Tagged Uninsured

Your School Assignment For The Day: Spelling And Specs

DELANO, Calif. — Daisy Leon struggles to sit still and read the letters on the eye chart. Her responses tumble out in a quiet, confused garble.

“You know your letters?” asks optometrist Jolly Mamauag-Camat. “Umm, ya,” says Daisy, almost inaudibly.

The 6-year-old kindergartner had her eyes examined for the first time on a recent Thursday morning. Although she hadn’t complained about headaches or blurry vision, her grandmother noticed she’d been inching closer to watch television.

After Daisy’s failed attempts at reading the eye chart, Mamauag-Camat inspects the little girl’s eyes through a phoropter and writes her a prescription for glasses.

At least 20% of school-age children in the U.S. have vision problems. But according to the Centers for Disease Control and Prevention, fewer than 15% of children get an eye exam before entering kindergarten. Because vision problems tend to worsen the longer they go undetected, many children suffer even though there are often simple, relatively inexpensive solutions such as prescription glasses.

Half of the states plus the District of Columbia require screenings or exams for preschoolers, according to the National Center for Children’s Vision & Eye Health. But California has no such requirement, said Xuejuan Jiang, an assistant professor of research ophthalmology at Keck School of Medicine of USC. California does require them for older children.

“The system in California is not as good as it can be,” Jiang said.

In much of California’s Central Valley, where roughly 1 in 5 people live in poverty, two school districts are working with two nonprofits, the Advanced Center for Eyecare and OneSight, to provide vision care to Kern County’s underserved and uninsured children.

Many of the neediest are the children of farmworkers.

“We are an agriculture-based community,” said Linda Hinojosa, coordinator of health services for the Delano Union School District. “Most of our families harvest table grapes 12 hours a day, with very limited time to take their children in for an eye exam.”

The program, funded by the nonprofits and the school districts, operates five school-based clinics in Bakersfield and Delano. Students receive comprehensive eye exams and glasses, along with free transportation. And breakfast.

Most of the children who visit the clinics have coverage through Medi-Cal, California’s Medicaid program for low-income people. There is no out-of-pocket cost for the eye exams and glasses for them, or for children who are uninsured, said Alexander Zahn, chief business development officer for the Advanced Center for Eyecare.

Almost half of the students examined need glasses.

“The need was very apparent” in the Central Valley, Zahn said. “Sixty dollars for an eye exam and $80 for glasses might be the difference between eating dinner a couple days a week.”

Daisy was among 12 students who were bused to the Delano Union School District Vision Center, adjacent to Pioneer School, an elementary school with about 1,000 students. Almost all the students at Pioneer are Hispanic and about three-quarters qualify for free lunches.

Students from throughout the Delano Union Elementary School District visit the clinic. Since it opened in 2018, the clinic has performed 961 eye exams and prescribed 517 pairs of glasses.

For Daisy, whose parents are farmworkers, the clinic has been a tremendous help.

“They prune out in the fields,” said Guadalupe Leon, Daisy’s grandmother. “They can’t afford to take days off.”

The Delano Union School District Vision Center is funded by multiple sources: OneSight, a nonprofit organization dedicated to increasing access to vision care in underserved communities around the world, donated the ophthalmic equipment and provided grant funding for the first year of operation. The Advanced Center for Eyecare provides staff and supplies. And the school district provides the facility, furnishings and transportation. (Heidi de Marco/KHN)

Twelve students from Nueva Vista Language Academy and Fremont Elementary School arrive by bus for their eye exams and follow-ups. Linda Hinojosa, a registered nurse for 20 years, says lack of transportation is a major barrier to vision care. “Parents a lot of times don’t have a car, or it can be a one-vehicle family,” she says. (Heidi de Marco/KHN)

Students are offered breakfast before their appointments with optometrist Jolly Mamauag-Camat. About three-quarters of students in the district are eligible for free/reduced-price meals. (Heidi de Marco/KHN)

Daisy Leon, a kindergartner at Nueva Vista Language Academy, takes a test to check for color blindness. Before beginning, the optical technician asks Daisy if she understands English. Because of the region’s large Spanish-speaking population, clinic staff members often act as interpreters. (Heidi de Marco/KHN)

