Healthcare in California

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This article summarizes healthcare in California.

California State Department of Health Care Services

The California Department of Health manages state government projects in California.

Contents

Health insurance

As of 2018, most insured Californians were in plans regulated by the California Department of Managed Health Care (DMHC) with about 60% regulated by either DMHC or the California Department of Insurance (CDI). [1] This dual regulation arose due for historical reasons, and when the DMHC was created in 2000, [2] the California legislature requested a report [2] on merging the health insurer responsibilities with the CDI. [3] Dual regulation has also raised questions around the applicability of premium tax to the DHMC-regulated entities, which have historically not paid premium taxes while CDI-regulated entities have. [4] Value-based pay for performance managed care plans where providers take on risk have arisen, and in 2019 the DHMC announced plans to regulate these "risk-bearing entities". [5]

Medi-Cal

Medi-Cal is California's version of Medicaid. Medicaid was enacted in 1965 by the United States federal government to provide a public insurance program for low-income patients. The funding for Medi-Cal is provided by the federal government. [6]

Additionally, under the Affordable Care Act, low-income coverage could be expanded to nearly all low-income patients depending on how states chose to use the funding provided by the ACA. After the passage of the ACA, 32 states used the funding of the ACA to expand their state's low-income insurance programs, such as Medi-Cal, and 19 states opted out. The 19 states, as of 2014, had a 15% higher poverty rate than the 32 states that chose to expand their services. California was one of the states to expand its Medicaid program. [6]

As of 2018, about one-third of California was covered by Medi-Cal. It is administered by the California Department of Health Care Services, which operates it in accordance with California's Medicaid State Plan and Title XIX of the Social Security Act. [7]

California relies on Affordable Care Act (ACA) funding to support the Covered California program. In 2014, a collaborative effort between UCLA and UC Berkeley produced a model aimed at estimating the impact of the ACA on insurance coverage in the state. This model compares real-time data sets of insurance coverage in 2014 to a baseline scenario without ACA coverage. By doing so, the model can project future enrollment numbers in California health programs. According to this model, at some point in time, an estimated 1.1 to 1.3 million Californians will be enrolled in Covered California. Simultaneously, Medi-Cal enrollment is anticipated to reach an unprecedented high, ranging from 7.4 to 7.8 million individuals. [8]

Notably, the model refrains from providing specific projected years or dates. This cautious approach stems from its reliance on 2014 data, preventing precise predictions of the evolving landscape of health insurance programs in subsequent years. Nevertheless, the model serves as a tool for policymakers and researchers, facilitating an understanding of how diverse segments of the population are likely to be covered under various health insurance plans. [8]

Private markets

As of 2015, about 14.1 million people were insured privately, including in self-funded plans; 1.3 million were in plans regulated by the CDI and 12.7 million were in plans regulated by the DHMC. [9] Kaiser Permanente had about 50% of the market, followed by Blue Shield of California, Anthem Blue Cross, and Health Net (a subsidiary of Centene). [9]

L.A. Care was among the top six in 2015, and the largest county-based insurer. [9] As of 2017, UnitedHealthcare was sixth-largest. [10]

Marketplace

Covered California is the health insurance marketplace.

Kaiser Permanente and Blue Shield of California had about two-thirds of the market share as of 2018. [11] In 2017 Anthem stopped selling on the exchange. [12]

Healthcare by region

Los Angeles

Los Angeles offers all available health care services. Notable health systems or hospitals in the region include Los Angeles County Department of Health Services, Kaiser Permanente, UCLA Health, Cedars-Sinai, Verity Health, Providence Health, UCI Medical Center, and Keck Hospital of USC.

San Francisco Bay Area

San Francisco offers all available health care services. Large health systems in Northern California include Sutter Health, Kaiser Permanente, UCSF Health, Dignity Health, and Stanford Medical. [13]

In 2018, a lawsuit was filed against Sutter Health for alleged antitrust. [14]

San Diego

San Diego offers all available health care services. Notable health systems or hospitals in the region include Scripps Health, Kaiser Permanente, Naval Medical Center San Diego, UC San Diego Health, Tri-City Medical Center, Palomar Health, and Sharp HealthCare.

Infrastructure

Proposed single-payer healthcare

A single-payer health care system for California has been suggested multiple times. Two bills in the California State Legislature that would have implemented universal health coverage were vetoed by Governor Arnold Schwarzenegger in 2006 and 2008, respectively. [15] [16] [17] A 2021 proposal for single-payer healthcare, AB 1400, also known as CalCare, was presented in the State Assembly, and renewed discussion about unilateral state-wide universal healthcare. [18] On January 31, 2022 the bill was shelved and not voted on by the assembly. [19] SB770 passed, allowing Medicare and Medicaid funds to be used in a potential single-payer system. [20] A single-payer system is set to be proposed again in early 2024. [21]

Outbreaks, plagues, and epidemics

See also

Related Research Articles

<span class="mw-page-title-main">Medicaid</span> United States social health care program for families and individuals with limited resources

In the United States, Medicaid is a government program that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by state governments, which also have wide latitude in determining eligibility and benefits, but the federal government sets baseline standards for state Medicaid programs and provides a significant portion of their funding.

