Nearly 10% of California residents have gained insurance coverage under Medicaid expansion, and 3.7 million residents could lose coverage if Medicaid expansion is reversed under a repeal of the Affordable Care Act, according to a recent study.
The impact of an ACA repeal would vary by county, because some counties have benefited more than others under Medicaid expansion, stated researchers in the study, titled ACA Repeal in California: Who Stands to Lose?
A reversal of Medicaid expansion would disproportionately impact low-income earners, young adults, part-time workers, and people of color, according to the study, which was conducted by the University of California Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research.
Of the 3.7 million people who gained coverage under Medicaid expansion,
47% are employed.
12% are either unemployed or actively looking for work.
51% are between the ages of 19 and 39.
In addition, 42% of the enrollees are Hispanic. White people make up the next-largest group (29%) of people who gained coverage, followed by Asian/Pacific Islanders (20%) and African-Americans (9%).
Overall, 9.4% of the state's population enrolled for coverage through Medicaid expansion. The percentage of enrollees in the state's 58 counties ranged from 4.9% to 13.9%. Placer County had the lowest percentage of Medicaid expansion enrollees at 4.9%, followed by Marin County at 5.6%.
Rural Mendocino and Humboldt counties had the highest enrollment rate, at 13.9%, followed by Trinity County with 13.6%, the study found.
Some residents who gained coverage could remain insured through employer-sponsored plans or other programs if Medicaid expansion is repealed, but the majority would likely become uninsured.
"Coverage would probably become unaffordable for most people," said Laurel Lucia, a healthcare program manager at the UC Berkeley Labor Center and a coauthor of the study.
Covered California by the Numbers
The study also broke down the percentage of state residents who gained coverage through subsidized plans on Covered California.
The study found that 3.1% of state residents—or 1.21 million—have purchased health plans on Covered California with the help of subsidies and the percentage per county ranged from 1.5% to 6.3%.
Lassen County and Kings County had the lowest percentage of residents receiving federal subsidies at 1.5%, and Mono County had the highest rate at 6.3%, followed by Nevada County at 6.2%, according to the study.
The final count was roughly 3% below last year's total, but was higher than the predicted enrollment of 400,000. More than 50,000 people enrolled during last two days.
Covered California ended open enrollment with more than 412,000 new sign-ups driven by a late surge of enrollees during the last two days of the enrollment period.
The final tally for the three-month period that began November 1, 2016 was 412,105 enrollees. The total was about 3% below last year's total of more than 425,000 enrollees, but it beat the predicted enrollment of 400,000.
The late rally was driven by a four-day extension of the enrollment period that pushed the original deadline from January 31 to February 4.
"California met our projections, driven by the nearly 50,000 consumers who signed up for health insurance in the last few days of open enrollment," said Peter V. Lee, executive director of Covered California.
Young adults age 18–34 accounted for 37% of all enrollees, compared to 38% last year, 34% in 2015, and 29% in 2014. Young adults tend to be healthier and use the healthcare system less than older people, which helps keep premiums down.
'A Good Mix'
"Covered California is continuing to enroll consumers in large numbers with a good mix of younger and older, which helps keep rates down for everyone and keeps the entire individual market stable," said Lee.
The decline in enrollment this year was expected, given that the percentage of uninsured residents in the state dropped from 17.2% in 2012 to 8.6% in 2016, according to data from the U.S. Census Bureau.
"We had a projected enrollment estimate for this year that we were able to surpass," said Covered California spokesperson James Scullary.
"With the number of uninsured people in the state declining each year, we would expect enrollment totals to decline since there are fewer people out there who need health coverage."
Nationally, enrollment figures for Healthcare.gov dropped 5% from last year, with approximately 9.2 million consumers signing up for coverage during the recently ended enrollment period compared to about 9.7 million last year.
During the last week of open enrollment on Healthcare.gov, only 375,000 people signed up for coverage compared to nearly 700,000 last year.
