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Key Efforts To Reform Health Reform

It has been quite a year. More than 3 million of you signed up for new health coverage in California. But many of you couldn’t find doctors who accepted your plans. Some of you were charged hundreds or thousands of dollars for desperately needed prescription medications.

And let’s not forget Medi-Cal, where legions waited for months to find out if your applications had been processed or couldn’t get help when complicated (and high-stakes) renewal forms landed in your mailboxes.

State lawmakers responded by trying to legislate changes. Gov. Jerry Brown and his veto pen, of course, had the final say.

In today’s column, I diverge from my usual formula of answering readers’ questions. Instead, I’ll explain which new laws will – or won’t – make your health coverage easier to use.

Covered California

Let’s start with Covered California, the state’s health insurance exchange.

SB 964: I am still receiving complaints from readers who purchased plans through Covered California or the private market but can’t find doctors because their health insurers have limited their choices.

This bill, authored by state Sen. Ed Hernandez, D-West Covina, and signed by Gov. Jerry Brown, will increase oversight of health insurers and their networks by state regulators. It also will boost transparency, Hernandez says, requiring insurance companies to report which doctors are participating in which plans.

The law’s provisions also apply to Medi-Cal, which is plagued with access problems. For Medi-Cal plans, insurers will have to report which providers accept new patients, the senator says.

Consumers “will know exactly which doctors to call to make appointments,” says Hernandez, chairman of the Senate Health Committee. “What was the biggest complaint that people had about Covered California and Medi-Cal? They would call, make an appointment and show up but learn that the doctor doesn’t accept” their plan.


Medi-Cal, our version of the federal Medicaid program, provides publicly funded health coverage to low-income Californians. The program’s eligibility criteria was expanded under the Affordable Care Act, and since Jan. 1, 2.2 million Californians have enrolled.

Applications for new Medi-Cal coverage have been backlogged for much of the year, keeping hundreds of thousands of Californians in limbo for months. The state also has mailed confusing renewal forms to millions of current Medi-Cal members.

SB 18: As part of the Medi-Cal renewal process, the state is using new forms, new eligibility criteria and new ways of defining income.

The renewal forms are being met by the same overwhelmed county workers who are processing backlogged first-time Medi-Cal applications, the same computer glitches that contributed to the backlog and the same lack of help for consumers.

The California Endowment, a private foundation, offered the state $6 million to provide assistance to people attempting to renew. The gift was no-strings-attached and would be matched by the federal government, bringing the total to $12 million.

The state declined the offer earlier this year, but Brown signed this bill, which requires the state to accept the grant. Which means, hopefully, that there will soon be more help on the ground for people who want to remain in the program.

SB 1124: Medi-Cal’s controversial Estate Recovery Program seeks reimbursement for a variety of medical services from some Medi-Cal beneficiaries after they die by going after their remaining assets. This measure would have limited the program.

Hernandez, author of the bill, calls estate recovery “fundamentally unfair,” noting that people who receive tax credits from Covered California won’t be asked to pay those back after they die.

But Brown vetoed it, saying “the cost of this change … needs to be considered alongside other worthwhile policy changes in the budget process next year.”

Prescription Drugs

Many of you faced sticker shock this year if your prescriptions were categorized as “specialty drugs” by your health insurer. These are expensive, high-deductible  medications that treat diseases such as cancer, HIV/AIDS, multiple sclerosis, Hepatitis C and rheumatoid arthritis.

SB 1052: This bill, signed by the governor, will require the Covered California website to link to its plans’ drug formularies starting next year. This will allow consumers to check if their medications are covered by their plans.

By 2017, all health insurers will be required to post their formularies online, using a standard format to be designed by the state.

AB 1917: This measure would have capped the amount you’d pay each month for prescription drugs at one-twelfth the annual out-of-pocket limit, or about $530. The aim was to prevent people who take one or more expensive specialty drugs all year from having to cough up thousands of dollars at once.

The bill never made it to the governor’s desk.

“We’ll continue to revisit this issue,” says Anthony Wright, executive director of Health Access California. “Once people are covered, the question is can we ensure they can actually get care? The two concerns we’ve heard raised is ‘Will I be able to see the doctor I need? And can I manage the cost sharing that comes after the premium?’”

Provided by the Center for Health Reporting at the University of Southern California.

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