The state’s health insurance exchange will zero out some patients’ hospital deductibles, up to $5,400; lower the copay of primary care visits from $50 to $35; and reduce the cost for generic drugs from $19 to $15. Some enrollees will also see their annual out-of-pocket spending capped at $6,100, down from $7,500.

Covered California CEO Jessica Altman argues these are tangible reductions — savings on deductibles and copays on top of subsidies to lower monthly premiums — that will affect hundreds of thousands of people and entice them to use their coverage.

“Deductibles uniquely detract people from seeking care, so that’s a significant focus,” Altman told California Healthline. “California is really grappling with affordability and thinking about, ‘What does affordability really mean?’ Many people simply do not have $5,000 sitting in their bank account in case they need it for health care.”

Additional reductions in patients’ out-of-pocket costs — on top of existing federal health insurance subsidies to reduce monthly premiums — will take effect in January for people renewing or purchasing coverage during Covered California’s next enrollment period, which begins in the fall. The state could go further in helping reduce patients’ costs in subsequent years with future budget increases, Altman said.

Still, those savings may be offset by higher costs elsewhere. Covered California announced July 25 that inflation and other factors are driving up annual premium rates on participating health plans by an average of nearly 10% next year, the largest average increase since 2018.

California started fining those without health coverage in the tax year 2020, establishing its own “individual mandate.” In that first year, the state raised $403 million in penalty revenue, according to the state Franchise Tax Board. It has continued to levy fines, paid for largely by low- or middle-income earners, the very people the new subsidies are intended to help.

Legislative leaders had pushed Newsom, a fellow Democrat, to funnel the tax revenue into lowering health care costs for low- and middle-income people purchasing coverage via Covered California — many of whom reported skipping or delaying care due to high out-of-pocket costs.

The governor for years resisted pleas to put penalty money into Covered California subsidies, arguing that the state couldn’t afford it and needed the money given looming economic downturns and the potential loss of federal premium subsidies — which could be threatened by a change in federal leadership.

But under ongoing pressure, Newsom relented in June and agreed to begin spending some of the money to boost state subsidies. According to the state Department of Finance, California is expected to plow $83 million next year and $165 million annually in subsequent years to expand financial assistance — roughly half the revenue it raises annually — into reducing Covered California patients’ costs. The remainder of the money will be set aside in a special health care fund that could be tapped later.

The budget deal also allows the Newsom administration to borrow up to $600 million in penalty revenue for the state general fund, which it must pay back. Penalty revenues are projected to bring in $362 million this year with an additional $366 million projected next year, according to Finance Department spokesperson H.D. Palmer.

Covered California board members approved the new plan design last week. They say the cost-sharing subsidies will lower out-of-pocket spending for nearly 700,000 people out of roughly 1.6 million enrolled in Covered California.

The boost in funding, which represents the state’s most significant effort to slash patients’ costs in Covered California, will largely benefit lower-income Californians who earn below 250% of the federal poverty level, which is $33,975 for an individual and $69,375 for a family of four for 2023, according to the exchange.

“Bringing down deductibles goes a long way to help middle-class California families struggling with increasing costs of living,” said Senate President Pro Tempore Toni Atkins, who rallied fellow Democrats to block a plan by Newsom and his administration to keep the revenue for the state general fund, which can be used for any purpose.

Atkins added, “We will continue our work to lower the costs even more in the years to come.”

Newsom spokesperson Brandon Richards defended the governor’s health care record, saying Newsom is committed to ensuring Californians can access health care. In addition to boosting assistance in Covered California, Richards said, the governor has expanded public health insurance coverage to immigrants lacking legal status and is increasing how much doctors, hospitals, and other providers get paid to see Medicaid patients.

Originally required by the federal Affordable Care Act, the so-called individual mandate to hold health coverage or pay a tax penalty was gutted by Republicans in 2017, eliminating the fine nationally. Newsom reinstated it for California when he took office in 2019 — a key component of his ambitious health care platform.

California is one of at least five states, along with Massachusetts, New Jersey, Rhode Island, and Vermont, as well as the District of Columbia that have their own health coverage mandate, though not all levy a tax penalty for remaining uninsured. Among them, California is most aggressively trying to lower health care costs and achieve universal coverage, said Larry Levitt, executive vice president for health policy at KFF.

“Even though they may disagree on the big picture of health care reform and single-payer, California Democrats have managed to come together and unify around these incremental steps to improve the current system,” Levitt said. “Step by step, they have put in place the pieces to get as close to universal coverage as they possibly can.”

Democratic leaders in the state have faced political blowback for not using the penalty revenue for health care, details first reported by California Healthline, even though Newsom and other Democrats vowed to spend the money to make health care more affordable in Covered California.

Advocates say the deal represents a win for low- and middle-income people.

“We’re excited that this money is protected for health care, and ultimately is set aside for future affordability assistance,” said Diana Douglas, chief lobbyist with the consumer advocacy group Health Access California.

Advocates want the state to tap those health care dollars to get more people covered, such as lowering health care costs for immigrants living in the state without legal permission.

A bill this year by Assembly member Joaquin Arambula, a Fresno Democrat, would require Covered California to establish a separate health insurance marketplace so that immigrants who lack legal status and earn too much to qualify for Medi-Cal, California’s version of Medicaid, can purchase comprehensive coverage that is nearly identical to plans sold on Covered California. Currently, immigrants without legal residency are not allowed on the exchange. Other states, such as Washington and Colorado, have set up similar online marketplaces.

“We’re working hard to create a system that has equal benefits and affordability assistance for everyone,” Arambula said.

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La bolsa de seguros médicos del estado eliminará los deducibles hospitalarios de algunos pacientes, hasta un máximo de $5,400; reducirá el copago de las visitas de atención primaria de $50 a $35; y reducirá el costo de los medicamentos genéricos de $19 a $15. Algunos afiliados también verán limitado su gasto de bolsillo anual a $6,100 en lugar de $7,500.

La CEO de Covered California, Jessica Altman, argumenta que se trata de reducciones tangibles —ahorros en deducibles y copagos además de subsidios para reducir las primas mensuales— que afectarán a cientos de miles de personas y les animará a utilizar la cobertura.

“Los deducibles evitan que las personas busquen atención médica, por lo que es un objetivo importante”, dijo Altman a California Healthline. “California busca lo asequible y se pregunta: ‘¿Qué significa realmente asequibilidad? Muchas personas simplemente no tienen $5,000 en su cuenta bancaria en caso de que lo necesiten para la atención médica”.

Las reducciones adicionales en los gastos de bolsillo de los pacientes —además de los subsidios federales de seguros de salud existentes para reducir las primas mensuales— entrarán en vigor en enero para las personas que renueven o adquieran cobertura durante el próximo período de inscripción de Covered California, que comienza en otoño. El estado podría ir más lejos en ayudar a reducir los costos de los pacientes en los próximos años con futuros aumentos presupuestarios, señaló Altman.

Aun así, esos ahorros pueden verse neutralizados por costos más altos en otros lugares. Covered California anunció, el 25 de julio, que la inflación y otros factores elevarán las tarifas anuales de las primas de los planes de salud participantes en un promedio de casi el 10% el próximo año, el mayor aumento desde 2018.

California comenzó a multar a aquellos sin cobertura de salud en el año fiscal 2020, estableciendo su propio “mandato individual”. En ese primer año, el estado recaudó $403 millones en ingresos por multas, según la Franchise Tax Board estatal. Ha continuado imponiendo multas, pagadas en gran parte por personas con ingresos bajos o medios, las mismas personas a las que se pretende ayudar con los nuevos subsidios.

Los líderes legislativos habían presionado a Newsom, también demócrata, para que canalizara los ingresos fiscales hacia la reducción de los costos de la atención sanitaria para las personas de ingresos bajos y medios que adquieren cobertura a través de Covered California, muchas de las cuales informaron de que habían dejado de recibir atención médica o la habían retrasado debido a los elevados gastos de bolsillo.

El gobernador se resistió durante años a las peticiones de destinar el dinero de las multas a los subsidios de Covered California, argumentando que el estado no podía permitírselo y que necesitaba el dinero ante la inminente recesión económica y la posible pérdida de los subsidios federales a las primas, que podrían verse amenazados por un cambio en el liderazgo federal.

