The Yes on Prop 35 campaign has raised over $48 million as of Sept. 9, according to campaign filings with the secretary of state. The measure would use money from a tax on managed-care health plans mainly to hike the pay of physicians, hospitals, community clinics, and other providers in Medi-Cal, the state’s version of Medicaid.

For many months, there was no organized opposition. But shortly after Labor Day, a small group of community advocates, including the League of Women Voters of California, California Pan-Ethnic Health Network, and The Children’s Partnership, announced they were united against it.

“We do not have the deep pockets that the proponents of the initiative do,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. No fundraising has been recorded from opposition groups thus far.

Gov. Gavin Newsom hasn’t taken a public stance, but he has warned that the proposal to lock in how proceeds from the managed-care tax are used would hamstring his administration’s ability to address the state’s yawning budget gap.

The people represented by some of the opposition groups include Medi-Cal patients who are among the state’s most vulnerable — children, seniors, people with disabilities, and the chronically ill — as well as some workers who provide ancillary care to them.

The opponents say that if Proposition 35 passes, the patients, workers, and programs they care about could lose millions of dollars included for them in this year’s state budget. That’s because the ballot measure would supersede the budget, and it leaves them out of the health tax proceeds.

The budget currently provides tens of millions of dollars a year to raise the pay of community health workers, nonemergency medical transport drivers, and private-duty nurses, among other personnel. It also funds the cost of a new program, scheduled to start Jan. 1, that allows children through age 4 to stay on Medi-Cal without requiring their families to prove eligibility every year. Child health advocates say that will help avoid potentially harmful gaps in coverage.

Mayra Alvarez, president of The Children’s Partnership, estimates the program would bring coverage stability to about 1.2 million California kids. But funding for it will be at risk if Proposition 35 passes, she warns.

It’s not that the money for that program, or the pay increases for ancillary health care workers, would necessarily go away forever. But advocates would have to fight for it in subsequent budget rounds.

Dustin Corcoran, CEO of the California Medical Association, told me that in addition to the Medi-Cal pay hikes, and some funding for medical education and extra residency slots, the initiative would provide $2 billion a year in 2025 and 2026 to the state’s general fund, “which the legislature can appropriate as they see fit, which vastly exceeds the cost of the programs you mentioned.” CMA and Planned Parenthood Affiliates of California are leading the charge on Proposition 35.

Corcoran’s comments suggest that the groups worried about losing funding if Proposition 35 passes should be able to get it restored in future budgets. Given the current fiscal crisis, however, not everyone is buying it.

“We’re short tens of billions of dollars,” says Ramon Castellblanch, vice president of the California Alliance for Retired Americans, which opposes the measure. “For these people to say, ‘Wait, the general fund is going to cover it’ — is that called gaslighting?”

Proposition 35 proponents say that children, seniors, and disabled or chronically ill people also use doctors, hospitals, and community clinics, for which the measure does provide extra money.

They argue the initiative will go a long way toward addressing Medi-Cal’s historically low pay rates, enticing more providers to participate in the program and enabling those who already do to take more Medi-Cal patients.

“This will be the most significant investment in the Medi-Cal system since the Affordable Care Act,” Corcoran says. “I think it holds great promise for improved access to care, improved quality of care, shorter wait times for all Californians in our ERs, and elimination of health care deserts that are popping up in too many parts of our state.”

Another concern raised by Proposition 35 skeptics is that a long-threatened change in federal rules governing how states collect managed-care taxes to fund Medicaid could torpedo the plans of California — and some of the other 18 states with such a tax.

Proposition 35 sets specific dollar amounts through 2026, which are based on the managed-care tax approved by the federal government last year. But the tax, which California has had in some form since 2009, must be renewed and federally approved every three years. That means that the tax requires another federal approval starting in 2027, the year the ballot measure would make funding permanent.

California’s managed-care tax comes from a levy imposed on health plans, based on monthly numbers of both Medi-Cal and commercial insurance enrollees. The money raised is matched by the federal government, doubling the spending power.

Federal rules require that the health plans be reimbursed for the tax they pay on their Medi-Cal membership. Since the Medi-Cal rate is around 100 times as much as the rate on commercial membership, 99% of the revenue from the tax is on the Medi-Cal side, thus holding many of the health plans almost entirely harmless and minimizing any impact on premiums.

But the federal government has been warning California for years, most recently in a letter it sent in late 2023 accompanying its approval of the managed-care tax, that it will require more balance between the commercial and Medi-Cal levies. Were it to change the rules in that direction, it could cause a major headache in California for a couple of reasons.

First, as proponents of Proposition 35 readily acknowledge, there is no political appetite for an increase in the amount of tax raised on commercial health plan memberships. That’s because it would likely lead to a rebellion by health plans or a jump in premiums that would anger employers, privately insured individuals, and plenty of other people. In that case, the only way to comply would be to lower the tax rate on Medi-Cal enrollment, which would significantly reduce revenue.

Second, though the ballot measure contains flexibility for small changes, it requires a three-fourths majority vote in the legislature for any major changes. That would be a tall order.

“Say the federal administration comes back and says, ‘You can’t do this anymore,’ which seems likely,” says Savage-Sangwan, who is also a spokesperson for the opposing coalition. “We’re going to be stuck with a whole lot less money.”

So far, however, the feds have not followed through on repeated warnings, and Proposition 35 proponents seem to be betting the threat of changes will prove nothing more than bluster.

We’ll see.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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The goal of the agency, established in 2022, is to make care more affordable and accessible while improving health outcomes, especially for the most disadvantaged state residents. That will require a sustained wrestling match with a sprawling, often dysfunctional health system and powerful industry players who have lots of experience fighting one another and the state.

Can the new agency get insurers, hospitals, and medical groups to collaborate on containing costs even as they jockey for position in the state’s $405 billion health care economy? Can the system be transformed so that financial rewards are tied more to providing quality care than to charging, often exorbitantly, for a seemingly limitless number of services and procedures?

The jury is out, and it could be for many years.

California is the ninth state — after Connecticut, Delaware, Massachusetts, Nevada, New Jersey, Oregon, Rhode Island, and Washington — to set annual health spending targets.

Massachusetts, which started annual spending targets in 2013, was the first state to do so. It’s the only one old enough to have a substantial pre-pandemic track record, and its results are mixed: The annual health spending increases were below the target in three of the first five years and dropped beneath the national average. But more recently, health spending has greatly increased.

In 2022, growth in health care expenditures exceeded Massachusetts’ target by a wide margin. The Health Policy Commission, the state agency established to oversee the spending control efforts, warned that “there are many alarming trends which, if unaddressed, will result in a health care system that is unaffordable.”

Neighboring Rhode Island, despite a preexisting policy of limiting hospital price increases, exceeded its overall health care spending growth target in 2019, the year it took effect. In 2020 and 2021, spending was largely skewed by the pandemic. In 2022, the spending increase came in at half the state’s target rate. Connecticut and Delaware, by contrast, both overshot their 2022 targets.

