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Coverage Expansions and the Remaining Uninsured: A Look at California During Year One of ACA Implementation

Executive Summary
  1. California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf

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Introduction
  1. CMS, Medicaid & CHIP Monthly Application, Eligibility Determination, and Enrollment Reports and Updated Data, March - December, 2014, as of February 23, 2015. December 2014 data are preliminary. Enrollment reports and updated data are available from CMS, http://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html

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  2. California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf and CMS, Medicaid & CHIP Monthly Application, Eligibility Determination, and Enrollment Reports and Updated Data, March - December, 2014, as of February 23, 2015. December 2014 data are preliminary. Enrollment reports and updated data are available from CMS, http://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html

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  3. Licata R, Arguello R, Garfield R 2014. The Uninsured at the Starting Line in California: California findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA,Kaiser Family Foundation, https://www.kff.org/uninsured/report/the-uninsured-at-the-starting-line-in-california-california-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/

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Background: ACA Implementation in California
  1. U.S. Census Bureau, 2010 American Community Survey

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  2. California Health Care Almanac, California Employer Health Benefits Survey: Workers Feel the Pinch (California HealthCare Foundation, January 2014), http://www.chcf.org/publications/2014/01/employer-health-benefits

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  3. Kaiser Family Foundation estimates based on the Census Bureau's March 2014 Current Population Survey (CPS: Annual Social and Economic Supplements). https://www.kff.org/other/state-indicator/distribution-by-raceethnicity/

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  4. U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, American Community Survey, Census of Population and Housing, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits , http://quickfacts.census.gov/qfd/states/06000.html.

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  5. California Department of Health Care Services. LIHP September2013 Monthly Enrollment (November 15, 2013).

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  6. California Department of Health Care Services, “California’s Low Income Health Program Transitions Hundreds of Thousands of New Members to Medi-Cal” (December, 2013), http://www.dhcs.ca.gov/formsandpubs/publications/opa/Documents/2013/13-07%20LIHP%20Medi-Cal%20Expansion%2012-31-13%20Final%20Version.pdf

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  7. UCLA Center For Health Policy Research, Health Economics and Evaluation Research, Safety Net Delivery System Redesign in California: Innovations in the Low Income Health Program (LIHP) (November 2013), http://healthpolicy.ucla.edu/publications/Documents/PDF/SafetyNetRT_FINAL_10-10-13.pdf

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  8. Gates A, Rudowitz R, Guyer J, 2014. An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers. Kaiser Family Foundation, https://www.kff.org/medicaid/issue-brief/an-overview-of-delivery-system-reform-incentive-payment-waivers/

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  9. Kaiser Family Foundation, California’s Uninsured on the Eve of ACA Open Enrollment (2013) https://www.kff.org/report-section/ca-uninsured-executive-summary/#endnote_link_note2.

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  10. Department of Health Care Services (DHCS). Full Scope Medi-Cal Coverage and Affordability and Benefit Program for Low-Income Pregnant Women and Newly Qualified Immigrants (NQI) Scenarios. Available at: http://www.dhcs.ca.gov/services/medi-cal/Documents/AffordabilityBenefitProgramEligibilityChart8-18-2014-draft.pdf.

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  11. California Department of Health and Human Services, May 2014 Medi-Cal Estimate, http://www.dhcs.ca.gov/dataandstats/reports/mcestimates/Documents/2014_May_Estimate/M1407_Regular_PC_Tab.pdf

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  12. California Pan-Ethnic Health Network, Summary of Medi-Cal Coverage for Immigrants. (Oct 2013), http://cpehn.org/sites/default/files/resource_files/cpehnimmigrantcoveragemedi-cal.pdf

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  13. California Department of Health Care Services, Communication documents for NQIs and Affordability & Benefit Program (Meeting dates consultation July 25, 2014 through September 5, 2014), http://www.dhcs.ca.gov/services/medi-cal/Documents/NQI%20notices/NQI_Stakeholder_Comments_DHCS_responses.pdf

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  14. California Immigrant Policy Center, How the Affordable Care Act Impacts Immigrant & Migrant Populations in California, (2014) http://www.caimmigrant.org/wp-content/uploads/2014/10/ACAs-Impact-on-Immigrants-CA.1.30.14-1.pdf

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  15. Covered California, Health Plans Booklet (2014), https://www.coveredca.com/PDFs/CC-health-plans-booklet-rev4.pdf.

