[Editor’s note: KHN is not affiliated with Kaiser Permanente.]
California lawmakers have authorized a controversial no-bid statewide Medi-Cal contract for HMO big Kaiser Permanente over the objection of county governments and competing well being plans. However key particulars — together with what number of new sufferers KP will enroll — are nonetheless unclear.
On June 30, with little fanfare, Gov. Gavin Newsom signed the bill that codifies the deal, regardless of issues first reported by KHN that KP was getting preferential remedy from the state that may permit it to proceed enrolling a more healthy pool of Medi-Cal sufferers, leaving different well being plans with a disproportionate share of this system’s sickest and costliest sufferers. Medi-Cal, California’s model of Medicaid, the government-funded medical health insurance program for individuals with low incomes, covers almost 14.6 million Californians, 84% of whom are in managed-care plans.
Now that the controversy is over, opponents of the KP deal are wanting forward.
“We sit up for working with the state on implementing the statewide contract, and we’ll proceed to advocate the worth and significance of native plans in offering care to their communities,” stated Linnea Koopmans, CEO of Native Well being Plans of California, which spearheaded the opposition.
Kaiser Permanente is a large participant in California’s medical health insurance market, protecting almost 1 / 4 of all Golden State residents. However its barely lower than 900,000 Medi-Cal enrollees are solely about 7% of that program’s whole managed-care membership.
Kaiser Permanente has lengthy been allowed to restrict its Medi-Cal membership by accepting solely individuals who have been KP members within the current previous — primarily in employer-based or Inexpensive Care Act plans — and their fast members of the family.
Underneath the brand new regulation, the variety of Kaiser Permanente enrollees in this system “can be permitted to develop by 25%” over the five-year lifetime of the contract, ranging from its degree on Jan. 1, 2024, when the contract takes impact, stated Katharine Weir-Ebster, a spokesperson for the Division of Well being Care Companies, which runs Medi-Cal. However that 25% determine is just not within the textual content of the regulation — and the exact magnitude of the supposed enrollment enhance for KP stays unclear.
Presently, most of KP’s Medi-Cal members are coated by way of subcontracts with native, publicly ruled well being plans across the state. Underneath the brand new regulation, these members can be coated straight by Kaiser Permanente below its statewide contract. Proponents say the change will enhance effectivity, cut back confusion for shoppers, and make Kaiser Permanente extra accountable to the state.
Opponents have argued that having a nationwide behemoth compete with native plans — particularly in locations similar to Orange, Ventura, San Mateo, and Sonoma counties, the place county-operated plans have been the only real Medi-Cal choice — might weaken neighborhood management over well being care and compromise the protection web system that serves California’s most weak residents.
The brand new regulation commits KP to growing its footprint in Medi-Cal by accepting sure classes of latest enrollees, together with present and former foster care youths, youngsters who’ve acquired companies from one other youngster welfare company, seniors who’re eligible each for Medi-Cal and Medicare, and enrollees who fail to decide on a well being plan and are assigned one by default.
Almost half of Medi-Cal enrollees in counties with a couple of well being plan are assigned by default, Weir-Ebster stated. The regulation, nevertheless, doesn’t specify what number of default enrollees Kaiser Permanente will settle for, saying solely that the quantity might be primarily based on KP’s “projected capability” in every county or area.
One other important supply of enrollment development for Kaiser Permanente might be sufferers — and their members of the family — transferring out of KP industrial plans in counties the place KP might be a Medi-Cal choice for the primary time.
Some distinguished client advocacy teams argue that any enhance in Kaiser Permanente’s Medi-Cal inhabitants is a constructive improvement, particularly for the reason that HMO will get excessive marks for the standard of its care.
“We predict that system is one thing that extra Medi-Cal members ought to have entry to, and this invoice is a step in that route,” stated Kiran Savage-Sangwan, government director of the California Pan-Ethnic Well being Community, which advocates for fairness in well being care.
Kaycee Velarde, head of Medi-Cal contracting for KP, stated through electronic mail that the deal will give extra individuals “entry to our high-quality Medi-Cal managed care plan” and permit for higher collaboration with the state “to enhance high quality for a broader variety of Medi-Cal enrollees.”
However precisely how the brand new association will work stays unclear.
The specifics — together with the enrollment development determine — are anticipated to be enshrined in a memorandum of understanding separate from the contract. That has raised some eyebrows, since MOUs aren’t sometimes binding in the identical means contracts are. Neither is it clear when the main points will come.
“Our expectation is that the Division of Well being Care Companies is creating the MOU,” Velarde stated. The division doesn’t have an estimate of when a draft might be issued, Weir-Ebster stated.
Many skeptics of the deal stay involved about its affect on the safety-net inhabitants. The regulation says Kaiser Permanente will present the “highest want” specialty companies to non-KP members in sure areas of the state. But it surely doesn’t specify which companies or the place they are going to be offered. These particulars, anticipated to be within the MOU, haven’t but been determined, Weir-Ebster stated.
Leslie Conner, CEO of Santa Cruz Neighborhood Well being, which runs three clinics in Santa Cruz County, stated entry to specialty care is a problem for sufferers. “That’s going to be a remaining drawback that I hope Kaiser would work with the neighborhood to handle,” she stated. “If we don’t all determine it out collectively, there’s going to be winners and losers, and, actually, the losers are at all times the low-income individuals.”
Lawmakers did make a small variety of adjustments to the unique invoice supposed to handle opponents’ issues. Considered one of them, aimed toward native well being plans’ concern of getting a sicker pool of Medi-Cal enrollees, says all Medi-Cal managed-care plans must be paid in “an actuarially sound method” in keeping with the medical threat of their enrollees.
One other one directs the state to evaluate, earlier than the contract begins, whether or not KP is sufficiently complying with behavioral well being protection necessities. The well being care big has come below fireplace lately for offering inadequate mental health services, and the state Division of Managed Well being Care is investigating the HMO’s psychological well being program after a pointy enhance in complaints, stated Rachel Arrezola, a division spokesperson.
Sal Rosselli, president of the Nationwide Union of Healthcare Staff, which has waged a pitched battle in opposition to KP over psychological well being care, stated the availability within the new regulation to evaluate compliance is inadequate. The union had wished KP to endure an annual certification course of that may have barred it from enrolling new Medi-Cal enrollees in any 12 months it wasn’t licensed.
“Are you able to think about any well being plan can be granted such a big growth of its Medi-Cal contract if it couldn’t present remedy for most cancers or cardiac care?” Rosselli stated.
Finally, KP’s contract creates extra alternative for the Medi-Cal inhabitants, stated Linda Nguy, a lobbyist with the Western Heart on Regulation & Poverty. However the group, which advocates for individuals with low incomes, pledged to regulate how the brand new regulation is rolled out.
“We might be monitoring it and definitely elevating points as issues come up,” Nguy stated.
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