It’s all a work in progress, and California’s agency will, to some extent, be playing it by ear in the face of state policies and demographic realities that require more spending on health care.

And it will inevitably face pushback from the industry as it confronts unreasonably high prices, unnecessary medical treatments, overuse of high-cost care, administrative waste, and the inflationary concentration of a growing number of hospitals in a small number of hands.

“If you’re telling an industry we need to slow down spending growth, you’re telling them we need to slow down your revenue growth,” says Michael Bailit, president of Bailit Health, a Massachusetts-based consulting group, who has consulted for various states, including California. “And maybe that’s going to be heard as ‘we have to restrain your margins.’ These are very difficult conversations.”

Some of California’s most significant health care sectors have voiced disagreement with the fledgling affordability agency, even as they avoid overtly opposing its goals.

In April, when the affordability office was considering an annual per capita spending growth target of 3%, the California Hospital Association sent it a letter saying hospitals “stand ready to work with” the agency. But the proposed number was far too low, the association argued, because it failed to account for California’s aging population, new investments in Medi-Cal, and other cost pressures.

The hospital group suggested a spending increase target averaging 5.3% over five years, 2025-29. That’s slightly higher than the 5.2% average annual increase in per capita health spending over the five years from 2015 to 2020.

Five days after the hospital association sent its letter, the affordability board approved a slightly less aggressive target that starts at 3.5% in 2025 and drops to 3% by 2029. Carmela Coyle, the association’s chief executive, said in a statement that the board’s decision still failed to account for an aging population, the growing need for mental health and addiction treatment, and a labor shortage.

The California Medical Association, which represents the state’s doctors, expressed similar concerns. The new phased-in target, it said, was “less unreasonable” than the original plan, but the group would “continue to advocate against an artificially low spending target that will have real-life negative impacts on patient access and quality of care.”

But let’s give the state some credit here. The mission on which it is embarking is very ambitious, and it’s hard to argue with the motivation behind it: to interject some financial reason and provide relief for millions of Californians who forgo needed medical care or nix other important household expenses to afford it.

Sushmita Morris, a 38-year-old Pasadena resident, was shocked by a bill she received for an outpatient procedure last July at the University of Southern California’s Keck Hospital, following a miscarriage. The procedure lasted all of 30 minutes, Morris says, and when she received a bill from the doctor for slightly over $700, she paid it. But then a bill from the hospital arrived, totaling nearly $9,000, and her share was over $4,600.

Morris called the Keck billing office multiple times asking for an itemization of the charges but got nowhere. “I got a robotic answer, ‘You have a high-deductible plan,’” she says. “But I should still receive a bill within reason for what was done.” She has refused to pay that bill and expects to hear soon from a collection agency.

The road to more affordable health care will be long and chock-full of big challenges and unforeseen events that could alter the landscape and require considerable flexibility.

Some flexibility is built in. For one thing, the state cap on spending increases may not apply to health care institutions, industry segments, or geographic regions that can show their circumstances justify higher spending — for example, older, sicker patients or sharp increases in the cost of labor.

For those that exceed the limit without such justification, the first step will be a performance improvement plan. If that doesn’t work, at some point — yet to be determined — the affordability office can levy financial penalties up to the full amount by which an organization exceeds the target. But that is unlikely to happen until at least 2030, given the time lag of data collection, followed by conversations with those who exceed the target, and potential improvement plans.

In California, officials, consumer advocates, and health care experts say engagement among all the players, informed by robust and institution-specific data on cost trends, will yield greater transparency and, ultimately, accountability.

Richard Kronick, a public health professor at the University of California-San Diego and a member of the affordability board, notes there is scant public data about cost trends at specific health care institutions. However, “we will know that in the future,” he says, “and I think that knowing it and having that information in the public will put some pressure on those organizations.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“The guy was up there screaming and squirming. Then the cab caught on fire,” Trammell says. “I couldn’t move him. He burned to death right there in my arms.”

Memories of that gruesome death and other traumatic incidents he had witnessed as a firefighter in Mountain View, California, didn’t seem to bother Trammell for the first seven years after he retired in 2015. But then he started crying a lot, drinking heavily, and losing sleep. At first, he didn’t understand why, but he would later come to suspect he was suffering from post-traumatic stress disorder.

After therapy failed to improve his mental well-being, he heard about the potential benefits of psychedelic drugs to help first responders with PTSD.

Last July, Trammell went on a retreat in Puerto Vallarta, Mexico, organized by The S.I.R.E.N. Project, a nonprofit that advocates the use of psychedelics and other alternative medicines to help first responders. He took psilocybin mushrooms and, the next day, another psychedelic derived from the toxic secretions of the Sonoran Desert toad. The experience, he says, produced an existential shift in the way he thinks of the terrible things he saw as a firefighter.

“All that trauma and all that crap I saw and dealt with, it’s all very temporary and everything goes back into the universe as energy,” Trammell says.

Abundant research has shown that psychedelics have the potential to produce lasting relief from depression, anxiety, PTSD, addiction, and other mental health conditions. Many universities around the United States have programs researching psychedelics. But experts warn that these powerful drugs are not for everybody, especially those with a history of psychosis or cardiovascular problems.

Most psychedelic drugs are prohibited under federal law, but California may soon join a growing number of local and state governments allowing their use.

A bill working its way through the California Legislature, would allow the therapeutic use of psilocybin; mescaline; MDMA, the active ingredient in ecstasy; and dimethyltryptamine, the active ingredient in ayahuasca, a plant-based psychoactive tea. The drugs could be purchased and ingested in approved locations under the supervision of facilitators, who would undergo training and be licensed by a new state board. The facilitators would need a professional health credential to qualify.

The bill, co-sponsored by Sen. Scott Wiener (D-San Francisco), Assembly member Marie Waldron (R-San Diego), and several other lawmakers, follows last year’s unsuccessful effort to decriminalize certain psychedelics for personal use. Gov. Gavin Newsom, a Democrat, vetoed that bill, though he extolled psychedelics as “an exciting frontier” and asked for new legislation with “regulated treatment guidelines.”

Wiener says the new bill was drafted with Newsom’s request in mind. It is supported by some veterans and first responder groups and opposed by numerous law enforcement agencies.

One potential roadblock is the state’s budget deficit, pegged at between $38 billion and $73 billion. Newsom and legislative leaders may choose not to launch a new initiative when they are cutting existing programs. “That is something we’ll certainly grapple with,” Wiener says.

The legislation, which is making its way through committees, would require the new board to begin accepting facilitator license applications in April 2026. The system would look somewhat like the one in Oregon, which allows the use of psilocybin mushrooms under the guidance of state-licensed facilitators at psilocybin service centers. And like Oregon, California would not allow for the personal use or possession of psychedelics; the drugs would have to be purchased and consumed at the authorized locations.

