networks in the region.

Covered California, in trying to get the best deal for consumers, “drove a very hard bargain” for health insurance plans, said Health Access lobbyist Beth Capell. Narrowing networks has allowed insurance companies to control costs.

Bay Area Council policy advisor Micah Weinberg said that in the past, innovative benefit design “hid a lot of non-transparent monkey business” that kept consumers from understanding how much healthcare actually cost, and who was paying for what. Now, however, that’s being eliminated, and the ACA is creating an incentive for providers to worry about the cost of their services.

Transparency remains an issue in other areas, said Maisel. Covered California doesn’t tell people shopping for healthcare plans what providers are in each network—and neither do many healthcare plans. Some plans, he said, neglect to update the information on their websites about the doctors and hospitals in their networks. And there’s no regulation to force them to provide this information. Even if you know the doctor you want to continue seeing, her office may not be able to provide that information. A doctor can apply to join a network—but the insurance company may not accept the application, and may not let the doctor know she’s been rejected.

Some of the confusion over whether or not the ACA has fulfilled its promises is due to flawed messaging about the law and our public dialogue.

Weinberg said that one problem with our conversations around the ACA is that “major policy changes have tradeoffs, and no one’s willing to talk about” them. Politicians on both the right and left like to say that a policy is going to make things better for everyone, said Weinberg. But that rarely turns out to be true.

“Ask Emily” columnist and healthcare reporter Emily Bazar, the panel’s moderator, added that both President Barack Obama and Peter Lee, the executive director of Covered California, promised that people could keep their plans and doctors after ACA implementation. They also promised that shopping for healthcare would be simple. Some people, however, have had to switch plans and doctors. And shopping for healthcare is a complicated process.

Capell said that people who work on healthcare policy were “taken by surprise” by how hard it was for people to shop for healthcare on the new exchanges. But when you take a step back, it makes sense: Health insurance is the second-most expensive purchase many of us make, after buying a car.

So what information should consumers use to make this important decision? It’s not just about the cost of premiums, cautioned Weinberg. If you decide to switch plans because one is $5 cheaper than another—as you would when buying a product online, say—you’re making a mistake. A new, cheaper plan often has a narrow network that may not include doctors you have seen for years. Building new relationships with doctors means scheduling more appointments and more tests—expenses that add up. Switching care providers is also bad for your health, particularly for if you suffer from chronic conditions.

Capell said that a particular plan might seem like a great deal when you buy coverage on the cheap—until you end up on the hook for the entire cost of a doctor’s appointment or prescription. Covered California, she said, is looking at how to redesign costs so that consumers can better understand what they’ll actually have to pay.

For now, though, the new healthcare landscape remains difficult to navigate for consumers. Bazar said that going into this new enrollment period, the best things Californians can do are avoid the Covered California website—which remains full of glitches—at all costs, and get help from expert assisters. Certified enrollment counselors, insurance agents, and health plan member services can help consumers navigate the process of enrolling free of charge.

In the audience question-and-answer session, the panelists were asked if there are enough of these assisters in the Sacramento area.

Weinberg said that in terms of quantity, there are plenty of people available to help you buy insurance. But their quality is inconsistent. “The program you have to go through to sell Covered California is not a Ph.D. program,” he said. “But to understand this stuff you need five to six years of being steeped in it.” He said that if you’re talking to someone who seems as if he doesn’t know what he’s talking about—he probably doesn’t know what he’s talking about.

Another audience member asked the panel to talk more broadly about the ACA and choice. What kind of choices has this law given people not just in terms of doctors and providers but also in their lives and careers?

Capell said that the ACA is a wonderful opportunity for people to leave jobs they’ve stayed in for the benefits in order to start small businesses or go back to school. If you lost your coverage because of a job change or a divorce, “the world is a better place for you” now, she said.

The post Has the Affordable Care Act Fulfilled Its Promises? appeared first on Zócalo Public Square.

But as healthcare in California becomes part of something very big, what happens to smaller, local plans and providers across the state? In cities from Sacramento to San Luis Obispo, doctors, insurance companies, and patients are all trying to strike a delicate balance between the benefits of a bigger healthcare system and the very particular needs of local communities throughout California.

In advance of the Zócalo/The California Wellness Foundation event “Does Obamacare Give Sacramento More Choices?”, we asked policymakers, journalists, and scholars of healthcare: What role is there for local health plans and providers in post-Obamacare California?

