Author: Kiwon Yoo

2013 OSHPD Clinic and Hospital Data Summaries

The attachments below are data overviews of OSHPD’s 2013 utilization and financial data for clinics and hospitals. Providers were analyzed by region, as well as by type. For the purposes of our analyses, non-comparable facilities (Kaiser, Shriners) were excluded.

2013 Statewide Clinic Overview 2013 Statewide Clinic Overview.pdf
2013 Statewide FQHC Overview 2013 Statewide FQHC Overview.pdf
2013 Statewide Non-FQHC Overview 2013 Statewide Non-FQHC Overview.pdf
2013 Bay Area Clinic Overview 2013 Bay Area Clinic Overview.pdf
2013 Central Coast Clinic Overview 2013 Central Coast Clinic Overview.pdf
2013 Central Valley Clinic Overview 2013 Central Valley Clinic Overview.pdf
2013 North Central Clinic Overview 2013 North Central Clinic Overview.pdf
2013 North Rural Clinic Overview 2013 North Rural Clinic Overview.pdf
2013 Southern California Clinic Overview 2013 Southern California Clinic Overview.pdf
2013 Statewide Hospital Overview by Region 2013 Statewide Hospital Overview by Region.pdf
2013 Statewide Hospital Overview by Type 2013 Statewide Hospital Overview by Type.pdf

Improving the Health of People Experiencing Homelessness: Issues and Recommendations

California’s decision to expand its Medicaid program provides federal funding opportunities to improve the health of its most vulnerable residents. Individuals experiencing homelessness have much to gain from Medi-Cal coverage, particularly considering that the homeless are in poorer health than their housed counterparts. Studies show that there is great potential for public cost reductions by improving the health and well-being of the state’s homeless residents.

Homeless adults, particularly the chronically homeless, frequently suffer from a complex blend of physical and behavioral health issues that necessitate a more comprehensive coordination of care than currently exists system-wide. To truly improve the health of those who are homeless, it will be important to coordinate funding, communication, and policy priorities across different providers, as well as across departments and agencies at the city, county and state levels. We provide the following policy recommendations to help achieve this goal:

  • Acknowledge that housing is a critical component to health care, and invest in permanent supportive housing for the chronically homeless to not only improve their well being, but for documented public cost savings.
  • Improve the Medi-Cal enrollment processes to require as few client visits/follow-ups/contacts as possible. Improve CalHEERS’ intersystem functionality to properly communicate with existing county eligibility systems, and allow for managed care plan selections online.
  • Case management should be a recognized and reimbursed service in assisting individuals experiencing homelessness.
  • In the absence of developing a universal data system for housing, health, behavioral health, and substance use providers, agencies and departments must develop a means to efficiently and securely share data about homeless patients for improved coordination of care.
  • Incorporate socio-demographic factors and social determinants of health in risk adjustment and quality outcome measures. Monitor access and utilization of health care in managed care plans, particularly behavioral health services and specialty care.
  • Prevent housing instability by updating hospital and criminal justice discharge policies, and coordinating necessary housing and supportive services to young adults who were formerly in the foster care system.

The full report is available for download:

Improving the Health of People Experiencing Homelessness: Issues and Recommendations Improving the Health of People Experiencing Homelessness: Issues and Recommendations.pdf

ER Visits Slowing at LA County Public Hospitals

A recent analysis of 75 hospitals by the Los Angeles Times found that visits to Los Angeles County ERs slowed in the first three months of ACA implementation. Between January and March of 2014, ER visits by patients who didn’t require hospitalization increased 1.7% at county facilities, a slowed increase compared to 3% and 5% growths in the two years prior.

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One benefit from this is that the use of high-cost emergency care for basic medical care may be declining. By emphasizing primary and preventive care, and redirecting patients to appropriate sites of care, the intent of the health reform law is to generate system savings while improving health. While it is premature to see what the lasting effects of the ACA are on ER use, particularly considering many did not fully enroll in coverage until March and April of this year, preliminary data hints at optimistic findings.

