Author: ITUP

U.S. House of Representatives Passes Bill that Will Lead to Millions of Uninsured

On May 4, 2017, the United States (U.S.) House of Representatives passed a budget resolution, the American Health Care Act (AHCA) (H.R. 1628), as amended. AHCA passed on a party line vote, 217-213. The AHCA is intended to deliver on the Republican pledge to “repeal and replace” the ACA.

Last minute amendments added funding for states to implement high-risk pools or other similar programs along with waivers of key provisions of the Affordable Care Act (ACA). AHCA allows states to waive ACA community rating protections that ensure consumers do not pay higher premiums based on health status, ACA limits on how much more older individuals must pay and the ACA essential health benefits requirement.

The version of AHCA passed by the House has not been scored by the Congressional Budget Office (CBO) but an earlier CBO analysis found that AHCA would result in more than 24 million Americans losing health coverage.  The provisions CBO determined contributed to the loss of coverage – reductions in Medicaid funding and elimination of the penalties for individuals and employers who don’t purchase or provide health coverage – remain in the bill.

The AHCA now goes to the U.S. Senate where it will most likely undergo significant changes. See the ITUP summary of AHCA here. A new CBO analysis is expected next week.

ITUP ACA Watch, Issue 3 — The False Equivalency of High-Risk Pools to Replace the ACA

Many Republican proposals to repeal, replace or rollback the federal Affordable Care Act (ACA) reintroduce state-based high-risk pools for individuals with pre-existing and high-cost health conditions. California’s pre-ACA experience with a state high-risk pool, discussed in this issue of ACA Watch, demonstrates that high-risk pools leave individuals who, by definition, most need access to comprehensive health services, with high premiums, low benefits and insufficient access to coverage. This issue highlights why high-risk pools would also likely not preserve the ACA’s promise to cover everyone regardless of pre-existing conditions. Ultimately, high-risk pools are a false equivalency to the ACA’s comprehensive coverage framework.

Download ACA Watch, Issue 3 here.

Notes from the Field: California Legislative Hearings Put a Spotlight on the Impact of the ACA

Insure the Uninsured Project (ITUP) recently had the honor of participating in several health reform public hearings held around California. At the invitation of state elected officials, ITUP’s executive director, Deborah Kelch, testified as an independent expert on California’s success in implementing the Affordable Care Act (ACA) and the emerging threats from federal “repeal and replace” efforts. (Click here to view the slides Deborah used for her presentations.)

Following the March 6, 2017 introduction of H.R. 1628, the American Health Care Act (AHCA), ITUP’s testimony included an overview of the House Republican-sponsored bill. Since this blog was originally posted, the House passed the AHCA and sent it to the Senate for consideration. (See ITUP’s analysis of the AHCA here.)

In this ITUP blog, Deborah shares highlights and moving stories from the events she attended.


Participating in recent legislative forums on emerging threats to federal health reform not only gave me a chance to publicly highlight California’s progress under the ACA, but also the opportunity to hear the first-hand stories of individuals, providers and community members around the state.

In my decades working on state policy and legislation, I heard many stories about Californians unable to obtain coverage because of health status or inability to afford the premiums. With that as backdrop, I was profoundly moved to hear the difference the ACA made in people’s access to care and coverage. Witnesses shared story after story about how coverage under the ACA changed, and saved, lives. What I heard clarified for me the importance of protecting California’s gains and continuing to improve access, care and health in the state.

Here are a few highlights of the testimony provided by consumers.