Daisy looks into an auto refractor as part of her eye exam. (Heidi de Marco/KHN)

Daisy and Jonathon Castro watch a movie as they wait for their eyes to dilate. This is the first eye exam for both of them. (Heidi de Marco/KHN)

Daisy sits on her knees to see through a phoropter, a device to help determine eyeglass prescriptions. Mamauag-Camat says children often can’t tell if they have vision problems because they don’t know any differently. “They can fall through the cracks,” she says. “They don’t know the difference between what’s clear and not clear.” (Heidi de Marco/KHN)

About 45% of Kern County’s population is on Medi-Cal. Medi-Cal covers vision care, including an eye exam and glasses every two years, but in communities like Delano, access is a problem. “We live in an area with a big shortage of providers, particularly specialty care providers like optometrists and ophthalmologists,” says Alexander Zahn, of the Advanced Center for Eyecare. (Heidi de Marco/KHN)

Daisy picks out glasses right after her exam, a pink pair that she had been admiring all morning. “We need to go where students are,” says Hinojosa. “Vision is absolutely vital.” (Heidi de Marco/KHN)

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Related Topics

California Cost and Quality Health Care Costs Health Industry Multimedia Uninsured

Trump’s Medicaid Chief Labels Medicaid ‘Mediocre.’ Is It?

The Trump administration’s top Medicaid official has been increasingly critical of the entitlement program she has overseen for three years.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, has warned that the federal government and states need to better control spending and improve care to the 70 million people on Medicaid, the state-federal health insurance program for the low-income population. She supports changes to Medicaid that would give states the option to receive capped annual federal funding for some enrollees instead of open-ended payouts based on enrollment and health costs. This would be a departure from how the program has operated since it began in 1965.

In an early February speech to the American Medical Association, Verma noted how changes are needed because Medicaid is one of the top two biggest expenses for states, and its costs are expected to increase 500% by 2050.

“Yet, for all that spending, health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care,” she said.

Verma’s sharp comments got us wondering if Medicaid recipients were as bad off as she said. So we asked CMS what evidence it has to back up her views.

A CMS spokesperson responded by pointing us to a CMS fact sheet comparing the health status of people on Medicaid to people with private insurance and Medicare. The fact sheet, among other things, showed 43% of Medicaid enrollees report their health as excellent or very good compared with 71% of people with private insurance, 14% on Medicare and 58% who were uninsured.

The spokesperson also pointed to a 2017 report by the Medicaid and CHIP Payment and Access Commission (MACPAC), a congressional advisory board, that noted: “Medicaid enrollees have more difficulty than low-income privately insured individuals in finding a doctor who accepts their insurance and making an appointment; Medicaid enrollees also have more difficulty finding a specialist physician who will treat them.”

We opted to look at those issues separately.

What About Health Status?

Several national Medicaid experts said Verma is wrong to use health status as a proxy for whether Medicaid helps improve health for people. That’s because to be eligible for Medicaid, people must fall into a low-income bracket, which can impact their health in many ways. For example, they may live in substandard housing or not get proper nutrition and exercise. In addition, lack of transportation or child care responsibilities can hamper their ability to visit doctors.

Benjamin Sommers, a health economist at Harvard University, said Verma’s comparison of the health status of Medicaid recipients against people with Medicare or private insurance is invalid because the populations are so different and face varied health risks. “This wouldn’t pass muster in a first-year statistics class,” he said.

Death rates, for example, are higher among people in the Medicare program than those in private insurance or Medicaid, he said, but that’s not a knock on Medicare. It’s because Medicare primarily covers people 65 and older.

By definition, Medicaid covers the most vulnerable people in the community, from newborns to the disabled and the poor, said Rachel Nuzum, a vice president with the nonpartisan Commonwealth Fund. “The Medicaid population does not look like the privately insured population.”

Joe Antos, a health economist with the conservative American Enterprise Institute, also agreed, saying he is leery of any studies or statements that evaluate Medicaid without adjusting for risk.