What could this data mean?

Fewer uninsured are seeking care at emergency departments

For the most part, the uninsured seek hospital/emergency services at county facilities, so this slowing rate of ER use could be indicative of the uninsured population’s health care seeking patterns. The Times did indeed find that the number of ER patients without coverage dropped from 18% to 16% in the last year. The proportion of those with Medi-Cal coverage increased from 32% to 38% in the same period.

Many of the newly insured are choosing private hospitals over county ones

This analysis also found that thousands of patients sought care at private hospital ERs, with Long Beach Memorial Medical Center seeing one of the largest increases at 16% from a year ago (285 patients per day). Fewer patients at county ERs could ease the long waits and overcrowding that is endemic to many public hospitals.

The county is doing a better job of preventing ER use by connecting patients with primary care doctors.

Los Angeles County health officials believe part of the decline in ER use is due to the fact that Medi-Cal patients are better connected to their primary care doctors, and preventing the need for the ER in the first place. In an ideal world, this should be the largest driver of declined ER use.

We don’t really know what it means.

The first three months of data are helpful, but in light of the fact that many did not enroll in coverage until close to the deadline, this effect may not necessarily be due to coverage expansions. In addition, the state suffered under the weight of a 900,000 Medi-Cal application backlog for much of the year, delaying hundreds of thousands from receiving coverage

We still need to help our communities understand health care and how to best use it.

These results seem to contradict an earlier Oregon health study, which found that increased Medicaid coverage correlated to increased ER use. In both instances, the data are yet inconclusive, but provide clues to how our communities seek care. According to a California Hospital Medical Center official, one in five ER patients doesn’t need emergency care; it has become the only open door for the uninsured, underinsured, and those who don’t have choices when it comes to their health care.

Increased health coverage is a solid first step, but altering healthcare-seeking patterns and weaning individuals off of ER reliance will take years. Not only are continued education and awareness needed, but there are greater structural changes required to allow constrained working families seek affordable, timely and culturally competent care. These preliminary findings bode well, but continued work on optimal utilization, as well as ensuring access and affordability to health care, will be critical.

No, not that CHCF

Have you heard of the California Health Care Facility? Aside from it sharing an acronym with the California HealthCare Foundation, you may not know much about this almost-purposefully-blandly-named facility. But if you knew more about it, you may develop some strong feelings on the matter.

Some facts.

1. It is a prison facility. It is actually the largest prison medical facility in the nation, with the capacity to house 1,722 prisoners in need of medical and/or mental health treatment. After breaking ground in 2012, the facility began admitting inmates in July of 2013. During the dedication ceremony in June 2013, corrections Secretary Jeffrey Beard stated, “We are serious about the health and well-being of the inmates entrusted to us.”

2. It was built to comply with a federal court order to improve health care for inmates to constitutionally acceptable levels. By housing the sickest inmates in one facility, the aim was to save on costs while producing better results for chronically ill patients. The Department of Corrections and Rehabilitation (CDCR) touted that the facility will create 2,200 permanent jobs, with $1 billion annually in economic benefit to the region.

3. It is severely understaffed. In December 2013, an LA Times investigation found that staffing shortages were so severe that the prison was “in jeopardy of losing its operating licenses. Nevertheless, officials continued to bring more inmates to the facility.” Recently, according to a union representing psychiatric technicians, prison employees were pressured into faking suicide-watch records. Supervisors instructed employees to sign log sheets certifying that they checked on inmates in the mental health crisis unit every 12-15 minutes, even when employees could not do so due to other work that was assigned to them.

4. Within months of opening, an inmate’s calls for help were ignored by nursing staff for over 30 minutes; the inmate died from excessive bleeding. This prompted the training of nurses on the prison’s bedside call system, a basic aspect of medical care.