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  16. California Department of Health Care Services, “California’s Low Income Health Program Transitions Hundreds of Thousands of New Members to Medi-Cal” (December 2013), http://www.dhcs.ca.gov/formsandpubs/publications/opa/Documents/2013/13-07%20LIHP%20Medi-Cal%20Expansion%2012-31-13%20Final%20Version.pdf.

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  17. Covered California Blog, Covered California’s Historic First Open Enrollment Finished with Projections Exceeded; Agents, Counselors, Community Organizations and County Workers Credited as Reason for High Enrollment in California, (April 2014) http://news.coveredca.com/2014/04/covered-californias-historic-first-open.html

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  18. The California Endowment, The Department of Health Care Services and The California Endowment Announce $23 Million in Grants to Boost County-Based Medi-Cal Enrollment Efforts (January 2014), http://tcenews.calendow.org/releases/department-of-health-care-services-and-the-california-endowment-announce-23-million-in-grants-to-boost-county-based-medi-cal-enrollment-efforts

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  19. California Department of Health Care Services, Outreach and Enrollment Workgroup (November 2013), http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/OEworkgroup.aspx

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  20. California Health Benefit Exchange. Outreach and Education Grant Webinar (September 27, 2012), http://www.healthexchange.ca.gov/StakeHolders/Pages/2012StakeholderArchive.aspx

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  21. California Health Benefit Exchange. Outreach and Education Grant Webinar (September 27, 2012), http://www.healthexchange.ca.gov/StakeHolders/Pages/2012StakeholderArchive.aspx

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  22. Health Resources and Services Administration, California: Health Center Outreach & Enrollment Assistance, (FY 2014) http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/ca.html

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  23. California Department of Health Care Services, Hospital Presumptive Eligibility (PE) Program, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/HospitalPE.aspx

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  24. California Department of Health Care Services, Express Lane Program, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ExpressLane.aspx

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  25. California Senate Committee on Health, First Open Enrollment for Affordable Care Act Implementation, Summary of Outcomes and Challenges, http://shea.senate.ca.gov/sites/shea.senate.ca.gov/files/Outreach%20%20Enrollment%20White%20Paper%20Final.pdf

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  26. California Senate Committee on Health, First Open Enrollment for Affordable Care Act Implementation, Summary of Outcomes and Challenges, http://shea.senate.ca.gov/sites/shea.senate.ca.gov/files/Outreach%20%20Enrollment%20White%20Paper%20Final.pdf

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  27. Covered California Blog, Covered California Outlines Additional Initiatives Tailored to Boost Latino Enrollment, (February 2014), http://news.coveredca.com/2014/02/covered-california-outlines-additional.html

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  28. California Department of Health Care Services, Memo Related to Processing Single Streamlined Applications, (January 2014) http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/MEDIL%20I13-14.pdf.

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  29. California Health Line, Judge Rules on Medi-Cal Backlog Suit, Orders State to Adhere to 45-Day Deadline (January 2015), http://www.californiahealthline.org/capitol-desk/2015/1/judge-finally-rules-on-backlog-lawsuit-orders-state-to-adhere-to-45-day-deadline

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  30. California Pan-Ethnic Health Network, Improving Enrollment of Communities of Color in Health Coverage: Recommendations from First Responders to Covered California and Medi-Cal.( June, 2014), http://shea.senate.ca.gov/sites/shea.senate.ca.gov/files/CPEHN_ImprovingEnrollmentforCommunitiesofColor_2014.pdf

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  31. California Senate Committee on Health, First Open Enrollment for Affordable Care Act Implementation, Summary of Outcomes and Challenges, http://shea.senate.ca.gov/sites/shea.senate.ca.gov/files/Outreach%20%20Enrollment%20White%20Paper%20Final.pdf.

