Ruling could greatly improve health in America, say UCSF policy specialists.

Claire Brindis, UCSF

Experts at UC San Francisco say the historic U.S. Supreme Court ruling on President Obama’s health care law has the potential to significantly improve the health of the nation and the education of future health professionals.

“To me, this is symbolic of our nation’s commitment to become a more moral and just society,” said Claire Brindis, Dr.P.H., director of the Philip R. Lee Institute for Health Policy Studies. “It’s monumental in its potential to make significant inroads to improve the health and well-being of every American.”

The 5-to-4 ruling, with Chief Justice John Roberts writing the majority opinion, upholds the Patient Protection and Affordable Care Act, considered President Obama’s key domestic legislation. Even its most contentious piece, the individual mandate, was upheld.

For Brindis, who says she’s been “on pins and needles” awaiting the high court’s ruling, the decision is a vindication of a century-long struggle to ensure that health care is affordable and accessible to all Americans.

“The lack of health coverage for nearly 50 million Americans has always been a black mark on this country and this historic legislation provides us with a platform to really make significant inroads in reversing this immoral stand.”

Brindis, who will be making media appearances for her expert reaction throughout the day, said this is a great day in America.

“This is an historic moment that we will remember for decades because the health care law has so many tentacles and touches every American,” she said.

As news of the ruling spreads across UCSF, faculty are reflecting on how it will affect their work providing health care and teaching the next generation of health professionals.

Rethinking health sciences education and training

“I think it’s a great step forward for health care in this country,” Molly Cooke, M.D., director of education for Global Health Sciences. “As an educator, it’s really difficult to do high quality clinical education in a dysfunctional care setting. Anything we can do to make care-delivery better, more accessible and more equitable rebounds to the benefit of education.”

“Students and residents — good and idealistic people — have a hard time when they see that some patients can get services within the system that they really need while others can’t. That doesn’t make sense to our learners.”

Catherine Lucey, M.D., vice dean of education for the UCSF School of Medicine, says the ruling is good news for many young UCSF students who are paying hefty bills. They will be better and more affordably insured as a result of the law. And it will mean rethinking health sciences education and training.

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The road to health care reform has been a long one in America.

The movement toward making health care accessible and affordable began more than 100 years ago.

Here is a look at highlights over the past three years that culminates today with the ruling of the U.S. Supreme Court to uphold the Patient Protection and Affordable Care Act, known as Obamacare:

• Feb. 24, 2009: President Barack Obama promises health care reform in his first address to a Joint Session of Congress
• March 5, 2009: The White House convenes a summit on reforming health care
• Sept. 9, 2009: President Obama lays out his vision for health care reform during an address to a Joint Session of Congress
• Dec. 24, 2009: The U.S. Senate passes the Patient Protection and Affordable Care Act by a vote of 60–39 with all Democrats and two Independents voting for, and all Republicans voting against it
• Jan. 27, 2010: In first State of the Union address, President Obama focuses on health care reform
• Feb. 25, 2010: The White House hosts a bipartisan summit on reform that leads to a productive discussion
• March 21, 2010: The U.S. House of Representatives passes the bill by a vote of 219–212, with 34 Democrats and all 178 Republicans voting against it
• March 23, 2010: President Obama signs the Patient Protection and Affordable Care Act, an historic overhaul of the American health care system
• June 10, 2010: Seniors see the first benefit of the Affordable Care Act as $250 rebate checks are sent
• July 1, 2010: Uninsured Americans with pre-existing conditions have access to health coverage
• Sept. 23, 2010: Patients can now take advantage of their first new set of protections under the new health care law
• Jan. 1, 2011: Medicare starts offering free preventive care for seniors and lower prescription drug costs for seniors. The new Health Care Innovation Center was established to research, develop, test, and expand innovative new ways to improve the quality and reduce the cost of care
• Sept. 1, 2011: Health insurers seeking to increase their rates by 10 percent or more must submit their request to state or federal reviewers to determine whether they are reasonable or not
• Dec. 14, 2011: The White House reports that since the new health care law came into effect in September 2010, 2.5 million more Americans under the age of 26 have received coverage by registering under their parents’ health insurance plans
• March 26-27, 2012: The U.S. Supreme Court hears arguments in the Patient Protection and Affordable Care Act cases
• June 28, 2012: The U.S. Supreme Court announces 5-to-4 ruling upholding the landmark health care law

Source: White House, Health Reform

UC experts convene in San Francisco on Friday, June 29, to discuss ruling’s aftermath.