5. Six months after opening, inmate patient admissions were halted due to negligence, inadequate medical care, and unsanitary conditions that led to a scabies outbreak. A report on the facility, “Achieving a Constitutional Level of Medical Care in California’s Prisons,” found that it was improperly managing its supply chain or keeping up with basic medical supplies; understaffed in key administrative and clinical positions, including psychiatrists; experienced significant glitches in the electronic health record system and warehouse inventory system; and serving food that failed state health inspections. A spokesperson for CDCR said, “It’s not uncommon for new facilities to have stops and starts during the activation process.”

6. Despite federal receiver Kelso’s insistence that a medical officer be in charge of the facility, the CDCR instead appointed Ronald Rackley as warden. During a tour of the facility with the LA Times, Rackley acknowledged he “had no experience with delivering medical care, boasting that he had never been admitted to a hospital.”

7. Previously under the oversight of the CDCR, inmates statewide have received unconstitutional levels of health care due to overcrowding, leading to outbreaks of valley fever causing the death of at least 40 inmates, unauthorized sterilizations of over 150 female inmates, lawsuits for wrongful death and inadequate health care, excessive use of isolation units that have been deemed by Amnesty International to “breach international standards on human treatment,” millions spent on salaries of physicians accused of malpractice, tens of millions in waste and “unnecessary work” due to poor departmental coordination, and use of excessive force against mentally ill inmates in violation of their constitutional rights.

8. As of July 21, 2014, the California Health Care Facility has resumed admissions. The complex has the capacity to house and treat 2,951 inmates. It is currently 50.3% occupied, with 1,483 inmate-patients and inmate workers being housed at the facility.

To read more about this topic, please refer to our timeline of prison health care. You will, however, need a healthy supply of adorable animal videos to recuperate.


Even though half of the 32 World Cup finalists have already been eliminated, that will not stop this health nerd from spending too much time with the World Health Organization’s world health statistics in determining arbitrary winners and losers in cherry-picked statistics (because England is not a WHO member state, the United Kingdom’s statistics were used instead).

Highest prevalence of tobacco-smoking adults: Russia, where a whopping 59% of males (over the age of 15) and 38% of females are smokers. The 32-country average is 30.3% for men and 18.2% for women.

Most fertile women: Nigeria has the highest total fertility rate (per woman) at 6.0. Bosnia and Herzegovina, South Korea, and Portugal have the lowest rate at 1.3 children per woman.

Shortest life expectancy: Cote D’Ivoire has the shortest for both men and women, at 52 and 54 years, respectively. Switzerland had the highest male life expectancy (81 years), with Japan leading in female life expectancy (87 years). The averages are 73 (men) and 78 (women).

Lowest % of people using improved sanitation: In Ghana, only 14% of its population has regular access to improved sanitation. The average is 86%.

Skinniest male population: Only 3.9% of Cote D’Ivoire adult men (over the age of 20) are obese, with the 32-country average being 17.4%

Not-skinniest male population: The United States wins, with 30.2% of its adult men being obese.


Skinniest female population: Japan had the lowest rate of female obesity at 3.5%. Mexico had the highest, at 38.4%.

Biggest health spenders: This shouldn’t come as a surprise to many, but the U.S. wins handily, with 17.7% of its GDP being spent on health care. Algeria spent the least (4.4%).


Highest crude birth rate: The winner is Nigeria, with 41.5 births per 1,000. Germany has the lowest birth rate, at 8.4 births per 1,000.

Lowest crude death rate: Colombia had the lowest (3.9 deaths per 1,000). Russia had the highest (14.7 per 1,000), almost five times higher than Colombia’s, and almost double the 32-country average (8.2 per 1,000).

Highest per capita spending: While one might have expected the U.S. to easily win this category, the honor actually goes to Switzerland, which spends US$9,248 per capita. We come in second, at $8,467 per capita. Cameroon spends the least, at US$64.

Most cell phone subscribers: Russia wins, but that’s not the interesting part. What’s fascinating is that Russia has 183 cellphone subscribers per 100, meaning most Russians have more than one mobile phone. For reference, the U.S. has 95 subscribers per 100.

