Four Sacramento area counties prepare for early test of Obama’s health care overhaul
The Sacramento Bee

One slice of President Barack Obama’s health care overhaul is coming early to the Sacramento region, providing a first glimpse at what the massive, complex law will look like.

All four Sacramento-area counties are joining a program that will insure tens of thousands of residents who have been without coverage, more than a year before federal health care changes kicks in.

For county governments and health care providers, the Low-Income Health Program is a chance to get a head start and work out some of the kinks in a new and complicated system – one that must emerge by Jan.1, 2014, but remains largely unformed.

For new patients, the plan could mean the difference between getting sporadic care in unfamiliar clinics (or simply staying sick), and having something that resembles full-fledged health insurance, paid for in county and federal dollars.

“It’s a very important jump start on health care reform,” said Gerald Kominski, director of UCLA’s Center for Health Policy Research. He said it will give early signs of how ready California is to absorb the “huge expansion of coverage in 2014 that doesn’t exist today.”

The 2010 federal law creates several new avenues for the uninsured to get coverage, starting in 2014. It requires states to build competitive marketplaces, called exchanges, for low- to middle-income people to buy insurance using federal tax credits.

For an estimated 16 million of the nation’s very poor – those with annual incomes up to about $15,000 for a single person – the law will make public insurance (Medicaid) available for the first time.

That Medicaid expansion is the piece that’s starting early in California – where the program is called Medi-Cal – and several other states, including Washington, Connecticut, Minnesota and New Jersey.

“California is definitely ahead of the pack in a lot of ways in terms of trying to prepare people for reform,” said Laurie Felland, director of qualitative research at the Center for Studying Health System Change, a national research firm based in Washington, D.C.

Sacramento, Yolo, Placer and nine other California counties are working to join the early-start program as soon as they can. More than 40, including El Dorado, have already started.

The plan will serve poor, childless adults under age 65 – a group that has slipped through the cracks of the health care system. Illegal immigrants are excluded.

A Public Policy Institute of California study found that most residents who will qualify are under age 40 and single. Until now, they weren’t eligible for Medicaid – which serves the disabled, pregnant women, and families with children – and couldn’t afford private coverage.

For some people, “this is the first time that they’re getting access to a real health care system, as opposed to just jumping in when they’re sick and then jumping out,” said Carmella Gutierrez, president of the patient-advocacy group Californians for Patient Care.

Program to be short-lived

The Congressional Budget Office expects the Medicaid change to cost the federal government $430 billion over 10 years. Between now and 2014, counties and the federal government will split the cost of the early-start programs. After that, almost all the new coverage will come on the federal dime.

In California, Kominski estimates that 2.5 million residents will qualify for the public insurance program by 2014. But he expects the Low-Income Health Program to enroll just 500,000 Californians ahead of time.

Come 2014, the Low-Income Health Program is designed to evaporate, as the people in it automatically switch into Medi-Cal.

Short-lived as it may be, the program will help counties ramp up their systems of care.

By New Year’s Day 2014, the federal law says, most adults with very low incomes must be eligible for Medi-Cal. But they can’t get started overnight.
Counties first need to vastly expand their corps of doctors’ offices that accept Medi-Cal, establish standards and payment systems, enroll patients, and educate them on how to use the new system.

“You can’t flip a switch like that. That’s impossible,” said Sandy Damiano, deputy director of the Sacramento County Department of Health and Human Services.

Health officials hope the program will also answer some important questions: Who exactly are the uninsured? What are the barriers to getting them enrolled? And could connecting them with regular, preventive care – a key goal of the federal law – cut down on costly, unnecessary trips to the emergency room?
No more ‘episodic care’

The new patients’ primary care will come through “medical homes” – regular, one-stop doctor’s offices where patients and providers develop relationships, where the staff knows the patients’ names and medical histories.

For people who are used to having comprehensive coverage, that’s not a new concept. The uninsured normally “hop,” said Gutierrez. “It’s episodic care, and they go from clinic to clinic.”

Each county determines how much it can spend on the program and therefore how many patients it can serve. Sacramento County says it can afford to serve only those making up to 67 percent of the federal poverty level – or about $600 a month for a single person.

Sacramento anticipates enrolling about 10,000 county residents between August and the end of 2013. That will cost approximately $40 million a year, half of it federal dollars.

Many challenges remain. Sacramento County’s contract with the state to join the Low-Income Health Program is not finalized.

So Molina Healthcare, the company that the county has tapped to run the program, is trying to recruit doctors to the new network on a promise of new patients and payments.

Counties continue to discover new expenses as the state Department of Health Care Services clarifies the program requirements.

Some people fear that the newly insured in 2014 will have so many unaddressed needs that they’ll overwhelm the health system and squeeze out other patients. Yet Kominski said a similar program tested in 10 California counties several years ago showed that the spike in demand levels out quickly.

The pieces are in place. There are financial resources available. The technology exists,” he said.

“But it is nevertheless a tremendous expansion,” Kominski added, “and it’s not something we have done in California or nationally since the implementation of the Medicare and Medicaid program in the 1960s. That’s well beyond the experience of most of us who are alive and well today.”