Author: Lucien Wulsin

Impressions from the Covered California Bus Tour — the Central Valley and Central Coast

The first stop was the Fresno Call Center, one of the three California call centers, where about 450 people work during the Open Enrollment. They handle about 14,000 calls a day from all over the state; they peak at over 20,000 calls. Five of the staff travelled on the bus with us – incredibly knowledgeable, hard working and compassionate individuals with great phone voices.

Fresno Call Center

Fresno stop

Fresno Call Center

Fresno Call Center


Next stop was Salinas where Pete Delgado, the CEO of the Salinas Valley Memorial Hospital hosted us. The hospital had just opened a rural health center in the underserved community of

Salinas Valley Memorial Hospital

Salinas Valley Memorial Hospital

Gonzalez and affiliated with a local multi-specialty physicians group to better serve the newly insured in their region. Their uncompensated care to the uninsured has dropped sharply and their

care to the newly insured has increased dramatically due to the ACA. At Salinas Valley Memorial Hospital, several thousand Covered California members have received care, including:

  • 2,574 incidents of general outpatient care.
  • 893 treatments for broken bones and trauma.
  • 141 incidents of care for pneumonia, heart attacks, strokes and kidney infections.
  • 138 incidents of maternal health and childbirth.
  • 51 incidents of pediatric care (including in neonatal intensive care units).
  • 29 incidents of gastrointestinal and urological surgeries.



David, a new subscriber, was able to enroll his family in coverage costing less than $300 a month – a huge savings from the $1500 a month he was paying before getting coverage under the Affordable Care Act.


David new subscriber

David, new subscriber

Next stop was a Community Health Center, Salud Para la Gente in Watsonville, where local enrollment in the Affordable Care Act had reduced the uninsured rate in the local clinic from over 30% to 9%. The clinic was being expanded to meet the medical needs of the local community; and local high school students were getting important training and exposure through the clinic for future jobs in providing health care for their community.


Watsonville stop

Watsonville stop

Salud Para la Gente in Watsonville

Community Health Center, Salud Para la Gente in Watsonville

My final stop on the day’s tour was the PHP Insurance agency in San Jose where enthusiastic young health insurance agents were serving the Vietnamese and Chinese communities in the Silicon Valley. The young agents sometimes stay in the office ‘til well after midnight processing the unprecedented numbers of new applicants now eligible for coverage under the ACA. I asked one young agent “why so many of their clients had no health coverage” and learned that they had temp jobs with no health benefits in local assembly plants.

San Jose stop at PHP

San Jose stop at PHP


PHP Insurance agency in San Jose

PHP Insurance agency in San Jose


Today’s Challenges in Trying To Get to Health Information Transparency For Patients

ITUP’s report, Today’s Challenges in Trying To Get to Health Information Transparency For Patients, takes a close look at the challenges patients face in trying to get information on the costs and outcomes of their medical procedures. Legislatures, public programs, and the private insurance market have all taken steps to improve transparency in the health care market. However, there is still much more that needs to be done in order to truly know the cost of care and its value based on quality outcomes. This paper examines the uses and goals of transparency, what current requirements exists for transparency at the state and national levels, how private insurers have responded to the call for greater transparency, the challenges that lie ahead, and what needs to occur before true cost and quality transparency for patients can be achieved in the healthcare system.

ITUP’s report, Today’s Challenges in Trying To Get to Health Information Transparency For Patients, can be downloaded for free here.

California §1115 Waiver Renewal Highlights

In an email to stakeholders, the California Department of Healthcare Services announced that a conceptual agreement around the major components of the §1115 Medicaid waiver renewal has been reached with the Centers for Medicare and Medicaid Services, and that the State’s existing waiver would be extended until December 31st while DHCS and CMS finalize the waiver’s details.

A brief overview of the core elements of the conceptual agreement follows:

  • Total federal funding is $6.218 billion over 5 years or $1.4 annually.
  • Global Payment Program includes five years of DSH funding and one year of Safety Net Care Pool funding at $236 million. Future SNCP funding will depend on an independent study of public systems’ uncompensated care. The Global Payment funds will be allocated based on “value” – in other words an emergency room visit to amputate an infected limb that was untreated would be a lower value than treating the infection in the first place and preventing the amputation. In the past DSH and SNCP funds were distributed based on the hospitals’ volume of uncompensated care.
  • DSRIP (Delivery System Reform Incentive Pool) is renamed as PRIME (Public Hospitals Redesign and Incentives in Medi-Cal). $3.266 billion over 5 years is allocated to Public Hospitals. $467 million over 5 years is allocated to district hospitals. PRIME is to strengthen public systems’ ambulatory care capacity.
  • Dental transformation incentive program is funded at $750 million over 5 years.
  • Whole Person Care Pilots are funded at $1.5 billion over 5 years. These are voluntary county-based pilots to provide better-integrated care for the highest cost, highest risk most vulnerable populations.

What’s missing from the initial state concepts?

  • Managed care transformation
  • Partnerships and integration between local managed care plans and local mental health plans
  • Improvements in maternity care
  • Workforce development
  • Supportive housing for the homeless who are high cost users of Medi-Cal services.