Sin embargo, ante las continuas presiones, Newsom cedió en junio y aceptó empezar a destinar parte del dinero a aumentar las subvenciones estatales. Según el Departamento de Finanzas del estado, se espera que California destine $83 millones el próximo año y $165 millones anuales en los años siguientes para ampliar la ayuda financiera —aproximadamente la mitad de los ingresos que recauda anualmente— a reducir los costos de los pacientes de Covered California. El resto del dinero se reservará en un fondo especial de asistencia sanitaria al que se podrá recurrir más adelante.

El acuerdo presupuestario también permite a la administración Newsom a pedir prestado hasta $600 millones en ingresos por multas para el fondo general del estado, que debe devolver. Los ingresos por multas se proyecta que traerá $362 millones este año con un adicional de $366 millones previstos el próximo año, según el portavoz del Departamento de Finanzas H. D. Palmer.

Los miembros del consejo de Covered California aprobaron el nuevo diseño del plan la semana pasada. Dicen que los subsidios de costos compartidos reducirá el gasto de bolsillo de casi 700,000 personas de aproximadamente 1,6 millones de inscritos en Covered California.

El aumento de la financiación, que representa el esfuerzo más importante del Estado para reducir los costos de los pacientes en Covered California, beneficiará en gran medida a los californianos de bajos ingresos que ganan por debajo del 250% del nivel federal de pobreza, que es de $33,975 para un individuo y $69,375 para una familia de cuatro en 2023, según el intercambio.

“La reducción de los deducibles es una gran ayuda para las familias de clase media de California que luchan contra el aumento del costo de la vida”, dijo el Presidente Pro Tempore del Senado, Toni Atkins, que se unió a sus compañeros demócratas para bloquear un plan de Newsom y su administración que mantendría los ingresos en el fondo general del Estado, aunque pueden ser utilizados para cualquier propósito.

Atkins añadió: “Seguiremos trabajando para reducir aún más los costos en los próximos años”.

El portavoz de Newsom, Brandon Richards, defendió la trayectoria del gobernador en materia de salud, afirmando que Newsom se ha comprometido a garantizar que los californianos puedan acceder a la asistencia sanitaria. Además de impulsar la asistencia en Covered California, dijo Richards, el gobernador ha ampliado la cobertura del seguro de salud pública a los inmigrantes que carecen de estatus legal y está aumentando la cantidad de médicos, hospitales y otros proveedores a los que se les paga para ver a los pacientes de Medicaid.

Originalmente requerido por la Ley de Cuidado de Salud a Bajo Precio (ACA), el llamado mandato individual de tener cobertura de salud o pagar una multa fiscal fue desmantelado por los republicanos en 2017, eliminando la multa a nivel nacional. Newsom lo restableció para California cuando asumió el cargo en 2019, un componente clave de su ambiciosa plataforma de atención médica.

California es uno de al menos cinco estados, junto con Massachusetts, Nueva Jersey, Rhode Island y Vermont, así como el Distrito de Columbia, que tiene su propio mandato de cobertura de salud, aunque no todos imponen una multa fiscal por permanecer sin seguro. De todos ellos, California es el estado que más intenta reducir los costos sanitarios para lograr la cobertura universal, según Larry Levitt, vicepresidente ejecutivo de política sanitaria de KFF.

“Aunque no estén de acuerdo en todo lo que implica la reforma sanitaria y el pagador único, los demócratas de California han conseguido unirse y unificarse en torno a estos pasos incrementales para mejorar el sistema actual”, señaló Levitt. “Paso a paso, han ido colocando las piezas para acercarse lo más posible a la cobertura universal”.

Los líderes demócratas en el estado se han enfrentado a críticas políticas por no utilizar los ingresos de la multa para la atención de la salud, detalles reportados por primera vez por California Healthline, a pesar de que Newsom y otros demócratas se comprometieron a gastar el dinero para hacer más asequible la atención de la salud en Covered California.

Para los activistas, el acuerdo representa una victoria para las personas de bajos y medianos ingresos.

“Nos gusta que este dinero esté protegido para la atención de la salud, y que en última instancia se reserve para la futura asistencia”, dijo Diana Douglas, del grupo de defensa del consumidor Health Access California.

Los activistas quieren que el estado aproveche ese dinero para dar cobertura a más personas, por ejemplo, reduciendo los costos sanitarios de los inmigrantes que viven en el estado sin permiso legal.

Un proyecto de ley presentado este año por el miembro de la Asamblea Joaquín Arambula, demócrata de Fresno, exigiría a Covered California establecer un mercado de seguros de salud separado para que los inmigrantes que carecen de estatus legal y ganan demasiado para calificar a Medi-Cal, la versión californiana de Medicaid, puedan comprar una cobertura integral que sea casi idéntica a los planes vendidos en Covered California. En la actualidad, los inmigrantes sin residencia legal no pueden acceder al mercado de seguros. Otros estados, como Washington y Colorado, han creado mercados en línea similares.

“Estamos trabajando para crear un sistema que ofrezca los mismos beneficios y asistencia asequible para todos”, señaló Arámbula.

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It was a tough sell for a new governor, and Newsom needed strong allies among state Democratic leaders, who at the time, in 2019, voiced concern about essentially levying a new tax on Californians unable to afford the rising cost of health care. Democrats, who, then as now, controlled the state legislature, ultimately backed Newsom in exchange for a promise: The state would levy the fine but use that money to provide financial assistance to offset out-of-pocket costs for Californians purchasing health insurance on the state exchange, Covered California.

But Newsom, now in his second term, has since backed off that promise. His administration is holding on to revenue raised from the so-called individual mandate — the requirement that people have health coverage or pay a fine. And his proposed budget for the upcoming fiscal year beginning July 1, which is being debated in the state legislature, funnels the money to the state’s general fund.

That is infuriating fellow Democrats who accuse him of breaking a promise and disregarding the millions of Californians who can’t afford their deductibles and copays.

California began fining the uninsured in 2020, raising an estimated $1.1 billion over the first three years — and the Newsom administration projects it will bring in more than $700 million more over the next two years, bringing the projected five-year total to $1.8 billion, according to the state Department of Finance. Democratic leaders said Newsom’s tactic of holding back the money for the general fund is a “rip-off.”

“Money from the mandate should stay in health care,” Senate President Pro Tem Toni Atkins told KFF Health News, arguing the state should be distributing money now to help people afford health coverage. “I don’t know what we’re waiting for. We’ve got to figure out a way to make health care more accessible, and there’s no question that the cost of health insurance is a barrier.”

Democratic lawmakers are expected to continue ratcheting up pressure on Newsom in hopes of reaching a deal by their June 15 deadline to pass a budget bill. “We’ve always felt that the money is meant to bring insurance costs down,” said Democratic Assembly member Phil Ting, chair of the Budget Committee.

Newsom in 2019 stumped for the individual mandate amid concerns over rising insurance premiums, vowing to reduce Covered California consumer health care costs while setting himself apart from then-President Donald Trump, who was attacking the insurance mandate as unfair. Congressional Republicans had gutted the federal penalty — part of the Affordable Care Act — in 2017. Newsom argued it would still work in California to lower health care costs, and to help him achieve his goal of universal health care — the centerpiece of his ambitious health care agenda.

Newsom now argues that federal health insurance subsidies that offset the cost of monthly premiums are sufficient. And, in the face of a projected $32 billion state budget deficit, Newsom says California cannot afford to spend the money and further reduce out-of-pocket costs. He argues spending the money to slash deductibles, for instance, would be “unsustainable.” His proposed budget would instead keep the money for the state’s general fund, to be used for anything California wants to spend it on.

But health care advocates who lobbied in favor of the fine, as well as many Democratic lawmakers, say the funds could be lifesaving and should be distributed now.

“The individual mandate was not intended to create funds for other government programs outside of health care,” said Democratic Assembly member Jim Wood, of Santa Rosa, chair of the Assembly Health Committee, at a heated budget hearing this spring. “The clear intent of the legislature was that this money was meant to go to affordability.”

Wood said he might have rejected Newsom’s plan if he had known the revenue it generated would be deposited directly into the general fund. “I don’t think I would have supported it,” he said. “It just feels like a violation of what we thought we were doing.”

