Posted on July
21, 2016 by Yves Smith
Yves here. This post on
Covered California gives an update of sorts on Obamacare. Recall that Covered
California is as good as Obamacare gets. Yet this article details how it has
fallen short, particularly for low income people,
By Sasha Abramsky, who writes
regularly for The Nation, and the author of several books, including “Inside Obama’s
Brain,” “Breadline USA” and “American Furies.” His latest book, “The American
Way of Poverty: How the Other Half Still Lives,” was published by Nation Books
in September. Originally published at Capital and Main
“Right now, I have a medicine
sitting at Wal-Mart pharmacy that I can’t purchase till payday,” Jacqueline, a
55-year-old San Diegan told me during a telephone interview in mid-April. She
asked that her last name not be used for this story. “I’ll go without, eight or
nine days till payday. It’s for my high cholesterol.”
Five years after the
Affordable Care Act became law, and more than three years after California
began moving aggressively to implement its provisions, upwards of three million
Californians remain without health care coverage; and millions more, like
Jacqueline, have basic coverage but continue to be grievously
under-insured.This is the story of how so many Californians continue to fall
through the ACA’s cracks.
Until a few years ago,
Jacqueline worked a hospital security job, which paid fairly decently. Then she
lost it and ended up with another security job, this one paying only $11 an
hour. It didn’t come with health insurance, and so Jacqueline went online to
buy insurance through California’s health insurance exchange, set up in the
wake of passage of the Affordable Care Act. Because her earnings left her well
below 400 percent of the federal poverty line – the upper limit for
insurance assistance under ACA — she qualified for subsidies.
These subsidies are calculated
on a sliding scale according to a recipient’s income, so that people pay
anywhere from two to 9.5 percent of their income. But,
Jacqueline dis covered, buying into a gold or silver plan would still cost
more than she could afford. And so, despite the fact that she suffered from
diabetes, high cholesterol, neuropathy and other ailments that required
frequent doctors visits and a steady array of medications, she bought into a
bronze plan.
Such plans essentially shift
the financial burden from now, when the monthly payment is due, to later – when
the bills come in from doctors; prescriptions have to be paid for out of
pocket. They cap out-of-pocket expenses at $6,850 for an individual and $13,700
for a family – which, for the working poor, represents a prohibitive outlay of
cash. (A Cost Sharing Reduction Subsidies program can
significantly reduce out-of-pocket maximums.) Take, for example, the story of
Maria Can de Tec, a laundry worker at an Orange County convalescent hospital,
who managed to buy subsidized Anthem-Blue Cross insurance for $151 per month
but, following an emergency room visit for internal pains and bleeding, ended
up with nearly a thousand dollars in bills that she is now having to pay off in
$76.92 monthly installments.
The bronze plan that
Jacqueline chose still cost her $50 per month — the upper limit of what she
could afford — and, as she found out once she began using its medical services,
it came with hefty copays and deductibles. It was, in many ways, barely more
than catastrophic coverage. Near the end of each month, with no money in the
bank and days to go until her next paycheck, she would run out of medicines.
“I can tell the difference
when I have my medicine and when I don’t,” she said. “I have more stress and
worry. I wanted to see the doctor about issues of mental health. Stress and
tension. And once I found out how much it was going to cost, I didn’t go. I
came to a decision that I really need this, but I couldn’t afford to go. And
I’m having really bad issues with my neck, back and legs – and I can’t afford
to go to the specialists.”
When the Affordable Care Act
was passed, California embraced its principles more assertively than did most
other states. It set up the nation’s biggest insurance exchange and invested
heavily in Covered California, the organization responsible for bringing the
uninsured into the insurance system; it added state dollars to provide
additional subsidies to anyone whose earnings placed them at less than 250 percent of the federal poverty line; it
expanded its Medi-Cal roles dramatically – the ACA allowed states to cover
anyone whose income was no more than 138 percent of the poverty line. And it
has spent heavily, for each of the last five years, on outreach to bring
children and other particularly vulnerable groups into primary care settings –
since studies indicate that previous expansions of the health care safety net,
from the State Children’s Health Insurance Program, to Medicare for the
elderly, have taken four to five years to bring in all the people they can, and
to reach a state of steady enrollment.
