Updated April 9, 4:05 p.m.
Patient advocates and a handful of lawmakers rallied on the steps of the Capitol in March to push a universal health care agenda they hope will bring the state closer to getting everyone insured.
Democratic Sen. Richard Pan says it all comes down to cost.
“We can’t tell people ‘you have to have insurance’, but not make it affordable,” he said. “There’s been tremendous work done in the legislature to try to see what we can do about affordability. We’re going to be sure that we continue to push that forward this year.”
A group called the Care4All California coalition unveiled a package of 21 bills that aim to either lower the cost of care, or get more people into the insurance market. Big-ticket items include expanding Medi-Cal eligibility to everyone regardless of status and imposing an individual mandate that would penalize people for not carrying insurance. Other bills address everything from drug pricing to emergency room costs.
The concept of single-payer —one government health plan for all Californians — isn’t on the list, though Gov. Gavin Newsom has said numerous times he wants to move the state in that direction
But everything has a price tag. And while Newsom seems gung-ho about improving health programs, Department of Finance spokesperson H.D. Palmer says it’s a balancing act. He points out that ambitious health care agendas have historically ended in cuts.
“Those program expansions were built on revenues that were thought to be ongoing in nature but turned out to be very short-lived,” Palmer said. “He doesn’t want to do that again.”
There are a few ways the state can pay for major changes. Scott Graves, director of research for the nonpartisan California Budget and Policy Center, says policymakers could use revenues from the General Fund without a tax increase, as they did when they expanded Medi-Cal to undocumented children in 2016.
Or they can go to revenue sources that generally rise over time, such as a personal income tax, a sales tax or a corporation tax. He says revenue sources that decline over time, such as tobacco taxes, are less effective at funding ongoing costs.
According to the Legislative Analyst’s Office, the general fund can absorb about $3 billion in new ongoing spending before shortfalls arise. The budget the governor proposed in January includes $2.7 billion in that category.
Here’s what lawmakers would like to see happen:
Introduced by Sen. Maria Elena Durazo (D-Los Angeles) / Asm. Rob Bonta (D-Oakland), David Chiu (D-San Francisco), Miguel Santiago (D-Los Angeles)
These bills would extend Medi-Cal eligibility to all income-eligible adults regardless of their immigration status. The state’s Legislative Analyst’s Office estimated last year that doing so would cost almost $3 billion. It would be a significant addition to the $20.7 billion in general fund money the state is expected to spend on Medi-Cal in the 2018-2019 fiscal year. Gov. Gavin Newsom has instead advocated for expanding eligibility only to undocumented people age 19 through 25 for an estimated $250 million. Undocumented children up to age 18 are already eligible.
Introduced by Asm. Cottie Petrie-Norris (D-Laguna Beach)
This bill would make it easier for eligible children and pregnant women in the federal Women, Infants, and Children program to enroll in Medi-Cal.
Introduced by Sen. Melissa Hurtado (D-Sanger)
This bill would require health plans to send notices to people who lose their coverage for any reason, and to inform them about Medi-Cal and Covered California. Plans must also provide a list of people who lost coverage to Covered California so the exchange can contact those who lost coverage directly. Hurtado says the bill will reduce coverage gaps when people’s income or other life circumstances change.
Asm. Rebecca Bauer-Kahan (D-Orinda)
This bill would extend the application period for Covered California by two weeks. Starting in 2018, most federally administered exchanges created under the Affordable Care Act shifted to a shortened enrollment period ending Dec. 15. In California, consumers have until Jan.15. This bill extends the deadline to Jan. 31.
Introduced by Asm. Petrie-Norris (D-Laguna Beach)
Federal waivers allow states to find new ways to improve health care in exchanges created under the Affordable Care Act. Last year, the Trump administration began allowing state exchanges to apply for waivers without explicit state legislative authority. Under the looser rules, health advocates are worried states will try to offer coverage that undermines the Affordable Care Act. Health Access and the Western Center on Law and Poverty are sponsoring the bill, which would prohibit Covered California from applying for a waiver without approval from the Legislature and the governor.
Making Insurance Cheaper
Introduced by Asm. Jim Wood (D-Santa Rosa) / Sen. Richard Pan (D-Sacramento)
These bills both would require Covered California to provide more financial help to low-income residents buying health insurance. Assembly Bill 174 would establish a tax credit beginning in 2020 for individuals who currently earn between 400 and 600 percent of the federal poverty level, or more than $48,000 a year for an individual and more than $100,000 a year for a family of four. These families are not currently eligible for Affordable Care Act tax credits. The Senate bill would require Covered California to implement premium contribution limits, while also reducing copayments and deductibles for people with incomes between 200 and 400 percent of the federal poverty level.