The U.S. Department of Health and Human Services (HHS) pulled nearly $5 million in marketing funds from efforts to promote enrollment during the final few days of the enrollment period, which might have affected the final enrollment total.
Covered California's last-week marketing push wasn't impacted by the HHS decision to withdraw federal funding from the program, officials said.
Some state exchanges reported an increase in enrollment. For example, Washington State's HealthplanFinder exchange reported that more than 225,000 people signed up for coverage during the 2016–2017 enrollment period, a 13% increase from last year.
The health system was penalized for not providing data on Medi-Cal managed care patients due to an issue with its health information technology, a Kaiser official said.
The California Department of Health Care Services (DHCS) has issued a fine of $2.5 million against Kaiser Permanente—the first fine levied against one of its Medi-Cal managed care plans in more than 15 years.
Kaiser, which currently serves about 700,000 managed care patients in 15 counties, is working to resolve information technology issues that prevented it from supplying data to the state, officials said.
Kaiser has been fined for failing to submit managed care data on how Medi-Cal members access care. The state uses this information to set rates and measure utilization, said DHCS Spokesman Tony Cava. The fine "was the first financial sanction levied against a managed care plan since at least 2000," said Cava.
Since 2014, DHCS has been working with Kaiser on data submission issues and accepted a corrective action plan (CAP) from Kaiser last spring to be in compliance by January 1, 2017, he said. "Kaiser failed to comply with the CAP, [which it] attributed to systems issues, so the sanction was issued."
In a January 13 letter to Kaiser Permanente, DHCS Director Jennifer Kent said Kaiser had missed reporting deadlines in June 2016 and January 1, 2017. She stated that Kaiser "was unable to submit" several different types of data required by the program.
These include physician-administered drugs (PADS) as well as external medical claims to DHCS and Kaiser's 13 plan partners in the Post Adjudicated Claims and Encounters System format.
The penalties included a fine of $742,500 for not submitting patient encounter data and a fine of nearly $1.8 million for not submitting PADS data for the March 2010–March 2015 reporting period.
The failure to report data was due to a health IT issue, which the health system is in the process of resolving, said Nathaniel Oubre, California vice president for Medi-Cal and Charitable Care at Kaiser Permanente.
"Kaiser Permanente is an integrated health system, therefore, our systems and technology—such as our electronic health records and online capabilities—are focused on quality, access, and integration of care," said Oubre.
"While our administrative systems and processes were not originally designed or fully updated to collect and report certain data in the format specified by DHCS, we are taking steps to change this and are making investments in technology that will facilitate compliance with the state."
The sanction was related to Kaiser's inability to capture certain administrative data for the Medi-Cal program and was not related to quality, patient care, or patient access; and "does not affect care or quality in any way," Oubre noted.
Cava said the DHCS "continues to have ongoing discussions with Kaiser to work through any remaining issues, and will do so until they are fully corrected."
The number of influenza cases in California escalated rapidly this month, with some hospitals reporting higher-than-normal emergency department visits and hospital admissions for the flu and flu-related illnesses such as pneumonia.
Influenza has been widespread for several weeks in Northern California and healthcare facilities in the region are dealing with dozens of outbreaks, officials at the California Department of Public Health (CDPH) stated.
"We are closely monitoring the impact of influenza on healthcare facilities," said CDPH Director Karen Smith, MD. "Some acute care hospitals in California are full and have diverted patients to other facilities."
The CDPH has received reports of 83 influenza outbreaks, about double the average in previous flu seasons, with most outbreaks affecting patients in long-term care facilities. As of January 21, the state had confirmed 14 flu-related deaths among adults age 65 and younger.
For the first week of January, Kaiser Permanente reported 10.2% of its patients in Northern California hospitals were admitted with severe flu or pneumonia, the highest percentage in more than 10 years.