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  32. Covered California Blog, Covered California’s Historic First Open Enrollment Finishes with Projections Exceeded; Agents, Counselors, Community Organizations and County Workers Credited as Reason for High Enrollment in California, (April 2014) http://news.coveredca.com/2014/04/covered-californias-historic-first-open.html

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  33. Enrollment data from: California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf  Eligible population data from: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and 2014 Current Population Survey. For a detailed explanation of our methodology, please see Methodology for Estimating the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act

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  34. Addendum to Health Insurance Marketplace Summary Enrollment Report, October 1, 2013 - March 31, 2014, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); May 1, 2014

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  35. Covered California Blog, Covered California Enrollment Surges in Los Angeles County to More Than 400,000; Interest in Medi-Cal Remains High ( May 2014) http://news.coveredca.com/2014/05/covered-california-enrollment-surges-in.html

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  36. Enrollment data from: California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf

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  37. Enrollment data from: California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf

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  38. CMS, Medicaid & CHIP Monthly Application, Eligibility Determination, and Enrollment Reports and Updated Data, March - December, 2014, as of February 23, 2015. December 2014 data are preliminary. Enrollment reports and updated data are available from CMS, http://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html

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  39. Covered California Blog, Covered California’s Historic First Open Enrollment Finishes wth Projections Exceeded; Agents, Counselors, Community Organizations and County Workers Credited as Reason for High Enrollment in California, (April 2014), http://news.coveredca.com/2014/04/covered-californias-historic-first-open.htmlhttp://news.coveredca.com/2014/04/covered-californias-historic-first-open.html

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  40. California Department of Health Care Services, California Eligibility and Enrollment Report: Insurance Affordability Programs for October 2013 through September 2014, http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CA_EligibilityandEnroll_ABx1_1-Quarterly.pdf

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Who gained coverage and who remained uninsured?
  1. Licata, Garfield, and Arguello, 2014.

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  2. Licata, Garfield, and Arguello, 2014.

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  3. Licata, Garfield, and Arguello, 2014.

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  4. Covered California Blog, Spanish-Language Enrollment Application Form Now Available On Covered California Website, (December 2013) http://news.coveredca.com/2013/12/spanish-language-enrollment-application.html

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  5. Based on comparison of 2013 and 2014 Kaiser Survey of Low-Income Americans and the ACA.

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  6. Kaiser Family Foundation analysis of 2013 Current Population Survey.

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  7. Licata, Garfield, and Arguello, 2014.

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  8. Licata, Garfield, and Arguello, 2014.

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  9. Wilper AP, Woolhandler S, Lasser KE, McComick D, Bor DH, Himmelstein DU. Hypertension, diabetes, and elevated cholesterol among insured and uninsured US adults. Health Affairs. 2009;28(6):w1151-9.

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  10. Coverage Matters: Insurance and Health Care, Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine, National Academy Press, 2001.

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Who is covered by different programs in California?
  1. Based on comparison of 2013 and 2014 Kaiser Survey of Low-Income Americans and the ACA.

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  2. Based on comparison of 2013 and 2014 Kaiser Survey of Low-Income Americans and the ACA.

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  3. Licata, Garfield, and Arguello, 2014.

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  4. Based on comparison of 2013 and 2014 Kaiser Survey of Low-Income Americans and the ACA.

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What has happened to access to care for the insured and remaining uninsured?
  1. Licata, Arguello, and Garfield, 2014.

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  2. Licata, Arguello, and Garfield, 2014.

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  3. Agency for Healthcare Quality and Research. CAHPS Item Set for Addressing Health Literacy (May 2012) https://cahps.ahrq.gov/surveys-guidance/item-sets/literacy/index.html

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  4. California Department of Health Care Services, Medi-Cal Managed Care 2013 CAHPS Survey Summary Report, (March 2013) http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Qual_Rpts/CAHPS_Reports/CA2012-13_CAHPS_Summary_Report_F3.pdf

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  5. Blue Shield of California Foundation, Langer Research Associates, Delivering on a Promise: Advances and Opportunities in Health Care for Low-Income Californians, (January 2015) http://www.blueshieldcafoundation.org/sites/default/files/publications/downloadable

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  6. Blue Shield of California Foundation, Langer Research Associates, Health Care in California: Leveling the Playing Field, (November 2013) http://www.blueshieldcafoundation.org/sites/default/files/publications/downloadable/BCSF_leveling_the_playing_field.pdf

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How do people view their coverage?
  1. Covered California, Health Plans Booklet (2014), https://www.coveredca.com/PDFs/CC-health-plans-booklet-rev4.pdf

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  2. Covered California, Health Plans Booklet (2014), https://www.coveredca.com/PDFs/CC-health-plans-booklet-rev4.pdf

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  3. Licata, Arguello, and Garfield, 2014.

