California has made great progress implementing the Affordable Care Act (ACA), with well over 6 million people newly enrolled in either Medi-Cal or Covered California since December 2013. The state strives to improve the quality, outcomes and effectiveness of care and the performance of its safety net delivery systems with its recent renewal of its §1115 Medicaid waiver. Beginning in 2017, the ACA offers another major opportunity for states to meet these goals with a §1332 waiver. These broad waivers would allow states the ability to waive several requirements of the ACA to create new and innovative models to improve and expand health coverage. They are intended to allow state experimentation with different models of coverage. There are five models to use in building towards universal coverage: 1) single payer private systems like Canada,[1] 2) employer mandates like Germany, 3) individual mandates like Switzerland, 4) socialized medicine like Great Britain where the government owns the hospitals and employs the doctors, and 5) a hybrid system like the Affordable Care Act (Obamacare) which combines employer and individual mandates with tax subsidies for those who cannot afford coverage. Depending on which path a state chose, the mandates of the ACA could become superfluous.

Thank heavens that someone finally asked the Presidential candidates about health care policy and the Affordable Care Act (ACA). Republican candidate Donald Trump replied with what sounded like a “word salad” riff on selling insurance without lines/ across state lines and enacting block grants and repealing Obamacare. Presidential candidate Hillary Clinton replied with a defense of the positive accomplishments of the ACA and CHIP, an acknowledgement of growing pain problems and a vow to improve affordability for individuals and small employers and to challenge the unwarranted (in her view) increases in premiums from some health plans and drug manufacturers; she then mentioned the public option as one way to improve affordability. Trump then accused Clinton of supporting Canadian style single payer, which he said Canadians did not like at all and they all come to the US for their health care. She replied that in fact the Canadians like their system a great deal, do not come flocking to the US for health care, but single payer is not what she supports for this country.

This explains and reviews the pros and cons of the California Ballot Propositions in 2016. They are extraordinarily consequential for California's health, for the schools, for criminal justice and for the financing of public services. Please vote.

The Commonwealth Fund contracted with the Rand Corporation to analyze the Clinton and Trump proposed health reforms. They recently analyzed four main proposals by Secretary Clinton to improve the functioning of the Affordable Care Act (ACA): 1) tax credits for individuals whose out of pocket spending exceeds 5% of income, 2) reductions in the maximum premium contribution from 9.66% to 8.5%, 3) capping families premium contributions at 8.5%, and 4) the public option for individuals in the Exchanges. This requires an understanding of how the Affordable Care Act works so each needs a little more explanation.

§1332 waivers allow states to waive specified provisions of the Affordable Care Act as long as they are cost neutral to the federal government, cover at least as many people as are already eligible, cover at least as many services as are already covered and are at least as affordable as the ACA. California’s waiver would seek federal approval so that the state Exchange (Covered California) can offer mirror coverage opportunities for the undocumented, but without any federal or state premium assistance or out pocket assistance.

§1332 waivers allow each state to tailor the Affordable Care Act (ACA) to its own local conditions. Hawaii was the first state to propose a §1332 waiver, and it is a very interesting one because Hawaii already has achieved one of the lowest uninsured rates and some of the lowest premiums in the country. Hawaii seeks to waive the requirement to establish a SHOP purchasing pool for small employers. The state’s rationale was that it’s expensive to establish and very few small employers participated.

This week, Human Rights Watch sponsored a showing of "The Return" a thoughtful examination of life after prison. It follows the lives of two prisoners released from life sentences and their re-integration into family and community life. One makes it, and the other is still struggling with mental illness and addiction by the story’s end.

Let’s talk about the real world and recent economic and political history for a moment.

Just in time for the debates, the Commonwealth Fund has presented a comparison of the Clinton and Trump health proposals. http://www.commonwealthfund.org/interactives/2016/sep/comparing-candidates-health-proposals/

The Committee for a Responsible Budget recently updated its analysis of the campaign promises and their costs over the next decade from Prospective Presidential Nominees Donald Trump and Hillary Clinton. See http://crfb.org/papers/promises-and-price-tags-preliminary-update and http://crfb.org/papers/promises-and-price-tags-fiscal-guide-2016-election

One of the best questions at last year’s ITUP conference involved the differences and overlap between Section 2703 Health Homes and the new Section 1115 waiver for whole person care pilots. Both address the same fundamental challenge in the American health system – the lack of important connectivity among its excellent but disparate parts. This is particularly problematic in Medi-Cal due to the behavioral health/physical health divide. Both initiatives address the same populations of severely ill patients who are high users of emergency rooms, many of whom have severe co-occurring physical and behavioral health conditions, and a significant number are homeless individuals.

CMS recently reported on Medicaid enrollment growth from the third quarter of 2013 compared to June 2016 (in other words the first 2 and ½ years of the ACA’s Medicaid expansion). California’s Medi-Cal enrollment growth was 54.6%. The average for all states adopting the Medicaid expansion was 35.6%.

I’ve had an utterly lovely six months off since leaving ITUP. It’s now time for me to get back to work. The Office of Lucien Wulsin is now open for business. I’ll be affiliating with organizations where our interests and skills align, and you’ll be hearing more about this soon I hope.

Presidential candidates Clinton and Trump now each have child-care and maternity leave proposals. Trump has just unveiled his proposal while the specifics of the Clinton plan have been out there throughout the primaries. The differences are quite large and highly instructive about the two candidates. 

Real household income went up by 5.2% -- the fastest growth on record – from 2014 to 2015. Poverty fell by 3.5 million – the largest one year drop since 1968. The uninsured rate fell to 9.1% -- its lowest rate ever. http://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-256.pdf and https://www.whitehouse.gov/blog/2016/09/13/income-poverty-and-health-insurance-united-states-2015

In 2012 the Commonwealth of Massachusetts set overall spending caps for insurers and providers. These global spending caps may be working. https://www.bostonglobe.com/business/2016/09/07/health-care-spending-mass-again-exceeds-target/7HvYRD1RGxeJAe3nFTsIEL/story.html

This is the most recent federal survey of the nation’s uninsured from the first quarter of 2016. These surveys are compiled and released quarterly and thus catalogue the nation’s remarkable progress in reducing its number of uninsured under the Affordable Care Act (ACA).

Seven or eight years ago, Walter Zelman approached me at the annual ITUP conference and said he had a student in his health policy class at Cal State LA who’d be a perfect fit at ITUP. He vastly underestimated how much Sara Watson would help us.

In the recent months, Aetna and United have stopped offering coverage through many Exchanges. In California, Blue Cross Anthem and Blue Shield increased their premiums by close to 20%. What’s happening? What lessons should we be learning? What corrective actions are needed?

The Kaiser Family Foundation has followed the impacts of the Affordable Care Act on uninsured Californians over four reporting periods. They followed a group of over 2000 uninsured from 2013 to 2016. Nearly three fourths gained coverage; primarily through Medicaid (1/3rd), then employment-based coverage (1/5th) and Covered California (1/10th). They were far more likely to report their health needs are being met, their financial worries lessened. Eighty percent said their experiences were positive; they are satisfied with their choice of hospitals and primary care doctors and over 2/3rds are pleased with their choice of specialists.