A Tent in the Parking Lot
Kaweah Delta Medical Center in Visalia was forced to open a tent in the parking lot of its emergency department to handle an overflow of patients with flu-like symptoms in early January. Clovis Community Medical Center converted its main lobby into a makeshift waiting room for ED patients with flu symptoms.
Most people hospitalized with flu or pneumonia have been 65 or older but hospitalization rates for people of all ages are higher this year compared to last flu season, said Erin Murray, an epidemiologist supervisor for the CDPH.
Although the number of cases in Northern California appears to be declining, the decline may be a temporary fluctuation, she said.
"We've seen the number of people hospitalized for influenza decrease in the Bay Area since mid-January but it's too early to tell whether the season has peaked," said Murray. "And we've seen the number of cases increasing in Central California and Southern California as well."
In Southern California, 2,433 influenza cases have been confirmed in Los Angeles County this year compared to 618 cases at this point during the 2015-2016 flu season, according to the Los Angeles County Department of Public Health.
The Orange County Health Care Agency said 1,218 cases of influenza have been reported so far this year, compared to 344 cases at the same time last year.
"The rapid rise in reports of illness and hospitalizations around the state make it likely that this year will be a severe flu season," said Orange County Health Officer Eric Handler, MD.
A California lawmaker has withdrawn a bill that would have allowed undocumented immigrants to buy health plans on Covered California, citing concerns about a potential overreach by the federal government.
Senate Bill 10 was authored by Sen. Ricardo Lara (D-Bell Gardens). The bill instructed Covered California, the state's health insurance marketplace, to request that federal officials allow undocumented immigrants to buy health plans on Covered California, albeit without federal subsidies.
Gov. Jerry Brown signed the bill into law on January 10. However, Lara subsequently withdrew the bill, calling it "the first California casualty of the Trump administration."
"I take Trump at his word that anyone is subject to deportation at any time, and California will not be part of a wasteful and inhumane campaign against immigrants who are working hard and playing by the rules," said Lara.
"We will continue to seek ways to expand health coverage even as Republicans in Washington move to take it away."
SB10 would have had a minimal impact on enrollment. Covered California officials estimate the waiver would have boosted enrollment by about 17,000 on an exchange that has more than 1.3 million enrollees.
Other Challenges
California is already bracing for an immigration battle with the Trump administration on other fronts.
State Sen. Kevin De Leon (D-Los Angeles) introduced a bill that would establish hospitals, schools, and courthouses as 'safe zones' for undocumented immigrants.
De Leon said Senate Bill 54, dubbed the California Values Act, would ensure that undocumented immigrants have access to hospitals and healthcare in the event federal officials enact an "over-reaching mass deportation policy."
State legislators and healthcare providers are still awaiting clarity on Republican efforts to repeal the Affordable Care Act (ACA).
Trump signed an executive order on January 20 that purports to allow the federal government to withhold funding for some provisions of the ACA, but the order does not specify what programs could be defunded or how.
More than 3.7 million state residents have gained coverage under the ACA through Medicaid expansion. The UCLA Center for Health Policy Research on January 20 released a study that detailed the impact Medicaid expansion has had on the state's poorest counties.
The study estimates that several California counties had more than 10% of their residents enroll for coverage under Medicaid expansion, which made Medi-Cal available to people with incomes up to 138% of the poverty level.
In addition, the study estimates that 13.9% of residents living in Humboldt and Mendocino counties gained healthcare coverage under Medicaid expansion. In Trinity County, an estimated 13.6% of residents gained coverage, as did about 12% of residents in Fresno County.
Overall, more than half of all residents in five counties are now covered under Medi-Cal. Leading the way is Tulare County at 55%, followed by Merced County at 51.5%.
Unaffordable Care
A rollback of Medicaid expansion would not eliminate coverage for all residents who gained coverage under the ACA but would likely make it unaffordable.
"Not every person who gained coverage under Medicaid expansion would become uninsured," said Laurel Lucia, a healthcare program manager at the UC Berkeley Labor Center.