For a better mechanism to gauge health outcomes under Medicaid, experts point to dozens of studies that track what happened in states that chose in the past six years to pursue the Affordable Care Act’s Medicaid expansion. The health law gave states the option to extend Medicaid to everyone with incomes up to 138% of the federal poverty level, or about $17,600 annually for an individual. Thirty-six states and the District of Columbia have adopted the expansion.

“Most research demonstrates that Medicaid expansion has improved access to care, utilization of services, the affordability of care, and financial security among the low-income population,” concluded the Kaiser Family Foundation in summarizing findings from more than 300 studies. “Studies show improved self-reported health following expansion and an association between expansion and certain positive health outcomes.” (Kaiser Health News is an editorially independent program of the foundation.)

Studies found the expansion of Medicaid led to lower mortality rates for people with heart disease and among end-stage renal disease patients initiating dialysis.

Researchers also reported that Medicaid expansion was associated with declines in the length of stay of hospitalized patients. One study found a link between expansion and declines in mechanical ventilation rates among patients hospitalized for various conditions.

Another recent study compared the health characteristics of low-income residents of Texas, which has not expanded Medicaid, and those of Arkansas and Kentucky, which did. It found that new Medicaid enrollees in the latter two states were 41 percentage points more likely to have a usual source of care and 23 percentage points more likely to say they were in excellent health than a comparable group of Texas residents.

Medicaid’s benefits, though, affect far more than the millions of nondisabled adults who gained coverage as a result of the ACA. “Medicaid coverage was associated with a range of positive health behaviors and outcomes, including increased access to care; improved self-reported health status; higher rates of preventive health screenings; lower likelihood of delaying care because of costs; decreased hospital and emergency department utilization; and decreased infant, child, and adult mortality rates,” according to a report issued this month by the nonpartisan Robert Wood Johnson Foundation.

Children — who make up nearly half of Medicaid enrollees — have also benefited from the coverage, studies find. Some studies report that Medicaid contributes to improved health outcomes, including reductions in avoidable hospitalizations and lower child mortality.

Research shows people on Medicaid are generally happy with the coverage.

A Commonwealth Fund survey found 90% of adults with Medicaid were satisfied or very satisfied with their coverage, a slightly higher percentage than those with employer coverage.

Accessible Care?

The evidence here is less emphatic.

A 2017 study published in JAMA Internal Medicine found 84% of Medicaid recipients felt they were able to get all the medical care they needed in the previous six months. Only 3% said they could not get care because of long wait times or because doctors would not accept their insurance.

Verma cites a 2017 MACPAC report that noted some people on Medicaid have issues accessing care. But that report also noted: “The body of work to date by MACPAC and others shows that Medicaid beneficiaries have much better access to care, and much higher health care utilization, than individuals without insurance, particularly when controlling for socioeconomic characteristics and health status.” It also notes that “Medicaid beneficiaries also fare as well as or better than individuals with private insurance on some access measures.”

The report said people with Medicaid are as likely as those with private insurance to have a usual source of care, a doctor visit each year and certain services such as a Pap test to detect cervical cancer.

“Medicaid is not great coverage, but it does open the door for health access to help people deal with medical problems before they become acute,” Antos said.

On the negative side, the report said Medicaid recipients are more likely than privately insured patients to experience longer waiting times to see a doctor. They also are less likely to receive mammograms, colorectal tests and dental visits than the privately insured.

“Compared to having no insurance at all, having Medicaid improves access to care and improves health,” said Rachel Garfield, a vice president at the Kaiser Family Foundation. “There is pretty strong evidence that Medicaid helps patients get the care they need.”

Our Ruling

Verma said that “health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care.”

Numerous studies show people’s health improves as a result of Medicaid coverage. This includes lower mortality rates, shorter hospital stays and more people likely to get cancer screenings.

While it’s hard to specify what “many patients having difficulty accessing care” means, research does show that Medicaid enrollees generally say they have no trouble accessing care most of the time.

We rate the claim as Mostly False.

Related Topics

Cost and Quality Insurance Medicaid States Uninsured

It’s Not Just Hospitals That Sue Patients Who Can’t Pay

Nashville General Hospital is a safety-net facility funded by the Tennessee capital city. For a patient without insurance, this is supposed to be the best place to go in a city with many hospitals. But for the uninsured, it may have been the worst choice in 2019.

