For more than a decade, Kern County has prepared for January 1, 2014, the landmark date when the country's health care system will undergo major changes decreed by the Affordable Care Act.
When the day comes, more than 9,800 people here will automatically moved into Medi-Cal, the state's version of the federal Medicaid insurance program for the poor, thanks to a program that connected thousands of Kern denizens with health care coverage in the run-up to the full launch of "Obamacare."
The hope is that those folks will be well prepared to navigate the health care system efficiently and understand how to get the care they need before an illness or chronic condition gets so bad that they end up in the hospital.
Partners in Kern County's version of the state's Low Income Health Program (LIHP) and its predecessor have enrolled more than 18,000 people in health care coverage since September 2007. Keeping those people enrolled in that coverage, known as the Kern Medical Center Health Plan or KMC Health Plan, proved to be one of their biggest challenges.
But the plan also retained thousands of enrollees and slashed their annual health care costs by nearly 43 percent.
Local and state leaders of the program said all the hard work plugging people in with health care coverage before the big day puts Kern County -- and California -- in a better place to cope with Affordable Care Act.
"We aren't starting from ground zero. We actually have a lot of people who've already started to receive care moving into the system," said Jane Ogle, deputy director for the California Department of Health Care Services.
Statewide, more than 667,000 Californians were enrolled in their counties' Low Income Health Programs as of September and nearly all of those people will qualify for Medi-Cal next year, according to the department.
As the Low Income Health Program winds down -- it ends this month -- local leaders are preparing for the transition and reflecting on the program's lessons and successes.
BUILDING ON A LEGACY
The KMC Health Plan offered coverage to Kern's low-income residents for years before the Low Income Health Program began.
The plan was christened in 2007 under California's Health Care Coverage Initiative. The program aimed to get some kind of health care coverage for low-income Californians who didn't qualify for other insurance efforts.
Kern was one of ten "legacy" counties chosen to receive money to craft such a program. Under a three-year agreement, Kern received $10 million a year and offered the KMC Health Plan to childless adults who earned up to 200 percent of the federal poverty level.
The county remained committed to the task when the state offered all of California's counties the chance to start similar programs through the Low Income Health Program three years later.
Under the so-called "Bridge to Reform" program, counties drew down federal matching money to expand their services and offer residents health benefits that were similar to a Medi-Cal insurance package, anticipating that those people would become eligible for Medi-Cal on Jan. 1, 2014.
"For (Kern County) it wasn't about if we were going to move forward with the LIHP, it was how (many) dollars can we truly put up," for federal matching funds, said Jacey Cooper, who has been with the plan since before the Low Income Health Program began.
Clinica Sierra Vista CEO Steve Schilling said Kern leaders were smart to pursue the program, in contrast to Fresno County, which did not. Clinica is one of the nation's largest federal qualified health centers and has sites in both Kern and Fresno counties. Kern County gained experience getting these patients into care, while Schilling said Fresno's ability to manage this new patient population will be tested next year.
"When Fresno blinked, Kern did not, and it was wise of Kern," Schilling said.
Ultimately, 53 of California's 58 counties signed on to the program.
In Kern, LIHP was open to childless adults who made up to 100 percent of the federal poverty level when it launched in mid-2011.
In March, Kern's LIHP expanded, offering coverage to people who made up to 133 percent of the federal poverty level, about $15,280 for a single person or $31,300 for a family of four.
KMC Health Plan members enrolled under LIHP received new benefits, including mental health and substance abuse treatment. All members of the plan can get health services including lab tests, prescriptions, aid for non-emergency transportation, and specialty physician visits at no cost to them.
Cindy Stewart, chief of managed care for Clinica Sierra Vista, said the patients who went from totally uninsured to cover under the program benefited and were more likely to get the care they needed.
"The patients [are] more apt to get their lab work done, radiology work done and fill their prescriptions and take them" when they have health care coverage, Stewart said.
Since 2007, Kern County has spent more than $181 million on health care for enrollees in LIHP and its precursor. Cooper said much of that money would have been reimbursed through other state and federal payments to the county. Exact figures were not immediately available.
The county was also reimbursed an estimated $80.8 million in matching funds for providing care under these programs.
"In our opinion, (if the county) is required to provide indigent care already to individuals that meet these (eligibility) standards, then it's better for the county to get 50 percent reimbursement than to get none. And that's in addition to the (other) funds that we got" to pay the county back for those expenses, said Cooper, who is KMC'S executive director of managed care.
LESSONS & SUCCESSES
Though more that 18,000 people enrolled in the KMC Health Plan through the LIHP and legacy programs since 2007, only about 11,300 are still part of the plan today.
Maintaining enrollment was one of the program's biggest challenges, Cooper said. People are eager to get insurance when they are sick but they might not see the value of maintaining their coverage once they are well.
Showing people how to work the health care system was also a hurdle. Many people eligible for the KMC Health Plan were used to only seeking health care only when they were sick and relied on emergency rooms for treatment.
"That was probably one of the bigger challenges is just teaching people to not go to the emergency room for a head cold or medication refill, but contact your primary care doctor and do that," she said. "We put a lot of time and resources into that education and teaching people about the preventive and primary care side of health care."
Spreading the word about the plan also proved trying, especially since Kern's LIHP kicked off with no budget for marketing, Cooper said.
"Day one of the project it would have been nice to have more of a marketing strategy," said Clinica's Stewart.
But the program got help overcoming communication hurdles this year with a grant, which paid for radio, newspaper and billboards ads.
Overall, Cooper said she and her staff learned valuable lessons about how to work with patients who are hindered by social barriers. Staffers mailed out hundreds of bus passes to enrollees so they could make their medical appointments and helped get people into homeless shelters or receive food baskets.
Beyond just getting these people health care, "we were trying to improve the health of everyone," Cooper said.
The programs also slashed costs. From 2007 to Friday, KMC Health Plan members' annual per patient cost fell from $5,748 to $3,289, Cooper wrote in an email.
MOVING INTO MEDI-CAL
In the final weeks of the year, LIHP staff are preparing for another big change: about 87 percent of the KMC Health Plan's members will transition into Medi-Cal next month.
More than 9,800 of the plan's participants will make the move, Cooper wrote. In all, an estimated 52,000 Kern residents are expected to become newly eligible when the program expands.
Eligible KMC Health Plan members will have to pick one of Kern's two Medi-Cal managed care plans: Kern Family Health Care and Health Net Community Solutions. Cooper said enrollees moving to Medi-Cal should be able to keep their current doctor and those who don't qualify for that program will be eligible to buy insurance on the state's exchange, Covered California.
Right now, Cooper and her staff are busy trying to create a path for enrollees to move on to new coverage, working with safety-net health care providers, the local Medi-Cal managed care plans and the state to ensure that the people they fought to reach for six years continue to get the care that they need.
Though LIHP will fade away, the KMC Health Plan will not. The plan will continue to cover Kern's medically indigent adults, whose income levels fall between 138 and 200 percent of the federal poverty level -- between about $15,850 and $22,980 for a single person and about $32,490 to $47,100 for a family of four this year, Cooper said.
As for LIHP, Ogle said the state will be looking back at the program with UCLA to evaluate how it performed in terms of access to care, quality and cost.
"(The program) went very well. The counties were really on top of this and this was mostly a county-run process. And they did a very good job of finding and enrolling people appropriately," she said.