Health insurance or medical insurance is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity.

Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system.

The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.

...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.

The California Medical Assistance Program is the California implementation of the federal Medicaid program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138% of federal poverty level. Benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, dental (Denti-Cal), vision, and long-term care and support. Medi-Cal was created in 1965 by the California Medical Assistance Program a few months after the national legislation was passed. Approximately 15.28 million people were enrolled in Medi-Cal as of September 2022, or about 40% of California's population; in most counties, more than half of eligible residents were enrolled as of 2020.

In the United States, health insurance helps pay for medical expenses through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.

Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, which amended the PPACA and became law on March 30, 2010.

<span class="mw-page-title-main">Health insurance coverage in the United States</span>

In the United States, health insurance coverage is provided by several public and private sources. During 2019, the U.S. population overall was approximately 330 million, with 59 million people 65 years of age and over covered by the federal Medicare program. The 273 million non-institutionalized persons under age 65 either obtained their coverage from employer-based or non-employer based sources, or were uninsured. During the year 2019, 89% of the non-institutionalized population had health insurance coverage. Separately, approximately 12 million military personnel received coverage through the Veteran's Administration and Military Health System.

Healthy San Francisco is a health access program launched in 2007 to subsidize medical care for uninsured residents of San Francisco, California. The program's stated objective is to bring universal health care to the city. Healthy San Francisco is not a true insurance program, as it does not cover services such as dental and vision care, and only covers services received in the city and county of San Francisco. The program itself acknowledges its limitations, and has stated that "insurance is always a better choice." Healthy San Francisco represents the first time a local government has attempted to provide health insurance for all of its constituents. The program is open to low-income city residents over the age of 18 who do not qualify for other public coverage, and who have had no insurance for at least 90 days. Eligibility is not conditional on citizenship, immigration, employment or health status. The program covers a range of services, but only pays providers within San Francisco. By July 2010, almost 90% of the uninsured adults in San Francisco — over 50,000 people — had enrolled in Healthy San Francisco.

The Department of Managed Health Care (DMHC) is a regulatory body governing managed health care plans, including Health Maintenance Organizations (HMOs) and most Medi-Cal managed care plans in California. The DMHC was created as the first state department in the country solely dedicated to regulating managed health care plans and assisting consumers to resolve disputes with their health plans. The DMHC Help Center educates consumers about their health care rights, resolves consumer complaints, helps consumers navigate and understand their coverage and assists consumers in getting timely access to appropriate health care services.

<span class="mw-page-title-main">California Health and Safety Code</span> U.S. state law

The California Health and Safety Code is the codification of general statutory law covering the subject areas of health and safety in the state of California. It is one of the 29 California Codes and was originally signed into law by the Governor of California on April 7, 1939.

Medicaid estate recovery is a required process under United States federal law in which state governments adjust (settle) or recover the cost of care and services from the estates of those who received Medicaid benefits after they die. By law, states may not settle any payments until after the beneficiary's death. States are required to adjust or recover all costs under certain circumstances, all involving long-term care arrangements. Federal law also gives states the option to adjust or recover the costs of all payments to health care providers except Medicare cost-sharing for anyone on Medicaid over the age of 55.

<span class="mw-page-title-main">L.A. Care Health Plan</span>

The Local Initiative Health Authority for Los Angeles County is a public agency that provides health insurance for low-income individuals in Los Angeles County through four health coverage programs including Medi-Cal.

<span class="mw-page-title-main">California Health Care Foundation</span>

Based in Oakland, California, the California Health Care Foundation (CHCF) is an independent, nonprofit philanthropy that focuses on improving the health care system for the people of California, especially low-income Californians. The organization has three main goals: improving access to coverage and care, promoting high-value care, and investing in people, knowledge, and networks that help to make meaningful change possible in California’s health care system.

<span class="mw-page-title-main">Covered California</span> Health insurance marketplace in California, U.S.

Covered California is the health insurance marketplace in the U.S. state of California established under the federal Patient Protection and Affordable Care Act (ACA). The exchange enables eligible individuals and small businesses to purchase private health insurance coverage at federally subsidized rates. It is administered by an independent agency of the government of California.

Healthy Way LA (HWLA) was a free public health care program available to underinsured or uninsured, low-income residents of Los Angeles County. The program, administered by the Los Angeles County Department of Health Services, was a Low Income Health Program (LIHP) approved under the 1115 Waiver. HWLA helped to narrow the large gap in access to health care among low-income populations by extending health care insurance to uninsured LA County residents living at 0 percent to 133 percent of the Federal Poverty Level (FPL). Individuals eligible for HWLA were assigned to a medical home within the LA County Department of Health Services (LADHS) or its partners, thus gaining access to continuous primary care, preventive and specialty services, mental health services, and other support systems. HWLA was one of the few sources of coordinated health care for disadvantaged adults without dependents in LA County. HWLA was succeeded by My Health LA, a no-cost health care program for low-income Los Angeles County residents launched on October 1, 2014.

