Welcome to Lucien's blog

Welcome to Lucien’s blog; we have much to celebrate in California’s implementation of the Affordable Care Act and a great deal to discuss and develop.

I’m retired from ITUP (www.itup.org) now and wanted to start a blog with my own perspectives on what lies ahead. I hope you find the ideas useful and will let me know your experiences.

As we all know, the national atmosphere for forward progress is incredibly toxic at the moment. Important opportunities for further progress lie ahead at the state of California level, at the plan and provider levels, and at the county and regional government levels.

I believe we have seven key challenges in front of us. Some of the first postings of this blog will address these challenges and the opportunities to resolve them here.

  1. We need coverage opportunities for over a million uninsured undocumented adults in California, and we need to develop a plan and financing to help them pay for basic coverage.
  2. We need more affordable coverage for families and older adults. The Affordable Care Act is the right building block, but it’s got affordability cliffs that can be very steep – at 400% of the Federal Poverty Level ($47,080), particularly for older adults, at 250% of FPL ($60,625 for a family of four) for working families, and at 138% of FPL ($16,242 for an individual) for persons with a raise, minimum wage increase, or new job such that they lose Medi-Cal. We should offer whole family care – same plan, same network for parents and their children. How can California use the waiver opportunities under §1332 and §1115 to integrate coverage and address these affordability cliffs?
  3. We need to turn our huge progress in enrollment into better health outcomes for those with new insurance. In California over the next year we will have 1.5 million with Covered California and 13.5 million with Medi-Cal coverage according to Governor Brown’s recently proposed budget. We need to begin to reimburse for better outcomes, for better value. How exactly do we do that?
  4. We need to assure an adequate workforce and strong delivery system particularly in underserved rural communities where risk factors are very high and the supply of physicians too small. How do we develop pipelines of local talent, how do we retain doctors and nurses, how do we use telemedicine, how do we better use California’s medical schools to help improve delivery systems in low income communities from Imperial to Tulare to Siskiyou?
  5. We did a great job of carving out services to develop excellence in specialty mental health or specialty pediatric, now how do we knit these programs back together to provide whole person care to those suffering with debilitating mental illness or severe substance addictions or terrible childhood illnesses.
  6. We slowed the rise in health costs, but now we need to assure that premium increases stay low and out of pocket costs become far more affordable in both public and private sector plans. How do we deal with health care pricing of natural and artificial monopolies? Are the oligopolies being created by mergers and acquisitions becoming anti-competitive and raising prices? Or are they delivering better care as integrated delivery networks at a lower price? I can’t help but notice the same plan and same benefits costs 50% more in the Bay Area than Los Angeles. Do we need to break up anti-competitive oligopolies, regulate the natural monopolies or build on them?  Is the pricing problem primarily at the plan level, the provider level or both? Increasing numbers of those newly insured in Covered California are selecting bronze plans that offer the most affordable monthly premiums but then face the challenge of high deductibles when they get sick and need care. Should we use the §1332 waiver opportunity to develop an enhanced bronze to improve the affordability of their coverage? How can the higher deductible employer plans be better structured to assure access for their lower wage workforces?
  7. We had 6 million Californians with new coverage last summer, and this may reach 7 million over the next year. Medi-Cal managed care enrollment has grown by almost 60% since December 2013. The new subscribers need consistent education from plans, providers, promotoras, the media and the education communities on how to use their new benefits and coverage so they don’t just go to the local ER. We need to pay plans and their delivery networks for performance, for better patient outcomes. We need the right incentives, and we need transparency of price, of quality, of outcomes if we are to get better value. We need consistent and compatible incentives from all plans and programs. How do we do that? 




Financing Care for Undocumented Adults