Soaring out-of-pocket health care costs, for insurance premiums and deductibles for instance, are leading people to forgo health care. In California, a staggering 52% of residents report having skipped or delayed treatment in the past year for financial reasons, according to a recent survey by the nonprofit California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

Diana Douglas, a lobbyist with Health Access California, which was part of the coalition that backed the state’s coverage mandate in 2019, said Newsom must recognize soaring costs and spend the money now on affordability assistance. “This penalty money should be used to help Californians afford coverage and care.”

Health insurance plans offered by Covered California are continuing to get more expensive. Deductibles for a midtier insurance plan, for example, will jump to $5,400 next year, according to Covered California, up from $4,750 this year and just $3,700 two years ago.

And even many Californians who are purchasing coverage are putting off treatment in the face of high costs. A survey by Covered California in 2022 found that 48% of its consumers delayed important medical care due to cost.

Newsom this spring dodged a question by KFF Health News about the criticism he is facing over his push to retain the mandate money, saying simply he’s “proud” to have established the state coverage mandate and noting that federal premium subsidies are available for Californians purchasing coverage via Covered California. His administration defended the push to funnel money into the general fund, saying revenues would be repaid to a special health fund and be available to use on health care eventually, if the federal government cuts back existing premium subsidies. Administration officials argue that Newsom is essentially borrowing the money and say it’ll be repaid later — though lawmakers have expressed concern that he’ll never make good on that promise.

Critics and some Democratic lawmakers say holding back the money is a double whammy for low- and middle-income residents who are struggling to pay for coverage, and argue that it amounts to a tax on the poor. “It feels like we’re trying to save it on the backs of our low-income communities,” said Democratic state Sen. Caroline Menjivar, who represents the state’s San Fernando Valley.

Democratic lawmakers this year are backing an alternative proposal, championed by Health Access California, to spend revenue from fining uninsured residents on increasing health insurance subsidies for low- and middle-income people. They would be making good on a deal advocates secured with state Democratic lawmakers last year to reduce or eliminate out-of-pocket costs in Covered California and scrap deductibles entirely for a mid-tier plan.

“We need to make sure people not only have health coverage, but that they can also afford to actually use it,” said Ronald Coleman Baeza, a health care lobbyist with the California Pan-Ethnic Health Network.

Although Newsom and his Democratic allies have passed major expansions in coverage, the state does not have universal health care. Experts say more than 2.5 million Californians remain uninsured, including unauthorized immigrants who earn too much to qualify for Medi-Cal, and lawmakers are growing increasingly agitated that not all residents who are insured can afford to use their coverage.

“There was a clear commitment that these dollars were going to be used to bring down heath care costs, and we haven’t done it,” said Assembly member Pilar Schiavo, a Democrat representing the Santa Clarita Valley, who introduced a bill that would require any revenue raised from the individual mandate be permanently set aside for health care. Though it died this year, it can be revived next year, and advocates say they will continue pressing Newsom to distribute the existing money to Covered California consumers.

“We need to keep our promises,” Schiavo said. “If you have insurance that you can’t afford to use, or you’re afraid to go see the doctor because of how high that bill might be, then you don’t truly have access or universal coverage.”

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Era una propuesta difícil de vender para un nuevo gobernador, y Newsom necesitaba aliados fuertes entre los líderes demócratas del estado, que en aquel momento, en 2019, expresaron su preocupación por la imposición de un nuevo impuesto a los californianos que no podían permitirse el creciente costo de la atención de salud.

Los demócratas que, entonces como ahora, controlaban la legislatura estatal, finalmente apoyaron a Newsom a cambio de una promesa: el estado cobraría la multa pero usaría ese dinero para ayudar con los gastos de bolsillo de los californianos que compraran un seguro de salud en el mercado de seguros de salud estatal, Covered California.

Pero Newsom, ahora en su segundo mandato, se ha retractado de esa promesa. Su administración se aferra a los ingresos recaudados por el llamado “mandato individual”, el requisito de que hay que tener cobertura sanitaria o pagar una multa. Y su presupuesto para el próximo año fiscal, que comienza el 1 de julio y se está debatiendo en la legislatura estatal, canaliza el dinero al fondo general del estado.

Esto ha enfurecido a sus colegas demócratas, que lo acusan de romper una promesa, y de no tener en cuenta a los millones de californianos que no pueden pagar deducibles y copagos.

California comenzó a multar a los no asegurados en 2020, recaudando un estimado de $1,1 mil millones en los primeros tres años, y la administración Newsom proyecta que agregará más de $700 millones en los próximos dos años, elevando el total proyectado de cinco años a $1,8 mil millones, según el Departamento de Finanzas del estado.

Los líderes demócratas dijeron que la táctica de Newsom de retener el dinero para el fondo general es una “estafa”.

“El dinero del mandato debe dedicarse a la salud”, dijo el presidente “pro tempore” del Senado Toni Atkins a KFF Health News, argumentando que el estado debería distribuir el dinero ahora para ayudar a las personas a pagar la cobertura de salud. “No sé qué estamos esperando. Tenemos que encontrar una manera de hacer que la atención médica sea más accesible, y no hay duda de que el costo del seguro de salud es una barrera”.

Se espera que los legisladores demócratas sigan presionando a Newsom con la esperanza de llegar a un acuerdo, antes de la fecha límite del 15 de junio, para aprobar un proyecto de ley presupuestario. “Siempre pensamos que el dinero se destinaría a reducir los costos de seguro”, señaló el miembro demócrata de la Asamblea Phil Ting, presidente del Comité de Presupuesto.

En 2019, Newsom hizo campaña por el mandato individual ante el aumento de las primas de seguro, prometiendo reducir los costos de atención médica de los consumidores de Covered California mientras se diferenciaba del entonces presidente Donald Trump, que calificaba el mandato de injusto.

Los republicanos del Congreso habían retirado la penalización federal —parte de ACA— en 2017. Newsom argumentó que todavía funcionaría en California para reducir los costos de atención médica, y para alcanzar su objetivo de atención médica universal, la pieza central de su ambiciosa agenda de salud.

Newsom argumenta ahora que los subsidios federales para el seguro médico que compensan el costo de las primas mensuales son suficientes. Y, ante un déficit presupuestario estatal previsto de $32,000 millones, Newsom afirma que California no puede permitirse gastar el dinero y reducir aún más los gastos de bolsillo.

Argumenta, por ejemplo, que gastar el dinero para recortar deducibles (la cantidad que pagas por la cobertura antes de que tu seguro empiece a pagar), sería “insostenible”. Su propuesta mantendría el dinero para el fondo general del estado, y se utilizaría en lo que California necesite.

Pero los activistas de la salud que presionaron a favor de la multa, así como muchos legisladores demócratas, dicen que los fondos podrían salvar vidas y deberían distribuirse ahora.

“El mandato individual no estaba destinado a crear fondos para otros programas gubernamentales que no fueran la atención de salud”, explicó el miembro demócrata de la Asamblea Jim Wood, de Santa Rosa, presidente del Comité de Salud, en una acalorada audiencia sobre el presupuesto esta primavera. “La clara intención de la legislatura era que este dinero se destinara a la asequibilidad”.

Wood dijo que habría rechazado el plan de Newsom si hubiera sabido que los ingresos que generara se depositarían directamente en el fondo general. “No creo que lo hubiera apoyado”, dijo. “Me parece una violación de lo que pensábamos que estábamos haciendo”.

El aumento de los gastos de salud, por ejemplo en primas de seguros y deducibles, está llevando a que las personas renuncien a la atención médica. En California, un asombroso 52% de los residentes afirma haber renunciado o retrasado un tratamiento en el último año por motivos económicos, según una encuesta reciente de la organización sin fines de lucro California Health Care Foundation. (California Healthline es un servicio editorial independiente de la California Health Care Foundation).

Diana Douglas, cabildera de Health Access California, que formó parte de la coalición que respaldó el mandato de cobertura del estado en 2019, señaló que Newsom debe reconocer el aumento de los costos y gastar el dinero ahora en ayudar al acceso a la salud. “Este dinero de la multa debe usarse para ayudar a los californianos a pagar la cobertura y la atención”.

Los planes de seguro de salud ofrecidos por Covered California siguen encareciéndose. Los deducibles para un plan de seguro de nivel medio, por ejemplo, subirán a $5,400 el próximo año, según Covered California, frente a los $4,750 de este año y los $3,700 de hace dos años.

Muchos californianos que compran cobertura también posponen el tratamiento ante los altos costos. Una encuesta realizada por Covered California en 2022 reveló que el 48% de sus consumidores aplazaron atención médica importante debido al precio.

