Will California become the first state in the U.S. with single-payer health care? State lawmakers are considering S.B.562, the Californians for a Healthy California Act. Introduced in February 2017 by Senator Ricardo Lara (D, Bell Gardens) and Senator Toni G. Atkins (D,San Diego), the bill would create a single-payer system in California, although the details of the financing and coverage specifics have not yet been finalized.
California residents voted on two healthcare-related propositions in November 2016: Proposition 61, The California Drug Price Relief Act, did not pass (it would have prohibited state agencies from paying more for any prescription drug than the lowest price the U.S. Department of Veterans Affairs pays for the same drug). But Proposition 56 passed, increasing the per-pack cigarette tax from $0.87 to $2.87; a majority of revenues are slated to fund health care for low-income Californians.
California’s state-run exchange, Covered California, is widely regarded as one of the most successful established under the Affordable Care Act. During the 2017 open enrollment period, 1.56 million people enrolled in private plans through Covered California, including 412,000 enrollees who are new to the exchange. Residents can also enroll in Medi-Cal (Medicaid) through Covered California; MediCal enrollment has grown by 57 percent since 2013, thanks to the ACA’s expansion of Medicaid.
The Golden State is one of only nine states where at least three insurers in each county are offering plans for 2017 through the exchange. About one-third of U.S. counties have only one carrier option in 2017. Rates for health insurance plans sold on Covered California increased by an average of 13 percent for 2017. Nationwide, rates jumped an average of 25 percent (both of those numbers are pre-subsidy; the ACA’s premium subsidies mitigated all or part of the rate increases for low and middle-income enrollees).
California health ratings
America’s Health Rankings, compiled by the United Health Foundation, ranked California 16th overall in 2016, the same spot the state held in 2015. Air pollution, pertussis, and disparity in health status by education level are the state’s biggest public health challenges. But the state has a low incidence of tobacco use, preventable hospitalizations, and infant mortality.
By comparison, the Commonwealth Fund’s Scorecard on State Health System Performance 2015 placed California 23rd in its most recent rankings. While the majority of the state’s health indicators had relatively middle-of-the-road placement, the state fared poorest when it came to:
- Adults ages 50 and older who received recommended screening and preventive care (#51)
- Children with a medical home (#50)
Noteworthy performances were a 10th place ranking for individuals under age 65 with high out-of-pocket medical costs relative to their annual household income and a 6th place ranking for children who received recommended vaccines. And California improved on 11 metrics (compared with the 2014 scorecard), while only worsening in two areas. See California’s Scorecard for additional scoring and details.
The 2016 edition of Trust for America’s Health also evaluates a variety of public health indicators. Visit the site for Key Health Data About California.
Given California’s size and diversity, a statewide view might not provide the level of information you want. Get county-by-county health rankings for California, which were developed by the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
2017 health insurance rates and carriers
While California’s exchange has more carrier options than many others, rates increased more in 2017 than they had in any of the years since the exchanges were implemented in 2014. Covered California announced July 19, that the statewide average rate increase for 2017 plans would be 13.2 percent. When this increase is averaged with 2015 and 2016, the three-year average is 7 percent, which is lower than the average pre-ACA annual increase.
The following 11 carriers offer coverage through Covered California in 2017:
- Anthem Blue Cross of California
- Blue Shield of California
- Chinese Community Health Plan (only San Francisco county and San Mateo county)
- Health Net
- Kaiser Permanente
- A. Care Health Plan
- Molina Healthcare
- Oscar Health Plan of California
- Sharp Health Plan (only San Diego county)
- Valley Health Plan (only Santa Clara County)
- Western Health Advantage (only North Bay area and Greater Sacramento)
Each county has at least three carriers from which to choose during 2017 open enrollment.
How has Obamacare helped California?
California embraced healthcare reform, creating a state-based exchange and expanding Medicaid. And, following the 2014 ACA open enrollment period, the state saw its uninsured rate significantly decline. According to U.S. Census data, the uninsured rate in California dropped from 17.2 percent in 2013, to just 8.6 percent in 2015.
HHS reported that 3,826,000 California residents gained coverage as a result of the ACA, between 2010 and 2015. That number has continued to increase since 2015, however, and ACA Signups reports that more than 4.9 million people in California could lose coverage if the ACA is repealed (a GOP replacement for the ACA would provide coverage for some of those people — assuming it could get enough votes to be enacted — but all of the GOP proposals would cover fewer people than the ACA).
Covered California has also helped Californians lower their prescription medication costs. In 2016, the state exchange rolled out a cap on prescription costs. Available to consumers purchasing off-exchange plans as well, the cap is linked to the metal level of the plan purchased and is $250 per specialty medication per month for the majority of consumers.