For a review of the original §1115 waiver renewal concepts, please see ITUP’s Summary of DHCS Waiver Renewal Concepts. For the CMS letter with details, please see DHCS, CMS Agree to 1115 Waiver Renewal Concept, Extend Current Waiver Through Dec. 31.

Open Enrollment: Lessons from the Field

California has been one of the nation’s leaders in implementing the ACA. This paper looks at the enrollment successes and delivery systems performance reported in our regional workgroups in the San Diego, Orange, North Central, Bay Area, Central Coast and Central Valley counties. It identifies both the successes and the next step challenges identified by those on the ground implementing the Affordable Care Act. It will be updated as we complete ITUP’s regional workgroups in the North Rural, Inland Empire and Los Angeles regions and as the OSHPD hospital data for 2014 is released. We hope it will be useful to all our workgroup participants as we enter year three of Open Enrollment.

Download the full report here: Open Enrollment: Lessons from the Field


Summary of the United States Census Bureau Current Population Survey

ITUP’s summary of the United States Census Bureau’s Current Population Survey is now available.

Some of the key noted in the summary:

  • About 46.7 million (14.8% of the population) lives in poverty about the same as the prior year.
  • Median household income is $53,657 about the same as the past three years.
  • About 33 million (10.4% of the population) are uninsured in 2014 down from the 42 million the prior year due to ACA implementation.
  • Massachusetts leads the nation with 3.3% of its residents uninsured, and Texas brings up the rear at 19.1% uninsured.
  • Kentucky led the nation in reducing its uninsured rates by 5.8 points from 14.3% uninsured to 8.5% uninsured. Other leading states are Nevada (5.5%), West Virginia (5.4%), Oregon (4.9%) and California (4.7%).
  • Coverage increased roughly equally for private individual insurance (the Exchanges like Covered California) and for Medicaid (Medi-Cal).
  • Coverage rates are now 98.6% for those over 65, 93.8% for those under 18, 89% for those 45-64 and 82% for those ages 26-34. The greatest increases in coverage were for those between the ages of 19 and 34.

ITUP’s complete summary of the report may be downloaded here.

The original findings can be viewed at the US Census Bureau: Income and Poverty in the United States: 2014 and Health Insurance Coverage in the United States: 2014.

Where Are We Going: Where Should We Be Going?

The Affordable Care Act in many ways represented the triumph of Republican ideas (dating back to President Richard Nixon, Senator Bob Dole and ultimately enacted by Governor Mitt Romney), passed by a narrow margin with Democratic votes only and implemented amidst enormous partisan criticism and unparalleled scrutiny. It was not perfect in its inception or in its implementation, but it was a vast improvement on the status quo ante and a welcome step towards universal coverage after 100 years of trying. Like many new programs (remember the early challenges in California’s implementation of Healthy Families or the nation’s slow implementation of Medicaid), it will take at least five years to work out the bugs without any help/interference by Congress – an unlikely scenario. California has made enormous strides in implementation and in improved affordability, but we are likely to reach an enrollment plateau in the next two to three years.

First, we must do a better job of educating California’s public, which has been saturated with a stew of misinformation, inadequate information and accurate information and does not know what to believe. Most are still confused: how the ACA works, how benefits are accessed in their health plan, the value and importance of preventive and primary health care, the interplay between the costs of premiums, deductibles and copays, the tax implications of timely reporting income changes or of dropping health coverage, and the importance and opportunity of patient engagement to achieve healthier outcomes.

In this article, we will discuss next steps for California to consider towards a better system. ACA §1332 allows us to begin this effort with ACA waivers as soon as the year 2017; we need to begin the thinking now. Section 1332 allows states to waive any or all of the following: the Exchanges, tax credits, qualified health plan requirements, individual and/or employer responsibility. It allows for a consolidation of waivers for Medicaid, Medicare and CHIP; this offers a state an unparalleled opportunity to “get it right”. States must provide coverage that equals or exceeds the ACA, and the costs may not exceed what the federal government is already spending. What could California do – examples would be a modern hybrid of Medicaid, the Exchanges, CHIP and Medicare or a public option or a Basic Health Plan or single payer or consumer-directed coverage or aligned payment incentives and integrated care for all. Below we review needed changes in the major sources of health coverage for Californians.

Download the full document here: Where Are We Going?

Summary of the Kaiser Family Foundation Survey of California’s Uninsured

The Kaiser Family Foundation has released a longitudinal survey of what has happened to California’s uninsured over a two-year period of ACA implementation. In 2013, 100% of those sampled were uninsured; in 2014 after the first open enrollment 58% were insured; and in 2015 after the second open enrollment 68% were insured.


Of the newly insured, about half went into Medi-Cal, a quarter into Covered California and a quarter into employment-based coverage. Among uninsured Hispanics, 60% were enrolled, 17% were eligible but not enrolled and 14% were undocumented and not eligible. Among non-Hispanic whites, 79% enrolled and 21% were eligible by remained uninsured.