UC San Francisco and UC Hastings experts will convene on Friday to discuss the impact of the U.S. Supreme Court ruling on the Patient Protection and Affordable Care Act, President Obama’s landmark domestic policy.

The event will be held on Friday, June 29, from 11 a.m. to 1 p.m. in Toland Hall on the UCSF Parnassus campus. It will be taped for broadcast and posted online on UCTV.

The Supreme Court’s decision is anticipated to have wide-reaching consequences or health care in America. The day after the ruling is announced on Thursday, UCSF will host a forum, “What Now? Health Reform in the Aftermath of the Supreme Court Decision,” with experts who will discuss the legal significance of the decision and the practical implications for health care.

The forum is sponsored by UCSF’s Philip R. Lee Institute for Health Policy Studies, one of the nation’s premier centers for health policy and health services research, in conjunction with UC Hastings and the UCSF-UC Hastings Consortium on Law, Science, and Health Policy.

The panel of experts are:

• Josh Adler, M.D., chief medical officer, UCSF Medical Center and UCSF Benioff Children’s Hospital;
• Andrew Bindman, M.D., professor of medicine, health policy, epidemiology and biostatistics, UCSF;
• David Faigman, J.D., director UCSF/UC Hastings Consortium, John F. Digardi Distinguished Professor of Law, UC Hastings; and
• Jaime King, J.D., Ph.D., associate director, UCSF/UC Hastings Consortium, professor, UC Hastings.

UCSF receives funding as part of national health care reform.

UCSF nurse Mimi Nolasco-Gaffud using new electronic health records system

UC San Francisco Medical Center‘s recent adoption of a new electronic health record system, called APeX, not only advances patient safety, it enables UCSF to comply with a federal mandate requiring all health providers and hospitals to shift to electronic medical records as part of national health care reform.

The Obama administration provided grants as incentives to implement electronic records as part of a movement toward creating a national private and secure electronic health information system. States have been asked to help build the infrastructure for a health information exchange, which enables health records to follow patients within and across communities, helping health care providers and patients to make the best decisions about care, according to the Office of the National Coordinator for Health Information Technology.

On June 19, the U.S. Department of Health and Human Services (HHS) announced that more than $5.7 billion in incentive payments have been paid to hospitals and health care providers for implementing electronic health records systems that meet federal standards.

UCSF has received its first payment from the Obama administration of $2.6 million and anticipates receiving an additional $2.9 million in September for implementing electronic medical records system.

“We should receive future incentive payments of $29 million between 2013-2017, as we demonstrate further adoption of the electronic health record,” said Pamela Hudson, executive director of clinical systems at the medical center and program director for APeX.

The total capital budget for implementing UCSF’s APeX is $165 million and the system cuts across approximately 168 clinics, two hospitals and the UCSF Orthopaedic Institute at Mission Bay.

The electronic medical records system is critically important to the academic medical center’s mission of teaching and training future health care professionals and an important a breakthrough in the way in which care is delivered, Hudson said.

Historic ruling on constitutionality of law to come on Thursday, June 28.

UC San Francisco health care professionals and policy experts are awaiting the highly anticipated U.S. Supreme Court ruling on President Obama’s health care law, which will come Thursday.

Whatever the high court’s ruling, Maa says, health care professionals should continue to work to improve the nation’s ailing health care system. Part of the problem with the Patient Protection and Affordable Care Act, is that not enough front-line clinicians — doctors, nurses, pharmacists and others — helped to craft it, Maa says.

Health care professionals “can play a very important role by having the courage to travel to Washington, D.C., to prepare white papers, and to submit testimony and to become involved in the discussion,” he said during an interview on Friday.