Colorado, following the passage of a ballot initiative in 2022, is creating a system of regulated “healing centers,” where people will be able to legally consume psilocybin mushrooms and some other psychedelics under the supervision of licensed facilitators. Colorado’s law allows for the personal use and possession of a handful of psychedelics.

In California, the cities of Oakland, San Francisco, Berkeley, Santa Cruz, and Arcata have effectively decriminalized many psychedelics, as have other cities around the United States, including Ann Arbor, Michigan; Cambridge, Massachusetts; Detroit; Minneapolis; Seattle; and Washington, D.C.

Psychedelics such as psilocybin, ayahuasca, and peyote have been used for thousands of years by Indigenous populations in Latin America and the current-day United States. And some non-Indigenous groups use these substances in a spiritual way.

The Church of Ambrosia, with locations in San Francisco and Oakland, considers psilocybin mushrooms, also known as magic mushrooms, a sacrament. “Mushrooms affect the border between this world and the next, and allow people to connect to their soul,” says Dave Hodges, founder and pastor of the church.

Hodges was behind an unsuccessful attempt to get an initiative on the California ballot this year that would have decriminalized the possession and use of mushrooms. He hopes it will qualify for the 2026 ballot.

The pending California legislation is rooted in studies showing psychedelics can be powerful agents in mental health treatment.

Charles Grob, a psychiatry professor at the University of California-Los Angeles School of Medicine who has researched psychedelics for nearly 40 years, led a study that found synthetic psilocybin could help reduce end-of-life anxiety in patients with advanced-stage cancer.

Grob says MDMA is good for couples counseling because it facilitates communication and puts people in touch with their feelings. And he conducted research in Brazil that showed ayahuasca used in a religious context helped people overcome alcoholism.

But Grob warns that the unsupervised use of psychedelics can be dangerous and says people should undergo mental and medical health screenings before ingesting them. “There are cases of people going off the rails. It’s a small minority, but it can happen, and when it does happen it can be very frightening,” Grob says.

Ken Finn, past president of the American Board of Pain Medicine, says that psychedelics have a number of side effects, including elevated blood pressure, high heart rate, and vomiting, and that they can trigger “persistent psychosis” in a small minority of users. Legal drugs also pose risks, he says, “but we have much better guardrails on things like prescriptions and over-the-counter medications.” He also worries about product contamination and says manufacturers would need to be tightly regulated.

Another potential problem is health equity. Since insurance would not cover these sessions, at least initially, they would likely attract people with disposable income. A supervised psilocybin journey in Oregon, for example, can cost more than $2,500.

Many people who have experienced psychedelics corroborate the research results. Ben Kramer, a former Marine who served in Afghanistan and now works as a psilocybin facilitator in Beaverton, Oregon, says a high-dose mushroom session altered his worldview.

“I relived the first time I was ever shot at in Afghanistan,” he says. “I was there. I had this overwhelming love and compassion for the guy who was shooting at me, who was fighting for what he believed in, just like I was.”

Another characteristic of psychedelic therapy is that just a few sessions can potentially produce lasting results.

Trammell, the retired firefighter, hasn’t taken psychedelics since that retreat in Mexico 10 months ago. “I just felt like I kind of got what I needed,” he says. “I’ve been fine ever since.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Until Jan. 1, 3 million Medi-Cal beneficiaries, mainly those who are aged, blind, disabled, in long-term care, or in the federal Supplemental Security Income program, faced limits on the value of financial accounts and personal property they could hold to qualify for coverage. Now, nearly 2 million of them will no longer face these restrictions, putting them on par with the roughly 12 million other Medi-Cal beneficiaries who don’t have asset limits.

They still must be below Medi-Cal’s income threshold, which for most enrollees is currently $1,677 a month for a single adult and $3,450 for a family of four. However, the change will eliminate a lot of paperwork for applicants and the county workers who verify their eligibility.

For a long time, this group of Medi-Cal beneficiaries could have no more than $2,000 in the bank — $3,000 for a married couple — though the home they lived in, as well as one car and certain types of other personal property, were exempt.

“If you had $5,000 in assets, you would have to spend $3,000 on something to prove that you were beneath the limit to qualify,” says Tiffany Huyenh-Cho, a senior attorney at the advocacy group Justice in Aging. “We had people who prepaid rent, spent money on car repairs, bought a new couch or appliances — things to reduce their assets in order to get to the $2,000 limit.”

Now, Huyenh-Cho adds, “you don’t have to remain in deep poverty. You can save for an emergency; you can save for retirement or for a security deposit if you want to move.”

And those who have hoped to leave a little something for their children when they die can now do so, even if they need expensive long-term care.

The first phase of the rule change was implemented in July 2022, when the threshold was raised dramatically to $130,000 for an individual and $195,000 for a two-person household, making it a nonfactor for the vast majority of those concerned. After all, most people with incomes low enough to qualify for Medi-Cal would not have that much saved. For this reason, the total elimination of the so-called asset test ushered in this year is expected to help fewer people financially than the first change did.

Still, there are some people with more than $130,000 in the bank whose savings would have been wiped out in shockingly short order had they needed long-term care in a nursing facility or at home. Now, they can qualify to have Medi-Cal pick up that cost.

Joanne Shinozaki, a resident of Granada Hills, a Los Angeles neighborhood, hired private full-time caregiving last year for her mother, Fujiko, who has dementia. But it cost nearly $11,000 a month, which Shinozaki quickly realized would burn fast through the roughly $200,000 in savings her father had left when he died early last year. Reluctantly, she put her mom in a memory care home, which was less expensive. But after a 10% increase in January, it is now costing $9,000 a month, although that includes food and utilities.

Because of the money Shinozaki’s dad left, her mom did not qualify for Medi-Cal under the old rules. But now, that money no longer counts against her. Shinozaki, a veterinarian who quit her job to coordinate her mother’s care, needs to return to work soon. She has applied for Medi-Cal for her mom and is waiting for it to be approved.

“It would mean being able to bring her back to the house where she’s lived since 1988, if she’s well enough to come home,” Shinozaki says. To do that, she will need to get her mom access to caregivers via Medi-Cal’s In-Home Supportive Services program.

Indeed, another benefit of the change in eligibility rules is that it supports the caregiver economy, says Kim Selfon, a Medi-Cal and IHSS policy specialist at Bet Tzedek Legal Services, which provides free legal assistance to people in LA County.

Advocates who work with Medi-Cal enrollees and applicants say they often have to explain the difference between assets and income. “I think a lot of people are confused,” says Stephanie Fajuri, program director at the Center for Health Care Rights, an LA-based nonprofit that helps people navigate Medi-Cal and Medicare. “They say, ‘What do you mean? I could be making $1 million a year?’ And we say, ‘No, that’s income.’”

