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When California voters head to the polls this month, they will decide on two specifically healthcare-related propositions. Proposition 61, The California Drug Price Relief Act, which would prohibit state agencies from paying more for any prescription drug than the lowest price the U.S. Department of Veterans Affairs pays for the same drug. The other will be Proposition 56, which would increase the per-pack cigarette tax from $0.87 to $2.87; a majority of revenues would be used to fund healthcare for low-income Californians.

And, when Californians who buy their own health insurance start shopping for 2017 plans this month, they will find, on average, lower rate increases and more carrier options than most of the U.S. California’s state-run exchange, Covered California, is widely regarded as one of the most successful established under the Affordable Care Act. It appears set up to continue this reputation as we enter the fourth open enrollment period since the healthcare reform law took effect.

The Golden State is 1 of 9 where at least three insurers in each county will sell plans through ACA exchange. About one-third of U.S. counties will have only one carrier option. Rates for health insurance plans sold on Covered California increased by an average of 13 percent. Nationwide, rates jumped an average of 25 percent.

California health ratings

America’s Health Rankings, compiled by the United Health Foundation, ranked California 16th overall. Lack of health insurance and disparity in health status are among the state’s biggest public health challenges. It performed particularly well in measures related to immunization and public health funding.

By comparison, the Scorecard on State Health System Performance 2015 places California 23rd in its most recent rankings. While the majority of the state’s health indicators had relatively middle-of-the-road placement, the state fared poorest when it came to:

  • Adults ages 50 and older who received recommended screening and preventive care (#51)
  • Children with a medical home (#50)

Noteworthy performances were a 10th place ranking for individuals under age 65 with high out-of-pocket medical costs relative to their annual household income and a 6th place ranking for children who received recommended vaccines. See California’s Scorecard for additional scoring and details.

The 2016 edition of Trust for America’s Health also evaluates a variety of public health indicators. Visit the site for Key Health Data About California.

Given California’s size and diversity, a statewide view might not provide the level of information you want. Get county-by-county health rankings for California, which were developed by the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.

2017 health insurance rates and carriers

While California’s exchange may have more carrier options than others, rates will increase in 2017. Covered California announced July 19, that the statewide average rate increase for 2017 plans would be 13.2 percent. When this increase is averaged with 2015 and 2016, the three-year average is 7 percent, which is lower than the average pre-ACA annual increase.

The following 11 carriers will offer coverage through Covered California in 2017:

  • Anthem Blue Cross of California
  • Blue Shield of California
  • Chinese Community Health Plan (only San Francisco county and San Mateo county)
  • Health Net
  • Kaiser Permanente
  • A. Care Health Plan
  • Molina Healthcare
  • Oscar Health Plan of California
  • Sharp Health Plan (only San Diego county)
  • Valley Health Plan (only Santa Clara County)
  • Western Health Advantage (only North Bay area and Greater Sacramento)

Each county is said to have at least three carriers from which to choose during 2017 open enrollment.

How has Obamacare helped California?

California embraced healthcare reform, creating a state-based exchange and expanding Medicaid. And, following the 2014 ACA open enrollment period, the state saw its uninsured rate significantly decline. A study by The Commonwealth Fund showed California’s uninsured rate dropping from 22 percent in July-September 2013 to 11 percent in April-June 2014.

Per Gallup, California is among the 10 states with the biggest drop its uninsured rate since 2013 and comes in 5th. By late-2015, the percentage of uninsured in California decreased 9.8 percentage points to 11.8 percent. However, the state’s percentage of uninsured is still higher than uninsured rate in other states that both expanded Medicaid and have a state-run exchange; the average uninsured rate for such states is 8.9 percent.

Covered California has also helped Californians lower their prescription medication costs. In 2016, the state exchange rolled out a cap on prescription costs. Available to many consumers purchasing off-exchange plans as well, the cap is linked to the metal level of the plan purchased and is $250 per specialty medication per month for the majority of consumers.

Californians’ enrollment in qualified health plans

Covered California reported that 1,414,668 individuals signed up for qualified health plans (QHPs) during the 2014 open enrollment period. Of that 1.4 million, about 1.1 million individuals paid their premiums and had their coverage take effect.

During the 2016 open enrollment period, there were 439,000 new private plan enrollees through Covered California. As of March 31, effectuated enrollment stood at 1,415,428. Of these enrollees, 87.6 percent were receiving premium subsidies that averaged $309 per month.

California and the Affordable Care Act

The Affordable Care Act was signed into law in March 2010. California’s Congressional delegation voted along party lines. Both Democratic senators voted yes, as did 34 Democratic representatives. Nineteen Republican representatives voted “No.”