    • A home care worker in her early 50s, and mother of seven adult children, suffers from two serious lung diseases, Pulmonary Hypertension and Chronic Obstructive Pulmonary Disease (COPD), even though she has never smoked. Doctors believe the illnesses are caused by the poor air quality in the Central Valley. Uninsured, she was without the resources to afford the treatments she needed.In January 2016, now covered by Medi-Cal, she was rushed to the emergency room with life-threatening pneumonia, received the treatment she needed to survive and maintenance medications made it possible for her to return to work. Worried that the ACA could be repealed, she discovered her regular medications would cost four thousand dollars a month, higher than her monthly income, not including the oxygen she needs twenty-four hours a day. She told members of the Senate Health Committee that “sickness has no gender, no color, no internationality.”
    • A Bakersfield resident suffering from severe mental illness was uninsured, homeless and without access to the medications that could treat his condition. Now covered under the ACA Medi-Cal expansion for adults, the symptoms of his mental illness are controlled, allowing him to begin job training and to have the hope of a productive future. He told legislators that if he were to lose coverage, and access to his medications, within two weeks he would most likely find himself confined in a mental health facility.
    • Prior to ACA implementation, a consumer on a salary of $1,640 a month, with Type 2 diabetes, paid $1,327 a month for ten medications. Now enrolled in coverage through Covered California, he pays $118 a month. He asked, “If I get the ACA taken away from me will I get an arm cut off, feet, go into a diabetic coma, lose my sight? I am working right now. Do they want me to go on disability? Or would they rather that I have health insurance so I can work?”
    • In the years leading up to passage of the ACA, a Fresno family of four, all of whom suffer from late-stage Lyme disease, had high deductibles and skyrocketing health care bills. With the economic downturn in 2008, the wife lost her job and her husband became too sick to work. The family’s health challenges launched them on a journey from an upper middle class life in Silicon Valley to homelessness and financial devastation in the Central Valley where they moved to be near relatives. The family clung to high-cost, high-deductible, COBRA coverage because it was the only option, knowing if they dropped the coverage all family members would be uninsurable because of their illness. Now covered under the ACA, the family no longer must decide between “no coverage forever or expensive nominal insurance without meaningful benefits.”
    • A San Diego resident in his 30s went without health insurance for over 10 years, paying out-of-pocket for over the counter remedies to address an episodic array of symptoms. Once insured under a Covered California health plan, his initial health screening revealed he was borderline diabetic. He believes that if he had not received timely intervention he would have died within two years.
    • When a San Diego 22-year old was diagnosed with non-Hodgkin’s lymphoma two weeks before her college graduation, she could rely on her parents’ policy under the ACA provision allowing young adults to keep parent coverage until age 26. Her mother tearfully told legislators about the challenges the family faced as their daughter navigated her illness, expressing deep gratitude that they did not have to worry about medical costs or coverage during the ordeal.

Providers throughout the state also shared the positive impacts of the ACA and the potential damage from ACA rollbacks.

    • Since 2012, Clinica Sierra Vista, a Federally Qualified Health Center (FQHC), serving uninsured and low-income patients in Fresno, Kern, and Imperial counties, experienced a reduction in the number of uninsured from 60,000 (39 percent) to 25,000 (16 percent). Clinica’s Medi-Cal population grew from 72,000 (46 percent) to 115,000 (68 percent) patients. The expansion of Medi-Cal and Covered California coverage improved the financial viability of Clinica Sierra Vista, allowing them to add staff and clinic capacity. Clinica recognizes that its current service level could not be sustained if the ACA or the Medi-Cal program are unraveled.
    • Neighborhood Healthcare, a FQHC in the San Diego area, increased its Medi-Cal enrollment by 20,000 patients. Neighborhood Healthcare’s rate of uninsured dropped from 18 percent in 2012 to 7 percent in 2016. With increases in coverage and pent-up demand from previously uninsured individuals, Neighborhood expanded clinic capacity, including extended evening and weekend hours in their Escondido clinic. Neighborhood is concerned that capping Medi-Cal federal funding would require them to cut back and reduce access for working families who benefit from being able to get health care during off hours.
    • From 2010 to 2015, California’s public health care systems expanded primary care capacity by more than 20 percent. Because of improved access to primary care, the systems also reduced the hospitalization rate of diabetes patients for short term complications by more than 20 percent. In this timeframe, public health care systems have reduced hospital acquired infections and increased patient safety. The ACA brought more stability to public health care systems and supported the shift to primary and preventive care, along with a greater focus on improved health outcomes. Repeal of the ACA would erode this progress and could result in reduced federal funding for public health care systems by as much as $2 billion and lost coverage for 560,000 patients in the systems.
    • Children’s hospitals treat California children with all types of medical conditions, including special needs children and rare conditions such as spina bifida, sickle-cell anemia or cystic fibrosis. Children with hard-to-treat rare conditions rely on the same pediatric specialists regardless of the source of coverage or payment. The stability of the regionalized network of pediatric specialists depends on both public and private payers. Stated differently, a cap on Medi-Cal federal funding does not just pose a risk for children on Medi-Cal but to all children in the state with complex medical needs.

These stories and messages tell us the real story of California’s successful implementation of the ACA and warn us about the potential impact of its repeal. ITUP will continue to highlight California’s success and analyze proposals that could reverse the state’s accomplishments. (Click here to watch the hearing videos.)

Notes from the Field: Resources

PowerPoint Presentations

ITUP Testimony Senate Health Committee 3-23-17

ITUP Testimony Assembly Health Committee 3-22-17

ITUP Testimony Senate Health Bakersfield 1-19-17

Senate Hearing Videos



San Diego

ITUP ACA Watch, Issue 2 — Congressional Budget Office Scores the American Health Care Act

The second Issue in the series provides information and analyses on the independent, nonpartisan Congressional Budget Office (CBO) review of the American Health Care Act (AHCA). The GOP proposed AHCA would dismantle significant portions of the federal Affordable Care Act. This ACA Watch describes key provisions of the AHCA and highlights the CBO’s most significant findings. Notably, CBO projects dramatic increases in the number of uninsured nationwide.

