Author: Jeffrey Kho

Obamacare 301: Essential Updates Before Open Enrollment

In order to prepare enrollers for the third Covered California open enrollment, which runs from November 1st, 2015 to January 31st, 2016, ITUP has prepared a presentation that outlines key aspects of ACA reforms and other important health coverage topics including:

  • Medi-Cal Expansion
  • Insurance Market Reforms
  • Essential Health Benefits
  • Covered California, California’s insurance marketplace
  • Open Enrollment
  • Individual Coverage Mandate
  • Employer Coverage Mandate
  • Standard Benefit Designs
  • Premium Assistance and Cost Sharing
  • Medi-Cal §1115 Waiver Programs
  • Drug Medi-Cal Benefit
  • Insurance Literacy
  • Care for the Remaining Uninsured

You can download the Obamacare 301 Powerpoint here.

ITUP Webinar: ACA §1332 State Innovation Waivers

The ACA §1332 Waiver provides States with an opportunity to design and implement innovative models to finance and deliver healthcare to their residents. ITUP has prepared a webinar providing an introduction to the §1332 waiver, its provisions, and the ways it could be used going forward to innovate healthcare delivery systems.

In this webinar, John Connolly outlines the ACA §1332 Waiver and discusses some innovative ways it could be used in California, including the following key topics:

  1. What is a §1332 Waiver?
  2. §1332 Waiver Requirements and Restrictions
  3. Financial Flexibility with Subsidies
  4. Mandate Waivers
  5. Broad Multi-Waiver Innovations
  6. Using a §1332 Waiver for Payment and Delivery System Reform

You may watch the webinar here on the ITUP website:

The slides used in this presentation may be downloaded here.

For further reading, ITUP’s paper, “Opportunities for California under §1332 of the Affordable Care Act,” provides a more in-depth exploration of how the §1332 Waiver could be used in California.

If you have any questions about the ACA §1332 Waiver, please email

Opportunities for California under §1332 of the Affordable Care Act

California has made great progress implementing the Affordable Care Act (ACA), with almost 4.7 million people newly enrolled in either Medi-Cal or Covered California since January 2014. The state now strives to improve the quality of care and the performance of its safety net delivery systems as it moves toward renewal of its §1115 Medicaid waiver. Beginning in 2017, the ACA offers another major opportunity for states to meet these goals with a §1332 waiver. These broad waivers would allow states the ability to waive several requirements of the ACA to create new and innovative models to improve and expand health coverage.

To create and finance a new coverage framework, a §1332 waiver would allow states to waive four major planks of the ACA:

  1. The individual mandate to have health coverage
  2. The employer mandate to offer coverage
  3. The health benefit exchanges and the essential health benefits requirement
  4. The premium and cost-sharing subsidies available through the Exchanges.

Nevertheless, the ACA requires that states’ §1332 programs would have to exceed or be comparable to the law’s standard coverage framework in the following four ways:

  1. The number of people covered
  2. The scope of health benefits
  3. Consumer affordability
  4. Containing the cost to the federal government

Read the full report, “Opportunities for California under §1332 of the Affordable Care Act,” here.

Delivery Systems and Financing Care for the Remaining Uninsured in Fresno, Imperial, Merced, Stanislaus and Tulare Counties

This paper provides an overview of the transitions that have taken place and the opportunities available throughout the health care system and insurance coverage landscape in California’s Central Valley, specifically Fresno, Merced, Stanislaus and Tulare. The paper also includes findings on Imperial County whose community demographics and health care access issues have many parallels with those in the Central Valley. The information presented is based on interviews with various stakeholders who care for the newly insured and remaining uninsured in these regions.

Read ITUP’s report on Remaining Uninsured in Stanislaus, Merced, Fresno, Tulare & Imperial Counties here.

Narrow Networks Not Necessarily an Impediment to Care

A recent study in Health Affairs finds that although health plans from California’s state-operated health exchange Covered California have narrower networks than their private commercial counterparts, they still have comparable hospital access and in some cases, higher hospital quality scores. The study assessed Covered California plans and compared them to the equivalent private plans offered by participating insurers.

The study finds that in the vast majority of California, residents had access to at least one hospital within 15 miles. On average, 92% of California residents live within 15 miles of a marketplace network hospital, compared to a plan average of 93% for a private network hospital, suggesting that marketplace and private plans have similar levels of access to care.