"Some could find coverage through employer-based plans or buy plans on the commercial market, though privately purchased coverage would probably be unaffordable for most people."
The California State Association of Counties (CSAC) is hoping to reach a compromise with state officials over a budget proposal that eliminates state funding to counties for In-Home Supportive Services (IHSS).
The $122.5 billion state budget unveiled by Gov. Jerry Brown on January 11 calls proposes phasing out elements of the state's Coordinated Care Initiative (CCI), including an IHSS program that provides funding to counties.
The CCI plan provides managed care for 114,000 dual-eligible Medicare-Medicaid patients in the state.
Phasing out the MOE "would add an estimated $625 million to county costs for IHSS in fiscal 2018 and an estimated $4.4 billion over the next six years," according to the CSAC.
'Devastating to Counties'
"This would be devastating to counties all over the state," said CSAC President and Alameda County Supervisor Keith Carson. "We undoubtedly would have to make cuts to other vital social services to cover these costs."
The shift represents "the single largest change in the budget from last year and unfairly burdens counties with costs they cannot control nor afford," according to a CSAC statement.
IHSS costs have increased sharply since the program began five years ago, driven by a hike in the state's minimum wage, new paid-sick-leave provisions for IHSS employees, and federal overtime regulations, CSAC officials said.
"Counties will have to find a way to pay for these additional costs, because the program is much more expensive now than it was five years ago," said Farrah McDaid Ting, a CSAC legislative representative.
"It will probably mean that counties will have cut health and mental health programs to deal with the additional costs, or take money out of the general fund."
The CSAC is hoping to work with state officials and legislators to develop a compromise plan that would provide counties with financial help for IHSS. "We're hoping to come up with legislation that will create a cost-sharing program to help counties with the added expense," said McDaid Ting.
The main component of the CCI program—Cal MediConnect—will remain in place because the program has demonstrated cost-savings. The budget proposes to extend the Cal MediConnect program and continue mandatory enrollment of dual-eligible members.
Cigarette Tax Funds
Some healthcare advocates have raised concerns about how the budget proposes to spend funds from a new cigarette tax. Proposition 56, which levies a $2-per-pack tax on cigarettes and an equivalent tax on e-cigarettes, was approved by voters last November.
The law will go into effect on April 1 and could generate as much as $1.2 billion in revenue in fiscal 2018.
Brown's budget proposal commits Proposition 56 revenue toward the General Fund and states that details on spending will be worked out with state legislators.
The California Medical Association (CMA) said that cigarette tax revenue was intended for Medi-Cal and smoking prevention programs.
"We're disappointed that Governor Brown's budget ignores the will of voters who supported Proposition 56 by proposing to offset general fund obligations with tobacco tax revenues rather than investing in the overburdened Medi-Cal system to improve access to care," said CMA President Ruth E. Haskins, MD.
Gardens Regional in Los Angeles closes after state officials and the potential buyer fail to reach an agreement on a requirement to provide charity care.
A Los Angeles-area safety net hospital began shutting down last week after state officials were unable to finalize a deal with a potential buyer.
Gardens Regional Hospital and Medical Center in Hawaiian Gardens began shutting down on January 18 after its proposed sale to Riverside-based Strategic Global Management Inc. fell through.
Strategic Global submitted a bid in August to purchase the assets of Gardens Regional Hospital, a 137-bed not-for profit acute care facility, for $19.5 million.
However, Strategic Global was apparently unable to meet the charity care provisions required by the state Attorney General as a condition of the sale.
Lawyers representing Strategic Global filed an emergency motion in U.S. Bankruptcy Court in Los Angeles to close the hospital, citing its "dwindling" cash on hand and no other buyers willing to acquire Gardens' assets as a going concern.
A Gardens Regional Hospital representative said the facility closed its emergency department at 7:00 a.m. on January 18, was no longer accepting new patients, and planned to shut down completely after its current patient base was discharged.