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How does coverage affect financial security?
  1. Covered California, Health Plans Booklet (2014), https://www.coveredca.com/PDFs/CC-health-plans-booklet-rev4.pdf.

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  2. Burke A, Misra A, Sheingold S, 2014, Department of Health and Human Services, ASPE, Research Brief, Premium Affordability, Competition, and Choice in the Health Insurance Marketplace http://aspe.hhs.gov/health/reports/2014/premiums/2014mktplaceprembrf.pdf

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  3. Addendum to Health Insurance Marketplace Summary Enrollment Report, October 1, 2013 - March 31, 2014, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); May 1, 2014.

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  4. Kaiser Commission on Medicaid and the Uninsured analysis based on the Council for Community and Economic Research (C2ER)'s ACCRA Cost of Living Index (COLI) for the third quarter of 2014. https://www.kff.org/other/state-indicator/cost-of-living-variation/

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  5. Licata, Garfield, and Arguello, 2014.

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  6. Licata, Garfield, and Arguello, 2014.

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  7. Licata, Garfield, and Arguello, 2014

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Why are people still uninsured and what are their coverage options?
  1. Gold, J. “As California Expands Medicaid To New Beneficiaries, Many Others Are Dropped.” Kaiser Health News. November 18, 2014.

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  2. California Healthcare Foundation, On The Path to Enrollment: Getting Californians Covered Under the ACA, (October 2013) http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/P/PDF%20PathEnrollmentACA.pdf

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  3. Licata, Garfield, and Arguello 2014.

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  4. California Healthline, Forum Examines Residually Uninsured (December 2014) http://www.californiahealthline.org/capitol-desk/2014/12/forum-looks-at-options-across-state-to-solve-residually-uninsured-issue

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Policy Implications
  1. California Health Line, Californians Received $3.2B in Federal Health Subsidies Last Year, (January 27, 2015) http://www.californiahealthline.org/articles/2015/1/27/californians-got-3-2b-in-federal-health-subsidies-last-year

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  2. Dorn S and Tolbert J, The ACA’s Basic Health Program Option: Federal Requirements and State Trade-Offs, (November 2014) https://www.kff.org/health-reform/report/the-acas-basic-health-program-option-federal-requirements-and-state-trade-offs/

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  3. Howard, H. and C. Shearer. “State Efforts to Promote Continuity of Coverage and Care under the Affordable Care Act.” Journal of Health Politics, Policy and Law, Vol. 38, No. 6, December 2013.

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  4. Covered California Blog, Spanish-Language Enrollment Application Form Now Available On Covered California Website, (December 2013) http://news.coveredca.com/2013/12/spanish-language-enrollment-application.html

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  5. Covered California, Lessons Learned, (October 2014) https://www.coveredca.com/PDFs/10-14-2014-Lessons-Learned-final.pdf

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  6. Covered California Blog, Covered California Partners with National Immigrant Rights Organizations to Reassure Consumers in California and Nationally That Immigration Information Is Safe, Secure and Confidential, (December 2014) http://news.coveredca.com/2014/12/covered-california-partners-with.html

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  7. Covered California Blog, Covered California’s Second Open Enrollment Yields Strong Numbers; Nearly 500,000 New Consumers Sign up for Health Plans, (March 2015) http://news.coveredca.com/2015/03/covered-californias-second-open.html

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  8. California Health Line, Jones Releases Emergency Rule Over Narrow Provider Networks, (January 6, 2015) http://www.californiahealthline.org/articles/2015/1/6/jones-issues-emergency-rule-over-narrow-provider-networks

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  9. California Department of Health Care Services, Medi-Cal 2020: Key Concepts for Renewal, (March 2015) http://www.dhcs.ca.gov/provgovpart/Pages/1115-Waiver-Renewal-Official-Submission.aspx

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  10. Department of Health and Human Services, Letter to Medi-Cal Managed Care Plans on Continuity of Care for Medi-Cal Beneficiaries Who Transition Into Medi-Cal Managed Care, (December 2014) http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-021.pdf

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