So, let’s be clear: Under the new rules, yes, you can have a second house. But if you are renting it out, that’s income — and given today’s rental prices, it will likely disqualify you from full Medi-Cal benefits. You can also keep an investment account regardless of the balance, but distributions from it as well as any interest, dividends, and capital gains it generates are also income.

Again, most beneficiaries are unlikely to have a large pool of assets and still have income low enough to qualify for Medi-Cal. But if you suddenly inherit a modest sum, or even a large one, now you can keep it, though it may briefly affect your coverage.

Unfortunately, the 1.1 million Medi-Cal beneficiaries receiving Supplemental Security Income are still subject to an asset test, because different rules apply to them.

Advocates and legal aid attorneys say there hasn’t been enough public education about the elimination of the asset limits and that many people still believe their bank accounts or personal property rule them out.

People may also fear the state will take their house and other assets after they die to recoup what it spent on their care. That worry could intensify now that people can keep all their assets and still be on Medi-Cal. But a 2017 change in the law restricted the state’s ability to put a claim on your house or other assets after you die and made it relatively easy to insulate them entirely.

The state can claim only up to the amount Medi-Cal spent on certain medical services, including long-term and intermediate care and related costs. Even in those cases, it cannot touch your home or any other asset if you have protected it by putting it in a living trust or through some other legal move that keeps it out of probate court. And the state can’t put a claim on it if there is a co-owner who outlives the Medi-Cal beneficiary.

“Now that people can hold unlimited assets, they need to be more cognizant of protecting them should they need long-term care,” says Dina Dimirjian, a staff attorney at Neighborhood Legal Services of Los Angeles County.

The Department of Health Care Services, which oversees Medi-Cal, has published on its website (dhcs.ca.gov) an FAQ on the elimination of the asset test. Another good source of information, and legal assistance, is the Health Consumer Alliance (healthconsumer.org or 888-804-3536).

The end of the asset test will also cure a big bureaucratic headache for beneficiaries and applicants and free up countless hours for Medi-Cal eligibility workers in county offices.

“People had to navigate this and figure out what counts and what doesn’t count, and they had to prove it, and the county had to verify it,” says David Kane, a senior attorney at the Western Center on Law & Poverty. “It’s a good thing we can say goodbye to it.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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A partir del 1 de enero, Medi-Cal implementará nuevos contratos estandarizados con sus 22 planes de salud gestionados, que cubren en total al 99% de los inscritos.

Los nuevos contratos refuerzan la aplicación de medidas de calidad, especialmente para mujeres y niños; y exigen que los planes de salud informen públicamente sobre el rendimiento de los proveedores médicos, ―y en algunos casos otras aseguradoras, en las que delegan atención―. También ordenan que los planes revelen la cantidad de inscritos que no tienen acceso a la atención primaria, y que inviertan más para cubrir esa brecha.

Además, comprometen a los planes a una mejor integración de la atención física y mental, y a una mayor capacidad de respuesta a las necesidades culturales y lingüísticas, la orientación sexual e identidad de género de los miembros.

Para cumplir con estas promesas, los reguladores estatales deberán ser más estrictos de lo que han sido hasta ahora. Pero eso podría ser difícil, ya que los cambios están ocurriendo al mismo tiempo que varias otras iniciativas que podrían competir por la atención del personal y confundir a algunos beneficiarios.

A partir del próximo año, más de 700,000 inmigrantes sin papeles serán elegibles para una cobertura completa de Medi-Cal. Además, se espera que aproximadamente 1.2 millones de beneficiarios en 21 condados deban cambiar de planes de salud después que el estado reorganizara el conjunto de aseguradoras el año pasado, y varios condados cambiaran la forma en que ofrecen Medi-Cal.

Algunos condados solo tendrán un plan. Donde haya más de uno, los inscritos que estén perdiendo su plan deberán elegir uno nuevo.

Kaiser Permanente, el gigante de la atención gestionada con sede en Oakland, comenzará un nuevo contrato directo con el estado en 32 condados, un gran cambio administrativo que no debería interrumpir la atención para la mayoría de los inscritos.

Y, por primera vez, se cambiará a miles de inscritos de Medi-Cal en cuidados residenciales a planes de atención gestionada, ya que el estado acelera su distanciamiento del Medi-Cal tradicional, de pago directo.

Todo esto ocurre en medio del llamado desmantelamiento de Medicaid (que comenzó cuando terminaron las protecciones de la pandemia), por el cual más de 900,000 personas han sido eliminadas de Medi-Cal hasta ahora, un proceso que, se espera,  continúe hasta el próximo verano.

“Mi cabeza está dando vueltas pensando en todo eso sucediendo al mismo tiempo”, dice John Baackes, CEO de L.A. Care Health Plan, el plan de Medi-Cal más grande del estado, con casi 2.6 millones de miembros. “Nuestro centro de llamadas está abarrotado”.

Tony Cava, vocero del Departamento de Servicios de Atención Médica (DHCS), que supervisa Medi-Cal, dijo que los nuevos contratos, firmados por todos los planes de atención gestionada de Medi-Cal, proporcionarán una “cobertura de calidad, equitativa y completa”, enfatizando en la prevención y “ofreciendo servicios que aborden las necesidades de atención a largo plazo a lo largo de la vida del miembro”.

Y en un acción innovadora, los nuevos contratos también requieren que los planes de salud reinviertan por primera vez una parte de sus ganancias, entre el 5% y el 7.5%, en las comunidades donde operan.

También ofrecen una serie de incentivos y penalizaciones, que incluyen retener un pequeño porcentaje de los pagos a los planes de salud con la posibilidad de que lo recuperen alcanzando objetivos de calidad y equidad en salud.

Y los planes de salud rentables que no cumplan con las expectativas deberán reinvertir un 7.5% adicional de sus ganancias en la comunidad. Todo esto se suma a las multas aumentadas que los reguladores pueden imponer a los planes de salud con bajo rendimiento.

Los nuevos contratos de Medi-Cal también consagran elementos clave de CalAIM, un experimento de $12 mil millones y cinco años, ya en marcha, en el que los planes de salud buscan proporcionar una variedad de servicios sociales para los miembros de Medi-Cal más necesitados, incluida asistencia para vivienda y comidas adaptadas médicamente, con el argumento de que la pobreza y las inequidades sociales relacionadas a menudo están en la raíz de los problemas de salud.

Hasta ahora, sin embargo, la implementación ha sido lenta.

Abbi Coursolle, abogada senior en la oficina de Los Ángeles del National Health Law Program, dijo que el requisito de que los planes informen públicamente sobre la atención proporcionada por sus proveedores médicos subcontratados debería aumentar la responsabilidad, ayudando a los inscritos a navegar mejor por Medi-Cal. “Esto es un avance en el que los defensores han estado prestando atención durante más de una década”, dice Coursolle. “Hay tanto ir y venir de la gente entre el plan de salud y el grupo de proveedores. Eso diluye tanto la responsabilidad”.

