The New Health Dialogue

The California Health Benefit Exchange held its third meeting today at an auditorium in downtown Sacramento. It was an opportunity for the Exchange staff to update the broader health policy community – many of whom were in attendance or watched the webcast – on progress toward planning the development of this new portal to coverage for the state.  The substantive focus was on integration with existing state programs and systems.

Leveling Up

“Level 1 or bust” has become the mantra of the Exchange team, particularly of Exchange board member Kim Belshé. She is the subcommittee of one charged with submitting the “establishment grant” applications to the federal government for this nascent state agency.  The first (“Level 1”) grant, which the Board plans to review at its next meeting on June 15^th and may approve at the following meeting on June 28^th, will among other things provide more funding to hire a staff for the Exchange.  (The June 15^th meeting will feature the participation of key federal government officials Joel Ario and Cindy Mann and will be held at the auditorium of the Department of Health Care Services.) 

Pending the approval of this grant, expected by the end of the summer, the Exchange is being run on a shoestring budget, staffed primarily by people from other parts of the government who have been assisted by consultants supported by charitable philanthropies.  Their work is being directed by Pat Powers, the Interim Administrative Director of the Exchange.  She promised that, after the Level 1 grant is submitted, there will be time to step back and think about the broader vision for this work and to do more strategic planning.

The compressed timeline and skeleton crew also meant that the documents for this board meeting were not posted far in advance and the formal process of stakeholder engagement has yet to be initiated.  These were issues of concern raised in public comment.   There has, however, been extensive informal stakeholder engagement, and the broader health policy community remains actively involved in this process as demonstrated by yet another packed auditorium.

Program Integration and Eligibility and Enrollment Systems

The substantive focus of this meeting was on one of the early-term tasks outlined by the ACA: program integration, particularly as it relates to the eligibility and enrollment systems currently administered by the state for its existing programs.  The ACA requires the Exchange to coordinate with many of the different organs of state governance.  Deborah Kelch, who is acting as one of the leading consultants focused on the state’s establishment grant application, gave an overview of program integration requirements.  She delivered an impassioned and well-received plea that California acknowledge that it already performs all of these functions and that we need to make sure to rely on the existing expertise, individuals, and departments of state government. 

Representatives of the Department of Insurance and the Department of Managed Health Care, California's two separate health insurance regulators, gave high-level overviews of the core functions of their agencies and their track records.  Left largely to be determined through an ongoing series of conversations was how the Exchange’s role as a quasi-regulator (through its certifying of Qualified Health Plans) will reinforce, overlap with, or undermine the activities of the state’s existing insurance regulators.  The idea of merging the DOI and the DMHC, which has a great deal of appeal particularly in the context of the standardization encouraged by federal healthcare reform, was also left unaddressed.

The second part of the briefing focused on the state’s existing eligibility and enrollment systems specifically. Bill Obernesser, who has been a lead consultant on this work, delivered a terrific presentation laying out the federal requirements and mapping out the state’s existing systems.  He was followed by representatives from the County Welfare Directors Association who spoke in greater detail about the county-based enrollment system for Medi-Cal, the state's Medicaid program, and by a representative from the Managed Risk Medical Insurance Board who talked about the separate state-based system for enrollment in Healthy Families, the state's children's health insurance program.  There was also a briefing by Terri Shaw the Project Director for Enrollment UX 2014, a national project designed to help develop technology solutions that will be available to states as they evolve their eligibility and enrollment systems through federal reform.

The picture that emerged from this discussion was of a set of systems in California that have made great strides, particularly within the past year, in terms of creating online portals to enrollment that have attracted some attention from the broader public.  On the other hand, the state still has a system in which applications to the Healthy Families program that look as if they should be routed to Medi-Cal are printed out and sent by mail to the county that will process the application.  And the "MEDS" database that is supposed to act as the interface between the different programs is probably not adequate to continue to perform that function. 

An Enormous Task

The public comment sections of the agenda attracted a long-line of both public and private stakeholders all expressing commitment to the project of creating an Exchange and offering their help in the task.  The consultants and staff who have been doing the work have done an excellent job of keeping their heads above water and moving the process forward.  And the board, still missing its fifth and final member, has shown that it is both engaged in and knowledgeable about these issues.

Nevertheless, it was impossible not to get the sense in this meeting that we’ve outlined a series of tasks for ourselves that are daunting at best.  It was also impossible to keep out of one’s mind the current proposals to create a Basic Health Plan which may or may not be a part of the Exchange and to roll Healthy Families into the state Medicaid program which may or may not be the best policy decision in terms of moving toward a more rational, accessible, and affordable system.  Certainly California is rushing, perhaps unavoidably, through these policy decisions without having a precise sense of what outcomes each is likely to create in isolation, let alone how they will interact with each other. 

Finally, the Exchange is a portal to all types of coverage, and transitions across programs must be, to use the word of the day, “seamless.”  But this agency will and should have to rely on other state departments particularly as it relates to enrollment into public programs.  The core function of the Exchange itself is as a more tightly regulated marketplace for federally-subsidized purchase of private health insurance.  Some of the presentations to the board have focused on this aspect of its work, but the surface of these issues has only been scratched.  It will be an enormous task to juggle all of the competing priorities for the Exchange while not losing sight of this central mission.