Newsom esquivó esta primavera una pregunta de KFF Health News sobre las críticas a las que se enfrenta por su presión para retener el dinero del mandato, diciendo simplemente que está “orgulloso” de haber establecido el mandato de cobertura estatal y señalando que los subsidios federales a las primas están disponibles para los californianos que compran cobertura a través de Covered California.

Su administración defendió la canalización del dinero al fondo general, diciendo que los ingresos serían devueltos a un fondo especial de salud y estarían disponibles para su uso en la asistencia sanitaria con el tiempo, si el gobierno federal recortara los subsidios premium existentes.

Funcionarios de la administración argumentan que Newsom está esencialmente pidiendo prestado el dinero, diciendo que será devuelto más tarde, aunque los legisladores dudan que vaya a cumplir esa promesa.

Los críticos y algunos legisladores demócratas dicen que retener el dinero es un doble golpe para los residentes de bajos y medianos ingresos que sufren para pagar la cobertura, y argumentan que equivale a un impuesto a los pobres. “Da la sensación de que estamos intentando ahorrar a costa de nuestras comunidades de bajos ingresos”, indicó la senadora estatal demócrata Caroline Menjivar, que representa al Valle de San Fernando.

La mayoría de los que pagan la multa son californianos de ingresos bajos y medios que ganan menos del 400% del umbral federal de pobreza, que es de $58,320 para un individuo y $120,000 para una familia de cuatro miembros, según los últimos datos disponibles de la Franchise Tax Board.

Los legisladores demócratas apoyan este año una propuesta alternativa, defendida por Health Access California, para destinar los ingresos procedentes de multar a los residentes no asegurados a aumentar los subsidios de seguros de salud para las personas de ingresos bajos y medios. De este modo, se cumpliría el acuerdo que los activistas alcanzaron el año pasado con los legisladores demócratas del estado para reducir o eliminar los gastos de bolsillo en Covered California, y erradicar por completo los deducibles en un plan de nivel medio.

“Tenemos que asegurarnos de que las personas no sólo tengan cobertura de salud, sino que también puedan permitirse utilizarla”, expresó Ronald Coleman Baeza, de la Red de Salud Pan-Étnica de California.

Aunque Newsom y sus aliados demócratas han aprobado importantes ampliaciones de la cobertura, el estado no ofrece salud para todos.

Expertos dicen que más de 2,5 millones de californianos siguen sin seguro, incluidos los inmigrantes indocumentados que ganan demasiado para tener derecho a Medi-Cal, y los legisladores están cada vez más inquietos porque no todos los residentes con seguro puedan permitirse el lujo de utilizar su cobertura.

“Hubo un claro compromiso de que estos dólares se utilizarían para reducir los costos de la atención sanitaria, y no lo hemos hecho”, afirmó la miembro de la Asamblea Pilar Schiavo, representante demócrata del Valle de Santa Clarita, que presentó un proyecto de ley que exigiría que los ingresos recaudados por el mandato individual se destinaran permanentemente a la atención de salud.

Aunque la propuesta fracasó, puede ser revivida el próximo año, y los activistas aseguran que seguirán presionando a Newsom para distribuir el dinero existente entre los clientes de Covered California.

“Tenemos que cumplir nuestras promesas”, enfatizó Schiavo. “Si tienes un seguro que no puedes permitirte usar, o tienes miedo de ir a ver al médico por lo elevada que pueda ser la factura, entonces no tienes realmente acceso ni cobertura universal”.

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Pero eso cambió en mayo, cuando California amplió Medi-Cal, su programa de Medicaid para personas de bajos ingresos, a adultos de 50 años en adelante, independientemente de su estatus migratorio. El problema fue que Embriz no se dio cuenta que podía ser elegible hasta que fue a una reunión comunitaria en San Francisco.

“Escuché que estaban dando Medi-Cal a las personas mayores de 50 años, pero no sabía que no tenías que estar” en el país legalmente, dijo Embriz, quien está esperando que se procese su solicitud. “Gracias a Dios no he tenido emergencias”.

Hasta octubre, el mes más reciente para el que hay disponibles datos, más de 300,000 adultos mayores inmigrantes que no tienen residencia legal se habían inscrito en el Medi-Cal completo, un 30% más que la proyección original del estado.

Funcionarios estatales de salud, que habían basado su estimación en el número de personas inscritas en una forma limitada de Medi-Cal que cubre solo servicios médicos de emergencia, no saben cuántos californianos mayores adicionales son elegibles, dijo Tony Cava, vocero del Departamento de Servicios de Atención Médica del Estado.

Ahora, algunos condados han contratado a un pequeño ejército de trabajadores comunitarios y educadores de salud para inscribir a tantos adultos mayores inmigrantes como sea posible. Estos trabajadores visitan centros para personas mayores, iglesias, clases de inglés, oficinas de inmigración, mercados y eventos comunitarios, con la esperanza de encontrar a personas como Embriz, que no estén enteradas de su nueva elegibilidad.

En el condado de Alameda, Juan Ventanilla, experto en el programa Medi-Cal, dijo que la agencia de servicios sociales está utilizando subvenciones estatales existentes para asociarse con ocho organizaciones comunitarias establecidas para ayudar a correr la voz sobre la expansión, y a las personas a inscribirse.

Dijo que los trabajadores se especializan en “ayudar a los más vulnerables del condado a obtener acceso a atención médica”.

Entre ellos están Ana Hernández y Bertha Ortega, de Casa Che, un centro de educación de salud comunitaria en el vecindario Fruitvale de Oakland, operado por La Clínica de la Raza.

Hernández y Ortega dijeron que la mayoría de las personas que conocen están ansiosas por inscribirse en Medi-Cal, pero no saben por dónde empezar. Muchas no hablan inglés, tienen una alfabetización limitada, y luchan por usar o acceder a una computadora. Los formularios están disponibles en 12 idiomas, pero los usuarios pueden no encontrar su idioma, como la lengua maya indígena Mam.

“El sistema parece amigable si tienes mucha experiencia usando una computadora”, dijo Ortega, pero ese no es el caso para la mayoría de los adultos mayores a los que ayuda. “Vienen aquí y tenemos que arreglar todo”.

Los californianos sin estatus legal constituyen la mayor parte de los residentes sin seguro del estado, un estimado de 3 millones, según el UC Berkeley Labor Center.

Para que muchos de ellos obtengan cobertura, los legisladores estatales han expandido Medi-Cal a los inmigrantes que viven en California sin papeles, implementando la cobertura en etapas: primero, a los niños en 2016; en 2020 a los adultos jóvenes de hasta 26 años, y a personas mayores el año pasado.

El próximo año, la cobertura completa de Medi-Cal estará disponible para todos los californianos que califiquen, independientemente de su edad o estatus migratorio. Cuando esto suceda, se espera que se inscriban cerca de 700,000 personas adicionales de 26 a 49 años, que no son ciudadanas, según la oficina del gobernador Gavin Newsom.

Entre todos los cambios, el de la expansión del programa a los adultos mayores puede haber sido el más trascendental. No solo tienden a necesitar más atención, sino que también es más probable que tengan afecciones crónicas como hipertensión y diabetes. Muchos no buscan atención médica o servicios sociales de manera regular, una tendencia que aumentó con la pandemia.

California será el primer estado en expandir la cobertura de Medicaid a todos los inmigrantes. Illinois y Oregon también han ampliado la cobertura financiada por el estado a los adultos mayores inmigrantes, y Nueva York planea hacerlo en 2024.

A pesar de que Medicaid es un programa conjunto federal-estatal, en el caso de las personas sin estatus legal, el gobierno federal interviene solo para cobertura relacionada con emergencias y con el embarazo. Esto significa que los contribuyentes de California pagan la mayor parte del costo de proporcionar cobertura, estimada en $878 millones para personas mayores inmigrantes el primer año, según funcionarios de presupuesto estatales.

Cuando se lanzó en mayo la expansión para las personas mayores, las de 50 años en adelante que ya estaban inscritas en la forma limitada de Medi-Cal fueron transferidas automáticamente a la versión completa, que ofrece tratamientos médicos, dentales, de visión, y cuidado de largo plazo sin costo para la mayoría de los afiliados.