At the state level, legislators moved quickly to pass bills in support of a state-based marketplace – making California the first state to do so. Former Gov. Arnold Schwarzenegger, Republican, signed both the Assembly and Senate bills into law on September 30, 2010.

Current Gov. Jerry Brown, a Democrat, called a special session in late 2012, enabling additional legislation to implement the ACA in California.

California Medicaid/CHIP

California embraced Medicaid expansion in addition to implementing a state-run marketplace. Expanding Medicaid eligibility to include nearly all non-elderly adults with incomes at or below 138 percent of poverty is one of the ACA’s main strategies to reduce uninsured rates. Between October 2013 and September 2014, California’s Medicaid enrollment increased by about 2.7 million people, or 31 percent.

California Medicaid is called Medi-Cal and is the largest Medicaid program in the nation, covering 11.9 million people as of June 2016. Since 2013, Medi-Cal enrollment has increased 55 percent, the ninth-highest enrollment change in the nation.

To learn more about California’s Medicaid program visit the California Department of Health Care Services. Note: California’s Children’s Health Insurance Program (CHIP) was previously known as Healthy Families. In 2013, California transitioned Health Families enrollees to Medi-Cal.

Does California have a high-risk pool?

Prior to the ACA’s reforms in the individual health insurance market, medical history was a factor in eligibility for private plans in nearly every state, including California.  Applicants with pre-existing conditions were often unable to buy individual plans in the private market, or if coverage was available it came with a higher premium or with exclusions on pre-existing conditions.

The California Major Risk Medical Insurance Board (MRMIB) was created in 1991 to provide a coverage option for people who were ineligible for coverage under a private plan because of medical history.

Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This change largely eliminated the need for high-risk pools, since pre-existing conditions are no longer a barrier to obtaining coverage.

The California Budget Act of 2014 included a provision for MRMIB to cease operations as of July 1, 2014. Most of the MRMIB insureds had already been able to obtain coverage through the exchange or expanded Medicaid, but remaining members were transitioned to the California Department of Health Care Services on July 1.

Medicare in the state of California

In 2015, California Medicare enrollment reached 5.6 million, about 14 percent of the state’s population. For comparison, 17 percent of the U.S. population is enrolled in Medicare.

Eighty-six percent of California Medicare recipients qualify based on their age alone, while 14 percent are on Medicare as the result of a disability.

Medicare spends about $8,598 per enrollee each year in California. At $50.6 billion per year, in 2009, the state ranked No. 1 in terms of overall Medicare spending.

Medicare Advantage plans offer additional benefits to Medicare-eligible individuals who want them. Medicare beneficiaries may select a Medicare Advantage instead of Original Medicare, and 38 percent of California’s Medicare beneficiaries make this selection. Nationwide, 31 percent of Medicare recipients are enrolled in Medicare Advantage plans.

About 37 percent of California Medicare beneficiaries are enrolled in Medicare Part D plans for stand-alone prescription drug coverage, compared with 45 percent nationwide.

Health reform legislation in California

Here’s a summary of legislative action regarding healthcare reform at the state level in California:

  • SB4 – The California Senate passed SB4 in early June 2015, the Assembly in September, and on October 9, 2015, Gov. Brown signed it into law. The legislation, renamed the Health for All Kids Act, focuses on Medi-Cal access for undocumented immigrant children under the age of 19. SBF will take effect in May 2016, and it has been estimated that 170,000 undocumented immigrant children will then become eligible for Medi-Cal based on their household income alone.
  • SB10 – This bill was introduced in 2015 and will be addressed in the 2016 legislative session. It would allow adults age 19 and older to enroll in Medi-Cal, regardless of immigration status, and would also allow those with incomes above the Medi-Cal threshold to purchase subsidized health plans through Covered California as long as HHS grants a waiver that allows them to do so.
  • AB1102 – Initially, the legislation was written to make pregnancy a qualifying event that would allow pregnant women a special enrollment period. The California Assembly passed AB1102 in June 2015 and was significantly revised in July. This bill, which is now inactive with the Senate, says that applicants that are rejected for coverage shall be directed to the California Major Risk Medical Insurance Program and/or Covered California for further assistance. MRMIP, Medi-Cal, and the Medi-Cal Access Program, which had its enrollment integrated into Covered California in October 2015, all have year-round enrollment for eligible applicants, including options for uninsured women who have become pregnant outside of open enrollment.
  • AB339 – Signed into law in October 2015, this bill applies to all non-grandfathered individual and small group plans in California. It limits the copayment for a 30-day supply of any medication to no more than $250. It takes effect January 1, 2017, and will last until January 1, 2020. For high-deductible health plans, the copay limit will apply after the deductible has been met.

Other California state-level health reform legislation includes:

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