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Hernández, who worked to launch and implement Healthy San Francisco as CEO of the San Francisco Foundation, pointed to three aspects of the program that made it a success. First, all of the players were at the table when Healthy San Francisco was built—not just the advocates or the payers but everyone, from major hospital systems to small businesses. Second, their goal was clear: Everybody “would enroll in a very simple process that would give them a medical home.” That meant having a primary care doctor, or a place to go for preventive care and to manage chronic diseases outside hospitals and emergency rooms. The third key to the program’s success was that everyone had to pay into the system in some way.

Has paying for Healthy San Francisco been an onerous burden on businesses? Healthy San Francisco and the San Francisco Health Care Security Ordinance required employers with a minimum of 20 employees to spend money on healthcare coverage for anyone working as few as two hours per week. The local restaurants that Deisy Bach works with raised a number of questions about that requirement. The city of San Francisco is surrounded by cities with lots of businesses that don’t have the same expenses, she said. On top of that, the restaurant industry is seasonal; as a result, the administrative costs of dealing with high levels of turnover are heavier.

However, said Hernández, it’s important to remember: “Small businesses want their employees to have access to care and ultimately have insurance.” Businesses don’t want an uninsured workplace; they’re concerned about how to pay for an insured workplace and how to comply with laws.

San Francisco Business Times reporter Chris Rauber, the evening’s moderator, asked Tangerine Brigham for her take on the big question of the night—lessons that can be drawn from San Francisco in the national implementation of the Affordable Care Act (ACA).

Brigham said that a big difference between Healthy San Francisco and the ACA is that Healthy San Francisco did not set out to spend a lot of money on administrative and outreach costs. There wasn’t a budget for bus ads, brochures, and fliers.

“Enrollment in San Francisco was very grassroots,” said Hernández—it was about in-reach, not outreach, and utilizing clinics and systems that were already in place.

Brigham said that the goal of the program was to create a system that was simple for both individuals and providers to use. And she said that it was important in San Francisco—as it will be for the rest of the country—to collect data showing that the health status of people participating in the program improved.

Healthy San Francisco looked at emergency room utilization for the city’s uninsured population for the two years prior to the program’s start and two years after in comparison to the rest of California. “We were able to show it went down during Healthy San Francisco, and at every other public hospital, it went up,” she said. People in the program “didn’t have to go to emergency rooms. They had someone they could call, they had a card, and they used it.”

This was key to the program getting every major hospital system to participate.

Prior to Healthy San Francisco, said Hernández, uninsured patients with diseases that shouldn’t be treated in the ER were showing up in emergency rooms “and causing all kinds of diversions and clogs in that delivery system.” Plus, the hospitals weren’t getting compensated. The question of whether or not the ACA will get people care in the right place has not yet been answered, she said, adding, “having an insurance card if you can’t get in to see a provider does not solve the problem we set out to solve with Healthy San Francisco.”

What’s next for Healthy San Francisco? Rauber said that roughly half the people previously enrolled in Healthy San Francisco are expected to move to one of the new healthcare exchanges or Medi-Cal. A large number of people remaining in the program are undocumented.

Brigham said that anyone ineligible for coverage under the ACA for any reason is still able to enroll in Healthy San Francisco.

Hernández added that if you are eligible for another program, you have to go into that program instead of Healthy San Francisco.

Bach said that some San Francisco employers were paying a significant amount of money for insurance, but for a variety of reasons, their employees opted to waive coverage. They didn’t understand the program, or they didn’t trust it or want to pay anything at all. Regardless of what program is providing coverage, real change won’t come until having insurance becomes the cultural norm, she said. Only people who have worked in a professional business environment and had insurance from their employer are used to having primary care; for everyone else, going to an emergency room is still acceptable, she said.

In the question-and-answer session, an audience member asked about the number of homeless people Healthy San Francisco enrolled—and whether the ACA will offer any opportunities to get healthcare to people who don’t have food, shelter, or clothing.

Brigham said that Healthy San Francisco managed to enroll homeless people who were already going into clinics by identifying them as they came in for care. But enrolling under the ACA has been challenging: You need to apply, you need an address, and you need a telephone number—and the assumption is that you’ll have that same address and number 12 months later. Then, the question is, once you get someone in, how do you ensure that they stay in the program?

The Affordable Care Act may push the government to consider homelessness a public health issue. But, as with so many of the questions raised by healthcare reform at the national level, we’re going to have to wait for answers.

The post Obamacare, Meet Your Schoolmarm. Her Name Is Healthy San Francisco. appeared first on Zócalo Public Square.

In advance of the Zócalo/The California Wellness Foundation Event, “What Can Obamacare Learn from San Francisco?”, we asked health policy experts: Based on your experience with health reform in San Francisco, how would you improve Obamacare’s implementation?

The post Where Obamacare Isn’t a Dirty Word appeared first on Zócalo Public Square.