Passion for health policy

Maa, an assistant professor of surgery and director of UCSF’s Surgical Hospitalist Program, describes health policy as his “passion” and has worked to bring a clinician’s perspective to discussions about health care reform, at both the state and national level. In 2004, he was selected as a Health Care Policy Research Fellow by UCSF’s Philip R. Lee Institute for Health Policy Studies, one of the nation’s premier centers for health policy and health services research.

John Maa, UCSF

His interest in reforming health began 20 years ago as a student at Harvard Medical School. Maa spent a six-month sabbatical in Washington, D.C., in the months after passage of the 2010 health reform law. “I witnessed the pitch battle between the Democrat and Republican parties over the law. It was very partisan, it was vitriolic and it was very disappointing to see the acrimony on Capitol Hill.”

After a lengthy national dialogue about “Obamacare” that was mired with misleading information about death panels, health care rationing and the like, the Supreme Court heard three days of hearings in March. The central challenge to the law is whether the government can mandate that individuals buy health insurance or pay a fine.

If the justices rule that the health care law is unconstitutional, a recent poll found that 77 percent of Americans want Congress and the president to work on new legislation to overhaul health care.

But Maa expects no real progress on health care reform in the months leading up to the November presidential election and, depending on the outcome, thinks it could be stalled for decades.

Maa says the nation should have an intelligent and thoughtful discussion to answer the fundamental question about whether basic health care should be a constitutionally protected right.

“I believe that our nation should work collectively towards crafting a 28^th amendment to the United States Constitution and determine whether access to basic and emergency health care is a constitutionally guaranteed right,” he says.

From there, Maa says, the nation can consider the equally important individual responsibilities that are inherent with that right, such as smoking cessation and not drinking alcohol too frequently.

“I think it will take many years to reframe the discussion, perhaps along the lines of what [UCSF] Chancellor [Emeritus] Phil Lee once said, ‘that health care is a public good.’ And I think we will have to separate self interests from societal best interests as we move forward in this discussion.”

Upcoming event: Supreme Court ruling: What now?

Up to 3.7M will enroll in new or more affordable insurance through California Health Benefit Exchange, Medi-Cal expansion.

Gerald Kominski, UCLA

>>UC Berkeley release

Nine out of 10 Californians under the age of 65 will be enrolled in health insurance programs as a result of the Patient Protection and Affordable Care Act (ACA), according to a joint study by the UC Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research.

Between 1.8 million and 2.7 million previously uninsured Californians will gain coverage by 2019, when the law’s effect is fully realized, the researchers said.

The report, which uses a sophisticated computer simulation model to project the ACA’s impact on insurance coverage, comes as the U.S. Supreme Court prepares to issue its ruling this month on the constitutionality of the law.

Under the ACA, more than a million Californians with the lowest incomes are set to become eligible as of 2014 for affordable health coverage through an expansion of Medi-Cal (the state’s Medicaid program), while several million more residents from low- and middle-income families will be eligible for subsidies through the new California Health Benefit Exchange, making their coverage more affordable.

Specifically, the researchers project that an expansion of Medi-Cal will result in between 1.2 and 1.6 million new enrollees, while between 1.8 million and 2.1 million state residents will enroll in subsidized coverage through the exchange.

Ken Jacobs, UC Berkeley

“If the Affordable Care Act is upheld by the Supreme Court and fully implemented, it will significantly expand access to affordable health coverage,” said Ken Jacobs, chair of the UC Berkeley Center for Labor Research and Education and the study’s lead author. “Based on our simulation, millions of Californians stand to gain, either through insurance they wouldn’t otherwise have or from more affordable premiums and increased benefit standards.”

The UC Berkeley and UCLA researchers project that by the time the ACA is fully implemented in 2019, between 89 and 92 percent of Californians under the age of 65 will have health coverage, versus 84 percent without the law. As many as 3.7 million uninsured or underinsured Californians will gain access to insurance or switch to better, more affordable policies as a result of the expansion of Medi-Cal and the exchange.

The study underlines the importance of outreach in maximizing the ACA’s benefits. Specifically, the authors note that greater coverage would be achieved by factors such as simplified enrollment and retention systems, aggressive outreach, and language accessibility.