Otro gran cambio para Medi-Cal es la eliminación de la llamada prueba de límite de activos para un cierto grupo de inscritos, incluidas personas de edad avanzada, ciegas, con discapacidades, en atención a largo plazo o en Medicare.

Además de cumplir con los requisitos de ingresos, las personas han tenido que mantener el valor total de sus activos personales por debajo de ciertos umbrales para calificar para Medi-Cal. Los activos contados incluyen ahorros, ciertas inversiones, segundas viviendas e incluso segundos automóviles.

Hasta el año pasado, esos límites eran tan bajos, $2,000 para un individuo, que las personas prácticamente no tenían la capacidad de acumular ahorros si querían estar en Medi-Cal. A mediados de 2022, sin embargo, el límite se elevó a $130,000, lo que significó que para la mayoría de las personas sujetas a la prueba, los activos ya no eran una barrera para la elegibilidad.

En 2024, la prueba de activos se eliminará por completo.

Pero dado el cambio del año pasado, la eliminación total probablemente genere solo unos pocos miles de nuevos inscritos en Medi-Cal. Aún así, debería prevenir que las personas tengan la molestia burocrática de tener que demostrar que están por debajo de cierto umbral de activos.

Si quieres tener más información sobre la prueba de límite de activos, el DHCS tiene respuestas sobre el tema en su sitio web (dhcs.ca.gov).

Si te preguntas si estás entre los 1.2 millones de miembros de Medi-Cal que necesitan cambiar de plan de salud, y aún no has recibido una comunicación al respecto, el departamento tiene una herramienta en línea para informarte sobre los planes disponibles en tu condado a partir del 1 de enero.

Casi la mitad de las personas que necesitan cambiar de plan son miembros de Health Net en el condado de Los Ángeles que serán transferidos a Molina Healthcare como parte de un acuerdo de compromiso que el estado alcanzó el año pasado, para evitar enredarse en demandas de planes de salud enojados que perdieron en una competencia de licitación.

Si necesitas cambiar de plan y tienes suerte, tus médicos pueden estar en el nuevo plan. Asegúrate de verificar. Si no están, es posible que puedas mantenerlos por un año o el tiempo suficiente para completar un tratamiento que ya está en marcha.

El DHCS tiene una hoja informativa que describe tus derechos a tener esa continuidad. También puedes contactar a tu plan de salud actual para obtener información adicional o preguntar en la oficina de Medi-Cal de tu condado.

La Health Consumer Alliance (1-888 804 3536, o healthconsumer.org) es otra fuente de información y asistencia, al igual que el defensor del cuidado gestionado de Medi-Cal (1-888-452-8609, o MMCDOmbudsmanOffice@dhcs.ca.gov).

A pesar de las mejores intenciones del estado, la grave escasez de profesionales médicos podría ser un gran obstáculo.

“Mientras estas expansiones de la cobertura y estas innovaciones están ocurriendo, se está construyendo sobre una fuerza laboral de salud que ya está tensionada”, dijo Berenice Nuñez Constant, vicepresidenta senior de relaciones gubernamentales en AltaMed Health Services, uno de los grupos de clínicas comunitarias más grandes del estado.

Con escasez de personal o no, los planes de salud deben cumplir con sus obligaciones contractuales. Anthony Wright, director ejecutivo del grupo de defensa Health Access California, dijo: “A cierto nivel, se trata de hacer que los planes sean responsables de lo que prometen y de obtener decenas de miles de millones de dólares por ello”.

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Starting Jan. 1, Medi-Cal, California’s Medicaid program, will implement new standardized contracts with its 22 managed care health plans, which collectively cover 99% of enrollees. The new contracts tighten enforcement of quality measures, especially for women and children; require the health plans to report publicly on the performance of medical providers ― and in some cases other insurers ― to whom they delegate care; and mandate that plans reveal the number of enrollees who don’t have access to primary care and invest more to plug the gap. They also commit plans to better integration of physical and mental health care and greater responsiveness to the cultural and linguistic needs, sexual orientation, and gender identity of members.

To realize these promises, state regulators will have to be tougher than they have been in the past.

But that might be difficult, because the changes are happening at the same time as a number of other initiatives that could compete for staff attention and confuse some enrollees.

Beginning next year, over 700,000 immigrants without permanent legal residency will become eligible for full Medi-Cal coverage. In addition, an estimated 1.2 million beneficiaries in 21 counties will need to change health plans after the state last year rejiggered the constellation of insurers and multiple counties switched the way they deliver Medi-Cal. Some counties will have only one plan left. Where there is more than one, enrollees who are losing their plan will have to choose a new one.

Kaiser Permanente, the Oakland-based managed care giant, will start a new direct contract with the state in 32 counties, largely an administrative shift that should not disrupt care for most enrollees. And thousands of Medi-Cal enrollees in residential care will be switched into managed care plans for the first time, as the state accelerates its move away from traditional, direct-pay Medi-Cal.

All of this is happening amid the so-called unwinding, in which over 900,000 people have been shed from Medi-Cal thus far, and disenrollments are expected to continue until next summer. The unwinding follows the termination of pandemic-era protections.

“My head is spinning thinking about all of that going on at the same time,” says John Baackes, CEO of L.A. Care Health Plan, the state’s largest Medi-Cal plan, with nearly 2.6 million members. “Our call center is stacked to the gills.”

Tony Cava, spokesperson for the Department of Health Care Services, which oversees Medi-Cal, says the new contracts, signed by all the Medi-Cal managed care plans, will provide for “quality, equitable, and comprehensive coverage,” emphasizing prevention and “offering services that address long-term care needs throughout a member’s life.”

And in a groundbreaking move, the new contracts also require health plans for the first time to reinvest a portion of their profits ― between 5% and 7.5% ― in the communities where they operate.

They also provide a number of carrots and sticks, which include withholding a small percentage of payments to health plans with a chance for them to earn it back by reaching quality and health equity benchmarks. And profitable health plans that don’t meet expectations will have to reinvest an additional 7.5% of their profits in the community. This is all on top of increased fines that regulators can levy on poorly performing health plans.

The new Medi-Cal contracts also enshrine key elements of CalAIM, a $12 billion, five-year experiment, already underway, in which health plans aim to provide a range of social services for the neediest Medi-Cal members, including housing assistance and medically tailored meals, on the grounds that poverty and related social inequities are often the root of health problems. So far, however, the rollout has been slow.

Abbi Coursolle, senior attorney in the Los Angeles office of the National Health Law Program, says the requirement for health plans to report publicly on the care provided by their subcontracted medical providers should increase accountability, helping enrollees better navigate Medi-Cal.

“This is a step forward that advocates have been paying attention to for over a decade,” Coursolle says. “There’s so much ping-ponging people back and forth between the health plan and the provider group. That dilutes accountability so much.”

