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ACA Blog: The Obamacare Roll-Out in California

October has been a roller coaster of health access-related news stories mixed in and muted by the political gamesmanship over the ACA that led the federal government to come to a halt for over two weeks. Now that we can stop being distracted by the government shut down, we can turn our attention squarely back to the biggest health policy change in a generation and its implications for California families.

1. Are the numbers good news or bad news?

Everyone is looking for some indication about whether the big rollout is a success or a disappointment, so eyes are on the numbers. The first numbers out of the gate were big: California’s marketplace, Covered California, got over 1.5 million hits in the first two weeks of implementation, more than any other state marketplace except New York. Which seems like good evidence that there is plenty of demand for health insurance in our big state.

After a wave of media attention about glitches with the online system, Covered California changed its initial data release plan and began reporting weekly enrollment numbers. In its first week, 29,000 individuals had enrolled. Not to sound greedy, but while they’re sharing these impressive numbers, I hope we will also get detail about those applications and new enrollees. Like how many applications are successful? How does that rate compare by region, by language, by race, by income, by family type? Covered California is surely tracking all that, and we look forward to being able to dig into the numbers. Until they do, it’s hard to know what the numbers really mean.

2. Obamacare’s patchwork quilt

As people get to know the law more, they’ll begin to appreciate that Obamacare is not a single program but rather a patchwork of programs and initiatives. The pieces of the quilt rely on one another for the whole to work properly. For some families, the approach will work fine; others will see the seams.

The two big components of the ACA are the Medicaid (Medi-Cal in California) expansion and private health coverage available through marketplaces, like Covered California. The straight-forward scenario is when all members of a family enroll in a Covered California plan, or all members of the family qualify for Medi-Cal.

But because there are different income thresholds for children and adults for these programs, some families will have adults covered by Covered California and children in Medi-Cal. These “mixed case” families represent a challenge to the agencies that administer the programs.  Medi-Cal is run at the local level by county social services agencies, whereas Covered California is a separate, quasi non-governmental agency. (Families with different immigration statuses present yet another challenge.)

Counties and Covered California are working hard behind the scenes to make this distinction as invisible to applicants as possible, but these families should expect some amount of bouncing back and forth between the two systems. Counties report that they’re already heard from callers who are confused about why their calls have been transferred to the county – and want to be transferred back to Covered California.

According to the UC Berkeley Labor Center, there will be more Medi-Cal than Covered California enrollees when all is said in done. So it is somewhat surprising that we haven’t heard much about how Medi-Cal applicants are faring compared to Covered California applicants. Maybe this implies that the quilt is holding together. Or maybe stories about low-income families’ access to the system hasn’t gained attention amid all the other news flying around.

3. Some families are left out

California is a generous, health-access conscious kind of state, which is why it went forward with expanding Medicaid and building its own marketplace, unlike many states. In those states, there is no Medicaid program for poor adults, though coverage is available to those adults whose income is equal to the federal poverty line or above, through the federally-run marketplace. So a parent who works at a fast-food restaurant will likely earn insufficient wages to make her eligible for subsidized coverage through HealthCare.org, and she has no good options for health coverage.

In California, that is not the story. All citizens, regardless of their income, qualify for some health access program. Thanks to the Governor and legislators, even recent legal permanent immigrants can get care though a state-funded program. But undocumented families are not eligible for coverage at all as they are excluded from coverage, with very few exceptions. The quilt does not cover them.

Research suggests there are over two million undocumented immigrants in California, one of the states with the highest rates of such immigrants. Governor Brown has recently demonstrated his understanding of the needs of this group of Californians by signing a number of laws that benefit them. Undocumented immigrants, like everyone, need access to health care, and they are likely to stay and grow old in California. Don’t they need to be woven into the quilt at some point?

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