Janet Coffman, PhD, an adjunct professor in the UCSF Department of Family and Community Medicine and the UCSF Philip R. Lee Institute for Health Policy Studies, is an expert on evidence-based medicine and health insurance coverage especially as it relates to prevention and California.
She is the principal analyst for medical effectiveness for the California Health Benefits Review Program, which provides the California State Legislature with data on the medical, cost and public health impacts of proposed health insurance benefit mandates and repeals.
Q: How does the health insurance exchange impact Healthy San Francisco, the city’s program that makes health care services accessible to uninsured San Francisco residents?
Some persons who currently are enrolled in Healthy San Francisco will be eligible for subsidized coverage through Covered California. Others will be eligible to enroll in Medi-Cal under the new eligibility rules. Nevertheless, Healthy San Francisco still will play an important role because some persons enrolled in the program, such as undocumented immigrants, will not be eligible for either Medi-Cal or subsidized coverage through Covered California.
Some of UCSF's leading experts weigh in about the potential impact of new health care coverage options under the Affordable Care Act (ACA), which begins enrollment on October 1.
Medi-Cal and Covered California are health insurance; Healthy San Francisco is not. Persons enrolled in Healthy San Francisco who are eligible for Medi-Cal or subsidized coverage through Covered California would benefit from transitioning to these programs because they would have greater choice of providers and would have coverage for more types of medical services. For example, Healthy San Francisco does not pay for care provided outside San Francisco, whereas Medi-Cal and Covered California health plans pay for care provided anywhere in California so long as the provider is in the health plan’s network.
Healthy San Francisco will help eligible enrollees apply for these programs.
Q: California was the first state to set up an exchange, called Covered California. What are the benefits or downsides to being the nation’s leader?
A major advantage of being the first state to set up an exchange is that California has had more time to plan and implement its exchange. The exchanges are so complex that states need a lot of time to develop them. Establishing the exchange early on also gave California more time to create a governing board, recruit staff and obtain input from consumers, health pans and other stakeholders.
The one downside to being first is that all eyes are on California. Any glitches that consumers experience here may be amplified.
Q: Some of the large insurers, such as Aetna, Cigna and UnitedHealth Group, decided not to sell insurance through Covered California. How do you think that will influence consumer choice?
I do not think the decisions of these health plans will have much impact in California because their market shares are low. Collectively, Aetna, Cigna, and United enroll only 14 percent of Californians with private health insurance and less than 7 percent of persons who have coverage through the individual insurance market.
In contrast, Kaiser Permanente, which enrolls 40 percent of all Californians with private insurance, is offering coverage in 18 of 19 pricing regions in Covered California’s individual exchange and is also participating in its small business exchange. Anthem Blue Cross, Blue Shield of California and HealthNet also are participating in both the individual exchange, and Blue Shield and HealthNet are participating in the small business exchanges.
Q. What do you think California residents need to know about Covered California?
A major advantage of Covered California is that health plans that participate are required to offer standardized health plans, which makes it easier for people to compare plans based on price and provider networks. All health plans sold by Covered California will have to cover the same “essential” health care services. Californians will be able to choose from between two to six health plans, depending on where they live.
Q: Will Californians who keep private insurance see a price increase in their insurance plans because of the exchanges?
Health insurance premiums may rise for some Californians who have private insurance through the individual health insurance market.
Beginning in January 2014, the Affordable Care Act will require that the same rules apply to health insurance sold to individuals and families inside and outside exchanges. This is a major change in California. In the individual market, health plans will no longer be able to deny coverage to anyone or exclude pre-existing conditions from coverage. Health plans will no longer be able to charge sicker people more than healthier people or impose annual or lifetime limits on coverage. They will also have to provide coverage for a comprehensive benefits package.
As a consequence, some younger and healthier persons who currently have individual health insurance that provides only limited benefits may have to pay more for coverage. How much more they will have to pay will depend whether they are eligible for subsidized coverage through Covered California.