Algunos condados del Área de la Bahía, incluidos Alameda, Contra Costa y San Francisco, estuvieron en ventaja para identificar a las personas elegibles porque administran programas de atención médica para residentes sin estatus legal.

En los últimos meses, defensores de salud de la comunidad se han concentrado en encontrar personas mayores elegibles que aún no hayan escuchado sobre la expansión. Algunos han aparecido en los programas locales de noticias de televisión y radio para hacer correr la voz.

“Sabemos que hay más que son elegibles pero que no están inscritos, dijo Seciah Aquino; directora ejecutiva interina de Latino Coalition for a Healthy California. “Estamos trabajando para asegurarnos de que los números puedan continuar creciendo y que todos los que ahora tienen el privilegio de acceder a este beneficio puedan inscribirse”.

Un estudio de grupo focal el verano pasado, financiado por la California Health Care Foundation, encontró que aproximadamente la mitad de los encuestados hispanos no habían escuchado sobre el cambio. Una proporción aún menor de asiáticos mayores inmigrantes lo sabía. Los asiáticos constituyen el segundo grupo más grande de inmigrantes de California después de los hispanos, que representan casi el 40% de los inmigrantes del estado. (California Healthline es un servicio editorialmente independiente de la California Health Care Foundation).

Algunas de las personas que permanecen sin inscribirse son difíciles de persuadir porque temen revelar su estatus migratorio a un programa gubernamental, informan los trabajadores de salud comunitarios. Los que solicitan Medi-Cal deben divulgar su estatus en la solicitud, pero los funcionarios estatales dicen que la ley exige que la información se mantenga privada, y no se comparta con las autoridades de inmigración.

Esas garantías a menudo se reciben con escepticismo.

Muchos adultos mayores elegibles señalan la política de “carga pública” de la administración Trump, que hizo que la inscripción en Medicaid fuera una razón posible para denegar la residencia legal en el país. Aunque esa política fue revocada en diciembre, el temor persiste.

Embriz, que tuvo la cobertura limitada de Medi-Cal durante muchos años, dijo que la dejó en 2020 debido a la política de carga pública. No quería que su inscripción en Medi-Cal arruinara sus posibilidades de obtener una tarjeta verde. Pero una vez que supo que registrarse no afectaría su solicitud de residencia permanente, estuvo de acuerdo.

“Haría una gran diferencia”, dijo Embriz acerca de obtener chequeos de rutina nuevamente. “Tengo muchas esperanzas”.

Para algunos inmigrantes mayores que se han inscrito, la capacidad de obtener cobertura total ha sido un regalo del cielo. Maria Rodríguez, de 56 años, de Hayward, aprendió en septiembre que era elegible mientras visitaba el Tiburcio Vásquez Health Center, una clínica local que atiende a pacientes sin seguro. Una trabajadora social la ayudó a completar la solicitud en línea después que un médico la diagnosticara con hipertensión y diabetes.

“Es como si Medi-Cal cayera del cielo”, dijo Rodríguez. “Es muy beneficioso para mi salud”.

Claudia Boyd-Barrett es reportera de California Health Report. Este artículo se ha producido en colaboración con California Healthline, California Health Report y El Tímpano.

Inscríbete en Medi-Cal

Los residentes de California de bajos ingresos, y de 50 años en adelante, pueden solicitar todos los beneficios de Medi-Cal, sin importar su estatus migratorio. Estas son algunas formas de aplicar: 

Covered California: https://www.coveredca.com. En la parte inferior de esta página encontrarás traducciones disponibles en varios idiomas. Para comunicarte por teléfono llama al número 800-300-1506 para que te atiendan en inglés, o al 800-300-0213 para hablar con una operadora en español. Las planillas para aplicar a Medi-Cal están disponibles en 12 idiomas, listas para imprimir.

Envía por correo el formulario completado y firmado a:

Covered California

P.O. Box 989725

West Sacramento, CA 95798-9725

CalWIN: https://www.mybenefitscalwin.org. Esta página web está disponible para que los residentes de 18 condados soliciten beneficios públicos de diversos programas; la lista incluye los condados de Alameda, Contra Costa, San Francisco, Solano y Sonoma.

Para encontrar otras agencias de servicios sociales por condado:

HealthyAC: https://healthyac.org. Solo para residentes del condado de Alameda. Este sitio web incluye una lista de organizaciones, ordenadas por código postal, que ofrecen asistencia con el proceso de solicitud. Llama al número 510-272-3663 para tramitar tu inscripción por teléfono o para pedir una planilla de solicitud. 

Casa CHE: Manejado por La Clínica de la Raza (https://laclinica.org/), Casa Che brinda asistencia para inscribirse en seguros médicos en los condados de Alameda, Contra Costa y Solano. Llama al 855-494-4658 para programar una cita.

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That changed in May, when California expanded Medi-Cal — its Medicaid program for residents with low incomes — to adults 50 and older, regardless of immigration status. The problem was that Embriz didn’t realize she would be eligible until she attended a community meeting in San Francisco.

“I’d heard that they were giving full Medi-Cal to people over 50, but I didn’t know that you didn’t have to be” in the country legally, said Embriz, who is waiting for her application to be processed. “Thank God I haven’t had any emergencies.”

As of October, the most recent month for which data is available, more than 300,000 older immigrant adults who lack legal residency had enrolled in full Medi-Cal benefits, 30% more than the state’s original projection. State health officials, who had based their estimate on the number of people enrolled in a limited form of Medi-Cal that covers only emergency medical services, don’t know how many additional older Californians are eligible, said Tony Cava, a spokesperson for the state Department of Health Care Services.

Now, some counties have hired a small army of community workers and health educators to enroll as many immigrant seniors as they can find. Workers visit senior centers, churches, English-language classes, immigration offices, markets, and community events, hoping to encounter people like Embriz unaware of their newfound eligibility.

In Alameda County, Medi-Cal program specialist Juan Ventanilla said the social services agency is using existing state outreach grants to partner with eight established community organizations to help get the word out about the expansion and help people sign up.

Workers, he said, specialize in “assisting the most vulnerable in the county in getting access to health care.”

Among those fanning out are Ana Hernandez and Bertha Ortega at Casa CHE, a community health education center in the Fruitvale neighborhood of Oakland that is operated by La Clínica de la Raza. Hernandez and Ortega said most people they meet are eager to enroll in Medi-Cal, but they don’t know where to start. Many don’t speak English, have limited literacy, and struggle to use or access computers. Forms are available in 12 languages, but users may not find their language, such as the Indigenous Mayan language Mam.

“The system looks friendly if you have a lot of experience using a computer,” said Ortega, but that’s not the case for most of the older adults she helps. “They come in here and we have to fix everything.”

Californians without legal status make up the largest portion of the state’s uninsured residents, estimated at 3 million by the UC Berkeley Labor Center.

To get many of them covered, state lawmakers have expanded Medi-Cal to immigrants living in California without legal authorization, rolling out the coverage in stages: First, to children in 2016, young adults up to age 26 in 2020, and seniors last year. Next year, full Medi-Cal coverage will become available to all qualified Californians, regardless of age or immigration status. Once that happens, close to 700,000 additional noncitizens ages 26 through 49 are expected to enroll, according to Gov. Gavin Newsom’s office.

Yet for all the changes, the program’s expansion to older adults may have been the most momentous. Not only do they tend to need the most care, they also cost more to treat because they are likelier to have chronic conditions such as high blood pressure and diabetes. Many don’t regularly seek medical care or social services — a tendency exacerbated by the pandemic.

California will be the first state to expand Medicaid coverage to all immigrants. Illinois and Oregon have also expanded state-funded coverage to older adult immigrants, and New York plans to do so in 2024.

Even though Medicaid is a joint state-federal program, the federal government chips in only for emergency and pregnancy-related coverage for people without legal status, which means California taxpayers foot most of the cost of providing coverage, estimated by state budget officials at $878 million for immigrant seniors the first year.

When the expansion to seniors launched in May, people age 50 and older who were already enrolled in the limited form of Medi-Cal were automatically transitioned to the comprehensive version that offers dental, vision, long-term care, and routine medical treatment at no cost to most enrollees. And some Bay Area counties, including Alameda, Contra Costa, and San Francisco, had a leg up in identifying eligible people because they run health care programs for residents without legal status.

In recent months, community health advocates have concentrated on finding eligible seniors who have yet to hear about the expansion. Some have appeared on local television and radio news shows to get the word out.

