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Happy 2nd Birthday, ACA!

Today marks the second anniversary since the Affordable Care Act was signed into law. Since then, California has worked to implement the §1115 Waiver, transform the Medi-Cal program in preparation for 2014, and develop the California Health Benefit Exchange.

Many counties are off to a strong start in implementing the state’s §1115 waiver from the federal government. CMSP and Path2Health have expanded mental health benefits to include counseling services and substance abuse treatment, and the opportunities under DSRIP have allowed the University of California San Diego Health System to focus on the prevention of surgical site infections (SSI) and hospital acquired pressure ulcers (HAPU). As this progress notes, practical strides have been made to improve care across the state.

Nonetheless, the challenges facing counties over the coming 18 months are difficult but achievable:1) move towards delivery systems that include all public hospitals, private non-profit community clinics, behavioral health and vital local doctors; and 2) coordinate care so the delivery system, shifts from emergency room centered episodic care to a primary care centered system that functions more like Kaiser and the best local managed care models. The first year’s enrollment under the waiver focused on county health’s existing patients with the most serious illnesses. Outreach in the next year needs to identify, reach and enroll the next level of uninsured individuals who will greatly benefit from primary care and prevention so that their health status is improved and existing conditions do not reach the levels of urgent and emergent care. It will also be crucial to also identify more local matches (in district hospitals, public health and behavioral health treatments) that will qualify for the federal matches now available.

In 2014, up to half a million individuals enrolled in Low-Income Health Programs (LIHPs) across the state will transition into Medi-Cal. The ACA will cover up to three million Californians through the program. Medi-Cal will need significant improvements to enroll and provide effective care for those newly enrolled.

First California’s legislature needs to pass legislation to implement the federal expansion; it will need to decide on the scope of covered benefits for the newly eligible. Second, the federal government affords California a unique opportunity to radically simplify and streamline a program with 150 separate aid codes and lengthy local delays to determine eligibility that gives the program a poor reputation.  It is time to replace the complicated local paper chase with a less costly modern IT system that uses computer cross checks to verify program eligibility as much as possible. Third, in many California communities, it is difficult to find doctors that participate in Medi-Cal. Under the ACA, Medi-Cal’s low reimbursement rates for primary care doctors can be upgraded to levels comparable to the Medicare program with 100% federal matching funds. This increase takes effect in 2013 and 2014, and it gives California an important opportunity to attract and then retain new doctors in the system.

Millions of more Californians will be entering the health care system in 2014. Under the ACA, Exchanges will seek to offer more affordable coverage to the uninsured, the private individually insured and small employers. California was the nation’s leader in establishing its Exchange; it is moving quickly to establish the IT for public program enrollment, set standards for participating health plans and design outreach, navigator roles and enrollment.  Key tasks for the coming year are the passage of state legislation to establish the underwriting reforms of guaranteed issue and renewal and the elimination of pre-existing condition exclusions for individuals and employers. It is essential to develop reinsurance and risk adjustment among those plans benefitting and suffering from adverse selection in and outside the Exchange markets.

California and its wide array of dedicated stakeholders have made significant progress in the past few years, and ITUP looks forward to continuing the good fight to provide everyone with affordable health care.

Read more on the §1115 Waiver, Medi-Cal transformation, or the California Health Benefit Exchange.