The ACA, says Anthony Wright,
executive director of the Sacramento-based advocacy organization Health Access
California, which campaigns for policies that would bring more Californians
into the health care system, “allowed us huge progress. We’ve cut the number of
uninsured by half. We had seven million uninsured prior to ACA. The modeling
suggested we would land at around three million – and that three or four
million would [eventually] be covered.” So far, California has already
outperformed these goals, with close to four million newly covered Medi-Cal
patients, and upwards of 1.5 million buying into subsidized insurance.
And yet, because of the way
the federal law was worded, as well as some of the unique demographic and
economic characteristics of the state, six years after the ACA’s passage many
millions of Californians remain uninsured; data from the 2014 California Health Interview Survey, the most comprehensive
study to date, estimates five million. They are, as researchers from the
University of California, Berkeley’s Center for Labor Research and Education,
and the University of California, Los Angeles Center for Health Policy Research
calculate, disproportionately Latino and male, and most of them work at least
30 hours per week. In addition to the uninsured, however, hundreds of thousands
more, like Jacqueline, bought into bronze plans that essentially provide
financial disincentives to seek medical attention and thus leave them
significantly underinsured.
There are the spouses and
children of workers whose employers provide them with health insurance but
either don’t offer coverage to family members or offer it only at a price that
renders it unaffordable. Because of an accidental miswording in the ACA, these
families, even if they are less than 400 percent of the poverty line, aren’t
eligible for subsidies. It’s a trap that advocates refer to as the “family
glitch” and it ought to be relatively easy to fix. But because the Republican
majority in Congress is more interested in defunding ACA than in filling in
holes in its coverage, the glitch remains in place. In 2011 UC Berkeley Labor
Center researchers calculated that 144,000 Californians were caught in this
trap.
“If my husband, daughter and I
all purchased insurance through his employer,” wrote Brenda, a 57-year-old
woman from the town of North Hills, to Bethany Snyder, who until last May was
director of communications at Health Access California, “that amount would be
half of his monthly take-home pay, leaving very little for food, housing and
other essentials.” While her husband was covered through his employer, and
their daughter was on another insurance plan, which cost them $161 per month,
Brenda herself was unable, because of this, to afford insurance. Instead, she
was relying on a cost-sharing plan for her medical bills run through Christian
Healthcare Ministries. It was better than nothing, but she still wanted, one
day, to be able to access proper health insurance.
In high-cost-of-living areas
of the state, there is another problem: families at just over 400
percent of the poverty line, who on paper ought to have plenty of disposable
income to buy nonsubsidized insurance, but who spend so much on housing that
they end up not having enough to buy insurance.
While there are tax penalties
in place for those who go uninsured, those penalties are not imposed on people
who can show that to access nonsubsidized insurance they would have to spend
more than eight percent of their income on health care policies. In some parts
of the Bay Area, for example, health care analysts have found clusters of
middle-aged people who are foregoing coverage because of extremely high housing
costs, and who are not subject to tax penalties because the cost of insurance,
which rises the older one gets, would be more than eight percent of their
income.
The last, and largest,
remaining group excluded from health care coverage consists of California’s
millions of undocumented residents. When ACA was passed, Congress explicitly
excluded them from access to Medicaid and to federally subsidized insurance
policies. As a result, even as most of the legally resident poor in California
have accessed some form of coverage in the years following the ACA’s passage,
the undocumented remain intensely vulnerable. Wright estimates that whereas,
before ACA, only one in five of the uninsured lacked legal residency status,
today upwards of half of the state’s uninsured are undocumented.