Most emotive coach: Mexico is peerless in this category.


The Tragedy of Prison Health Care in California: An Extended Timeline

While the Affordable Care Act has ensured that millions of Californians have access to affordable, quality health care, the same cannot be said for California’s prison and county jail inmates.  This timeline chronicles the fraught history of the state’s prison health care system, from 2002 to the present.

January 30, 2002
Settlement announced for Plata v. Schwarzenegger

Lawyers announce the settlement of Plata v. Schwarzenegger, the largest ever prison class-action lawsuit in which prisoners alleged that the State violated their constitutional right to medical attention, as prison officials inflicted cruel and unusual punishment by being deliberately indifferent to serious medical needs. The settlement agreement requires the Department of Corrections to completely overhaul its prison health care system. The state must phase in new policies over several years, with progress being audited by an independent medical panel.

January 3, 2003
State audit: serious problems in care

The state’s Office of the Inspector General releases an audit of the California substance Abuse Treatment Facility and State Prison in Corcoran, CA, which found “a large number of serious problems,” including “serious deficiencies in the medical care provided to inmates […], placing the health of inmates and staff at risk and exposing the State to possible legal action.”

April 6, 2004
State audit: 77% of contracting done without competitive bidding

At the request of the Joint Legislative Audit Committee, the Bureau of State Audits concludes that “Corrections does not adequately ensure that it enters into medical service contracts that are in the State’s best interest.” The audit found that in the previous five years, 77% of prison contracts for health care services were awarded without competitive bidding, with contract costs increasing by 150%. “Not only is Corrections unable to demonstrate that its contracts are in the State’s best interest, but also its prisons may be paying inappropriate and invalid medical claims.”

August 11, 2004
Federal court report: “The only requirement for hiring is a medical license”

A federal court report finds that incompetent doctors, including some with a history of substance abuse, have been hired by the state’s prison system, contributing to serious deficiencies. After conducting reviews of medical treatment at about half a dozen of the state’s 32 prisons, a panel of two doctors and a nurse practitioner concluded that the department had hired many incompetent doctors with a history of problems, and failed to monitor them: “the only requirement for hiring is a medical license.” Specific examples include:

  • “An incompetent retired cardio-thoracic surgeon manages complex internal medicine patients and makes serious life-threatening mistakes on a continual basis.”
  • Obstetricians treating HIV patients
  • Physicians who are only allowed to conduct exams while inmates are in their cells (only contact is through a 4-inch x 12-inch food port)
  • Corrections official in Sacramento who has authority over hiring physicians but is not a doctor
  • Written requests by inmates to see a doctor “had not been reviewed for months.”
  • At one facility, half of the eight doctors had prior criminal charges, loss of privileges at community hospitals, or mental health problems. At another, seven of 20 doctors had similar problems

September 22, 2004
Prison doctors will be subject to evaluations

Under a court agreement, physicians working in the state’s prison facilities by 2006 must complete a series of written and oral examinations. Doctors who do not pass the exams must be retrained or banned from working with inmates.

September 29, 2004
Los Angeles Times: Prison doctors disciplined or sued five times more than other CA physicians

Documents obtained by the Los Angeles Times shows one in five CA prison doctors has been disciplined by the state Medical Board or sued for medical malpractice, almost five times the rate for other doctors in the state.

October 5, 2004
Family of inmate who died of heart failure after wisdom tooth extraction files wrongful-death lawsuit

The family of a former Solano State Prison inmate files a wrongful-death lawsuit against Governor Arnold Schwarzenegger and two state Department of Corrections officials. Anthony Shumake, age 41, was serving a 12-year sentence for corporal injury to a spouse, stalking, and a drug offense. He died of heart failure on June 28, 2004, less than one week after a wisdom tooth extraction led to an infection and swelling in his neck that made breathing difficult. On the day Shumake died, an ambulance called to the prison arrived 90 minutes later and was sent to a hospital more than 75 miles away. A report by the ambulance company that transported Shumake said he complained that he hadn’t eaten in several days.