More surprisingly, the study also finds that marketplace plans provide access to hospitals with similar or better quality assessment scores, depending on the set of metrics used. Based on an index of 12 AHRQ-specified quality indicators, differences in hospital quality were found to be statistically insignificant. However, measures from the Leapfrog Hospital Survey pointed to a slight but statistically significant quality advantage among marketplace hospitals.

The findings suggest that despite being portrayed as a failure on the part of public exchange plans, narrow networks are not necessarily an impediment to high quality and accessible hospital care. They also shed light on the need for further discussion of measures used to assess quality of care at hospitals to ensure that metrics accurately and reliably reflect patient experiences. Nonetheless, the issue of access to care remains pertinent – while this study notes rosy statewide averages, severe provider shortages still exist in many areas across California and the United States.

The full study can be read at Health Affairs, but a subscription or one-time fee is required for access.

Assembly Bill Could Allow Nurse Practitioners to Provide Primary Care

On Thursday, May 7th, the California Senate voted 25–5–9 to pass SB 323 (Hernandez), which sets down a framework that would allow nurse practitioners to provide primary care in California. Nurse practitioners would be allowed to perform basic diagnosing and prescribing roles without direct physician oversight in settings including community clinics, IPAs and group practices.

The shortage of providers in parts of the state has been a long-standing issue, reflecting a larger trend of provider shortages in rural areas across America. The United States Department of Health and Human Services’ Health Resources and Services Administration currently designates approximately 6,100 areas as a “primary care health professional shortage area,” meaning that the physician to population ratio is 1:3,500 or higher. Nearly 40% of these areas are located in California. Proponents of the bill hope to address the persistent primary care provider shortage that has plagued these parts of the state.

The California Medical Association voiced its opposition to the bill, citing concerns about the need for oversight for nurse practitioners, who do not go through the same training required by doctors. State Senator Richard Pan (D-Sacramento) echoed their concerns, stating that the California Board of Registered Nurses was not adequately prepared to oversee diagnosis and treatment, an action typically handled by the California Medical Board which oversees doctors. State Senator Ed Hernandez, the bill’s author, noted that nurse practitioners currently play a key role in providing care for Medicaid patients, and that allowing nurse practitioners to prescribe medication has not led to an increase in medical malpractice rates. He also highlighted that 20 other states have already expanded the scope of practice for nurse practitioners, with 17 states also allowing them to prescribe medication as they can in California.

SB 323 completed its first reading before the State Assembly on May 7th, and is currently under consideration.

Governor’s Order Could Improve California’s Air Quality and Health

While great progress has been made developing a culture of health and wellness in California, access to care is only one part of a larger array of health-impacting factors. An individual’s lived-in environment contributes significantly to their wellbeing (or lack thereof). In developing a culture of health and wellness, policymakers, citizens and providers must be cognizant of the diverse factors that impact health outside of the healthcare setting, even before illness and injury.

Air quality is a particularly relevant health factor for Californians. In addition to creating unsightly smog clouds, air pollution can cause significant short-term and long-term effects. Ground-level ozone can cause throat and lung irritation, exacerbated asthma, and long-term lung damage. Particulate matter (small dust particles and liquid droplets which can penetrate the lungs) is also threatening: in addition to causing respiratory distress, they increase the mortality risk for people with lung and cardiovascular disease. The American Lung Association ranked Los Angeles the worst county in the nation for air quality based on its high levels of ground-level ozone and particulate matter.

The health impacts of air pollution are a stark reminder that health and wellness are not addressed simply by good living habits and access to care. Health and wellness require addressing the totality of factors impacting well-being. Even if an individual receives quality care for respiratory issues, their quality of life remains degraded as long as their workplace and/or home environment is contaminated with air pollutants. Ensuring health requires that these environmental factors are also addressed.

A recent executive order issued by California Governor Jerry Brown may spur progress in this front. The order requires the State to cut its greenhouse gas emissions 40% below 1990 levels by 2030, and 80% under 1990 levels by 2040. While the proposal does not directly address air pollutants such as ozone and particulate matter, it would nonetheless push for a reduction in the use of fossil fuels, which are a major contributor to air pollutants. Future proposals or legislation could go further, by mandating stringent restrictions backed by regulatory power on greenhouse gas emissions and air pollutants released into the atmosphere. As pollution becomes a bigger issue, policy makers will need to pay as much attention to environmental factors that impact health as they did to healthcare reform.