Download ACA Watch, Issue 2 here

ITUP ACA Watch — FAQs on ACA Repeal and Replace

Insure the Uninsured Project (ITUP) today launched a new publication series to be known as ACA Watch.

In the wake of the 2016 Presidential election, California’s reform progress, and progress around the country, is at risk. President-Elect Trump, and Republican members of Congress now in the majority in both houses, campaigned on a platform of repealing and replacing the ACA. It is, however, far from clear what comes next.

As the federal repeal and replace debate unfolds, ITUP’s ACA Watch will periodically highlight emerging federal proposals, Congressional and administrative actions and potential impacts for health care and health reform in California.

The first issue in the series, “An Uncertain Future for the ACA: FAQs on Repeal and Replace,” highlights the legal and administrative context for any repeal or rollback of the ACA. Given Congressional rules and federal administrative procedures, there are limits and specific requirements for pursuing repeal legislatively or through administrative action.

Download ACA Watch, Issue 1 here.



Where Should We Be Going?

The Affordable Care Act (ACA) created a hybrid with many moving parts: incorporating employer mandates, individual responsibility and refundable tax credits (shared responsibility), and a Medicaid expansion. It is unclear which parts over time will give way to others. Some predict the demise of employment-based coverage; there is no evidence that is happening.  Others predict death spirals in the individual market where only the very ill participate; there is no evidence of that either.  So far there appears to be a steady equilibrium between employment-based coverage, the Medicaid expansion, and the individual market Exchanges; employment-based coverage is holding steady while the Exchanges and Medi-Cal grow to cover the uninsured. Both the young and middle aged are participating in the Exchanges.

The ACA shifts the delivery system away from the hospital emergency room towards primary care and prevention. It builds incentives for plans and providers to improve quality and outcomes.  It creates important incentives to restrain the growth in health spending.  In the following report, we highlight where we should be going with health reform implementation and where we are at in the present.

Download the full report here: Where Should We Be Going?


California’s §1115 Waiver Renewal

California’s §1115 waiver recently expired on October 31, 2015, and HHS granted a temporary extension of the waiver until December 31, 2015.  On October 31, 2015, DHCS and CMS announced
a conceptual agreement that outlines the major components of the waiver renewal. There are several improvements in the renewed waiver, while also room to continue to improve the MediCal
program. Highlights of provisions in the new waiver, known as Medi-Cal 2020 are included in this ITUP report.

Download ITUP’s full report here:  California §1115 Waiver Renewal

10 More Reasons to Attain Health Insurance Through Covered CA

Open Enrollment closes tomorrow! For those that need a last minute nudge, here are 10 more reason why you should get covered!

1. Because you will need a Doctor’s note when you call into work sick and go fishing instead

2. In case your new belly piercing gets infected

3. Because you need glasses to watch movies on your Iphone

4. So you don’t have to make a choice between setting your broken leg or buying a new snow board after your awesome crash

5. Your asthma is keeping you from achieving the Genius Book of World Record for underwater belching

6. Because giving up your morning triple shot toasted coconut and salted caramel macchiato would make life not worth living

7. You need professional help when your friend refuses to help you put that stuff on your gnarly toenail fungus again

8. When an ambulance ride to the ER cuts into the vacation fund that you saved by eating nothing but ramen noodles (the freeze-dried kind) for the past two years

9. When you eat a habanero pepper (with seeds) that your ex-friend told you was “not hot at all” and now you have a hole in your tongue the size of a jawbreaker!!!!

10. Because all the cool kids have CoveredCA Health Insurance Cards!

The Evolving Safety Net in Southern California: Building New Models of Care for the Remaining Uninsured

Throughout the summer of 2014, ITUP met with health care leaders in Southern California to discuss caring for the remaining uninsured post-ACA implementation, building consensus and strengthening collaboration. Through one-on-one interviews with stakeholders, county-specific meetings bringing together a myriad of stakeholders, and extensive data analysis, we prepared in-depth reports on organizing care and coverage for the uninsured in Los Angeles, Orange, San Diego, Kern, Riverside, and San Bernandino counties. The project, funded by the California Wellness Foundation, resulted in a summit of key leaders from across the six counties in October.

This page is a resource for participants in the project. The documents below are password protected (participants have been emailed the password), however additional reports available to the public are forthcoming.

Summary of Ideas for Discussion

Consolidated Summary of Remaining Uninsured Meetings

Community Clinic Data

Hospital Data


Public Reports:

For a detailed overview of the remaining uninsured and policy options to cover them, see ITUP’s series on the remaining uninsured.

For information on models of financing care for the undocumented, see ITUP’s report.