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Medi-Cal Transformation

This report is an updated version that was distributed at our 16th annual conference in February.

Executive Summary

In 2014, up to three million uninsured low income Californians will be eligible to enroll in Medi-Cal, joining the 7.3 million already in the program, and another 3 million uninsured will be eligible for private insurance the Exchange. Some want to shift an additional 1 million persons with incomes between 133 and 200% of FPL from the Exchange to a Basic Health Plan operated by Medi-Cal. The Governor has proposed adding another million low and moderate Healthy Families children to the Medi-Cal program.

Projected participation rates by the newly eligible parents, children and other adults in the Medi-Cal program vary by a factor of two. If we fail to fix Medi-Cal we will likely have low enrollment. New program participants will need an eligibility and enrollment system that is easy to understand and use, a primary care doctor and a well-managed delivery system built on prevention and dedicated to improvement in health status.

Since the federal government will pay 100% of the costs of the new eligibles for the first three years, eventually declining to 90% by 2019, this is an enormous opportunity and a daunting challenge for the Medi-Cal program, for those policy makers, advocates and clinicians who care about the health status and health needs of low-income Californians. State policy makers will need to make important decisions about: eligibility, scope of services, reimbursement levels, financing and delivery systems.

To take advantage of the opportunity, we must address the following before 2014: 1) financing the system, 2) simplifying eligibility and enrollment, and 3) improving reimbursement, outcomes and provider participation. Without making these improvements, participation, subscriber health outcomes and provider satisfaction are likely to be low. This paper is intended to promote this discussion and hopefully its resolution. Our recommendations are at the close of each section.


The full report is available for download.

Medi-Cal Transformation Medi-Cal Transformation.pdf