“Outreach is the key to coverage,” said Gerald Kominski, director of the UCLA Center for Health Policy Research and a co-author on the study. “Helping California’s diverse population understand the different types of coverage available and the enrollment process should significantly boost enrollment rates and broaden the risk pool, which is essential to keeping down costs.”

All of California’s counties will see increased coverage under the law, according to the study. Los Angeles County will account for 30 percent of new Medi-Cal enrollees and 31 percent of subsidized enrollees in the California Health Benefit Exchange. While Angelenos make up 27 percent of the state’s population, they accounted for 32 percent of the uninsured in 2009. Likewise, the San Joaquin Valley has 10 percent of the state’s population but will account for 14 percent of new Medi-Cal enrollees.

Even with the increase in coverage, California will still have between 3 million and 4 million people without insurance by the time the ACA is fully implemented in 2019, the UC Berkeley and UCLA researchers project. Of these, slightly more than 1 million will be ineligible for coverage due to their immigration status.

The projections were made with the California Simulation of Insurance Markets (CalSIM) model, a micro-simulation developed by researchers at the two centers with support from The California Endowment. CalSIM uses a range of official data sources, including the California Health Interview Survey, to estimate the impact of various elements of the ACA on employer decisions to offer insurance coverage and individual decisions to obtain coverage in California. The range of predictions results from two scenarios: one based on typical responses to expanded coverage, and another based on the more robust enrollment and retention strategy.

Expanded eligibility for Medi-Cal under the ACA will enable families with incomes up to 138 percent of the federal poverty level ($14,856 for an individual, $31,809 for a family of four in 2012) to enroll; make childless adults eligible based on income alone for the first time; eliminate asset tests; and simplify enrollment and retention rules, among other changes.

The establishment of the California Health Benefit Exchange as part of the new law will assist consumers in making informed choices among private health plans while providing subsidies for individuals with incomes up to 400 percent of the federal poverty level ($44,680 for an individual and $92,200 for a family of four in 2012) who don’t qualify for Medi-Cal and have no family members with an offer of affordable job-based coverage.

The study was funded by the California Health Benefit Exchange.

Read the policy brief: “Nine out of Ten Non-Elderly Californians Will Be Insured When the Affordable Care Act Is Fully Implemented.”

The UC Berkeley Center for Labor Research and Education, a public service and outreach program of the UC Berkeley Institute for Research on Labor and Employment, was founded in 1964 to conduct research and educate on issues related to labor and employment, such as job quality and workforce development.

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health-related information on Californians.

The California Health Benefit Exchange’s mission is to increase the number of insured Californians, improve health care quality, lower costs, and reduce health disparities through an innovative, competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value.

How UC Health is increasing quality and decreasing costs.

University of California Health is transforming health care delivery so patients receive better care at lower costs. By harnessing the strengths of its system, UC Health is finding ways to make health care safer, smarter and a more positive experience for patients and their families. A new brochure details how UC Health is increasing quality and decreasing costs, such as reducing hospital-acquired infections and bedsores.

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UCSF training program marks its 40th anniversary.

Kevin Grumbach, UC San Francisco

As the United States marks the second anniversary of the passage of national health care reform, the UCSF Family and Community Medicine Residency Training Program at San Francisco General Hospital and Trauma Center (SFGH) will celebrate another milestone, its 40^th anniversary.

And its theme could not be more apropos: Preparing Family Physician Leaders in Health System Change.

As the U.S. Supreme Court prepares to consider constitutional questions in the Patient Protection and Affordable Care Act on Monday, those on the frontlines of primary care are exploring the challenges posed by a greater demand on family medicine as the previously uninsured seek primary care physicians to gain access to the health care system.

“It’s an exciting time and a wonderful opportunity to help shape the direction of the whole health system,” said Kevin Grumbach, M.D., chair of the UCSF Department of Family and Community Medicine at SFGH. “We’re developing new models of team-based care, where family doctors are working with nurses and community health workers, pharmacists and social workers to provide a comprehensive team model of care.”

