Covered California to lower patient costs

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 KFF Health News. "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.

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 does a long way to help midle 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 KFF Health News, 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 Assemblymember 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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