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The Affordable Care Act (ACA) is divided into 10 titles and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020. Below are some of the key provisions of the ACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.

<span class="mw-page-title-main">Partnership HealthPlan of California</span>

Partnership HealthPlan of California, is an independent, public/private organization serving over 950,000 Medi-Cal beneficiaries in 24 northern California counties: Butte County, Colusa County, Del Norte County, Humboldt County, Glenn County, Lake County, Lassen County, Marin County, Mendocino County, Modoc County, Napa County, Nevada County, Placer County, Plumas County, Shasta County, Sierra County, Siskiyou County, Solano County, Sonoma County, Sutter County, Tehama County, Trinity County, Yolo County, Yuba County. It began operations as a County Organized Health System in 1994, and is currently the largest Medi-Cal Managed Care Plan in Northern California.

A considerable portion of the United States' population is foreign-born. Undocumented immigrants make up about 28% of the foreign-born residents. A model analyzing data from 1990-2016 estimates the number of undocumented immigrants in the US range from 16.7 million to 22.1 million.

References

  1. ↑ "Issue Brief: Estimates of Sources of Health Insurance in California for 2019" (PDF). California Health Benefits Review Program.
  2. 1 2 "Making Sense of Managed Care Regulation in California" (PDF). California HealthCare Foundation. 2001.
  3. ↑ Kelso, J. Clark (2001). "Regulatory Jurisdiction Over Health Insurance Products: The Department of Managed Health Care & The Department of Insurance" (PDF). Archived (PDF) from the original on 2015-09-09. Retrieved 2019-10-12.
  4. ↑ "New California Court of Appeal Decision May Impose Premium Taxes on California Health Plans". C&M Health Law. 2015-10-12. Retrieved 2019-11-29.
  5. ↑ Oppenheim, Charles B.; Gross, Stephanie (16 May 2019). "Changes Ahead for California's Managed Care Regulatory Scheme". Archived from the original on 18 December 2019. Retrieved 29 November 2019.
  6. 1 2 Davenport, Lisa (2018). "Barriers to health care access for low income families: a review of literature". Journal of Community Health Nursing 35, No. 1. 35 (1): 28–37. doi:10.1080/07370016.2018.1404832. PMID   29323941. S2CID   24374244.
  7. ↑ "California's Medicaid State Plan (Title XIX)". California Department of Health Care Services.
  8. 1 2 Roby, Dylan; Jacobs, Ken; Watson, Greg; Bronshteyn, Alla; Graham-Squire, Dave; Keller, Michelle (July 2014). "Health care reform in the US: an analysis of implementation of the Affordable Care Act in California". BMC Health Services Research. 14 (S2): P103. doi: 10.1186/1472-6963-14-S2-P103 . ISSN   1472-6963. PMC   4122896 .
  9. 1 2 3 "The Private Insurance Market in California, 2015". California Health Care Foundation. Retrieved 2019-06-13.
  10. ↑ "2019 Edition — California Health Insurers". California Health Care Foundation. Retrieved 2019-10-14.
  11. ↑ "Evolving Market Share Of Health Plans In Covered California". IMK. 2018-10-09. Retrieved 2019-06-13.
  12. ↑ Bartolone, Pauline; Gorman, Anna; Terhune, Chad. "Anthem's retreat leaves Californians with fewer choices, more worries". The Sacramento Bee.
  13. ↑ "Hospital consolidation in California linked to higher health prices". SFChronicle. 5 September 2018.
  14. ↑ "Suit against Sutter spawns fight with Bay Area hospitals over trade secrets". SFChronicle. 15 October 2018.
  15. ↑ Korcok, Milan (October 10, 2006). "Schwarzenegger vetoes single-payer bill". Canadian Medical Association Journal. 175 (8): 860. doi:10.1503/cmaj.061200. PMC   1586096 . PMID   17030932.
  16. ↑ "Bill Status - SB-840 Single‑payer health care coverage". leginfo.legislature.ca.gov.
  17. ↑ Rojas, Aurelio (September 30, 2008). "Gov. Schwarzenegger again vetoes single payer bill". Physicians for a National Health Program. Retrieved 2021-04-09.
  18. ↑ "Letter: Health care for all California". Davis Enterprise. April 7, 2021. Retrieved 2021-04-09.
  19. ↑ "Single-payer healthcare proposal fizzles in California Assembly". Los Angeles Times. February 1, 2022.
  20. ↑ "New California law takes a step toward single-payer healthcare". Los Angeles Times. 2023-10-08. Retrieved 2023-10-24.
  21. ↑ "California Will Again Weigh Single-Payer Health Care in 2024". Bloomberg.com. 2023-10-10. Retrieved 2023-10-24.
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