Officials from Strategic Global Management did not return calls seeking comment.
A January 17 letter from the Los Angeles County Emergency Medical Services Agency notified emergency medical personnel in the area that Hawaiian Gardens would no longer be a receiving hospital for emergency transport.
Gardens Regional filed for bankruptcy in June 2016 and entered an acquisition agreement with Strategic Global in August. In its bankruptcy filing, the hospital cited several factors for its financial problems.
"Medi-cal and Medicare reduced their payment rates in the range of 2.9% to 10% in or after 2010, which whittled down our reimbursement revenues," the filing stated.
Court documents also stated that Gardens Regional needed to generate $119,474 per day in revenue to cover its operating costs but was only generating $91,830 per day.
The facility faced unanticipated operational costs, a decline in bariatric and other surgeries, and difficulties in implementing required changes to electronic health records and in managing patients' length of stay, according to the filing.
The Inland Empire Health Information Exchange and California Integrated Data Exchange combine will include more than 16 million insurance claims and medical records.
In what could be the largest exchange of its kind in the U.S., the Inland Empire Health Information Exchange (IEHIE) and the California Integrated Data Exchange (Cal INDEX) announced plans to merge in a partnership that would create an exchange with more than 16.7 million insurance claims and medical records.
The merger plan is expected to close in the first quarter of 2017—pending regulatory approval—with former Obama Administration Advisor Claudia Williams leading the new group as CEO.
The merger will pool the resources of Cal INDEX and its 11.7 million records with the 5 million records of the Inland Empire exchange. The new exchange will be named when the merger is finalized.
"The creation of this new statewide, health information exchange is an important milestone in transforming California's healthcare system into a coordinated system that delivers higher quality and more efficient care to all Californians," said IEHIE Chairman Bradley Gilbert and Cal INDEX Chairman Mark Savage in a joint statement.
Williams will take over as CEO of the new exchange on February 1. She most recently served as senior advisor for Health Innovation and Technology in the White House Office of Science and Technology Policy and director of HIE for the Office of the National Coordinator for Health Information Technology.
"Our goal is to deliver compelling products and services that support California hospitals, providers, and patients in their efforts to improve care coordination, reduce inefficiencies, address gaps in care, and enhance patient experience," said Williams.
The merger would create the largest health information exchange in the United States in terms of volume, eclipsing the Indiana Health Information Exchange and its 12 million patient records.
Cal INDEX was formed in 2014 with $80 million in seed money from Anthem Blue Cross and Blue Shield of California. Exchange participants include Dignity Health and St. Joseph Hoag Heath, which became its newest member in December 2016.
IEHIE includes four public health information exchanges that connect providers in 18 counties in the state. Participants include more than 50 hospitals and health systems including Dignity Health, Prime HealthCare, and Universal Health Services.
Gov. Jerry Brown is proposing a $122.5 billion state budget for fiscal 2018 that includes additional funding for Medi-Cal and would cut a program that provides managed care for dual-eligible Medicaid-Medicare beneficiaries.
In his budget address, Brown mentioned the uncertainty surrounding the Affordable Care Act and a potential repeal that could impact the state's Medi-Cal program, which has added more than 3.5 million new members through Medicaid expansion.
The proposed fiscal 2018 budget includes $800 million in additional spending to support growth in Medi-Cal, which now covers 14.3 million state residents, but has no contingency plan for potential cuts in federal funding for Medicaid expansion, which is financed through $15 billion in federal funds.
"We can't budget for something that hasn't happened yet," Brown told reporters at a news conference last week. "That's why we have to hang onto to our hat here. It's going to be a rough ride and we can't tell where we'll be in a few months."
Recent proposals in Congress have suggested major changes to the Medicaid program, but it's not clear what those changes will be and when they will take effect. The administration "stands ready to work within the fiscal constraints facing the state," Brown said.