“They have to rely on the emergency
room for all their health care needs,” explains Don Nielsen, director of
government relations at the California Nurses Association. (Disclosure: CNA is
a Capital & Main financial supporter.) We’ve met opposite the Capitol
building in a café frequented by the political classes. Nielsen is wearing
Ray-Ban sunglasses and a black suit with a “Bernie” pin on a lapel. The CNA
had, months earlier, endorsed Bernie Sanders’ presidential campaign in large
part because of his commitment to single-payer health care. “That’s a big roll
of the dice,” Nielsen says. “They [ERs] have to accept everyone, but they are
only required to ‘stabilize’ them. They don’t have to do anything beyond that.
It’s real hit and miss.” CNA’s slogan on health care reform was simple: “Everybody
in, nobody out.” Under single-payer, Nielsen states, no one, regardless of
their immigration status, could be denied access to health care.
Says one Sacramento resident,
who was undocumented for 16 years and asks to remain anonymous, “My Dad has needed
a surgery for a hernia operation for years.” Her parents, who live in the
southern part of the state, remain undocumented. “He’s just been waiting,
hanging on, hoping there will be a time he can afford surgery and time to
recover. It’s a struggle. There’s no safety net.” The woman’s father had worked
for years in a factory that made RVs. But then he became injured and could no
longer do the heavy lifting required in the factory, and he was out of work.
“It’s kind of a sad tune we
are all familiar with,” his daughter explains. “We know we’re forgoing care.
It’s too expensive. It’s too bad, you know?”
Many California counties, no
longer having to provide indigent care for poor, able-bodied adults now covered
under Medi-Cal, have used some of their savings to expand basic clinic
coverage for undocumented residents – realizing that it is actually cheaper to
provide more comprehensive primary care coverage than to have to pick up the
emergency room bills accrued when the undocumented finally seek treatment in
hospital settings. Forty-seven counties are now providing more than just
emergency care to these residents, up from only nine just last year. But while that change has been welcomed by
advocates, in the long run it is only a scattershot solution to a vast problem
– and one that leaves the undocumented vulnerable to changing financial and
political winds at the county level.
A more systematic approach
has, in the past year, emerged at the state legislative level: In October of
last year, Governor Jerry Brown signed a bill that would allow California to
use state dollars to provide Medi-Cal to undocumented children. The provisions
of this law, which follows passage of similar state measures and city
ordinances in Massachusetts, New York, Chicago and Washington State, went into
effect in early May of this year, meaning that with good outreach in the coming
months almost all of California’s children could end up with health coverage.
Wright and other advocates believe that upwards of 175,000 of the estimated
250,000 undocumented children in the state will soon be enrolled in Medi-Cal.
The state is also using its own dollars to cover refugees who don’t have their
green cards, as well as DACA (Deferred Action for Childhood Arrivals) students.
If the U.S. Supreme Court allows DAPA (Deferred Action for Parents of
Americans) to proceed, California will stand ready to expand health care access
to this group, too.
For the past year, Sacramento
has also discussed legislation that would allow undocumented adults to buy
nonsubsidized insurance plans on the Covered California exchange. The legislation
would require a federal waiver, but since the exchanges are no longer federally
funded, such a waiver is likely to be granted. And this year state Senator
Ricardo Lara (D-Bell Gardens) has pushed Senate Bill 10, a proposal that would
expand Medi-Cal access, again paid for with state rather than federal dollars,
to undocumented adults too. Polling from 2015 indicates 58 percent of Californians
support this move.
Slowly, California is plugging
the ACA’s gaps. It has taken five years to halve the number of uninsured in the
state. It will likely take several more years to make a serious dent in the
remaining numbers. And some of the problems, such as the family glitch, will
likely still remain even at the back-end of years of effort.
But, unlike on the federal
level, statewide there is at least now the political will to tackle this
problem. And that’s a huge accomplishment in and of itself.