Its emergency room was taking more patients to court for unpaid medical bills than any other hospital or practice in town. A WPLN investigation found the physician-staffing firm that runs the ER sued 700 patients in Davidson County during 2019.

They include patients such as Sonya Johnson, a 52-year-old social worker and single mother. By juggling her care between a nonprofit clinic and Nashville General, Johnson had figured out how to manage her health problems, even though she was, until recently, uninsured.

In 2018, she went to see her doctor, who charges patients on a sliding scale. Her tongue was swollen and she was feeling weak. The diagnosis? Severe anemia.

“He called me back that Halloween day and said, ‘I need you to get to the emergency [room], stat — and they’re waiting on you when you get there,’” she recalled.

Nashville General kept her overnight and gave her a blood transfusion. They wanted to keep her a second night — but she was worried about the mounting cost and asked to be sent home.

Staying the one night meant she was admitted to the hospital itself, and the bill for that part of her care wasn’t so bad, Johnson said. The institution’s financial counselors offered a 75% discount because of her strained finances and because her job didn’t offer health insurance at the time.

But emergency rooms are often run by an entirely separate entity. In Nashville General’s case, the proprietor was a company called Southeastern Emergency Physicians. And that’s the name on a bill that showed up in Johnson’s mailbox months later for $2,700.

“How in the world can I pay this company, when I couldn’t even pay for health care [insurance]?” Johnson asked.

Social worker Sonya Johnson received a civil warrant to appear in court when the company that runs Nashville General Hospital’s emergency room threatened to sue her over a $2,700 ER bill — long after she’d already negotiated a reduced payment schedule for the rest of her hospital stay.(Blake Farmer/WPLN)

Johnson didn’t recognize the name of the physician practice. A Google search didn’t help much. There’s no particular website, though a listing of webpages that do turn up in such a search suggests the company staffs a number of emergency departments in the region.

Johnson said she tried calling the number listed on her bill to see if she could get the same charity-care discount the hospital gave her, but she could only leave messages. And then came a knock at her apartment door over the summer. It was a Davidson County sheriff’s deputy with a summons requiring Johnson to appear in court.

“It’s very scary,” she said, and she recalled thinking “What have I done? And for a medical bill?”

Handoff Of Lawsuits?

Being sued over medical debt can be a big deal because it means a business can get a court-ordered judgment to garnish patients’ wages, taking money directly from their paycheck. The strategy is meant to make sure patients don’t blow off their medical debts. But this is not good for the health of people who are uninsured, said Bruce Naremore, chief financial officer at Nashville General.

“When patients owe money, and they feel like they’re being dunned all the time, they don’t come back to the hospital to get what they might need,” he said.

Under Naremore’s direction in the past few years, Nashville General had stopped suing patients for hospital fees. He said it was rarely worth the court costs.

But Southeastern Emergency Physicians — which, since 2016, has been contracted by the hospital to run and staff its emergency department — went the other way, filing more lawsuits against patients than ever in 2019.

Naremore said the decision on whether to sue over emergency care falls to the company that staffs the ER, not Nashville General Hospital.

“It’s a private entity that runs the emergency room, and it’s the cost of doing business,” he said. “If I restrict them from collecting dollars, then my cost is going to very likely go up, or I’m going to have to find another provider to do it.”

This is a common refrain, said Robert Goff, a retired hospital executive and board member of RIP Medical Debt. The nonprofit helps patients trapped under a mountain of medical bills, which are the No. 1 cause of personal bankruptcy.

“So the hospital sits there and says, ‘Not my problem.’ That’s irresponsible in every sense of the word,” Goff said.

The practice of suing patients isn’t new for Southeastern Emergency Physicians or its parent company, Knoxville, Tennessee-based TeamHealth. But such lawsuits have picked up in recent years, even as the company has stopped its practice of balance-billing patients.

TeamHealth is one of the two dominant ER staffing firms in the nation, running nearly 1 in 10 emergency departments in the United States. And its strategy of taking patients to court ramped up after it was purchased by the private equity giant Blackstone, according to an investigation by the journalism project MLK50 in Memphis, Tennessee.