Another big change for Medi-Cal is the elimination of the so-called asset limit test for a certain subset of enrollees, including people who are aged, blind, disabled, in long-term care, or on Medicare. In addition to meeting income requirements, people have had to keep the total value of their personal assets below certain thresholds to qualify for Medi-Cal. The assets that are counted include savings, certain investments, second homes, and even second cars.

Until last year, those limits were so low ― $2,000 for an individual ― that people had virtually no ability to accumulate savings if they wanted to be on Medi-Cal. In mid-2022, however, the limit was raised to $130,000, which meant that for the majority of people subject to the test, assets were no longer a barrier to eligibility. In 2024, the asset test will be eliminated altogether.

But given last year’s change, the total elimination will likely generate only a few thousand new Medi-Cal enrollees. Still, it should save people the bureaucratic headache of having to prove they’re below a certain asset threshold.

If you want to learn more about the asset limit test, the DHCS has an FAQ on the subject on its website (dhcs.ca.gov).

If you wonder whether you are among the 1.2 million Medi-Cal members who need to change health plans, and you haven’t already received communication on the subject, the department has an online tool to tell you the plans that will be available in your county as of Jan. 1.

Nearly half the people who need to switch plans are Health Net members in Los Angeles County who are being transferred to Molina Healthcare as part of a compromise agreement the state struck last year to avoid becoming mired in lawsuits by angry health plans that lost out in a bidding competition.

If you need to change plans and you’re lucky, your doctors may be in the new plan. Make sure to check. If they are not, you may be able keep them for up to a year or long enough to finish a course of treatment that is already underway. The DHCS provides a fact sheet outlining your rights to continuity. You can also contact your current health plan for additional information or ask your county Medi-Cal office. The Health Consumer Alliance (1-888‑804‑3536, or healthconsumer.org) is another source of information and assistance, as is Medi-Cal’s managed care ombudsman (1-888-452-8609, or MMCDOmbudsmanOffice@dhcs.ca.gov)

Despite the state’s best intentions, an acute shortage of medical professionals could be a big obstacle. “As these coverage expansions are happening, and as this innovation is happening, it is being built on a health workforce that is already strained,” says Berenice Nuñez Constant, senior vice president for government relations at AltaMed Health Services, one of the state’s largest community clinic groups.

Labor shortage or not, the health plans must deliver on their contractual obligations. Anthony Wright, executive director of the advocacy group Health Access California, says, “On some level, this is about holding the plans accountable for what they are promising and getting tens of billions of dollars for.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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La mujer de 48 años, que trabaja como gerente administrativa en una organización sin fines de lucro, puede recibir atención de emergencia por un paquete limitado de beneficios que el estado pone a disposición de los inmigrantes sin papeles.

También ha podido tener sus mamografías, radiografías y análisis de sangre en clínicas que cobran en base a los ingresos del paciente. Sin embargo, conseguir citas lleva mucho tiempo y a menudo están lejos de su casa. “Es muy frustrante, porque tienes que tener tiempo para ir, y no puedes simplemente perder un día de trabajo”, dijo Milagro, quien pidió que no se publicara su apellido por temor a las autoridades de inmigración.

Milagro y su esposo se encuentran entre los más de 700,000 inmigrantes de entre 26 y 49 años que se espera que califiquen para el seguro de salud completo a partir del 1 de enero.

Ese día, California dará el paso final para abrir Medi-Cal, el programa de atención médica del estado para residentes con bajos ingresos, a todos los que cumplan con los requisitos de elegibilidad, independientemente de su estatus migratorio.

Como he informado con frecuencia, obtener atención de calidad a través de Medi-Cal puede ser un desafío. Pero esta población —a menudo sostén económico del hogar que no puede permitirse enfermar— podría obtener un acceso mucho mejor a servicios como atención primaria y especializada, chequeos dentales de rutina, medicamentos recetados, atención hospitalaria, análisis, pruebas de imagen, y servicios de salud mental.

Los nuevos inscritos se sumarán a más de 655,000 niños, adultos jóvenes de hasta 25 años y adultos de 50 años y más que ya se han registrado en Medi-Cal a través de expansiones anteriores para residentes sin papeles, según los datos más recientes del Departamento de Servicios de Atención Médica del estado.  

Defensores de inmigrantes indican que las personas sin seguro médico generalmente están más enfermas y mueren más jóvenes. “Esto cambiará la vida de las personas que ahora podrán hacerse chequeos regulares, análisis, saber si pueden tener diabetes o hipertensión”, dijo Sarah Dar, directora de políticas en la oficina de Los Ángeles del California Immigrant Policy Center.

Milagro dice que está emocionada. “Nunca tuve chequeos regulares cuando era más joven”, dice. “Ahora, soy más consciente de que necesito cuidar de mi salud”.

Extender la cobertura completa de Medi-Cal a individuos elegibles de entre 26 y 49 años, independientemente de su estatus migratorio, se estima que costará al estado $1.4 mil millones en los primeros seis meses y $3.4 mil millones al año con la implementación completa.

La estimación del estado de poco más de 700,000 nuevos inscritos se basa en el número de personas en el grupo de edad que ya están registradas para un conjunto más pequeño de beneficios, conocidos como Medi-Cal de “alcance limitado”, una de ellas, Milagro. Este grupo se transferirá automáticamente al Medi-Cal completo el 1 de enero.

El estado ha comenzado a enviar avisos informándoles de los beneficios ampliados y dirigiéndolos a elegir un plan de salud de Medi-Cal, a menos que vivan en un condado que solo tenga un plan.

Será más difícil llegar a los inmigrantes restantes en el grupo de 26 a 49 años cubiertos por esta expansión, ya que el estado no sabe quiénes son, dónde están ni cuántos son. Defensores de pacientes, grupos comunitarios y oficinas de bienestar de los condados enfrentan varios obstáculos: barreras de idioma, desconfianza en las agencias gubernamentales y el temor de que inscribirse en beneficios públicos pueda poner en peligro las posibilidades de obtener la tarjeta de residencia (green card).

Un desafío es convencer a los inmigrantes de que estar en Medi-Cal es poco probable que afecte su futuro estatus migratorio bajo la llamada regla de carga pública.

Defensores señalan que California de todos modos no comparte la información de los inscritos con las autoridades federales de inmigración. Pero el fuerte sentimiento anti inmigrante que fue tan fuerte durante la administración Trump, y persiste mientras la nación se prepara para las elecciones de 2024, “envió un mensaje a estas comunidades de que deberían vivir en las sombras y de que no merecen beneficios”, explicó Dar.

Incluso será difícil encontrar a aquellos que ya están en la versión limitada de Medi-Cal si su información de contacto no está actualizada. Y podrían no ser incluso conscientes de que formaban parte de Medi-Cal. Si, por ejemplo, tuvieron una crisis de salud, los llevaron a la sala de emergencias y simplemente se les pidió que firmaran algunos documentos para cubrir su tratamiento, podrían no entender lo que significa recibir un correo de Medi-Cal.

