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Sustaining and Extending Health Care Reform: Perspectives on the ACA from California



February 28th, 2012

GrantWatch Blog invited E. Richard Brown, a professor at the University of California, Los Angeles, School of Public Health, to report some highlights from a February symposium on health reform.

“Health care reform is not self-implementing,” said Peter Long, president and chief executive officer (CEO) of the Blue Shield of California Foundation, as he led off the UCLA Center for Health Policy Research’s recent symposium on “Sustaining and Extending Health Care Reform.” Some 290 people attended the event; the audience included policy staff and advocates, as well as researchers. Long captured the message of all of the symposium speakers who emphasized the opportunities and challenges in developing policies aimed at getting all eligible people enrolled in coverage that meets their needs for affordable, high-quality health care and improves their health.

During one panel discussion, Anthony Wright, executive director of Health Access of California, a large consumer advocacy coalition, noted that the Affordable Care Act is not only the largest expansion of health care coverage in more than a generation. It is also the largest advance ever in creating a patients’ bill of rights, because it puts a national floor under protections that will help people get and keep affordable coverage, he said. The Affordable Care Act also at least attempts to make patients the focal center of health care services. But getting there will require forceful leadership to go up against powerful interest groups and a political system that they dominate, he explained.

Kimberly Belshé, one of five governing board members of the new California Health Benefit Exchange, emphasized that the exchange has a short timeframe in which to develop a consumer-centered process with “no wrong door.” (Belshé was secretary of the California Health and Human Services Agency from 2003 to 2010 and is now a senior policy adviser at the Public Policy Institute of California.) By January 1, 2014, the exchange must be ready to enroll adults and children in private health insurance and public programs, provide them subsidies if they are eligible, and ensure that they can readily access health services that they need. The California legislature, as in about half the states that have established exchanges thus far, gave the exchange the power, and a mandate, to be an “active purchaser” of health insurance by selectively contracting with health plans that meet its standards.

Achieving Kim Belshé’s vision would require converting the current system to one with a new mission—to get everyone into affordable, high-quality coverage, and this will require monumental changes in private health insurance and Medicaid alike, each of which will provide about half the national gains in coverage. Medicaid eligibility and enrollment processes were designed almost fifty years ago, mainly to keep out adults who did not fit one of the narrow federal welfare categories—extremely poor adults who were in a family with dependent children, or those who were disabled or older than age sixty-five.

The Affordable Care Act turns that orientation on its head. California’s Health Benefit Exchange must now create a new user-friendly system that welcomes all and ensures that they are enrolled in affordable coverage that meets their health care needs, whether it’s the Medicaid program (Medi-Cal) or private health insurance. Unfortunately, the Affordable Care Act prevents state exchanges from serving undocumented immigrants; in California there are two million undocumented people, more than half of whom are uninsured. Their care will be left to their own resources and overburdened local health care safety nets.

The big change required from Medicaid will have to be concurrently matched by a transformation of the current private health insurance market for individuals and small groups, an unfriendly and largely “caveat emptor” environment. The Affordable Care Act and California state implementation legislation make clear that the exchange is expected to create a regulated marketplace designed to protect consumers from high-cost, low-value health plans. The exchange’s active purchaser powers enable it to begin transforming this marketplace. In addition, an initiative that is likely to be on the California ballot in November would give health insurance regulators the power to set rates.

All of the speakers at the symposium emphasized the important and necessary changes that the Affordable Care Act has set in motion, and also the immense challenges that face those charged with implementing it, particularly at the state level. The changes attempt to modify coverage and health service delivery incentives that now strongly favor the interests of insurers and providers, changes that will require these actors to pay closer attention to the needs of patients, improve health outcomes, and be more affordable. The challenges are the vested interests of those insurers and providers and the clout they wield in health policy.

Diana Bontá, president and CEO of the California Wellness Foundation, and Robert M. Kaplan, director of the National Institutes of Health’s Office of Behavioral and Social Sciences Research, both emphasized at the symposium that the Affordable Care Act’s larger goal is to improve the health of the population and reduce social disparities in health outcomes. Improving population health will require more than the clinical preventive services that the federal health reform law now makes more accessible. More fundamentally, it requires broad social policies that promote healthy eating and active living through policy changes and that reduce inequalities in income and wealth through redistributive policies.

Editor’s note: The symposium honored the work of the UCLA Center for Health Policy Research, as well as the work of E. Richard Brown, founding director emeritus of the center, who wrote this post.

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1 Response to “Sustaining and Extending Health Care Reform: Perspectives on the ACA from California”

  1. sonyaschwartz Says:

    Hi Rick, It was great to hear that UCLA (my alma mater even if I did attend the law school!) had such an exciting and inspiring forum related to health reform implementation. So glad you shared it through the blog or I would not have known about it.

    I am so focused on state implementation that I forget that some people out there don’t realize how critical the state role is in health reform, or how much work states really need to do if they want to get it right.

    I don’t know if you’ve seen it, but NASHP has set up a roadmap for states — with 109 steps toward implementation — on statereforum.org, and California is making great progress so far, but there’s still a long road to 2014. Here’s the link to the California page: http://www.statereforum.org/states/ca

    Best, Sonya

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