Implementing Health Care Reform; Early Learnings From California

California is at the forefront of health care reform but success will depend on a partnership between doctors and the state, according to a new analysis led by UCSF.

Implementation here also is complicated by a harsh reality: California is expected to have more newly insured people – approximately 3.4 million – in 2014 than any other state, and currently faces unprecedented economic challenges.

Andrew Bindman, MD

California was one of the first states to pass legislation enabling a new health insurance exchange, and has been granted a five-year, $8 billion Medicaid expansion demonstration waiver that gives states more flexibility to use federal Medicaid funds in preparation for expanded insurance coverage.

“Ultimately, improved access to care and better health outcomes, in California and in other states, will depend on how effectively physicians are engaged in implementation of the Affordable Care Act,” said Andrew Bindman, MD, lead author and professor of Medicine, Health Policy, Epidemiology & Biostatistics at UCSF. 

The Perspective article, titled “Catching a Wave – Implementing Health Care Reform in California,” is available online today in the New England Journal of Medicine.

According to Bindman, California is pursuing three main implementation strategies: expand coverage to the uninsured before 2014 on a county-by county basis; use federal resources available under the Medicaid waiver to invest in its public safety-net hospitals; and expand use of Medicaid managed care by mandating the enrollment of approximately 320,000 aged and disabled people.

However, California ranks 47th among states in Medicaid physician-payment rates and has one of the country’s lowest rates of physician participation in Medicaid, according to the analysis.  On average, there is one primary care physician for every 1,700 people in the state; for Medi-Cal, the ratio is one for every 2,000 enrollees

“There are some short-term payment mechanisms in place to incent physicians to care for additional Medicaid patients, but uncertainty about payment in the long-term makes it unclear how eagerly they will embrace new policies,” Bindman said.

Without an effective partnership among states, which will control more of the health care financing, and physicians, the wave of new resources could be directed from more cost-efficient, patient-centered, effective care to unnecessary hospitalizations and emergency-room visits, he said.

Bindman also is director of the California Medicaid Research Institute (CaMRI), a partnership between the California Department of Health Care Services and the University of California charged with conducting research and evaluation of the Medi-Cal program.

Co-author is Andreas G. Schneider, JD of the George Washington School of Public Health, Washington, DC.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.