April 14, 2005
Expert panel finds that most deaths were preventable, records missing for 30% of inmates

A court-appointed panel of medical experts finds conditions at San Quentin State Prison to “demonstrate multiple instances of incompetence, indifference, cruelty and neglect” in providing health care to inmates. The panel was inspecting progress on the 2002 court order to provide adequate health care to inmates by 2008, found that overall compliance with the court order was “nonexistent.” After reviewing the medical records of 10 inmates who died over the last few years, the panel finds that most deaths were preventable; doctors and nurses misdiagnosed illnesses, gave patients the wrong medications, neglected them for months and even years, or delayed sending them to emergency rooms until they were fatally ill. Doctors reported that records could not be found for at least 30% of the inmates they examined.

May 29, 2005
Los Angeles Times: Scientology-linked rehabilitation programs present in prisons

A Los Angeles Times report finds that hundreds of inmates at Corcoran State Prison have participated in a rehabilitation program through Criminon International, the secular arm of the Church of Scientology, which rejects traditional mental health care, particularly psychiatry and medication as treatment options. Experts interviewed expressed concern that Criminon’s presence could undermine the ability of licensed clinicians to treat mentally ill patients. Authorities at corrections headquarters claimed to have no evidence that has occurred, and were unaware of their presence at prisons.

July 1, 2005
Federal judge orders takeover of prison health care system by federally-appointed receiver

U.S. District Judge Thelton Henderson orders that a federal receiver take control of the state’s prison health care system to correct deplorable conditions and stop the needless deaths of inmates due to medical malfeasance. Experts note that the order was unprecedented in its scope, given that the prison system provides health care to 164,000 inmates at an annual cost of $1.1 billion. Henderson said he was motivated by an “uncontested statistic,” provided by a court-appointed expert, “that a prisoner needlessly dies an average of roughly once a week.”

The full timeline, which continues to 2014, is available for download:
The Tragedy of Prison Health Care in California: An Extended Timeline The Tragedy of Prison Health Care in California: An Extended Timeline.pdf

Birthday gif(t)s

Happy belated fourth birthday, ACA. We totally didn’t forget.


Apologies for not mentioning it earlier, but everyone is a little busy right now.


If not, they should be.


The Medicaid Apologist Is In

The Medicaid program has been painted as the red-headed stepchild of the ACA, ever since the Supreme Court ruled that Medicaid expansion was optional, not mandatory, for states. Even when it does well – namely, adding 4 million Americans to the program in October and November alone – neither side of the political aisle is willing to take any credit. And when there’s bad press, poor Medicaid gets beat like a rug.


Most recently, it has been charged with increasing costly visits to the emergency room. An analysis of the Oregon Health Insurance Experiment (OHIE) data published in Science has shown that Medicaid coverage was correlated with 41% more trips to the ER, which some have likened to “undermining [the] central rationale for Obamacare” and “contradicting health-overhaul backers.”

As always, the truth is a smidge more complicated than that.

FACT #1: This was the ‘old’ Medicaid program, which Oregon knew needed to be fixed.
This study was conducted in 2008, when Oregon expanded their Medicaid program to a limited number of beneficiaries through a lottery system. In the past two years, Oregon has actually seen a decline in Medicaid ER visits.

“That study was looking at the old system and the old way of doing things,” says Sean Kolmer, deputy chief of policy and programs for the Oregon Health Authority, which runs the state’s Medicaid program. “It reflects what we knew would happen, but that’s the old world.”

FACT #2: Oregon is fixing it, and it looks like it’s working.
Recognizing the potential problems of accessing care, Oregon has been testing different versions of Medicaid: the state is divided into 15 regional “coordinated care organizations,” each of which was provided a block grant to pay for their beneficiaries’ care. Each CCO is provided some flexibility in meeting their spending targets, which are phased in and require steady and ever greater improvements.