62% of those enrolled in Covered California reported being helped, and 20% reported being hurt; for the remaining 17%, there was no impact. 43% of those enrolled in Medi-Cal reported being helped, and 8% reported being hurt; for the remaining 46%, there was no impact. 10% of those enrolled in employer-sponsored coverage reported being helped, and 21% reported being hurt; for the remaining 59%, there was no impact.


Most (63%) of the newly insured stayed with the same plan, while 17% changed to a different plan from 2014.

Most (62%) of the newly insured reported they were automatically re-enrolled and 35% reported having to take action to re-enroll.

Most said the costs were what they had expected or less; 20% reported that they were more than they expected, including 28% of those with Covered California and 31% of those with employment-based coverage.

76% said their experiences with their new plans were positive and 18% were negative. 80% of the newly insured had no problems getting a doctors; 16% experienced difficulties.

The remaining uninsured were 1/4th Medi-Cal eligible; 1/4th Covered California subsidy eligible, and 41% undocumented and ineligible. 1/4th of the remaining uninsured were between 26-34; 36% between 35 and 49, 1/4th 50-64, and 1/6th between 19 and 25.

Of the remaining uninsured, 2% were opposed to the ACA; 23% were not eligible, and 44% could not afford insurance. About 1/3rd have tried to enroll but were unsuccessful.


84% of the remaining uninsured knew about the mandate, but only ½ knew about the Medi-Cal expansion or financial assistance through Covered California.

Half of the remaining uninsured Hispanics were concerned about the impacts on their immigration status or those of family members if they enrolled.

1/4th enrolled by phone, 1/3rd in person, 1/5th on the internet and 1/10th by mail. About 34th said the process was easy and 1/5th said it was difficult.

85-90% of the remaining uninsured had not visited the Covered California website or called the 800 number.

This summary of the Kaiser Family Foundation’s findings on California ‘s Uninsured is available for download.

Summary of Gallup Poll on State’s Progress in Reducing the Numbers of Uninsured

The latest Gallup Poll findings showed California ranked 6th in the nation by successfully reducing its rates of uninsured from 21.6% to 11.8%.

Arkansas led the nation with a reduction from 22.5% uninsured to 9.1% uninsured. Kentucky reduced its rates of uninsured from 20.4% to 9.0%. Oregon reduced its uninsured rate from 19.4% to 8,8%, Rhode Island reduced its uninsured rate from 13.3% to 2.7% and Washington cut its uninsured rates from 16,8% to 6.4%.

Six states now have uninsured rates of 5% or less – Rhode Island, Massachusetts, Vermont, Connecticut, Minnesota and Iowa.

Even in a state that have led the resistance to the ACA, such as Texas, the uninsured fell from 27.0% to 20.8%. In Florida, which is still badly divided on adopting the Medicaid expansion, the uninsured rate dropped from 22.1% to 15.2%.

The full poll findings may be accessed on the Gallup website.

This ITUP summary is available for download.

San Francisco, The Spirit Of The Pioneers: Taking Steps To Improve Both Healthy San Francisco And The ACA

San Francisco is pioneering yet again. It’s proposing to modernize the “City Option” by creating a new Bridge to Coverage and expanding its Healthy San Francisco program for the remaining uninsured. Most city businesses either offer coverage to their employees or help pay for their care through medical reimbursement accounts or Healthy San Francisco. This updates them to better coordinate with the Affordable Care Act (ACA).


The Bridge to Coverage will offer financial help with premium assistance under Covered California as well as with more affordable copays and deductibles. It will supplement the ACA’s refundable tax credits available in Covered California and help working San Franciscans better afford the premiums for coverage and the out of pocket for care. It limits out of pocket exposure to 5% of an individual’s income. It will extend financial assistance to workers and their families who are eligible for Covered California as long as their employer contributed to the “City Option” for their coverage rather than purchasing employment based coverage for them. This will be particularly important for the flex workforce and for the employees of smaller businesses – about 3,000 to 4,000 San Franciscans will be helped.


The proposal will also align the Healthy San Francisco program with the ACA. Eligibility is extended to those with incomes up to 500% of FPL who are not eligible for any public programs and either cannot afford the Covered California premiums or are exempt from the individual mandate. We think that it is vital to parallel existing county health programs like Healthy San Francisco for the uninsured with the ACA’s coverage expansions. It will be far simpler to understand and administer for everyone involved “you are either eligible for the ACA or for Healthy San Francisco”, there is no overlap and everyone is covered. About 15,000 San Franciscans will qualify.

The proposal will also help to design and create a new Employee Wellness Fund to reimburse for employee wellness programs for those employers who have contributed to the “City Option”. In concert these programs should help the San Francisco residents to improved health status and better financial security. They will be considered by the Health Commission on Tuesday, August 4.

What a great way for a City to celebrate the 50th Birthday of Medicare and Medicaid.

Summary of Covered California Premiums for 2016

Covered California has announced its 2016 premiums. It reports that the over-all increase (weighted average, assuming purchasing patterns are the same as last year) is 4%. The average increase for the lowest priced bronze plans is 3.3%. The increase in premiums for the lowest priced silver plan is 1.5% and the second lowest cost priced silver will cost 1.8% more on average. If customers seek to buy the lowest cost plan, they would save 4.5% on their premiums.

You may read the full report summary here.