Memo to Washington: Lessons Learned From California's Obamacare Rollout

At the same time that California was releasing its latest enrollment numbers under Obamacare on Wednesday morning, advocates, experts and government officials at all levels gathered in Washington, D.C. to talk about … the Affordable Care Act in California.

Certainly, the rollout of Obamacare in the state has not been without its challenges and yet -- California has 12 percent of the nation's population and nearly 25 percent of all sign-ups nationwide. In addition to the more than 800,000 people currently enrolled in California, another 877,000 Californians are likely to be eligible for Medi-Cal. That's on top of another 652,000 people who transitioned to Medi-Cal from the Low Income Health Program (more on that in a minute). That's well over 2 million people total.

Diana Dooley, secretary of California's Health and Human Services Agency, wasn't about to gloat. "California is certainly not ready to put up a mission-accomplished banner," she noted. But there was a lot of respect for California -- and a desire to learn -- from those in the room at the briefing.

Low Income Health Program Was Key 

While it's been quite underreported, the Low Income Health Program (LIHP) is one pillar of the ACA's success in California. Toby Douglas, director of California's Department of Health Care Services, said they "thought it was a stretch goal" to enroll 500,000 people in 2010 when the state began implementation of the program.

Despite concerns that the transition from LIHP to Medi-Cal would be bumpy, it "really was a smooth transition," said Dr. Mitch Katz, director of the Los Angeles County Department of Health Services. Katz said that adding people into LIHP over several years, instead of all at once into Medi-Cal on Jan. 1, made for a much smoother expansion of Medi-Cal.

Linked to the Medi-Cal expansion is the importance of changes to the delivery system. "Insurance is not health care," Katz said. "We still want to leave people feeling cared for. That's a huge change for Los Angeles, which traditionally has had an episodic, emergency room-driven" system of providing health care.

Several speakers talked about moving people into primary-care medical homes -- as happened to enrollees in the Low Income Health Program, Douglas said -- to better coordinate their care.

Challenges Remain

While acknowledging the state's successes, Anthony Wright of Health Access pointed to what he thinks are the challenges that remain: undocumented immigrants who are not eligible for ACA benefits; people earning more than 400 percent of poverty and not eligible for subsidies, but above 10 percent of income to pay for health insurance; and the "kid glitch" -- those with employer-based health insurance who are exempt from subsidies to cover their children but can't afford insurance for dependents.

"I wish the conversation would change to trying to make the system work for everybody," Wright said.

Rachel Garfield, senior researcher with the Kaiser Family Foundation, presented findings about California's uninsured. More than 2,500 adults were interviewed in the weeks leading up to the opening of the Covered California marketplace on Oct. 1, 2013 -- and the foundation plans to follow the people they surveyed to assess how the ACA changes how people use the health care system and to track what happens to people who remain uninsured, despite the ACA.

Of adults under 65 who are uninsured:

• 52 percent have income less than 138 percent of the federal poverty level (the cutoff for the Medicaid expansion)
• 52 percent are Hispanic
• 64 percent are U.S. citizens and another 17 percent are legal immigrants

In addition, 67 percent had no preventive care visit in the past year -- yet 30 percent have an "ongoing health condition" or take a medication on a regular basis.

Presumably at least some of those uninsured have since enrolled in coverage, either Medi-Cal or Covered California, but still, Garfield noted, they need help to "navigate the health care system."

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