The state is now starting to analyze data collected from CCOs, and they’re seeing successes. In the first year, the CCOs saw a 9% reduction in ER visits by Medicaid patients since 2011 (see chart below), with an 18% reduction in ER spending. In addition, outpatient primary care visits increased 18%, with decreased hospitalization for chronic conditions such as congestive heart failure (29%), chronic obstructive pulmonary disease (28%), and adult asthma (14%). These results directly address the “failings” noted in the recent Science publication, which is much more damning about the state of our healthcare system in its previous incarnation than it is about Obamacare.

Emergency department utilization by Oregon Medicaid beneficiaries

FACT #3: The greater the urgency, the greater the cost.

“While these higher costs don’t come as a surprise to many, it has left us wondering why do Democrats call it the Affordable Care Act if the law doesn’t lower the cost of heath care.” – U.S. Rep. Dave Camp (R-Michigan), chairman of the House Ways and Means Committee.

As anyone who has contemplated overnight shipping will know, time sensitivity and cost are directly correlated. This truism extends to healthcare, and is the underlying reason why emergency care is so costly; poor health conditions necessitate immediate, oftentimes expensive care.

We’ve neglected our collective health for a long, long time, and it is incredibly naïve to think that we can improve it at no cost. A considerable proportion of the newly eligible have gone without care for a significant period of time, so it is not hard to imagine that they would require costly, urgent care services. But once their health is improved, maintaining health through primary care and preventive services is significantly cheaper. Repair costs almost always outweigh maintenance costs, and humans are no exception.

FACT #4: Our health care system is complicated, and we need to do a better job connecting patients to appropriate sites of care.

“This [study] will make the states that didn’t expand look even smarter, because they didn’t fall for the promise of lower ER use, and the states that did expand Medicaid will have even more crowded emergency rooms.” – Michael Cannon, director of health policy studies at the Cato Institute

The Harvard study highlighted one of the problems that the ACA aims to fix, which is inappropriate use of emergency services for “primary care treatable” conditions. Indeed, in the OHIE study, Medicaid coverage correlated with increased primary care treatable visits and non-emergent visits in an emergency setting. More recent data from Oregon’s CCOs show that this trend is being reversed, and it is upon us to make sure that all patients are directed to appropriate sites of care with robust primary care and preventive services before health conditions deteriorate.

In California, we’re well aware of the fact that coverage expansions are merely a start. Our goal is to ensure that every Californian is healthy, and that can only be achieved if patients can see their primary care doctors/providers. It is imperative that we make it as easy as possible for them to do so, which will require a combination of improved access, primary care capacity, patient education and payment reforms.

FACT #5: The undocumented aren’t the ones flooding emergency rooms.
In fact, according to a recent study, they were less likely to visit the ER than U.S born, naturalized citizens, or lawfully permanent residents. Despite having the lowest rates of insurance, the undocumented are the least likely to have sought care in an emergency department.

ER use by documentation status

In addition, a UCLA study of Mexican immigrants actually found that many chose to return home to seek care, due to insurance, access, language and cultural barriers.

FACT #6: Medicaid expansion can save lives.
Really, it can. By 19.6 deaths per 100,000 adults, which translates to a 6.1% reduction. That number may not seem like much, but 6.1% of 7 million (the number of uninsured adults who would be eligible for coverage if their home state were kind enough to expand Medicaid) is 427,000. That’s approximately how many Americans die from tobacco smoking each year.


Citing increased ER use as a reason not to expand Medicaid eligibility is prematurely blaming the solution for having caused the problem. Affordability and cost are undoubtedly important aspects to health reform; we’ve started seeing health spending growth slow in recent years, but the greater savings are still to come. In the meantime, we need to make sure the ACA makes meaningful changes, particularly in the lives of those who could benefit the most from it.