“We know that there are more out there that are eligible but unenrolled,” said Seciah Aquino, acting executive director for the Latino Coalition for a Healthy California. “We are working to make sure that numbers can continue growing and that everyone who now has the privilege to access this benefit is able to sign up.”

A focus group study last summer, funded by the California Health Care Foundation, found that about half of Hispanic respondents hadn’t heard about the change. An even smaller share of older Asian immigrants knew about it. Asians make up the second-largest group of California immigrants after Hispanics, who account for almost 40% of the state’s immigrants. (California Healthline is an editorially independent service of the California Health Care Foundation.)

Some of the people who remain unenrolled are hard to persuade because they fear disclosing their immigration status to a government program, community health workers report. Medi-Cal applicants are required to disclose their immigration status on the application, but state officials say they are required by law to keep the information private and don’t share it with immigration authorities.

Those assurances are often met with skepticism.

Many eligible seniors point to the Trump administration’s “public charge” policy that made enrollment in Medicaid possible grounds for denying people legal residency in the U.S. Although that policy was overturned in December, fears linger.

Embriz, who had limited Medi-Cal coverage for many years, said she pulled out in 2020 because of the public charge policy. She didn’t want her Medi-Cal enrollment to ruin her chances of obtaining a green card. But once she learned that signing up wouldn’t affect her green card application, she agreed.

“It would make a big difference,” Embriz said about getting routine checkups again. “I have a lot of hope.”

For some older immigrants who have signed up, the ability to get full coverage has been a godsend. Maria Rodriguez, 56, of Hayward, learned in September that she was eligible while visiting the local Tiburcio Vasquez Health Center, a clinic that serves uninsured patients. A social worker helped her fill out the application online after a doctor had diagnosed her with diabetes and high blood pressure.

“It’s like Medi-Cal fell from heaven,” Rodriguez said. “It’s very beneficial for my health.”

Claudia Boyd-Barrett is a reporter with California Health Report. This article is produced in collaboration with California Healthline, California Health Report, and El Tímpano.

Sign Up for Medi-Cal

California low-income residents age 50 or older can apply for full-scope Medi-Cal regardless of immigration status. Here are ways to apply:

Covered California: https://www.coveredca.com. Language translations available at the bottom of the page. By phone, call 800-300-1506 for English and 800- 300-0213 for Spanish. Medi-Cal applications in 12 languages are available to print: https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/SingleStreamApps.aspx

Mail completed and signed applications to: 

Covered California

P.O. Box 989725

West Sacramento, CA 95798-9725

CalWIN: https://www.mybenefitscalwin.org. The website is available to residents in 18 counties, including Alameda, Contra Costa, San Francisco, Solano, and Sonoma, to apply for public benefit programs.

To find other county social services agencies: https://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx

HealthyAC: https://healthyac.org. For Alameda County residents only. The site includes a list of organizations searchable by ZIP code that can offer application assistance. Call 510-272-3663 to enroll over the phone or to request a mail-in application.

Casa CHE: Operated by La Clínica (https://laclinica.org/), Casa CHE provides health insurance enrollment assistance in Alameda, Contra Costa, and Solano counties. Call 855-494-4658 to schedule an appointment.

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Becerril earns about $52,000 a year at a nonprofit in California’s Central Valley, putting her and her husband, Armando, at more than double the limit to qualify for Medi-Cal, the state’s Medicaid program for people with low incomes and disabilities. Private insurance would cost $1,230 a month in premiums, money needed for their mortgage.

“We’ve been resorting to home remedies to get through the pain,” Becerril said through a Spanish translator. Her husband has needed hernia surgery for 20 years. “It’s frustrating because we pay our taxes, but we can’t reap any of the benefits of where our taxes are going,” she added.

While many Californians who earn too much to be eligible for Medi-Cal can get subsidized coverage through Covered California, an estimated 460,000 residents aren’t allowed to buy insurance through state-run insurance plans under the Affordable Care Act because they lack legal status. One Democratic lawmaker says it’s a small but glaring gap and is crafting a bill that could test Democratic Gov. Gavin Newsom’s commitment to reach universal health care.

“We’re going to need to figure out how to provide universal coverage for all who call this state home,” said the bill’s author, Assembly member Joaquin Arambula. “It’s an area our state has not leaned into enough, to provide coverage for those who are undocumented.”

Arambula’s bill would direct the state to ask the federal government to allow immigrants living in the state without authorization to get insurance through Covered California. Arambula sees the move as the critical first step to expand coverage. If approved, the Fresno lawmaker intends to push for state subsidies to help pay for insurance.

Both elements are essential for immigrants lacking legal status, said Jose Torres Casillas, a policy and legislative advocate with Health Access California, a consumer health group working with Arambula’s office on the measure.

“Access is one thing, but affordability is another,” Torres Casillas said.

Since taking office in 2019, Newsom has approved expanding Medi-Cal to all qualified residents regardless of immigration status. In doing so, the politician continuously rumored to be preparing for a presidential bid described the state as moving “one step closer” toward universal health care. But in January, Newsom announced a $22.5 billion state deficit and made no mention of new proposals for the state’s estimated 3 million uninsured residents.

Newsom’s health secretary, Dr. Mark Ghaly, acknowledged the pressure to go further but he would not commit to a timeline.

“Up until now we’ve had so many other things to focus on,” Ghaly said. “This will become, frankly speaking, one of the most important next issues that we take on.”

California needs permission from the federal government to open Covered California to immigrants without legal residency because it is currently closed to them, and Arambula said he is in talks with Newsom administration officials about how to structure the bill.

Once the federal government opens Covered California up to all migrants, the state could set aside funding for subsidies. About 90% of enrollees in Covered California qualify for financial assistance, which is paid for with both state and federal funds. Since 2020, the state has spent $20 million a year on those subsidies, a fraction of the cost, because Congress has given states an infusion of money during the pandemic.

Previously, lawmakers had allocated roughly $300 million to lower insurance premiums for Covered California enrollees. Any financial assistance to people living in the state without authorization would likely have to come from state funds, and the costs could vary widely.

For instance, Colorado enrolled 10,000 such immigrants into a new insurance program designed solely for them at a cost of $57.8 million in state funds, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. The program covered the full cost of insurance for enrollees.

In Washington state, immigrants who lack legal status can take advantage of a state fund next year to help all income-eligible state residents pay for insurance, said Michael Marchand, chief marketing officer for the Washington Health Benefit Exchange. State lawmakers have added $5 million to the fund for immigrants without legal authorization.

“It would serve as an incentive for additional undocumented immigration into our country,” said Sally Pipes, president and CEO of the Pacific Research Institute, a think tank that advocated against Medi-Cal expansion to immigrants without legal standing. “And put taxpayers on the hook for additional government health care costs and the inevitable higher tax bills to pay for them.”

California officials have previously considered allowing all immigrants to buy insurance from its state-run program before, submitting a request to the federal government in 2016. But the state rescinded its application after President Donald Trump took office, given his anti-immigration rhetoric and policies.

The Biden administration in December approved an exception to federal law for Washington state — a game changer in the eyes of immigration advocates, said Rachel Linn Gish, a spokesperson for Health Access.

“Seeing what other states have done and the waivers that are happening under Biden, it makes a huge difference in our approach,” she said.

But even if lawmakers pass a plan to open California’s insurance marketplace to all immigrants regardless of status, advocates said the state will have to wait until Jan. 1, 2024, to ask the federal government for permission, and it could take half a year or longer to get a response.

That means it could be years before Becerril can get coverage. Instead, she’s preparing for the worst.

“I’m paying for funeral coverage,” she said. “It’s more economical than paying the health coverage premium.”

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The upheaval, which begins in April, will put millions of low-income Americans at risk of losing health coverage, threatening their access to care and potentially exposing them to large medical bills.

In California, where about 15.2 million people are enrolled in its Medicaid program, known as Medi-Cal, up to 3 million could lose coverage because they no longer qualify or fail to reenroll, state officials forecast.

This month, the state is launching a massive media campaign via radio, social media, and billboards to alert Medi-Cal members that they must apply to renew their coverage this year. In coming months, the state will enlist federally funded navigators and other community health workers to help people update their contact information and ease the reenrollment process — or to shepherd them into new coverage, if their income exceeds Medicaid’s eligibility limits.