Under pressure from journalists, TeamHealth ultimately pledged to stop suing patients and to offer generous discounts to uninsured patients.

Officials from TeamHealth declined WPLN’s request for an interview to answer questions about how widespread its practice of suing patients for ER doctors’ services and fees has been.

“We will work with patients on a case by case basis to reach a resolution,” TeamHealth said in an email.

According to court records obtained by WPLN, the firm filed about 700 lawsuits against patients in Nashville in 2019. That’s up from 120 in 2018 and just seven in 2017. Its only contract in the city is with Nashville General’s ER, and the patients reached by WPLN said they were uninsured when they were sued.

What’s surprising to Mandy Pellegrinwho has researched medical billing in Tennessee at the nonpartisan Sycamore Institute, is that it was all happening at Nashville General — where treating uninsured patients is part of the hospital’s mission.

“It is curious that a company that works for a hospital like that might resort to those sorts of actions,” Pellegrin said.

A Pledge To Drop Cases

As for Sonya Johnson — she eventually went to court and worked out a payment plan of $70 a month over three years.

And now TeamHealth tells WPLN that its intent is to drop pending cases.

“We will not file additional cases naming patients as defendants and will not seek further judgments,” a TeamHealth spokesperson said in an emailed statement. “Our intent is not to have these pending cases proceed. We’re working as expeditiously as possible on resolving individual outstanding cases.”

Johnson said she has been told that the lawsuit Southeastern Emergency Physicians filed against her will be dropped — but that she still owes the $2,700 bill.

This story is part of a reporting partnership that includes WPLN, NPR and Kaiser Health News. 

Related Topics

Cost and Quality Courts Health Care Costs Insurance States Uninsured

Analysis: Who Profits From Steep Medical Bills? The People Tasked With Fixing Them.

Every politician condemns the phenomenon of “surprise” medical bills.

Last week, two committees in the House were marking up new surprise billing legislation. One of the few policy proposals President Donald Trump brought up in this year’s State of the Union address was his 2019 executive order targeting “balance bills.” In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.

Patients, of course, hate surprise bills most of all. Typical scenarios: A patient having a heart attack is taken by ambulance to the nearest hospital and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network. A patient selects an in-network provider for a minor procedure, like a colonoscopy, only to be billed thousands for the out-of-network anesthesiologist and pathologist who participated.

And yet, no one with authority in Washington has done much of anything about it.

Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.

That explains why Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war among the players in the health care industry over who gets to keep the fortunes generated each year from patient illness: $3.6 trillion in 2018.

Here’s how they came to be:

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into society’s top 1%, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in copayments or deductibles.

That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?

Commercial insurers as well as Blue Cross Blue Shield plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.

Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.

As the battle for revenue has heated up, each side has added weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important, they limited the networks of providers to those that would accept the rates they were willing to pay.

Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.

And, for a time, all sides were basically fine with this arrangement.

But as the scope and the scale of surprise bills have grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have become impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participate in insurance, so every ambulance ride costs hundreds or even thousands of dollars?

These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball-style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view.

So, nothing has changed at the federal level, even though it’s hard to imagine another issue for which there is such widespread consensus. Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly 8 in 10 Americans say they want federal legislation to protect patients against surprise bills.

States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.

Now members of Congress have yet another chance to tackle this obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?

Related Topics

Cost and Quality Health Care Costs Health Industry Insurance Uninsured

Surge In Enrollment As Californians Avoid Penalty, Receive State Aid

Hundreds of thousands of new enrollees signed up for 2020 coverage through Covered California, driven by new carrot-and-stick state policies that provide financial aid to help some people afford their premiums while penalizing those who don’t have coverage, state health officials announced Tuesday.

Covered California Executive Director Peter Lee said the health insurance exchange is giving consumers who remain uninsured another chance to enroll: Effective immediately, those who were not aware of the new penalty or financial aid can sign up for coverage during a special enrollment period that will last through April.

Covered California is the state’s Affordable Care Act health insurance marketplace, where eligible individuals, families and small businesses can purchase plans and may qualify for federal tax credits and/or the new state-based subsidies based on their incomes.