Related: Family medicine residency at SFGH: Past, present and future (Click image to view story)

The UCSF SFGH program has an emphasis on training residents and students to work in partnership with patients. “The UCSF SFGH Family and Community Medicine Residency has a distinctive mission to prepare family physicians to care for families and underserved populations,” said Grumbach. “It marries the best of the academic attributes of UCSF with a mission-driven ethos of commitment to the public and health disparities that are part of SFGH and the San Francisco Department of Public Health.”

In addition to serving as a reunion to celebrate the accomplishments of the program’s graduates, a symposium on Saturday will provide an opportunity for alumni to weigh in on how to train the next generation of family physician leaders in delivering patient-centered, effective and affordable care.

The symposium also will draw leaders in primary care from across the country to learn about the future of primary care, training, community engagement and education. Keynote speaker Mary Wakefield, Ph.D., R.N., the administrator in the Health Resources and Service Administration (HRSA) in the U.S. Department of Health and Human Services, will explain how HRSA works to fill in the health care gaps for people who are uninsured, isolated or medically vulnerable.

Educating future primary care physicians

With plummeting numbers of U.S. medical school graduates going into primary care fields, it’s more important than ever to support the specialty in a robust way.

“We need to rebuild what had been an inadequately supported primary care structure in the U.S.,” said Grumbach. “The last five years there has been a big wave of renewal of primary care and it is what feels like a Renaissance in family medicine. But before that there was a lack of investment in innovative models of modernizing care in primary care and things were languishing.”

People are very mindful of the lessons of Massachusetts when then they passed the Universal Coverage Act of 2006, according to Grumbach. “All these people were insured, but couldn’t find a primary care doctor or nurse practitioner to gain entry into the system. Now we have a potential influx of patients seeking care and we’re seeing this kind of medical homelessness where people are insured but can’t find a medical home to coordinate their care needs.”

Having a primary care doctor not only streamlines access for patients, but helps deliver a better value to the entire health care system. Understanding patients by taking a comprehensive medical history and performing thorough exams results in family practitioners knowing a patient’s underlying issues and understanding their physical and mental health. That, in turn, reduces extraneous testing and emergency services. “It’s about improving a patient’s wellbeing while reducing unnecessary costs,” Grumbach said.

Grumbach has seen the evolution of family medicine since his early days at UCSF when he was a resident in 1985. He still has a patient who was one of the first babies he delivered during his residency. “I’ve stayed all these years because I love the blend of the academic culture of UCSF with feeling so powerfully moved by attachment to people at SFGH,” he said.  “It’s one of the main things that keeps me here.”

Study authors call for national health care policies designed to discourage inappropriate care, regardless of region.

Salomeh Keyhani

There is no solid evidence to support the widely held belief that regions of the United States that spend more on health care and have higher rates of health care use deliver more unnecessary care to patients, or that low-cost areas deliver higher quality and more efficient care, according to a study led by Salomeh Keyhani, M.D., a physician at the San Francisco VA Medical Center and an assistant professor of medicine at UCSF.

The study authors called for national health care policies designed to discourage inappropriate care, regardless of region.

“Geographic variations in health care have captured the attention of researchers for the past 30 years, especially during the recent health care reform debate,” said Keyhani. “The assumption is that areas that spend more are delivering more inappropriate care in the form of unnecessary tests and procedures.” In turn, she said, “this has led policy makers to hold up low-cost areas as models of high-quality health care, and to propose policies that cap spending.”

That assumption is unwarranted, according to Keyhani and her co-authors. “The literature is so limited that you cannot either support or refute such an assertion. There is just not enough data,” said Keyhani.

In their study, the scientists reviewed 114,830 peer-reviewed articles, published between Jan. 1, 1978, and Jan. 1, 2009. They found only five that analyzed detailed clinical data in relation to geographic region, and concluded that the results of those papers “did not lend support” to the idea that higher cost regions deliver more inappropriate care. Their literature review was published in the March issue of the journal Medical Care.

“Do we have any evidence to say that the differences in cost of care in different localities are actually related to inappropriate care? No,” asserted Keyhani.

She concluded that “instead of focusing on geographic variations, more of our efforts should be directed at designing policies that will reduce inappropriate care in general, regardless of region.”