The $122.5 billion budget represents a slight decrease from last year's $122.7 billion budget and reflects concerns about a potential shortfall in tax revenues for the last six months of 2017 that may total up to $2 billion.
Coordinated Care Phase-out
The budget proposes phasing out elements of the state's Coordinated Care Initiative (CCI)—a program launched in 2014 that provides managed care for dual-eligible patients along with long-term care—and eliminating a related In-Home Supportive Services (IHSS) program that provides funding to counties.
The net result of these changes is a General Fund reduction of $626.2 million in 2017-2018, according to budget estimates. The state is required to determine, on an annual basis, whether CCI is cost-effective.
If CCI is not cost-effective, "it ceases operation in the following year," the budget proposal notes. "The budget estimates CCI will no longer be cost-effective, even with the recent enactment of an allowable managed care tax.
Therefore, pursuant to provisions of current law, the program will be discontinued in 2017-2018."
Dual-eligible members
Some elements of the CCI program will be retained and the budget proposes to "extend the Cal MediConnect program, continue mandatory enrollment of dual-eligible members, and integrate long-term services and supports (except IHSS) into managed care."
Cal MediConnect launched as a three-year pilot program in 2014 to provide managed care for dual-eligible patients and currently has more than 114,000 members.
The proposal to phase out CCI would also end the state's IHSS Maintenance of Effort agreement and shift more costs for in-home services to counties.
The California State Association of Counties (CSAC) said the plan would shift more than $4.4 billion in costs from the state to counties over a six-year period with no additional revenue to cover those expenses.
"This would be devastating to counties all over the state," said CSAC President and Alameda County Supervisor Keith Carson. "We undoubtedly would have to make cuts to other vital social services to cover these costs."
Another proposed budget cut would eliminate $33.4 million in healthcare workforce funding that was allocated to address a primary care physician workforce shortage in California. The $33.4 million represents first-year funding for a three-year, $100 million program.
"Community health centers recognize that it's going to be a challenging year for healthcare in America, but we're alarmed to see the elimination of the state's investment in healthcare workforce funding," said Carmela Castellano-Garcia, president and CEO of California Health+Advocates.
"We are committed to working with the Legislature and the Governor to forge solutions that protect our state's most vulnerable communities."
A report from the California Department of Public Health (CDPH) shows that 85.4% of hospital employees received flu vaccines during the 2015-2016 flu season, a slight increase from 85% during the 2014-2015 season.
However, vaccination rates for non-employee healthcare personnel edged lower, at 66.1% compared to 66.4% in 2014-2015. The rate for volunteers and workers at hospitals was 78%, up from 77.2% in 2014-2015.
The report also found that 154 hospitals—or about 40% of hospitals in the state—reported employee vaccination rates that were higher than 90%. State health officials have established a 2020 Healthy People goal of having 90% of all hospital workers receive flu vaccines.
The rate of hospital employees receiving flu shots has started to flatten after rising sharply for several years. CDPH data shows the percentage of hospital workers receiving flu shots jumped from 67.8% of employees in 2011-2012 to 74% in 2012-2013 and to 81% in 2013-2014.
During that time, dozens of counties adopted mask policies that require employees who choose to not be vaccinated to wear a surgical mask at work during flu season.
The CDPH report found that 34 counties now have mask policies in place in hospitals, an increase from 31 counties during the 2014-2015 flu season. The report found that vaccination rates in counties with mask policies was 3 percentage points higher than in counties without mask policies and suggested that “local public health policy may be influencing vaccination coverage in California hospitals.”
The CDPH survey included responses from 316 hospitals in the state. Ninety-two percent of hospitals surveyed offer flu shots during all work shifts, including nights and weekends; and 79% provide flu vaccines using mobile carts that bring the vaccine to workers.
The survey also found that 96% of hospitals surveyed have mask policies for employees who choose to not be vaccinated.