November Covered California Board Meeting: Plan Cancellation Conversion Policy, Pediatric Dental Benefits

In the Executive Director’s report, Peter Lee noted that California not hampered by problems that the federal exchange ( is facing.  In fact, Covered California has seen enrollment numbers improve in recent weeks. Some highlights:

  • As of November 19, 360,000 individuals determined eligible for coverage in either Medi-Cal or Covered California
  • combining enrollment in low income health programs (LIHP), almost 1 million Californians currently found to be eligible for ACA coverage expansions
  • last week averaged more than 10,000 individual applications completed per day
  • 73% of those who picked a plan through Covered California said it was easy to do so
  • young people (under 35) are enrolling at the same rate as the general population
  • 26% of enrollees are Spanish speakers
  • 60% of certified enrollment counselors (CECs) and over 13% of licensed insurance agents speak Spanish

Plan Cancellation Conversion Policy

To accommodate individuals/families who were facing plan cancellations because their plans were not grandfathered, President Obama announced that insurers have the option to offer renewals to consumers in non-compliant plans who were enrolled on October 1, 2013.  The implementation of this new transition policy has been left up to the states, and is subject to state law.

So what will California do?

After considering three options, the board voted to not allow the extension of such plans, but extend the enrollment period for conversion and allow for enrollment by 12/23/2013, with payment due by 1/5/2014. Other adopted policies include:

  • Implement a Covered California hotline with a dedicated unit of specially trained service center representatives to address consumer concerns about potential premium increases.  This hotline will be available starting 11/25/2013 at 1-855-857-0445 (Monday – Friday, 8am -8pm)
  • Partner with health plans to coordinate an additional 1.1 million co-branded notices to all eligible individuals informing them of their options
  • Collect and report data on a regular basis on conversion consumers, and report to Congress and the White House on the affordability for all consumers impacted

Extending these plans through 2014 could destabilize the market, increase confusion for consumers with inconsistent rules and varying benefits, and risk even steeper premium changes in 2015. For more details, read our previous blog post on the news.

Pediatric Dental Plans in 2015

Staff presented updated recommendations for standalone pediatric dental (SAPD) plans in 2015:

  • Option A: change (or receive a waiver) CMS regulations to add second lowest 70% standalone dental premium for calculating the advanced premium tax credit (APTC), and screen for pedi-dental plan purchase at checkout
  • Option B: work with issuers to offer a 10.0 embedded essential health benefits plan (i.e. covers all 10 of the benefits in one plan), and 0.5 dental plans (i.e. standalone dental plan for children)
    • Require dental-only deductible
    • Require protected dental out-of-pocket maximums, where possible
    • Require single out-of-pocket maximum for high deductible plans (including catastrophic plans)
    • Consider changing age curve to eliminate cross subsidization of embedded pediatric dental benefit, as the costs currently fall on adults, regardless if they have children or not
  • Option C: solicit both embedded 10.0 plans, as well as 9.5 plans (i.e. everything but pediatric dental) plans, except for the silver level which will be 10.0 plans only. Screen for pedi-dental plan purchase at checkout

Staff recommended Option B, while dental plans voiced concerns over an embedded plan; the California Association of Dental Plans urged Covered California staff to look at the successes in Nevada and Kentucky, both of which mandate the purchase of dental benefits, and offer both 10.0 and 9.5 plans.

Revised recommendations will be presented later this year, with the board taking action in December.

Board Action

The following staff recommendations were adopted by the board:

Identity proofing policy

  • Proposed revision to policy:
    • Online/phone applicants will respond to Remote Identity Proofing RIDP) supplied questions to verify identities (CalHEERS interface with federal data services hub)
    • Ways to verify identity:
      • Paper application – signature under the penalty of perjury
      • In-person – verify through review of photo documentation or other acceptable proof
      • Non-paper application – Federal Data Services Hub Remote Identity Proofing Process or in-person proof of identity or mail/electronic transmission of proof of identity