However, said Keyhani, “you need good scientific evidence to design such policies, and right now, that evidence is lacking.” In a related literature review based on the same 30-year data base, published on January 23 in the Archives of Internal Medicine, Keyhani and her colleagues found only 172 peer-reviewed articles that addressed the general topic of health care overuse.

One reason for the dearth of such literature, Keyhani said, is an overall lack of patient care guidelines by which researchers might judge overuse of tests and procedures: “There are not enough guidelines, and most of those that do exist don’t address inappropriate care. Guidelines state when you should give a diagnostic test, for example, but they don’t say when you shouldn’t. And if you have no standards, how can you say when care is inappropriate?”

Creating guidelines is “expensive and very labor intensive,” acknowledged Keyhani. “And it’s not something one health system can do by itself. There needs to be a national investment.”

Nonetheless, she said, the long-term benefits of such guidelines for the U.S. health care system would be considerable. “Overuse isn’t just a matter of unnecessary expense, but of patient safety,” she noted. “People assume that more care is better. In fact, we know that unwarranted procedures can add to health risks and lead to poor outcomes.”

Co-authors of the Medical Care paper are Raphael Falk, M.D., M.P.H., of UCSF; Tara Bishop, M.D., M.P.H., of Weill Cornell Medical College; and Elizabeth A. Howell, M.D., M.P.P., and Deborah Korenstein, M.D., of Mount Sinai School of Medicine. The study was supported by funds from the Commonwealth Fund and the Department of Veterans Affairs.

Co-authors of the Archives paper are Deborah Korenstein, M.D.; Raphael Falk, M.D.; Elizabeth A. Howell, M.D.; and Tara Bishop, M.D., M.P.H. The study was supported by funds from the Commonwealth Fund and the Department of Veterans Affairs.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

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

Health care reform changes likely to magnify problem.

Elizabeth Ozer, UC San Francisco

With no specific clinical preventive care guidelines targeting young adults, health care providers are missing key opportunities to improve the health of this population through preventive screening and intervention.

Yet a new study from the University of California, San Francisco, shows that when the ages of 18-26 years are carved out of existing professional guidelines across specialty groups, there are a broad number of evidence-based recommendations that can inform the care of young adults.

The transition from adolescence to young adulthood can be a challenge often associated with greater engagement in health damaging behaviors, with the highest rates of mental health problems, substance abuse and sexually transmitted infections.

Because these health problems largely are preventable, primary care visits can present a key opportunity to improve the health of young adults, with evidence supporting the efficacy of preventive services.  But this group also is the least likely to be insured, seek outpatient care or have a primary care physician, according to researchers.

“This is really a key time to intervene,” said lead study author Elizabeth Ozer, Ph.D., an associate professor of pediatrics in the UCSF Division of Adolescent Medicine. “Yet even when young adults use primary care, they infrequently receive preventive health care”.

The study, “Young Adult Preventive Health Care Guidelines: There But Can’t be Found,” is available in the March 2012 issue of Archives of Pediatrics and Adolescent Medicine. The research team conducted a careful analysis of existing guidelines for adolescents and adults and identified preventive care guidelines relevant to young adults.

According to the authors, the expansion of health insurance to young adults up to age 26 years through the 2010 Affordable Care Act (ACA) creates an urgent need for specific guidelines for young adult preventive care. While the ACA provides an “unprecedented opportunity,” to improve the health of young adults, it also will create an influx of this population seeking services, thus increasing the demands on the health care system, and the need to provide preventive services, the team states.

Recent data from the National Health Interview Survey (NHIS) found that in the first quarter of 2011, approximately 2.5 million more young adults had health insurance compared to the previous year.

“The good news is that there is no need to reinvent the wheel when developing comprehensive preventive services for young adults.  Existing evidence based guidelines can inform this process,” said Ozer.  “This review is an important first step in moving forward to create guidelines for young adult health care that outline a core set of preventive services that will better enable clinicians and young adults to talk full advantage of the primary care opportunity.”