California Still Leads the Way During Special Enrollment

33,000 have enrolled during the special enrollment period.Following the creation of a special enrollment period for individuals unaware of the tax penalties for being uninsured, over 33,000 people have signed up for healthcare via Covered California.

At the end of the 2015 tax-filing season, many people learned that they would have to pay tax penalties for not having health insurance. Because the 2015 open enrollment period had already ended, a special enrollment period was created from February 23rd to April 30th. Although enrolling during this period will exempt individuals from 2015 tax penalties, they will be able to avoid receiving the harsher penalties that go into effect in 2016 ($650 or 2.5% of income, whichever is higher).

Open enrollment seems to have worked especially well in California, whose volume of special enrollees is 10 times higher than that of states under the Federal Health Exchange, which has created a similar special enrollment period. On average, each of the 36 states using the Federal Exchange had enrolled less than 2,000 each as of April 13th.

Even during the late special enrollment period, California continues to lead the nation in extending coverage to the uninsured.

If you haven’t yet signed up for coverage under Covered California, tomorrow is the last day of the open enrollment period. Except in certain cases, the next chance to get coverage will be November 15th, 2015, when the next open enrollment period begins. You can enroll here or find a Certified Enrollment Counselor who can assist you here.

2014 and 2013 Workgroups

ITUP conducts a series of regional and statewide issue workgroups every year and provides executive summaries of all proceedings in addition to compiling relevant materials for workgroup.

Below you can find all of the materials from the 2013 and 2014 Workgroups:


ITUP hosted seven regional workgroups in 2014. To find more information about these workgroups, please click here.

2014 Workgroup Materials

2014 Executive Summaries: Issue WorkgroupsBay Area Regional WorkgroupNorth Central Regional WorkgroupCentral Coast Regional WorkgroupCentral Valley Regional WorkgroupNorthern Rural Regional Workgroups


2013 Workgroup Summaries



Risks vs. Outcomes: How Does Your County Measure Up?

How healthy is your county? How many years are lost to premature deaths? How frequently are babies born underweight? Does it do better than the state average? Better than the national average?

What about wellness? Do residents have insurance? Can they find physicians when they need care? Are they able to exercise? Is the air clean? Are there resources to help individuals achieve wellness? How effective are they?

Why not check out the data on County Health Rankings? The database, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, uses 34 measures of health risk factors and outcomes to assess and rank health risk factors and performances in every state in the nation. It also allows for easy comparison of risk and performance factors in between different counties.

For example, take Los Angeles County and Imperial County. The disparity between how healthy a county is and how many challenges there are to achieving wellness can be quite striking. Imperial county is ranked last in the State of California for its health risk factors1, indicating that there are many more challenges to achieving good health outcomes than there are in Los Angeles County, which is rated 36th in the State2. The health risk factor differences are quite significant, and in some cases, seemingly impossible to overcome. In Imperial County, there are 4,537 residents per primary care physicians compared to 1,389 residents per primary care physician in Los Angeles County. Nearly a tenth of the population in Imperial County has been exposed to unsafe drinking water, as opposed to only 1% in Los Angeles.

Nonetheless, Imperial County on the whole is ranked 25th in the State for its health outcomes, ahead of Los Angeles County, ranked 26th despite having a better health risk profile. This suggests that on the whole, Imperial County consistently overcomes serious barriers to wellness. This apparent disparity between health risk factors and health outcomes suggests avenues for investigation, such as how is Imperial County improving its residents’ health outcomes, and can those measures can be replicated elsewhere in the State.

Useful insights can also be achieved even when looking at counties with similar levels of performance, as data insights can illustrate the unique challenges faced by different counties. Los Angeles County, ranked 26th in California for health outcomes and 36th for health risk factors, reports poorly on indicators such as STI occurrence, high school graduation rate, violent crime, and severe housing issues. Sutter County, ranked 27th for health outcomes and 37th for health risk factors, reports poorly on a different set of indicators such as access to exercise opportunities, unemployment, and injury deaths3. Despite the similar risk levels and health performance of the two counties, they face distinct challenges to well-being. Policy makers, community workers, managed care organizations, and local governments need to be cognizant of those unique challenges to craft well-targeted effective solutions.

By making data both easy to find and easy to use, it is in turn easier for policy makers and community workers to incorporate data-driven insights into their work, allowing them to better understand the populations they work with and develop more effective solutions to the challenges they face using the resources they have.