Introduced by Sen. Richard Pan (D-Sacramento) / Asm. Bonta (D-Oakland)
Both of these bills would establish an individual insurance mandate, including a state-level penalty for people who don’t carry health insurance. It would replace the federal fine that disappeared beginning this year. Covered California would determine the penalty and who would be exempt. Gov. Gavin Newsom wants to use revenue from the fine to fund subsidies in Covered California. He anticipates it will generate $500 million a year.
Introduced by Asm. Wood (D-Santa Rosa)
Currently, seniors who earn more than about $15,000 a year and are enrolled in the Medi-Cal Aged and Disabled program must pay a monthly out-of-pocket fee for medical services, even though most adults who earn up to roughly $17,000 a year have free Medi-Cal. This bill would reduce the number of seniors who have to pay the fee by raising the maximum income level for the Medi-Cal Aged and Disabled program to $17,000.
Introduced by Asm. Wendy Carrillo (D-Los Angeles)
Seniors in the Medi-Cal Aged & Disabled program are currently restricted to $2,000 in a bank account, or $3,000 for couples, because of something called the “assets test.” These types of restrictions were eliminated for most other Medi-Cal enrollees under the Affordable Care Act. Senior advocates say the rule requires seniors to deplete their assets in order to be eligible for health coverage, and that it disproportionately affects seniors of color. The bill would raise the limit to $10,000 for an individual, exclude certain items from the assets test, and eliminate the test for Medicare Savings Programs.
Introduced by Asm. Wood (D-Santa Rosa)
This bill affects seniors who are enrolled in both Medicare and Medi-Cal. These seniors sometimes lose their Medi-Cal coverage when the state begins paying their Medicare Part B premiums, because those payments bump them above the Medi-Cal income eligibility threshold. Wood’s bill would make it so the Medicare payment is not counted as income.
Combating Health Disparities
Introduced by Asm. Kansen Chu (D-San Jose)
This bill aims to improve translations in the Medi-Cal program. It would require the Department of Health Care Services and Medi-Cal managed care plans to review translated materials for Medi-Cal beneficiaries for accuracy, cultural appropriateness and readability.
Introduced by Sen. Holly Mitchell (D-Los Angeles)
The state’s health department is currently required to maintain a maternal and child health program, and the Office of Health Equity must track ethnic and racial health statistics on infant and maternal mortality, among other issues. This bill would require hospitals, birth centers and clinics that provide perinatal care to implement an implicit bias program for all providers, in an effort to reduce racial disparities. The providers would have to complete training at the outset, and a refresher course every two years. The bill would also change the way deaths of pregnant women are recorded on certificates.
Introduced by Asm. Wood (D-Santa Rosa)
This bill would require California’s Department of Health Care Services to create a rating system for Medi-Cal managed care plans. Advocates say the state should be holding plans accountable for improving quality and reducing health disparities.
Introduced by Asm. Luz Rivas (D-Arleta)
This bill would require the Covered California board to make information on health plans’ cost reduction efforts, quality improvements and disparity reductions public. The board would have to post the data on its website annually in a way that “demonstrates the compliance and performance of a health plan, but protects the personal information of an enrollee.”
Introduced by Asm.Ash Kalra (D-San Jose)
Under current law, health plans offering individual or small group coverage must file information about total earned premiums and incurred claims with the California Department of Insurance or the Department of Managed Health Care at least 120 days before implementing a premium rate change. This bill would require plans offering large group coverage to do the same and would impose additional disclosure requirements.
Introduced by Sen. Pan (D-Sacramento)
This bill would remove an exclusion in state law that allows certain health systems, including Kaiser Permanente, to keep some insurance costs and hospital financial information private. Under the bill, Kaiser would be held to the same data disclosure requirements as its competitors.
Introduced by Asm.David Chiu (D-San Francisco)
This bill would limit what hospitals can charge a patient, or the patient’s plan, for emergency care in cases where the hospital does not have a contract with the patient’s health plan. It’s an effort to stop what advocates call “surprise billing”, or hospitals landing patients with large and unexpected costs after providing care.
Introduced by Asm. Monique Limón (D-Santa Barbara)
This bill would require most large group health plans to cover medically necessary prescription drugs.
Introduced by Asm. Wood (D-Santa Rosa)
Wood says brand name drug manufacturers sometimes enter into contracts with generic drug manufacturers, whereby the generic company delays marketing their version of a drug in exchange for payment. Wood’s bill would outlaw the practice.
Editor's note: A previous version of this story referenced 21 bills. A new bill was introduced, changing the total to 22.
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