Nadereh Pourat, Director of Center for Research (UCLA), is the author of two recent policy briefs examining the likely beneficiaries of health care reform in California. Dr. Pourat looked at those likely to be eligible for both the new California Health Benefit Exchange program and the expansion of Medi-Cal. Up to 4.6 million residents may gain coverage, with many of them being working-age, single men. Here Pourat talks about how those numbers might change, how both programs can be improved, and how we should all start preparing now for implementation in 2014.
Q: The Center studies estimate up to 4.6 million Californians may be eligible for coverage under health care reform. However, this may change. Can you explain the processes in motion that may affect the final tally?
Dr Pourat - The final number of eligible and participating individuals will depend on the actions of health insurance plans, employers, state governments and individuals. Health insurers may raise premiums prior to, or even after, the passage of the law. Employers, particularly smaller ones, may opt to pay the penalties rather than pay for health insurance for their employees. State governments have to decide on whether and how to implement the Health Benefit Exchange or Basic Option and how to coordinate enrollment with the Medicaid programs. And ultimately, individuals may not choose to participate in the Exchange or enroll in Medicaid despite the individual mandate.
Q: Medi-Cal and the California Health Benefit Exchange program estimate income and eligibility differently. What effect does this have and how might it be streamlined?
Dr Pourat - Currently, Medi-Cal determines eligibility based on monthly income. The Exchange determines eligibility based on annual income. This is a problem because many individuals' income changes throughout the year dramatically, including seasonal workers and the self-employed. As a result, they could lose Medi-Cal eligibility for some months in a given year. The eligibility and enrollment process has to be coordinated so that no one is left uninsured for part of the year because of different enrollment and eligibility determination processes.
Q: What steps can California take now to prepare for 2014?
Dr Pourat - California has already passed legislation and begun the implementation process in preparation for 2014. The California Health Benefit Exchange program has been created and the Exchange board has begun meeting. California has also used the recent 1115 Medicaid Waiver to create the Low Income Health Program (LIHP) to provide coverage for low-income individuals, many of whom will be Medi-Cal eligible by 2014. The program is implemented at the county level and allows counties to use federal funds to supplement county funds for providing health care. This program paves the way for reform by determining programmatic and health care delivery approaches that are likely to have the biggest impact on individuals' health for the lowest expenditures. It is hoped that this program may reduce the initial pent-up demand on the system after ACA implementation.
In the long term, we should also be thinking about system-wide key challenges of implementation including shortage of primary care physicians, who are the cornerstone to the delivery of low-cost but effective primary care; reducing waste and duplication of services; and ways of engaging patients in better self-care.