Y algunos pueden temer cualquier contacto con el gobierno.

Lena Silver, directora de políticas y defensa administrativa en Neighborhood Legal Services of Los Angeles County, dijo que condujo una sesión de capacitación donde una mujer que trabaja con jornaleros dijo que muchos tenían miedo de abrir los sobres que habían recibido.

El Departamento de Servicios de Atención Médica está liderando una campaña de divulgación en 19 idiomas que incluye anuncios en radio, televisión y redes sociales.

Lo que potencialmente complica las cosas es el hecho de que la expansión de los beneficios de salud a este último (y más grande) grupo de inmigrantes coincide con la llamada cancelación de Medi-Cal, en la que más de 900,000 beneficiarios, hasta ahora, han sido eliminados del programa, principalmente debido a trámites incompletos, al expirar las exenciones por la pandemia.

Los inmigrantes con Medi-Cal limitado también deben demostrar que continúan siendo elegibles en base a sus ingresos, para evitar ser eliminados en el proceso de cancelación, lo que también puede resultar confuso cuando dicha solicitud se suma al aviso que les informa sobre sus nuevos beneficios recién ampliados.

Si tú mismo eres indocumentado, o un amigo o un ser querido, hay recursos disponibles para ayudar a navegar el proceso de inscripción en Medi-Cal. Una página en el sitio web del Departamento de Servicios de Atención Médica (dhcs.ca.gov) explica la expansión y tiene preguntas y respuestas frecuentes en varios idiomas detallando los nuevos beneficios.

Si necesitas ayuda para inscribirte en un plan de Medi-Cal o llenar formularios para demostrar tu elegibilidad, prueba con Health Consumer Alliance (healthconsumer.org o 1-888-804-3536).

Las clínicas comunitarias también son buenas fuentes, al igual que las oficinas de los condados que administran Medi-Cal.

Brenda, residente del condado de Los Ángeles de 33 años que también pidió que no se publicara su apellido porque no tiene papeles, dijo que será “una gran bendición” obtener beneficios completos de Medi-Cal.

Brenda llegó desde México cuando era niña y ha tenido que pagar la mayoría de sus necesidades de atención médica de su propio bolsillo. Rara vez va al médico, no ha visto a un dentista en tres años a pesar de los dolores de muelas, y ha usado los mismos anteojos por cinco años.

En enero, planea hacerse una prueba de detección de cáncer de mama y diabetes, que es frecuente en su familia. Y dijo: “definitivamente quiero arreglar mis dientes. Siempre he querido una sonrisa Colgate”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The 48-year-old, who works as the office manager at a nonprofit, can get emergency care through a narrow set of benefits the state makes available to immigrants without legal residency. And she has been able to get mammograms, X-rays, and blood tests at clinics that charge according to income. But it can take a long time to get such appointments, and they are often far from home.

“It’s very frustrating, because you have to have the time to go, and you can’t just lose a day of work,” says Milagro, who asked that her last name be withheld due to fear of immigration authorities.

Milagro and her husband are among the more than 700,000 immigrants ages 26-49 expected to newly qualify for full health insurance come Jan. 1. That’s when California takes the final step in opening up Medi-Cal, the state’s health care program for low-income residents, to everyone who meets eligibility requirements, regardless of their immigration status.

As I have frequently reported, getting quality care through Medi-Cal can be a challenge. But this population — often household breadwinners who can’t afford to get sick — stand to gain far better access to services such as primary and specialty care, routine dental checkups, prescription medications, inpatient hospital care, lab tests, scans, and mental health services.

New enrollees will join more than 655,000 children, young adults through age 25, and adults 50 or over who have already signed up for Medi-Cal through previous expansions to residents lacking legal authorization, according to the most recent data from the state Department of Health Care Services.

Advocates for immigrants note that people without health insurance are generally sicker and die younger. “This is life-changing for people to now be able to go get regular checkups, get labs drawn, see if they might be diabetic or have high blood pressure,” says Sarah Dar, policy director in the Los Angeles office of the California Immigrant Policy Center.

Milagro says she is excited about what is coming. “I never had regular checkups when I was younger,” she says. “Now, I am more conscious of the fact that I need to take care of my health.”

Extending full Medi-Cal coverage to eligible individuals in the 26-49 age range regardless of immigration status is projected to cost the state $1.4 billion in the first six months and $3.4 billion a year upon full implementation.

The state’s estimate of just over 700,000 new enrollees is based on the number of people in the age group who are already signed up for a narrower set of benefits, known as “restricted scope” Medi-Cal, including Milagro. They will be automatically switched over to full Medi-Cal on Jan. 1. The state has begun mailing notices informing them of expanded benefits and directing them to choose a Medi-Cal health plan unless they live in a county with only one plan.

The remaining residents in the 26-49 age range covered by this expansion will be harder to reach because the state does not know who, where, or how numerous they are. Patient advocates, community groups, and county welfare offices face a number of obstacles: language barriers, wariness of governmental agencies, and fear that signing up for public benefits could jeopardize the chances for legal residency.

One challenge is to convince immigrants that being on Medi-Cal is unlikely to affect their future immigration status under the so-called public charge rule. Advocates point out that California doesn’t share enrollees’ information with federal immigration authorities anyway.

But the fierce anti-immigrant sentiment that was so prevalent during the Trump administration and lingers as the nation gears up for the 2024 elections “sent a message to these communities that they should live in the shadows and are not deserving of benefits,” says Dar.

Even those already in the restricted version of Medi-Cal will be a challenge to reach if their contact information is not up to date. And they could be unaware that they were part of Medi-Cal at all. If, for example, they had a health crisis, were taken to the emergency room, and were simply asked by hospital staff to sign some paperwork to cover their treatment, they might not understand what a mailing from Medi-Cal means.

And some may fear any contact by the government. Lena Silver, director of policy and administrative advocacy at Neighborhood Legal Services of Los Angeles County, says she conducted a training session where a woman who works with day laborers said many of them were afraid to open the envelopes they’d received.

The Department of Health Care Services is spearheading an outreach campaign in 19 languages that includes ads on radio, TV, and social media.

Potentially complicating matters is the fact that the expansion of health benefits to this last ― and largest — group of immigrants coincides with the so-called Medi-Cal unwinding, in which over 900,000 beneficiaries and counting have been disenrolled, mostly due to incomplete paperwork, as pandemic-era exemptions expire.

Immigrants with restricted Medi-Cal must also demonstrate their continued income eligibility in the unwinding, which can be confusing when such a request is piled on top of notices informing them of their newly expanded benefits.

If you, a friend, or a loved one is an immigrant without legal residency, resources are available to help navigate the Medi-Cal enrollment process. A page on the Department of Health Care Services website (dhcs.ca.gov) explains the expansion and contains an FAQ in multiple languages detailing the new benefits that come with it.