“This has proven the case that the Affordable Care Act, as designed and not kneecapped, works and works well,” Lee said.

The new state penalty encouraged people to check the insurance exchange, he said. The subsidies encouraged people to buy.

About 418,000 Californians newly enrolled in individual or family plans through Covered California by the Jan. 31 enrollment deadline, 41% more than last year and the highest new enrollment since 2016, according to preliminary data from the exchange.

About 1.1 million existing Covered California enrollees also renewed plans, bringing the total number of enrollees to more than 1.5 million.

On healthcare.gov, the federally run health insurance exchange, about 8.3 million people enrolled in new plans or renewed their coverage this year, down slightly from 8.4 million in 2019.

California is one of six states and the District of Columbia that require most of their residents to purchase health insurance or face a penalty. Congress eliminated the Affordable Care Act’s federal tax penalty, effective last year.

California’s penalty mirrors the federal one that was nullified. In many cases, it will amount to $695 for a single adult and about $2,000 for a family of four. But for a lot of people, the financial hit could be substantially larger.

The state projects the penalty could raise $317 million in the first year, which is intended to partially fund the subsidies. Lee said he would forgo the extra revenue if it meant people are getting covered.

“The penalty is on the books but nobody wants the money,” he said. “We want it to be an economic nudge to get people to get covered.”

People who were motivated by the penalty to shop for insurance might have found coverage cheaper than last year.

Some of the new state financial aid is available to low-income customers, but California became the first state to offer subsidies to middle-income people who make too much to qualify for the federal tax credits: people whose incomes are between 400% and 600% of the federal poverty level, or about $51,000 to $76,000 a year for an individual and $104,800 to $157,200 for a family of four. Those thresholds are too high to qualify for federal aid but low enough to make health insurance a financial burden.

The average state assistance for this group is about $500 a month, Lee said.

About 625,000 people qualified for the new state subsidies, including 32,000 middle-income enrollees, Lee said.

The subsidies vary by income, household size, location and age. Some went to low-income residents who also qualify for federal tax credits.

Evette Tsang and her husband, both insurance brokers in Sacramento, serve mostly Chinese-speaking immigrants. Her clients used their state subsidies this year to purchase more comprehensive silver-tier plans with higher premiums rather than the cheaper bronze plans with lower benefits.

“After these few years, they start to see the importance of health insurance,” Tsang said. “Before, they only wanted bronze, but now they’re going to silver.”

Deborah Kelch, executive director of the Insure the Uninsured Project, said a lot of the success of this year’s enrollment numbers was the product of an aggressive marketing campaign urging Californians who hadn’t been able to afford insurance in the past to take a second look.

“They did so much great outreach,” Kelch said. “At this stage, Covered California has a really good formula they’re using. There are TV ads, they have their bus tour, they work with community organizations.”

According to Lee, Covered California budgeted $47 million for advertising this year, including $6 million for the special enrollment period.

Despite the advertising dollars, Lee said, there still isn’t enough awareness about the penalty and subsidies, necessitating the special enrollment period through April 30.

While she wants everyone to get covered, insurance broker Tsang isn’t looking forward to the new enrollment period and the extra work it will bring. Nearly all her clients knew about the penalty, she said, and it was the No. 1 reason they signed up.

California already has a longer enrollment window than the federal government’s healthcare.gov exchange, which lasts only six weeks.

Combined with other factors, the extended period encourages higher enrollment and a better mix of healthy and sick people in the insurance pool, said Laurel Lucia, director of the Health Care Program at the Center for Labor Research and Education at the University of California-Berkeley.

“With the state mandate and the new state subsidies, we project the uninsured rate will remain flat over the next few years,” Lucia said.

That’s the important comparison, according to Lee. While new enrollment in the federal exchange has dropped by 48% since 2016, new enrollment in Covered California has been relatively stable since then, dropping by 2%.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Related Topics

Covered California Insurance States The Health Law Uninsured

Appeals Court Shoots Down Arkansas’ Medicaid Work Requirements In Latest Legal Blow For Trump Administration