The outreach campaign is backed by $25 million in state funds, with material provided in 19 languages.

Still, state health officials worry that people may get left behind and that the state’s all-time low 7% uninsured rate could spike.

“We acknowledge that this is going to be a bumpy road,” California Health and Human Services Secretary Mark Ghaly said. Federal health insurance subsidies will help prevent people from falling through the cracks, he said.

Almost three years ago, as covid sent the national economy into free fall, the federal government agreed to send billions of dollars in extra Medicaid funding to states on the condition that they stop dropping people from their rolls.

But legislation enacted in December will be phasing out that money over the next year and calls for states to resume cutting off from Medicaid people who no longer qualify.

Now, states face steep challenges: making sure they don’t inadvertently disenroll people who are still entitled to Medicaid and connecting those who no longer qualify to other sources of coverage, such as subsidized health plans on the Affordable Care Act marketplaces.

Even before the pandemic, states struggled to stay in contact with Medicaid recipients, who in some cases lack a stable address or internet service, do not speak English, or don’t prioritize health insurance over more pressing needs.

Ordinarily, people move in and out of Medicaid all the time. States, which have significant flexibility in how they run their Medicaid programs, typically experience significant “churn” as people’s incomes change and they gain or lose eligibility.

The so-called unwinding will play out over more than a year.

The Biden administration has predicted that 15 million people — 17% of enrollees — will lose coverage through Medicaid or CHIP, the closely related Children’s Health Insurance Program, as the programs return to normal operations. While many of the 15 million will fall off because they no longer qualify, nearly half will be dropped for procedural reasons, such as failing to respond to requests for updated personal information, according to federal estimates.

Millions of people losing Medicaid coverage will be eligible for free or low-cost coverage through the ACA marketplaces, but choosing a plan is complicated. Unlike Medicaid, so-called Obamacare plans often include deductibles and copayments — though some people, depending on income, can get financial help to lower those expenses.

People who lose Medicaid coverage — in the more than 30 states covered by the federal marketplace — will have until July 31, 2024, to sign up for ACA coverage, CMS announced on Jan. 27. It’s unclear whether the state-based marketplaces will offer the same extended open-enrollment period.

California will move some people who lose Medicaid eligibility to a subsidized private plan on the state’s marketplace, Covered California. Enrollees will have to agree and pay a premium if they don’t qualify for a free plan. But for those who don’t qualify for a zero-premium private plan, the premium could be as low as $10 a month, said Jessica Altman, executive director of Covered California. (Altman’s father, Drew Altman, is president and CEO of KFF. KHN is an editorially independent program of KFF.)

“We want to make it easier to say yes to coverage,” Altman said.

The state will initially try to verify enrollees’ income automatically using data from government databases, such as from the Internal Revenue Service. During the yearlong unwinding, current enrollees could still qualify if the databases show their income is no more than 20% above the thresholds for Medi-Cal eligibility, said Tony Cava, a Department of Health Care Services spokesperson. For example, a California parent in a family of three would still qualify with an income of up to $41,168.

Medi-Cal members who aren’t renewed automatically will be sent a form requesting updated information, due within 60 days. People who do not complete the process will have their coverage terminated.

Medi-Cal members will have 90 days to appeal after being disenrolled.

Federal law bars states from disenrolling anyone solely because mail was returned as undeliverable until the state has made a “good faith effort” to contact the person another way, such as by phone or email.

The federal government recently expanded subsidies for some people buying coverage through Obamacare exchanges, and those could cushion the blow for people losing Medicaid in the unwinding.

States will give Medicaid recipients at least 60 days to respond to requests for information before dropping them, said Jack Rollins, director of federal policy at the National Association of Medicaid Directors.

States are enlisting Medicaid health plans, doctors, hospitals, state insurance marketplaces, and an assortment of nonprofit groups, including schools and churches, to reach out to people at risk of losing coverage. But even in states taking the boldest actions to keep people covered, Medicaid officials worry what the next year will bring.

“We have no illusion that this will be beautiful or graceful, but we will be doing everything we can not to lose anyone in the process,” said Dana Hittle, Oregon’s interim Medicaid director.

Oregon plans to allow children to stay on Medicaid until age 6 and to give everyone else up to two years of eligibility regardless of changes in income and without having to reapply. No other state provides more than one year of guaranteed eligibility.

Oregon is also creating a subsidized health plan that would cover anyone who no longer qualifies for Medicaid but has an annual income below 200% of the federal poverty level, which amounts to about $29,000 for an individual, state officials said. The program will have benefits similar to Medicaid’s at little or no cost to enrollees.

Rhode Island will automatically move people who are no longer eligible for Medicaid — and with annual incomes below 200% of the poverty rate — into an Obamacare plan and pay their first two months of premiums.

Nevada has developed a mobile app to communicate with members, but only 15,000 members have signed up so far. Nevada has about 900,000 members.

Altman said Covered California does not have estimates on how many people would transition out of Medi-Cal and onto the state Obamacare exchange, but she said California’s efforts will go far in helping the state reach its goal of universal health coverage.

“This is when we really need to be protective of the gains that we have made, and do everything we can to reach Californians to support them in navigating our health care system,” she said.

KHN correspondents Daniel Chang in Florida and Katheryn Houghton in Montana contributed to this report.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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 federal government recently fixed a controversial Treasury Department rule tied to the Affordable Care Act that denied assistance to many families whose workplace coverage busted their budgets.

Because of the so-called family glitch, if a worker had access to employee-only coverage deemed affordable under federal guidelines, a spouse or dependents could not get help to buy a health plan through Covered California, the state’s ACA insurance marketplace, even if it was not affordable to put them on the employer plan.

This affected an estimated 5.1 million people nationally, more than half of them children, since employers often contribute only to an employee’s premium, leaving workers to pay full fare for other family members.

Under a new rule that took effect Dec. 12, if the cost of having you and your family on a workplace plan exceeds an affordability threshold — set at 9.12% of household income for 2023 — your spouse and dependents could qualify for financial aid to purchase insurance through Covered California. Affordability will be determined by how much you would have to pay to have them — and you — on your employer’s cheapest health plan.

ACA insurance subsidies come in the form of federal tax credits that can be taken upfront or settled with the IRS when you file your taxes the following year.

Estimates from the UCLA Center for Health Policy Research and the UC Berkeley Labor Center show that 391,000 Californians previously excluded from subsidies in Covered California would be eligible for them under the new rule. Of those, an estimated 149,000 would likely enroll in a Covered California plan. Those switching from an employer-sponsored plan would save an average of $1,478 per person in 2023, according to the two centers.

“Fixing the family glitch is a critical step in really delivering on the promise of the ACA,” says Jessica Altman, executive director of Covered California. “If you don’t have affordable coverage from another source, the marketplace is where you should be able to come for affordable coverage.”

So, if you are paying too much to cover your family members on your employer’s health plan, it is definitely worth finding out whether you can get a tax credit to help pay their premiums on a Covered California plan. But finding the answer is complicated and will take considerable legwork.

If you have steady employment, this year’s income will probably be a good proxy for 2023, adding any pay raise you expect for the coming year. You’ll also need to calculate how much you would pay for your employer’s lowest-cost health plan — both for employee-only coverage and for family coverage. If the cost for you alone is under the 9.12% threshold, you will not qualify for a subsidized Covered California plan, even if your spouse and dependents do. That means a family could be split between two policies, with separate deductibles and different provider networks.

You also need to determine whether the lowest-cost plan offered by your employer meets the minimum coverage standard under the ACA. That means it must cover at least 60% of your total allowed medical expenses during the year and provide sufficient coverage for hospital and physician services. If it does not meet those requirements, you and your family might be able to get a subsidized plan through Covered California, depending on your income.

If two spouses have access to employer coverage, you’ll need to perform this exercise for both options.

Is your head spinning yet? You’re not alone.

“This stuff is just really complicated,” says Kevin Knauss, an insurance agent in Granite Bay. “And how can we possibly expect families that are doing all kinds of different things — kids, Christmas — to really focus on this stuff?”

But don’t ignore the new rule, because you could be leaving money on the table. Covered California has a worksheet to help calculate your eligibility for subsidies. Your human resources department might be willing to help you fill it out. Or you could seek professional help, whether an insurance agent or other certified enroller. You wouldn’t need to pay a penny for either.