Co-authors are John T. Urquhart, B.A.; Claire D. Brindis, Dr.P.H.; M. Jane Park, M.P.H.; and Charles E. Irwin Jr, M.D., all with the UCSF Division of Adolescent and Young Adult Medicine, Department of Pediatrics. Ozer also is affiliated with the UCSF Office of Diversity and Outreach. Brindis is affiliated with the UCSF Philip R. Lee Institute for Health Policy Studies.

The study was supported by grants from the U.S. Department of Health and Human Services.

Limited English proficiency could limit those who enroll for coverage, UC Berkeley-UCLA study finds.

Language barriers could deter more than 100,000 Californians from enrolling in the Health Benefit Exchange, according to a study released today by the California Pan-Ethnic Health Network, the UCLA Center for Health Policy Research, and the UC Berkeley Center for Labor Research and Education.

The study presents findings from a UC Berkeley-UCLA micro-simulation that estimates the likely enrollment in health care reform programs in California. Specifically, the study projects that more than 1 million limited-English proficient (LEP) adults will be eligible to receive tax credits to purchase affordable coverage in the state’s Health Benefit Exchange, which expands access to affordable health coverage as part of the Patient Protection and Affordable Care Act.

However, only 42 percent of eligible LEP adults are expected to enroll in the program.

“The evidence suggests that Californians who do not speak English very well are at a disadvantage in terms of accessing health care reform programs,” said Daphna Gans, a research scientist at the UCLA Center for Health Policy Research and the lead author of the study.

The UC model shows that if language is not a barrier, participation by LEP adults could increase to 53 percent, a difference of approximately 110,000 individuals.

“These are difficult times for California families, and ensuring every Californian has access to quality, affordable health care is vital for our economic recovery,” said California Assembly Speaker John A. Pérez, who authored legislation (AB 1602) in 2010 establishing the exchange. “The Health Benefit Exchange will help lower the cost of health insurance for every Californian, but it’s vital for every eligible Californian to enroll to ensure we bring health care costs down as much as possible for California’s working families.”

In California, more than 15 million residents speak a language other than English at home and nearly half (7 million) of them have limited proficiency in English. The study shows the importance of adopting a diverse strategy for outreach and education.

“The exchange is a key opportunity to make Californians healthier,” said Ellen Wu, executive director of the California Pan-Ethnic Health Network. “We have to do this right. Our success in implementing this new program will be measured not just by the number of people enrolled but by the state’s ability to reach those who are most often left behind. We have to target resources through multicultural and multilingual outreach to ensure that communities of color who are eligible, particularly people who speak English less than very well, enroll in coverage.”

The study was conducted based on analyses using the California Simulation of Insurance Markets model, a micro-simulation developed by UCLA and UC Berkeley researchers, which uses a range of official data sources (including the California Health Interview Survey) to estimate the impact of various elements of the Patient Protection and Affordable Care Act on employer decisions to offer insurance coverage and on individual decisions to obtain coverage in California.

The development of the model was supported through funding by The California Endowment, the California Health Benefit Exchange and the California Pan-Ethnic Health Network.

Read the study, “Achieving Equity by Building a Bridge From Eligible to Insured.”

The California Pan-Ethnic Network (CPEHN), celebrating 20 years as a champion for health equity, works to eliminate health disparities by advocating for public policies and sufficient resources to address the health needs of communities of color.

The UC Berkeley Center for Labor Research and Education is a public service and outreach program of the UC Berkeley Institute for Research on Labor and Employment that conducts research and education on issues related to labor and employment.

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California.

Analysis: Act will expand insurance coverage but also may increase redundant spending for health care.

Kenneth Kizer, UC Davis

While the Affordable Care Act will expand health insurance coverage for low-income persons through Medicaid and state health insurance exchanges, including much-needed care for 1.8 million uninsured veterans in the U.S., the new insurance coverage option also may have a number of unintended negative effects on health care for veterans, said Kenneth W. Kizer, director of the Institute for Population Health Improvement at UC Davis Health System.

His viewpoint, including recommendations for evaluating services in preparation for 2014, appears in today’s (Feb. 22) issue of the Journal of the American Medical Association.

