The State of California has already been rolling out
health system changes outlined by the Affordable Care Act. It's
implementing the health benefit exchange, expanding Medi-Cal, and
it has passed laws to enhance and extend health coverage. The
Supreme Court hearings this week raised questions about the future
of health changes in California.
[The following is a transcript from a longer version
of an interview with Secretary Dooley. A shorter version of
this interview aired on Capital Public Radio and can be viewed here
Secretary Dooley: California has a long history of innovation
in the delivery of health care. For the past decade, California has
had a number of legislative efforts from mandating employers carry
it early in the decade; in '07 and '08, there was a strong effort
that had bi-partisan support across insurers and employers. Some
liked it, some didn't. But the recognition in California that the
people who don't buy insurance are shifting those costs to the
people who do buy insurance has been a principle that's been
understood in California for a very long time.
Bartolone: And you would say that's why California is
a leader in implementing health reforms?
Secretary Dooley: Yes. Making the playing field fair is at the
heart. Everybody uses healthcare, but not everyone pays for it. And
so getting to a system where the people who need the care pay for
the care, or if they can't they are on a government program, that
this sliding scale of your ability to pay will even out the market
and reduce the really significant cost-shifting that occurs from
the people without insurance to the employers and the individuals
that are paying for insurance and doing their part to be
Bartolone: If the Supreme Court were to strike down
the entirety of the Affordable Care Act, how would that affect how
California is rolling out with health reform?
Secretary Dooley: California is building a health benefit
exchange with funds provided under the Affordable Care Act. And
those funds are available through 2014. My agenda is to use as much
of that as possible, as quickly as possible, to be sure that
California has a marketplace even if we don't have the full promise
of the ACA - the Affordable Care Act. I believe that the
constitutional questions will be answered in favor of the law. I
believe that the law will be upheld. But I'm also working very hard
to assure that we have as much benefit for California as possible,
even if we don't have the full promise of the Act.
Bartolone: So for the common person who may be
interested in getting insurance come 2014, can they expect to see a
health-benefit exchange in 2014 regardless of what happens with the
Secretary Dooley: We are going to do everything we can to have
an operational health benefit exchange in January 1, 2014. The
extent to which we will be able to do that will be decided in part
by the Supreme Court this summer and in part by the election in
November. Those are parts of our process that we will accommodate.
We are making an investment in the future of California, and we
hope and believe that that marketplace will be available.
Bartolone: Tell me a little bit more about using the
federal funds to implement the exchange. Would the exchange also
need money from the federal government to operate the exchange once
it's already set up?
Secretary Dooley: Under the terms of the Affordable Care Act
and the California legislation that implemented that, both require
that the exchange be self-supporting in 2015 so that as a
marketplace for people to buy insurance, the insurance providers
that are offering their product will pay a fee for this
marketplace. So the federal funds are to start up the exchange, but
it must be self-supporting, whether or not the Affordable Care Act
Bartolone: Would the exchange work without the
Secretary Dooley: With the mandate, the operation of the
exchange will move more quickly at the outset. But there is a
strong appetite in the marketplace for people to buy insurance. And
if the exchange can offer insurance at an affordable price, in
transparent… people know what they're getting and they know which
doctors and hospitals they can go to, there will be a marketplace
for that even without the mandate and the subsidies. It will be
very hard to do because many well-intentioned people would like to
buy insurance now but they can't afford it. So it's much more about
Bartolone: Would California consider its own state
individual mandate? That people get insurance and participate in
Secretary Dooley: California has considered a state mandate in
the past…California was one of the first to have mandatory auto
insurance, and I think California could well be one of the first to
have mandatory health insurance.
Bartolone: Is that something that you would
Secretary Dooley: I think we have to look at the broader
context of making the system fair, and having everybody pay a fair
share. And so if you're going to get healthcare at an emergency
room or in a catastrophic situation, to shift that cost to the
people who are being responsible and buying their health insurance
is not something that can be sustained over time. So I think we
would have to look very carefully at the need in California to
reduce the burden of the cost shift that occurs without a
requirement that everyone be insured.
Bartolone: There are already things that California
has implemented under the Affordable Care Act that require federal
money, right? There's the Pre-Existing Condition Insurance Plan,
there's the Medicaid expansion through the Low-Income Health
Insurance Program [Low-Income Health Program]. What would happen to
those programs if the Affordable Care Act were overturned in the
courts and that money would be unavailable?
Secretary Dooley: Some of what California has done will
survive any court decision. California has acted to stop insurance
companies from rescinding or cancelling insurance. The Act itself
requires plans to offer coverage to dependent children up to age
26. We have a regulatory system in place in California to review
rates and control costs and rate increases in insurance. All of
that is in California. The expansion of Medi-Cal to low-income
populations in the counties was done through a federal waiver
process that is existent in Medi-Cal law that is related to the
Affordable Care Act but it isn't dependent on the Affordable Care
Act. If those populations don't move into regular Medi-Cal, we will
still have a contract with the federal government to provide that
Bartolone: Is there any aspect of health reform in
California that you feel that California couldn't move forward on
without the federal government's support?
Secretary Dooley: I think the most significant challenge that
California faces in the short run is our budget deficit. We have
had to make very serious reductions because of the recession. There
are more people without jobs and therefore without health insurance
now than even five years ago when California was looking at
healthcare reform. So in the short run, it will be very hard for us
to move forward to expand health coverage without the additional
federal funds that we would have under the Affordable Care Act. We
simply have to balance our budget and get California on a strong
footing to do any of this work.
Bartolone: So it sounds like the Supreme Court
decision will help determine "how" California moves forward with
health reform, not "if"?
Secretary Dooley: I think that's a very fair characterization.
The Supreme Court will define how California will move forward and
how quickly California will move forward, but I believe our history
and our current understanding of the real mess that the healthcare
system - loosely called a system - is in need of reform. And if we
have to do it without our federal partners we will find a way to do
it. But it will be a much better transition to better health if we
can do it with the benefits of the Affordable Care Act.