To find an insurance agent or certified enroller, log on to Covered California’s website (www.coveredca.com) and click on the “Support” tab. Or call 800-300-1506. Covered California has a very useful FAQ all about the fix to the family glitch.

The enrollment period for 2023 coverage started on Nov. 1 and runs through Jan. 31. You have until Dec. 31 to buy coverage that starts Jan. 1. If you buy coverage in January, it starts Feb. 1.

The family glitch fix isn’t the only new thing with Covered California. Starting in 2023, you can put a dependent parent or stepparent on your health plan, as long as they are not eligible for or enrolled in Medicare.

And, in case you missed it, Congress extended through 2025 the supplemental tax credits that increase aid to people who were already getting some before and are available to many middle-class households that did not previously qualify for financial assistance.

The idea behind the expanded financial help is to limit the amount people spend on health care premiums to no more than 8.5% of household income, no matter how much money they make.

Knauss said he talked to a man in Marin County who was seeking a Covered California health plan for his family of four and qualified for a monthly subsidy of $1,400, even though he makes $200,000 a year. Being over 60 and living in Northern California, an expensive region, pushed his family’s premium to a level that opened the door for significant financial assistance, Knauss said.

If you are already enrolled in Covered California, don’t simply renew coverage for 2023. Prices and provider networks can change from year to year, and there might be a new, cheaper option in your region. So shop around.

And whether you are new or returning to Covered California, know what your medical needs are likely to be. If you have a condition that requires intensive services, you might consider paying a higher premium in exchange for lower deductibles and coinsurance when you seek care.

Happy hunting.

Jessica Altman is the daughter of Drew Altman, who is president and CEO of KFF. KHN is an editorially independent program of KFF.

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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Caudillo said she feels like a “prisoner” to the three major pharmaceutical companies that control the price of insulin, which ranges from $300 to $400 per vial without insurance. The price Caudillo paid in 2017, when she was diagnosed, is etched into her memory: $274.

“I remember crying my eyes out at CVS and realizing it’s going to be like this for the rest of my life,” said Caudillo, 24, a college student who lives in La Puente, in Southern California. She now has insurance that covers the entire cost of the lifesaving drug but still has trouble affording her insulin supplies and paying the monthly premium for her plan.

“This disease is really expensive, and I’m barely making it every month,” Caudillo said.

Gov. Gavin Newsom’s administration said roughly 4 million Californians have been diagnosed with diabetes, a disease that can destroy organs, steal eyesight, and lead to amputations if it’s not controlled. One in 4 people who have diabetes and rely on insulin cannot afford it, forcing many to ration or forgo the drug, the administration added.

Newsom is asking state lawmakers to pump $100 million into an ambitious initiative to launch California’s generic drug label, CalRx, and begin producing insulin in the next few years, said Alex Stack, a Newsom spokesperson. The state is also working to identify other generic drugs it could bring to market, targeting those that are expensive or in short supply.

To start, the goal is to dramatically slash insulin prices and make it available to “millions of Californians” via pharmacies, retail stores, and mail order, said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency.

But state health officials are still negotiating a contract with a drug manufacturer to make and distribute insulin and have not answered key questions such as how cheaply insulin could be produced and what patients would pay. To be successful, California — and the company it partners with — must navigate a complicated pharmaceutical distribution system that relies not only on drug manufacturers but also middleman companies that work hand in hand with health insurers. Those companies, known as pharmacy benefit managers, negotiate with manufacturers on behalf of insurers for rebates and discounts on drugs — but insurers don’t always pass those savings on to consumers.

“Insulin has long epitomized the market failures that plague the pharmaceutical industry, which have resulted in keeping insulin prices high,” Vishaal Pegany, assistant secretary of the Health and Human Services Agency, told lawmakers in May. He argued that high prices “have directly harmed Californians.”

Newsom said in early May that disrupting monopolistic drug prices requires state intervention and that California can pull it off because the state — with 40 million residents — “has market power.”

But the nonpartisan Legislative Analyst’s Office questioned whether California can produce its own drugs and achieve lower insulin prices. Luke Koushmaro, a senior fiscal and policy analyst with the office, warned at a legislative hearing in May that the effort could be hampered by “considerable uncertainties” — a sentiment echoed by some Democratic lawmakers.

The Newsom administration thinks state-made insulin could cut some insurers’ spending on the drug as much as 70% — savings it hopes would trickle down to consumers. But “there is no guarantee” that the administration’s predictions of dramatic savings or wide distribution of insulin will materialize, state Assembly member Blanca Rubio (D-Baldwin Park) said at the hearing. “Who is going to write the prescriptions for this magic insulin?” she asked. “Hope is not a strategy. I’m not hearing any strategies as to how this is going to become available.”

The price of insulin has soared in recent years. A 2021 U.S. Senate investigation found that the price of a long-acting insulin pen made by Novo Nordisk jumped 52% from 2014 to 2019 and that the price of a rapid-acting pen from Sanofi shot up about 70%. The investigation implicated drug manufacturers and pharmacy benefit managers in the increases, saying they perpetuated artificially high insulin prices.

“Insulin manufacturers lit the fuse on skyrocketing prices by matching each other’s price increases step for step rather than competing to lower them, while PBMs, acting as middlemen for insurers, fanned the flames to take a bigger cut of the secret rebates and hidden fees they negotiate,” U.S. Sen. Ron Wyden (D-Ore.) said when the report was released.

Contacted by KHN for comment, the trade associations that represent brand-name drugmakers, pharmacy benefit managers, and California health insurers blamed one another for the increase in prices.

Under Newsom’s plan, generic forms of insulin — known as “biosimilars” because they are made with living cells and mimic brand-name drugs on the market — would be widely available to insured and uninsured Californians.

If Newsom’s $100 million initiative is approved by lawmakers this summer, the state would use that money to contract with an established drugmaker to begin supplying CalRx insulin while the state constructs its own manufacturing facility, also in partnership with a drugmaker.

The administration is currently negotiating with drug companies that can produce a reliable supply of insulin under a no-bid contract, but no partnership has been formalized. The insulin would be branded with images associated with the state, such as the “California Golden Bear.” And, Pegany said, the packaging could boast that the lower-priced insulin was brought to patients by state government.

“There’s a short list of people who would even compete for this,” Ghaly told KHN in May. “We’re going to put together competition and get a partner we think is going to deliver not just the soonest, but something that we think is sustainable.”

On the short list is Civica Rx, a nonprofit drugmaker based in Utah. Civica announced independently in March that it was preparing to produce biosimilar insulin — exactly what California is seeking. The FDA last year approved the first biosimilar, interchangeable insulin product, and Civica plans to make three types of generic insulin to compete with the brand-name versions made by Eli Lilly and Co., Sanofi, and Novo Nordisk.

Allan Coukell, Civica’s senior vice president of public policy, told KHN that the drugmaker has had discussions with the Newsom administration and is in talks with other states.

Civica aims to market insulin for close to the cost of making it, rather than charging markups and making profits, he said. Coukell said the company plans to bring biosimilar insulin to the market for roughly $30 per vial and $55 for a box of five pen cartridges.

Coukell acknowledged that Civica may have to work with pharmacy benefit managers, which also help health insurers determine which drugs they will cover, to distribute the medicine but doesn’t expect that to cause a big price increase. “Our goal is to make these insulins available to any American who needs them,” Coukell said. “Our goal is to have market impact, not market share.”

The state has had discussions with other companies, including celebrity investor Mark Cuban’s for-profit drug company, the Mark Cuban Cost Plus Drug Company. It is building its own manufacturing plant, like Civica, but for now sells drugs online to anyone at wholesale cost plus a 15% markup. Founder Dr. Alex Oshmyansky said that the company’s talks with California fizzled out early on but that he’d be open to future discussions. Cuban is the chief investor in the company, Oshmyansky said.

“America is the wealthiest country in the history of human civilization, so for our citizens to not be able to afford medications, including insulin, due to market manipulations is terrible,” Oshmyansky said.

For people with diabetes like Caudillo, relief can’t come fast enough. She stockpiles insulin in case she can no longer afford health insurance and donates extra to other people in need.

“I know how expensive it is when you aren’t covered, and if you don’t pay that money, you’re going to be in the hospital fighting for your life,” she said. “Your body goes into decay, and your organs slowly shut down. It’s very painful. No diabetic should have to go through that.”

KHN senior correspondent Samantha Young contributed to this report.

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).