If you need help enrolling in a Medi-Cal plan or filling out forms to demonstrate your eligibility, try the Health Consumer Alliance (healthconsumer.org, or 1-888-804-3536). Community clinics are also good sources, as are county offices that administer Medi-Cal.

Brenda, a 33-year-old Los Angeles County resident who also asked to withhold her last name because she lacks legal immigration status, says it will be “a big old blessing” to get full Medi-Cal benefits. She arrived from Mexico as a child and has had to pay for most health care needs out of her own pocket. She rarely goes to the doctor, she hasn’t seen a dentist in three years despite toothaches, and her glasses are five years old.

Come January, she plans to be screened for breast cancer and diabetes, which runs in her family. And, she says, “I definitely want to fix my teeth. I always wanted a Colgate smile.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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She was taken to a hospital in Clovis, a city in Fresno County, near where the Reisz family lives. But the severity of Megan’s injuries — four broken ribs and a partially collapsed lung — prompted doctors to transport her 12 miles by ambulance to the Level I trauma center at Community Regional Medical Center in Fresno.

While Megan was still recovering at home from her injuries, she received a $2,400 bill from the ambulance company — after the family’s health plan had paid nearly $2,200.

“When we received the bill, I thought our insurance company was processing the claim incorrectly,” says Jennifer Reisz. An attorney, Reisz says she then spent hours on the phone with the health plan, the ambulance company, and a few consumer advocates. She learned that the ambulance company was not in the health plan’s network and was permitted to bill patients for any uncovered portion of its charges — a practice known as balance billing.

Starting Jan. 1, ground ambulance operators will be barred from doing that because of a new law signed by Democratic Gov. Gavin Newsom. California is the 14th state to provide some protection against balance billing for ground ambulance rides.

At the federal level, an advisory committee established under the No Surprises Act is working on a plan to address the problem nationally.

Both the federal law, which took effect in 2022, and a California law that predates it largely banned balance billing for hospital care and air ambulance services, but not ground ambulance services.

And that is hardly fair, since patients have zero control in a medical emergency over which ambulance company responds, whether it is in network, or how much it will charge.

In California, nearly three-quarters of emergency ground ambulance rides result in out-of-network bills. The average surprise bill for a ground ambulance ride in California is $1,209, the highest in the nation, according to a December study.

The new law, which applies to about 14 million Californians enrolled in state-regulated commercial health plans, limits how much a non-network ambulance operator can charge patients to the amount they would pay for an in-network ambulance.

The law also caps bills for uninsured people, stipulating they can’t be charged more than the Medi-Cal or Medicare rate, whichever is greater. (Medi-Cal is California’s Medicaid program, providing coverage to people with low incomes or disabilities.) And it prohibits ambulance operators and debt collectors from reporting patients to a credit rating agency or taking legal action against them for at least 12 months after the initial bill.

Under current law, people in distress sometimes decline to call an ambulance for fear of a huge bill, putting themselves or a loved one at risk, says Katie Van Deynze, policy and legislative advocate for Health Access California, which sponsored the legislation. With the new law, she says, “they will have peace of mind.”

Existing laws already protect Medicare and Medi-Cal beneficiaries from surprise ground ambulance bills. The new law does not cover the nearly 6 million Californians enrolled in the subset of employer-sponsored health plans that are federally regulated.

The advisory committee working on a federal fix agreed last week on nonbinding proposals that would, among other things, prohibit balance billing for the vast majority of ambulance rides and cap patients’ financial liability at $100. The committee plans to formally report its recommendations to Congress early next year for potential legislation.

Under California’s new law, patients can expect to save an average of nearly $1,100 per emergency ambulance ride and over $800 per nonemergency ride in the first year, according to a legislative analysis conducted this year.

Health plans will be required to pay ambulance operators the rates set by county authorities, which the study said would increase the average amount insurers pay per ride by around $2,000.

Since ambulance rides account for a tiny percentage of overall health plan spending, those increases should not raise premiums by much.

But local authorities might be tempted to hike ambulance rates over time to increase revenue for publicly run ambulance operators, such as fire departments, says Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. That could prompt health plans to raise ambulance copays, offsetting some of the consumer savings from the new law, Adler says.

Jenn Engstrom, director of CalPIRG, an advocacy group that helped shepherd the law through the legislature, notes there will be built-in accountability, since the legislation requires public reporting of ambulance rates. “If we notice that things start to skyrocket, there will be a need for legislative action or local action,” Engstrom says.

Reisz says the ambulance company that transported her daughter wrote off the bill after she made it clear she had no intention of paying it — and after her health plan ponied up a little more. But as she notes, not everyone is a lawyer adept at arguing their cause.

Even if you are no rhetorical wizard, you can take simple steps to protect yourself against errors or ambulance operators that disregard the new law.

Check your insurance policy to know your deductible and any copay or coinsurance should you ever need an ambulance. If you get an ambulance bill, don’t pay it right away. Check your insurer’s explanation of benefits to make sure what it says you owe matches what you think your cost-sharing amount should be. If the bill is higher, the ambulance company may be trying to pull a fast one. Call the ambulance company and tell them they need to knock the bill down. If they don’t, file a complaint with your health plan and include a copy of the bill.

If you disagree with your plan’s decision, or it takes more than 30 days for the plan to respond, take your complaint to the regulator.

The new law requires your insurer to tell you if your health plan is regulated by the state and thus subject to the statute. If it is, the regulator is likely to be the Department of Managed Health Care. You can contact that agency online (www.healthhelp.ca.gov) or by phone at 1-888-466-2219. If your health plan is regulated by the Department of Insurance, you can file a complaint online (www.insurance.ca.gov) or call 1-800-927-4357.

Another good resource is the Health Consumer Alliance, which offers free legal assistance in multiple languages. Call 1-888-804-3536.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

The office was already closed, but the whole eye care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again — heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure, or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A 2016 study published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing, or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit Prevent Blindness and Regeneron Pharmaceuticals, showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, founding director of the Southern California Eye Institute at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost, and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions — or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting refractive errors, which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects about 3 million people in the U.S., attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is five times as prevalent among African Americans as in the general population.

Nearly 10 million in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some 20 million people age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: Half of people 75 and older have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic group at high risk for certain eye diseases.

And don’t forget children. Multiple eye conditions can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, a clinical spokesperson for the American Academy of Ophthalmology and executive director of the Glaucoma Center of San Francisco.

Minimize stress, get regular exercise, and eat a healthy diet. Also, quit smoking. It increases the risk of major eye diseases.

And consider adopting habits that protect your eyes from injury: Wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone, and wear goggles when working around the house or playing sports.

The Prevent Blindness website offers information on virtually everything related to eye health, including insurance. Other good sources include the American Academy of Ophthalmology’s “EyeSmart” site and the National Eye Institute.

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).