“The Affordable Care Act will not affect health care for the majority of veterans differently than it will affect nonveterans, and it will not change eligibility for VA health care, covered benefits, co-payment for services, or how the VA health care system is administered or operated,” Kizer said. “But it will affect health care for many veterans through its effects on access, fragmentation and quality of care, utilization of services, the health care workforce and cost. We need to define and quantify the potential impacts that additional health-insurance choices from the Affordable Care Act will have on the delivery of health care services for veterans in 2014.”

Kizer is a member of the Institute of Medicine of the National Academy of Sciences and a fellow of the National Academy of Public Administration. A former undersecretary for health in the U.S. Department of Veterans Affairs and a veteran of the U.S. Navy, he engineered the internationally acclaimed transformation of the VA health care system, including the most rapid and largest ever deployment of a systemwide electronic health record and a comprehensive quality improvement and performance management system. Kizer also founded the National Quality Forum (NQF) and led efforts to establish national standards for reporting of health care quality, which are widely used by the federal government and throughout American health care.

The health insurance plans for the nation’s 22 million military veterans fall into three categories. The majority, 56 percent, have private health insurance or are covered by a non-VA health plan. Thirty-seven percent receive health care services through the Department of Veterans Affairs (VA) health care system, which bases eligibility on having a service-connected disability, low-income level and net worth or other specific circumstances. More than 80 percent of VA enrollees older than 65 years also are covered by Medicare, and about 25 percent are beneficiaries of two or more non-VA-federal health plans, such as Medicare, Medicaid, TRICARE or Indian Health Service. Seven percent of veterans have no health insurance.

The Affordable Care Act will expand health care choices and potentially increase convenience and timeliness of care for veterans, but Kizer believes that having more health insurance options can also cause fragmentation, diminishing continuity and coordination of care, resulting in more emergency department use, hospitalizations, diagnostic interventions and adverse events. He believes it also may shift care from VA facilities with experienced staff to private practice physicians who may be less prepared to treat conditions prevalent among veterans, and potentially result in decreased use of VA facilities, endangering volume-sensitive services, such as intensive care or complex surgery, which can affect local access to care and some health care worker training programs. In addition, with more than 30 million newly insured persons nationwide seeking services, some VA and non-VA facilities in rural and medically underserved areas already struggling with health care worker and specialist shortages may be overwhelmed with increased demands for care.

According to Kizer, increasing health insurance options for VA health care enrollees also will increase redundant spending for veterans’ health care.

“In 2009, the VA spent $3.2 billion to care for nearly 775,000 veterans who were also enrolled in Medicare Advantage plans,” Kizer said. “These expenditures were overwhelmingly for routine inpatient and outpatient care covered by the Medicare Advantage plan, but federal law precludes the VA from being reimbursed for services provided to Medicare Advantage beneficiaries. As a result, the federal government paid twice for care of the same person in many instances.”

To streamline services and costs in preparation for the post Affordable Care Act health care environment, Kizer developed the three recommendations:

1. comprehensively evaluate and prioritize solutions for coordinating VA and non-VA health care resources for veterans,
2. assess current and projected VA health care workforce needs and service utilization vulnerabilities, including expansion of telehealth and home-care services, and
3. develop a shared vision for veteran’s health care considering its role as a safety net provider, the declining numbers of World War II and Vietnam War veterans, increasing number of female veterans, and variables affecting federal funding.

UC Davis Health System is improving lives and transforming health care by providing excellent patient care, conducting groundbreaking research, fostering innovative, interprofessional education, and creating dynamic, productive partnerships with the community. The academic health system includes one of the country’s best medical schools, a 631-bed acute-care teaching hospital, an 800-member physician’s practice group and the new Betty Irene Moore School of Nursing. It is home to a National Cancer Institute-designated cancer center, an international neurodevelopmental institute, a stem cell institute and a comprehensive children’s hospital. Other nationally prominent centers focus on advancing telemedicine, improving vascular care, eliminating health disparities and translating research findings into new treatments for patients. Together, they make UC Davis a hub of innovation that is transforming health for all. For more information, visit healthsystem.ucdavis.edu.