Californians’ enrollment in qualified health plans
Covered California reported that 1,414,668 individuals signed up for qualified health plans (QHPs) during the 2014 open enrollment period. Of that 1.4 million, about 1.1 million individuals paid their premiums and had their coverage take effect.
During the 2016 open enrollment period, there were 439,000 new private plan enrollees through Covered California. As of March 31, effectuated enrollment stood at 1,415,428. Of these enrollees, 87.6 percent were receiving premium subsidies that averaged $309 per month.
During the 2017 open enrollment period, 1.56 million people enrolled in QHPs through Covered California, including 412,000 new enrollees.
California and the Affordable Care Act
The Affordable Care Act was signed into law in March 2010. California’s Congressional delegation voted along party lines. Both Democratic senators voted yes, as did 34 Democratic representatives. Nineteen Republican representatives voted “No.”
At the state level, legislators moved quickly to pass bills in support of a state-based marketplace – making California the first state to do so. Former Gov. Arnold Schwarzenegger, Republican, signed both the Assembly and Senate bills into law on September 30, 2010.
Current Gov. Jerry Brown, a Democrat, called a special session in late 2012, enabling additional legislation to implement the ACA in California.
California embraced Medicaid expansion in addition to implementing a state-run marketplace. Expanding Medicaid eligibility to include nearly all non-elderly adults with incomes at or below 138 percent of poverty is one of the ACA’s main strategies to reduce uninsured rates. Between October 2013 and November 2016, California’s Medicaid enrollment increased by about 4.5 million people, or 57 percent.
California Medicaid is called Medi-Cal and is the largest Medicaid program in the nation, covering 12.2 million people as of November 2016. Since 2013, Medi-Cal enrollment has increased 57 percent, the ninth-highest percentage enrollment change in the nation.
To learn more about California’s Medicaid program visit the California Department of Health Care Services. Note: California’s Children’s Health Insurance Program (CHIP) was previously known as Healthy Families. In 2013, California transitioned Healthy Families enrollees to Medi-Cal.
Does California have a high-risk pool?
Prior to the ACA’s reforms in the individual health insurance market, medical history was a factor in eligibility for private plans in nearly every state, including California. Applicants with pre-existing conditions were often unable to buy individual plans in the private market, or if coverage was available it came with a higher premium or with exclusions on pre-existing conditions.
The California Major Risk Medical Insurance Board (MRMIB) was created in 1991 to provide a coverage option for people who were ineligible for coverage under a private plan because of medical history.
Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This change largely eliminated the need for high-risk pools, since pre-existing conditions are no longer a barrier to obtaining coverage.
The California Budget Act of 2014 included a provision for MRMIB to cease operations as of July 1, 2014. Most of the MRMIB insureds had already been able to obtain coverage through the exchange or expanded Medicaid, but remaining members were transitioned to the California Department of Health Care Services on July 1.
Medicare in the state of California
Eighty-six percent of California Medicare recipients qualify based on their age alone, while 14 percent are on Medicare as the result of a disability.
Medicare Advantage plans offer additional benefits to Medicare-eligible individuals who want them. Medicare beneficiaries may select a Medicare Advantage instead of Original Medicare, and 39 percent of California’s Medicare beneficiaries were enrolled in Medicare Advantage in 2016. Nationwide, 31 percent of Medicare recipients are enrolled in Medicare Advantage plans.
Health reform legislation in California
Here’s a summary of recent legislative action regarding healthcare reform at the state level in California:
- SB4 – The California Senate passed SB4 in early June 2015, the Assembly in September, and on October 9, 2015, Gov. Brown signed it into law. The legislation, renamed the Health for All Kids Act, focuses on Medi-Cal access for undocumented immigrant children under the age of 19. SBF will take effect in May 2016, and it has been estimated that 170,000 undocumented immigrant children will then become eligible for Medi-Cal based on their household income alone.
- SB10 – This bill was introduced in 2015 and was signed into law by Gov. Brown in June 2016. It would have allowed undocumented immigrants to purchase unsubsidized coverage in the exchange, but the state needed a waiver from HHS in order to implement the law (the ACA does not allow undocumented immigrants to purchase coverage in any state’s exchange, even if they pay full price). California submitted a waiver proposal to HHS, but ultimately withdrew the waiver two days prior to President Trump’s inauguration. California State Senator Ricardo Lara (D, Bell Gardens) had introduced and championed SB10, but he requested that the waiver proposal be withdrawn (and Gov. Brown agreed) because the state was concerned that the Trump Administration could use information from the exchange to deport undocumented immigrants.
- AB339 – Signed into law in October 2015, this bill applies to all non-grandfathered individual and small group plans in California. It limits the copayment for a 30-day supply of any medication to no more than $250. It took effect January 1, 2017, and will last until January 1, 2020. For high-deductible health plans, the copay limit will apply after the deductible has been met (Covered California already implemented a similar restriction, starting in 2016).
Other California state-level health reform legislation includes: