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Last updateTue, 18 Sep 2018 1pm

In a scramble to keep people enrolled in health-care plans, what did New Jersey, Vermont and the District of Columbia do earlier this year that California has not done?

They began requiring that their residents carry health coverage or face a state penalty for going without it. Such “individual mandates” aim to replace the federal mandate—perhaps the most controversial but essential part of the Affordable Care Act, often called Obamacare —that sought to force people to sign-up for health insurance or pay a tax penalty. The Republican Congress and the Trump administration have repealed that federal penalty, effective next year.

The clock is ticking. Obamacare has led to a record number of Californians having medical coverage. But a new study warns that if the state does nothing to counteract the Trump administration’s moves to undermine Obamacare, up to 1 million more Californians could be without health insurance within the next five years.

What’s kept California from enacting its own mandate? Some state Democratic leaders are wary of enacting a state mandate without also making health insurance cheaper for Californians.

“Providing subsidies is a better reality for members of our community than providing penalties,” said Assemblyman Joaquin Arambula, a Fresno Democrat who co-chaired the select committee on universal healthcare that conducted town halls across the state last summer. “It’s the carrot versus the stick.”

Sacramento State Sen. Richard Pan, a Democrat who chairs the Senate Health Committee, said the Legislature is focused on keeping the state’s insurance market exchange, known as Covered California, strong. Some 2 million Californians buy health coverage through the exchange, which provides federal subsidies to low-income purchasers.

“We are going to do what we can in California to stabilize the insurance market, to do what we can to make health insurance, particularly on Covered California, affordable,” said Pan, who has not yet endorsed any particular remedy. “We are up against a federal administration that is doing the opposite and forcing people to pay higher premiums.

“As we look at options—like do we want to do an individual mandate?—we also need to recognize part of what is driving that is not only the removal of the federal mandate, but also actions taken to increase insurance premiums,” said Pan.

Since the Affordable Care Act was implemented in 2013, the state’s uninsured rate has dropped from 20 percent to 7 percent. Currently, 3.4 million Californians are uninsured, with undocumented immigrant adults making up the majority of that group.

But without more aggressive state intervention to counter Washington’s retreat from the program, an estimated 500,000 to 800,000 more Californians under 65 will be uninsured by 2023, according to the new study from the UC Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research.

A mandate and state subsidies are among options the Legislature will be exploring to combat the expected exodus from insurance. But both are controversial. An Economist/YouGov poll found that 66 percent of Americans oppose a mandate. And although a few other states such as Vermont and Massachusetts do offer state subsidies, in California, state subsidies could cost up to an estimated $500 million, at a time when an incoming Democratic governor and Democratic supermajorities in the Legislature have promised pricey programs such as universal healthcare and universal preschool.

So far, Covered California enrollment, now underway through Jan. 15, is meeting projections—with a big caveat. As of the end of November, more than 90,000 newly insured people signed up, said Peter Lee, its executive director. But those projections already were lowered by 10 to 12 percent compared to last year, because it was unknown what effect the removal of the penalty would have on sign-ups.

“There’s no question that a penalty imposed on individuals for whom health insurance is affordable is a good policy,” said Lee, who said he would follow whatever rules the Legislature adopts. “The penalty encourages people to participate in a system that, if they don’t, we all bear the cost. And it encourages people to do the right thing for themselves.”

Covered California is working on a report commissioned by the Legislature on how to best bolster the system. It’s due in February, and Lee said a variety of options are on the table including a mandate, expanding subsidies and using state money to lower premiums, a process called reinsurance.

Some of those ideas echo the recommendations UC researchers offered in their study: incorporate a state mandate with penalty funds going to toward making insurance more affordable, state-funded subsidies in addition to the existing federal subsidies, and a Medi-Cal expansion to include low-income undocumented immigrants.

These are not new ideas, but they are politically and financially costly, said Gerald Kominski, a fellow at the UCLA Center for Health Policy Research.

“We know that the mandate drives people into the market,” said Kominski. “If you’re going to pay a tax penalty and not have health insurance, why not look for insurance when almost 90 percent of those who buy in through Covered California received some sort of subsidy?”

“The state could consider bringing the whole threshold down for everybody,” he continued. “The point is to lower the thresholds and make people pay less out of pocket. That would increase affordability for lots of families.”

Some advocates agree that a potential state mandate must also include a mechanism for making insurance more attainable.

“We don’t want to require people to buy coverage that they can’t afford. And what they can afford may be different in a high-cost-of-living state like California,” said Anthony Wright, executive director of Health Access, which advocates for consumers. “That’s why it’s hard to have a conversation about a mandate without affordability assistance.”

Under the federal mandate, Americans were compelled to carry health insurance or pay a penalty of $695 per adult, or 2.5 percent of household income, whichever is higher, unless insurance costs more than 8 percent of a household’s income.

With the repeal of that ultimatum, California is bracing for the biggest dropouts among its residents who have been buying insurance through the subsidized Covered California program. The program projects it could lose 10 to 30 percent of its participants.

But the state also expects wider losses, including among the 46 percent of Californians who get insurance through employers, because they also will no longer be required to have it. Even Medi-Cal, the state-paid program for low-income Californians, will lose about 350,000 people, the study estimates, because the lack of a federal mandate may deter people from seeking health coverage at all—meaning they’ll never discover they qualify for Medi-Cal.

Last year, the California Legislature considered creating a state mandate as part of budget discussions that included making insurance more affordable, but neither idea made it into the final budget proposal submitted to the governor.

Experts and advocates are hopeful that these ideas may gain traction under Gov.-Elect Gavin Newsom, who has talked a big game on health care and access pledging during his campaign to support single payer and universal coverage.

If more Californians drop their health insurance, everyone pays. People most likely to drop out are the young and the healthy, expert say. But they are critical to keeping the whole operation afloat, because the system cannot be made up of only sick people.

California already has taken steps to shore up the Affordable Care Act: banning short-term health plans, adopting legislation barring work requirements for Medi-Cal, and offering a longer open enrollment period.

CALmatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Politics

Many Republicans predicted that the Affordable Care Act, aka “Obamacare,” would send this country into utter chaos.

Of course, this didn’t happen. Nonetheless, there is murmuring among a few 2016 Republican presidential candidates that repealing the ACA would be one of the first things they’d do if elected. But in reality, the plan is working so well that it would be political suicide to try to repeal it at this point—and I am one of the millions of Americans who have benefited from the plan.

On July 3, 2014, I was diagnosed with a detached retina. A blow to the back of the head a week earlier and two subsequent airplane rides caused the injury. I was in South Bend, Ind., meeting my partner’s family for the first time, when I got the news. I was given a choice: I could have surgery in Indiana, and be forbidden to fly for six weeks (not an option), or fly home to Palm Springs as soon as possible and have surgery there. A detached retina is a serious situation, and time is of the essence, but since my retina was already completely detached, the doctor said a few days would not make much of a difference.

I was barely absorbing this information, since I was pretty much hysterical. Thank God for my partner, Eric, who calmly took control of the situation. It was after 5 p.m. on Thursday, July 3, the day before a major holiday. The office was closing up, and the janitor was vacuuming the carpet. Luckily, the ophthalmologist I had seen was kind enough to stay until we could make the arrangements. I will never forget the sight of Eric sitting on the floor, urgently trying to get through to someone in the Inland Empire Health Plan office in Palm Springs to set up an appointment ASAP. Fortunately, he got through.

We flew back to the desert on Saturday night, saw the IEHP folks on Sunday, and met with the surgeon on Monday; I had the surgery on Thursday, July 10. A series of miracles, to be sure.

My surgery—a vitrectomy—involved removing the liquid from the eye and inserting a gas bubble in the eyeball, which then pressed the retina back into place. The rehab is ghastly—six weeks of sleeping face-down on a special cut-out pillow—and keeping your head down at all times. Yes, at all times. That includes sitting, standing, walking, showering—everything, so that gravity can do its work.

I was a dutiful patient, and followed directions to the letter. Thankfully, the outcome was good: The vision in my left eye is at 99.9 percent, and will likely keep improving. Another miracle.

None of this would have happened if Eric and I had not received health insurance coverage from the Affordable Care Act, just two months before all this occurred. Eric and I are both professional performers, but we also have “job jobs” to pay the bills. He had just been hired to sell Steinways for SoCal Pianos in San Marcos, and I work part-time as the activities assistant at a local senior health care facility. Neither of us could afford health insurance before the advent of “Obamacare.”

In addition to my surgery, I had to fill five or six different prescriptions for eye drops (some of which I am still using more than a year later); go through cataract surgery the following January; and endure many, many follow-up appointments. My total out-of-pocket expense has been $30—to rush some lab work. Had I not had “Obamacare,” there is no question I would now be blind in my left eye. A friend of mine has a cousin who suffered a detached retina and did not have insurance. He lost his sight.

Of course, there are thousands of people like me who made it through catastrophic injury or illness because of the Affordable Care Act. Like 58-year-old Kathy Bentzoni of Slatington, Pa., who got a life-saving transfusion after being diagnosed with a rare blood disorder. Her previous insurance company called it a pre-existing condition and denied her coverage. Or 41-year-old Mike O’Dell of Kansas, who received a new heart after his heart developed an infection. His old health plan would not cover the $4,000 a month for anti-rejection medicine following the transplant.

Those who still disparage the ACA are ignoring the facts. According to a 2014 article in the Los Angeles Times, nearly 10 million previously uninsured people now have health care coverage because of the ACA. The nonprofit Rand Corp. indicates that fewer than a million people who had health plans in 2013 are now uninsured—and that’s because their plans were canceled for not meeting new standards set by the law. Fox News personality Juan Williams says half of those people can get better coverage for a lower price, and some will even get subsidies to help them pay for it. What the ACA basically did was put in place consumer protection so that health insurance companies could no longer take advantage of people by giving them crappy coverage.

It’s important to remember what insurance companies can no longer do because of the ACA: They can no longer cancel your policy if you get sick, deny you coverage or charge you more for a pre-existing condition, or impose lifelong caps on your health coverage. The ACA also mandates that your insurance company must pay for the ambulance ride if you are rushed to the hospital. Those are long-overdue, positive changes—so what’s all the fuss about?

So the next time you hear someone railing against “Obamacare,” think about the millions of people who now have access to healthcare who once did not. Think about Kathy Bentzoni and Mike O’Dell.

I will. And I will be filled with gratitude that I can today see a beautiful desert sunrise—with both eyes.

Published in Community Voices

Editor's Note: While the Independent has a policy against running press releases, we've agreed to run this piece from Covered California, as it contains important information about the availability of health insurance—which can be a life-changing situation. 

Despite the best-laid plans, life can sometimes throw you a curveball.

So it is with health care.

After months of planning, promotion and outreach, Covered California successfully completed its first open enrollment period of the historic Patient Protection and Affordable Care Act—helping more than a million consumers gain health insurance coverage.

Some people, however, may have had a change in life circumstances since open enrollment ended on March 31, and suddenly, they have a new need for coverage. If so, the door is not closed. They can still gain coverage through Covered California’s special-enrollment option.

“We continue to remind people that we still are open for business,” said Covered California executive director Peter V. Lee.

Through Nov. 15, 2014, consumers can sign up for health insurance as long as they do so within 60 days of a qualifying life event. The following circumstances are among the more common reasons that make someone eligible:

• They lose their health care coverage because they’ve lost or changed jobs.

• They lose their Medi-Cal coverage.

• They get married or enter a domestic partnership.

• They have a baby, adopt a child, or place a child in adoption or in a foster home.

• They move and gain access to new Covered California health insurance plans that were not available where they previously lived.

• They become a citizen, national or lawfully present individual.

For other examples that may qualify you for coverage through special enrollment, visit www.CoveredCA.com/coverage-basics/special-enrollment.

You must report changes and select a plan within 60 days of the qualifying life event to purchase a Covered California health insurance plan outside of open enrollment. Medi-Cal is available all year, however, and no qualifying life event is required to enroll in Medi-Cal.

If you have additional questions about whether you qualify for a special-enrollment period, you can call the Covered California Service Center at (800) 300-1506.

How do I avoid gaps in coverage?

You will need to plan ahead to avoid gaps in health coverage. It helps to know that in general, the start date for coverage depends on the date you enroll. If you enroll by the 15th day of the month, your coverage will start on the first day of the next month. If you enroll after the 15th day of the month, your coverage will start on the first day of the second month. For example, if you enroll on Aug. 13, your coverage will start Sept. 1. If you enroll on Aug. 16, your coverage will start Oct. 1. You can use this rule as a guideline to help plan your new coverage and avoid gaps.

(Note: If you go without coverage for three consecutive months during the year, and you don’t fall under an exemption permitting you to do so, you will be subject to a tax penalty.)

For most qualifying life events, the start date for coverage depends on the date you enroll, as described above, but there are a few exceptions:

• If you lose your Medi-Cal coverage, job-based coverage or other coverage, and you use a special-enrollment period, your coverage would start on the first day of the next month following your plan selection, regardless of when during the month you make your plan selection.

• If you get married and use a special-enrollment period, your coverage will start on the first day of the next month following your plan selection, regardless of when during the month you make your plan selection.

• If you have a child, adopt a child or place a child in adoption or foster care, and you use a special-enrollment period, your coverage starts on the date of the birth, the adoption or the placement for adoption or foster care.

• On a case-by-case basis, Covered California may start your coverage earlier.

Larry Hicks is the public information officer for Covered California.

Published in Community Voices

Michelle Brodeur makes regular trips to Mexico for her eyeglasses and contacts.

At 50, the self-employed graphic artist and writer is in good health. That’s a good thing, too, because Brodeur hasn’t had health insurance in nearly a decade—and her uninsured status isn’t about to change any time soon, despite the roll-out of the Affordable Care Act.

Brodeur, who earned about $23,000 last year, said she makes too much to qualify for free or reduced-cost Medicare or Medi-Cal, expanded under President Barack Obama’s signature health-care reform effort, dubbed “ObamaCare.” With insurance plans that she considers decent starting at roughly $175 per month for her, Brodeur said her premium would be too big of a financial bite.

So, Brodeur said she’s opting out.

“If it was $95 or $100 a month, I’d be able to manage,” said Brodeur, who lives in Palm Springs, where the median per-capita income is $36,627. “It’s a conundrum. I’ve not had insurance since I lost my job nine years ago.”

Early efforts to get people to sign up for insurance under the controversial law got off to a rocky start with lagging enrollment numbers, after much-publicized glitches at healthcare.gov. (California’s signup site, Covered California, at www.coveredca.com, worked much better, though it did suffer through some glitches.)

The fine for opting out this year is relatively small—$95, or 1 percent of a person’s income, whichever is greater. But the fine incrementally increases to $695 by 2016, or 2.5 percent of a person’s income. After 2016, the penalty is indexed to inflation.

Brodeur’s far from alone when it comes to opting out.

The UC Berkeley Labor Center estimated in a 2013 report that nearly 4 million Californians under the age of 65 this year will be eligible for health insurance, but will not get coverage. The reasons vary.

“Any time coverage has expanded in the past, it’s taken at least a few years for enrollment to scale,” said Laurel Lucia, a policy analyst at the University of California at Berkeley Center for Labor Research and Education. “As people figure out the system and the system improves, more people will get coverage.”

Some opt out simply because they do not qualify for Medi-Cal or the exchange subsidies. Others find the enrollment process confusing and cumbersome. About a million will be ineligible because of their immigration status. And roughly 400,000 Californians will find the exchanges, as Selena Solis has, unaffordable.

The 19-year-old Columbia College Hollywood student said she hasn’t decided whether she’ll get insurance or pay the fine.

“I’m still debating whether or not I should,” said Solis, who graduated from Palm Springs High School in 2012. “I work two jobs. I just can’t fit another bill into my budget.”

The Obama administration has struggled to sign up young invincibles like Solis. She’s a prized demographic, among the people age 18 to 34 who are relatively healthy and inexpensive to care for—and who are necessary for the pool to subsidize older enrollees.

“I understand that it’s for my own benefit, but what if it’s something I really just do not need at the moment?” Solis said.

Experts say about 40 percent of enrollees need to be young and healthy for Obama’s signature program to succeed.

In three months since the October roll-out, 23,417 Riverside County residents enrolled in the health-care exchanges, according to Covered California, which released a report in January. That number is 58 percent of the 40,377 the agency expects to enroll during open enrollment, which began Oct. 1 and ends March 31. Of the counties highlighted in the January report, only Fresno and San Bernardino counties had a smaller percentage of the uninsured enrolling compared to projections, with 47 percent and 45 percent, respectively.

“We are focusing in a regional campaign to increase those numbers in those counties,” said Edith Lara-Trad, a Covered California spokeswoman. “The good news is that we have (more time) to work on this.

“We are very confident that we are going to reach those numbers.”

Latinos, African Americans and the young are being targeted for the agency’s outreach and education efforts, Lara-Trad said.

In the first three months of the enrollment period, more than 500,000 people statewide—86 percent of the six-month projection—had enrolled in plans through Dec. 31, the agency reported. 

Covered California is the state’s health-care marketplace, created under the Affordable Care Act to offer coverage to the uninsured.

The Congressional Budget Office estimates 6 million Americans will pay the opting-out penalty in 2016. It is unclear how many will elect to pay the fine this year.

An estimated 48 million Americans—or nearly 16 percent of the nation—were uninsured in 2012, according to the U.S. Census Bureau.

In California, an estimated 7.3 million people—or roughly 19 percent of Californians—were uninsured, according to a 2012 report by the California HealthCare Foundation.

Signed into law by Obama in 2010, the Affordable Care Act was enacted to insure more Americans and lower skyrocketing health-care costs. It represents a significant overhaul of the U.S. health-care system, the first since 1965 with the passage of Medicare and Medicaid.

“It’s a shitty system. I understand what they’re trying to do. I just wish it had been a single-payer (system),” said Brodeur, referring to a health-care system paid for by the government rather than private insurers.

“They did it wrong, in the spirit of compromise.”


About the penalty

For the Affordable Care Act to work, it requires everyone who can afford health insurance to purchase health insurance. Those who don’t will face a penalty.

In the first year, the penalty is $95 per adult and $47.50 per child, or 1 percent of the yearly household income, whichever is greater.

That fine jumps incrementally over the next two years, to 2 percent, or $325 per person in 2015; and 2.5 percent, or $695 per person, in 2016. After 2016, the penalty is adjusted for inflation.

If you happen to be uninsured for part of the year, one-twelfth of the penalty applies to each month you’re not covered.

After open enrollment ends March 31, no one will be able to get health coverage through the marketplace until the next annual enrollment period, absent a qualifying life event such as moving to a new state, getting married or divorced, or having a child.

Source: healthcare.gov


By the Numbers

The Affordable Care Act was an ambitious and historic piece of legislation signed into law in 2010 to extend health insurance to uninsured Americans in 2014. In California, officials estimate the new law, which requires individuals to purchase or otherwise acquire health insurance, will lead 4.6 million people to enroll.

Here’s a look at the uninsured and enrollment in California:

  • About 7 million Californians were uninsured in 2013.
  • 6.4 million Californians received Medi-Cal insurance in 2013.
  • More than 1.6 million Californians have signed up for coverage via Covered California, Medi-Cal or Medicare through Jan. 31.
  • Young invincibles are enrolling at a rate of about 26 percent. Healthy 18 to 34 year olds represent about 25 percent of the state’s population.
  • Latino enrollment statewide is about 28 percent. Even still, two-thirds of Latinos are estimated to remain uninsured, although they will comprise roughly 45 percent of the state’s population in 2020. Latinos remain a key demographic because people of color are more likely to be without health insurance.

Source: Covered California, UC Berkeley Labor Center, Kaiser Family Foundation.

Editor's note and correction: A previous version of this story said that plans for Michelle Brodeur started out at $175; actually, basic plans for Brodeur would start out at around $75. Brodeur researched a variety of health care plans with differing salary ranges through Covered California, looking for the best deal. The $175 monthly premium she found was the amount she most readily recalled, not the cheapest plan. Having recently again gone over her options, Brodeur said she will still opt out of purchasing a health care plan through the exchanges in 2014.

Published in Local Issues