SHOP appeals process

  • Proposed appeals regulations
    • Employer/employee can appeal eligibility determination or failure to make one; or failure of the SHOP to provide written notice of an employer’s eligibility determination within 15 calendar days of receiving application
    • Employer/employee has 90 days to request appeal
    • Employer/employee shall have an informal resolution period
    • Appeals not resolved during the informal resolution will go to a formal hearing with the Department of Social Services
    • Appeals decisions will be issued to the appellant within 90 days of the appeal submittal date

Incompatible activities policy

  • Examples of incompatible activities for Covered California employees and officers:
    • Accepting a gift with the knowledge that it was given for the purpose of influencing official action
    • Directly or indirectly selling goods/services to Covered California
    • Maintaining a professional health care practice
    • Performing any act as a private citizen while knowing or having reason to know that act later will be subject to the employee’s review as a state official

Quality ratings system

  • Previously considered using a mix of quality rating systems (CAHPS, HEDIS), but based on staff and public recommendations, the staff explored using only CAHPS information for quality reporting in 2014
    • CAHPS information available for 9 of 11 issuers and 11 of 13 plans
      • Chinese Community or Valley Health Plans have no scores; no score to be posted for Alameda Alliance
      • Information available for all plans offered in 17 of 19 regions
  • Recommendation: use 10 CAHPS measures common to both commercial and Medi-Cal plans, a single summary score for each plan compared to the regional PPO benchmark, and a 1-4 star rating system
    • Earliest available presentation is January 2014
  • Other considerations:
    • Use single measure of overall rating of plan (like Colorado exchange); not feasible since measure is sensitive to type (HMO/PPO/Medi-Cal)
    • National vs. state benchmarks: insufficient number of plans at state level to be meaningful; national numbers masked known western region differences related to population served

The next board meeting, which will be the last before coverage expansions begin in January 2014, will be held in Sacramento on December 19, 2013. All meeting materials are available online.

Covered CA October Enrollment Statistics Released

Covered CA and the state Department of Health Care Services (DHCS) announced today that 200,000 applications were started since the launch of the website on October 1.  Almost 100,000 of those applications were completed, covering over 170,000 individuals. An additional 72,000 applicants were found to be eligible for the Medi-Cal program; this is a count of only individuals who entered through Covered California and excludes applicants for current coverage through county human services agencies.  Not included are the 625,000 enrollees in low income health programs across the state; these individuals will be eligible for Medi-Cal expansion and will be automatically enrolled in January 2014.


Interestingly, out of 30,830 individuals enrolled in health coverage through Covered CA, only 4,852 were eligible for federal premium assistance and cost-sharing reductions.  Since in-person assistance programs were not fully operational on launch day and the bulk of certification is expected to be completed in November, this figure is expected to increase significantly with continued outreach and education efforts.


The website and service centers continued to receive consumer interest, with almost half a million unique visits to the website in one week alone.  Service centers received about 65,000 calls in the first week of November, with an average wait time of 12 minutes and handling time of 16 minutes.


Nationally, about 850,000 applications were completed through all exchanges, and 106,185 individuals selected an exchange plan. Among states implementing their own marketplace (SBM), almost 80,000 individuals have already selected a marketplace plan; these states include California, Colorado, Connecticut, the District of Columbia, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New York, Oregon, Rhode Island, Vermont, and Washington. California alone was responsible for a third of all individuals who chose a plan.

Washington and Kentucky also reported notable enrollment figures. Washington state’s exchange had 64,990 completed applications and 7,091 individuals having selected a plan. Over 50,000 applications were started through Kentucky’s state-based exchange, with 5,586 individuals having selected a plan.  Kentucky also reported high rates of enrollment by young adults under 35 years old (40%) and women (59%).

Enrollment overall may seem lower than anticipated, but there are some factors to consider:

  • Health insurance is a foreign concept to many, and these individuals/families will have to familiarize themselves with the application process, as well as products available for purchase
  • Some marketplace websites experienced exceptionally well-documented technical difficulties
  • Congressional shenanigans (ad nauseam)
  • The full outreach, education and marketing push has yet to begin
  • Coverage won’t begin for over a month
  • Procrastination plagues us all