Improving Medicaid Access in Times of Health Policy Change: Solutions from Focus Groups with Frontline Enrollment Workers.

Enrollment navigators and government-employed Medicaid workers were an important element in the Affordable Care Act's (ACA) initial enrollment success. The Centers for Medicare and Medicaid Services eliminated 41% of funding for 2017 navigator programs and 90% of funding for outreach, arguing less investment was needed. Given that many remain uninsured, it is critical to identify effective enrollment practices. This study characterizes barriers and enrollment strategies from the perspective of California's Medicaid government and community-based enrollment workers (n=101 in eight focus groups). Participants identified a need for communication with policymakers, the state exchange, and each other regarding changing enrollment processes. Solutions include increased contact between enrollment workers to share strategies and policy updates regarding application processing, uniform policy interpretation, and details of ACA-related immigration law. Given efforts to weaken the ACA, it is critical to engage frontline workers in problem solving to streamline enrollment strategies, particularly for vulnerable populations.

Universal Health Care: Lessons From San Francisco.

The San Francisco Health Care Security Ordinance is the country's only local law designed to promote universal health care. It provides access to health services for the uninsured while requiring employers to contribute financially toward employees' health care costs. Enrollment in Healthy San Francisco, a program for the uninsured that is one component of the ordinance, fell significantly after the Affordable Care Act extended other types of coverage. Healthy San Francisco continues as a major source of care for undocumented people. Many other California counties have programs that provide at least some nonemergency care to undocumented residents, which demonstrates the versatility of this approach for localities. San Francisco employer contributions also fund medical reimbursement accounts that help insured people pay their health costs, including through a program added in 2016 to make Marketplace insurance more affordable. The city's experiences show that programs to help people pay for private coverage should be simple and include strong outreach and education and that the affordability of Marketplace coverage would be most easily addressed at the state level.

"There is no help out there and if there is, it's really hard to find": a qualitative study of the health concerns and health care access of Latino "DREAMers".

PURPOSE: Young immigrants without documentation who qualify for the Deferred Action for Childhood Arrivals (DACA) program are eligible for temporary legal status but excluded from the Affordable Care Act's Medicaid expansion and Health Care Exchanges. Little is known about this population's health or access to care. METHODS: Sixty-one DACA-eligible Latinos aged 18-31 years were recruited from community and Internet settings to participate in nine focus groups in California. An advisory board of immigration and health advocates assisted in the project's design and validation of results. RESULTS: Participants reported avoiding the health care system whenever possible, first turning to family members and unlicensed community healers, then seeking safety net providers if necessary. Barriers to care included cost, limited intergenerational knowledge about the health care system, lack of a driver's license, and mistrust of providers due to fear of discrimination and deportation. Mental health care was the greatest unmet health need. They wanted more information about their health care options and access to primary care, dental, and vision benefits. Participants reported refraining from high-risk behaviors to avoid associated financial and legal burdens that might threaten their immigration status. CONCLUSIONS: As the first study to describe DACA-eligible young adults' health needs, these data demonstrate their profound mental health challenges and numerous barriers to health care access. Many barriers were attributed to their undocumented status and persisted even when they gained temporary legal status. This work provides a foundation for evidence-based policy changes to address the health needs of this and other undocumented populations.

The California Health Policy Research Program - supporting policy making through evidence and responsive research.

This article explores the creation, design, and execution of a university-based collaboration to provide responsive research and evidence to a group of diverse health care, labor, and consumer stakeholders through convening a funded series of deliberative meetings, research briefs, peer-reviewed journal articles, ad hoc data analyses, and policy analyses. Funded by the California Endowment, the California Health Policy Research Program was created by researchers at the University of California, Berkeley Center for Labor Research and Education, and the UCLA Center for Health Policy Research. The collaboration not only allowed new research and analyses to be used by stakeholders and policy makers in decision making but also allowed university researchers to receive input on the important health policy issues of the day. The guidance of stakeholders in the research and policy analysis process was vital in driving meaningful results during an important time in health policy making in California. The manuscript discusses lessons learned in building relationships with stakeholders; meeting research and analytic needs; engaging stakeholders and policy makers; building capacity for quick-turnaround data collection and analysis, dissemination and publication; and maintaining the collaboration.

Large repayments of premium subsidies may be owed to the IRS if family income changes are not promptly reported.

Subsidies for health insurance premiums under the Affordable Care Act are refundable tax credits. They can be taken when taxes are filed or in advance, as reductions in monthly premiums that must be reconciled at tax filing. Recipients who take subsidies in advance will receive tax refunds if their subsidies were too small but will have to make repayments if their subsidies were too high. We analyzed predicted repayments and refunds for people receiving subsidies, using California as a case study. We found that many families could owe large repayments to the Internal Revenue Service at their next tax filing. If income changes were reported and credits adjusted in a timely manner throughout the tax year, the number of filers owing repayments would be reduced by 7-41 percent and the median size of repayments reduced by as much as 61 percent (depending on the level of changes reported and the method used to adjust the subsidy amounts). We recommend that the health insurance exchanges mandated by the Affordable Care Act educate consumers about how the subsidies work and the need to promptly report income changes. We also recommend that they provide tools and assistance to determine the amount of subsidies that enrollees should take in advance.

Proposed regulations could limit access to affordable health coverage for workers' children and family members.

Key Findings. The Patient Protection and Affordable Care Act (ACA) is designed to offer premium subsidies to help eligible individuals and their families purchase insurance coverage when affordable job-based coverage is not available. However, the law is unclear on how this affordability protection is applied in those instances where self-only coverage offered by an employer is affordable but family coverage is not. Regulations recently proposed by the Department of the Treasury would make family members ineligible for subsidized coverage in the exchange if an employee is offered affordable self-only coverage by an employer, even if family coverage is unaffordable. This could have significant financial consequences for low- and moderate-income families that fall in this gap. Using an alternative interpretation of the law could allow the entire family to enter the exchange when family coverage is unaffordable, which would broaden access to coverage. However, this option has been cited as cost prohibitive. In this brief we consider a middle ground alternative that would base eligibility for the individual worker on the cost of self-only coverage, but would use the additional cost to the employee for family coverage as the basis for determining affordability and eligibility for subsidies for the remaining family members. We find that: Under the middle ground alternative scenario an additional 144,000 Californians would qualify for and use premium subsidies in the California Health Benefit Exchange, half of whom are children. Less than 1 percent of those with employer-based coverage would move to subsidized coverage in the California Health Benefit Exchange as a result of having unaffordable coverage on the job.