California was the first state under the microscope as the Kaiser Family Foundation last week began a multi-state review of how previously uninsured people are faring under the Affordable Care Act (ACA.)

“We are starting with California because everyone else in the country is watching the implementation of the Affordable Care Act there,” said Drew Altman, Ph.D., president and CEO of the Kaiser Family Foundation, which is based in Menlo Park and Washington, D.C.

“It’s a giant state with a big and diverse population, had money for outreach and has been out front implementing the ACA. Its successes and challenges matter for the country,” said Altman, adding “if the ACA falters in California that would be a very big deal. That is not happening. It looks like a relative ACA success story.”

Kaiser last week released a new report, The Uninsured at the Starting Line in California, based on survey responses from 2,500 adults who were uninsured at the start of open enrollment last fall. The survey was funded by the Blue Shield Foundation of California,* which will pay for three more surveys among the same group over the next two years to track how and if people who were previously uninsured are accessing insurance and health care.

To get a sense of how people are faring now that coverage has begun, Kaiser paired the report’s release with a panel discussion held in Washington, D.C. on February 19, featuring health officials from California, including state secretary of health and human services Diana Dooley, who said that “at the heart of the Affordable Care Act is the notion that we have to move to a system of population health.”

The panelists included Toby Douglas, Director, California Department of Health Care Services, Mitchell Katz, M.D., Director, Los Angeles County Department of Health Services, Anthony Wright, Executive Director, Health Access California and Ronald Yee, M.D., Chief Medical Officer, National Association of Community Health Centers.

As of February 4^th, according to data released at the Kaiser meeting, 22 percent of Californians who were previously uninsured had signed up for coverage, the fourth highest rate in the country behind Rhode Island, Vermont and New Hampshire. Kaiser’s Drew Altman said at the event that if the rest of the country had signed up at the same rate as California, national signup would be double the 3 million people recently announced and above the 6 million mark that many had hoped for by this point.

According to Toby Douglas, 650,000 Californians were signed up early under the Medicaid expansion allowed under the ACA “and it was more than sign up,” said Douglas. “We bought them into the delivery system and assigned to medical homes. And we started to add on mental health and substance abuse services. We made sure to create systems so we didn’t lose [beneficiaries] when we moved from a county based system. We’ve had bumps, but for 98 percent it has been a smooth transition,” Douglas said.

An example of innovation Douglas shared in California was “express lane” enrollment for people in the state’s Calfresh (food stamps) program. “In just a couple of weeks they had over 65,000 enrolled in the ACA through that outreach,” said Douglas.

Some of the panel discussion focused on the challenges beyond outreach. “The healthcare.gov startup problems, I think, gave everyone a sense that this was all just about making websites work and finding healthy people to balance the risk pool,” said Altman. “This really is not just Travelocity or Kayak or Amazon.com, it’s a vastly more complicated, hands-on, community-based outreach challenge accessing care and keeping people covered as jobs and incomes change in a given year.”

Peter Long, head of the Blue Shield Foundation of California, and former senior vice president at the Kaiser Family Foundation, moderated the panel and pointed out to the audience, largely made up of journalists, health advocates and policy staff members that the ACA “is not self-implementing.” The Kaiser report, for example, points out that while there is much focus on the initial push to enroll people in coverage under the ACA, enrollment is not a “one shot” effort that will be completed in the first few months of implementation–millions of Californians lose and gain coverage throughout the year because of job changes, income fluctuations, or problems at renewal and implementing the ACA will require ongoing efforts to enroll and keep people in coverage.

Another key finding of the report is the importance of continuing ACA marketing efforts beyond 2014. “As more people are enrolled in coverage under the ACA, the focus of these efforts may also shift from initial enrollment to ensuring continuous, stable coverage,” according to the report. And even once Californians have insurance, the survey found, they may face issues with their plans covering the range and scope of the services they need.

Accessing care was a key topic for the Kaiser panel members. “We know how to get people through the hoops …to get the coverage they need. But I can tell you insurance is not health-care. It may or may not enable you to gain health care and just because you get health care, doesn’t mean you feel cared for,” said Dr. Katz. “That doesn’t prove the person feels attached to the provider, or the provider is ready to meet the needs of their patients.”

In very low-income populations, added, Dr. Katz, the real challenges are not medical, they’re also social issues such as housing, low incomes and abusive relationships.

Katz also spoke about the need to change the patient visit model. “There is no way in LA or anywhere where you can use the visit model and have success. If that’s the model we have to already agree we have failed. There aren’t enough specialists.” LA is working on electronic consultations, not just to expand provider time, but also to determine whether a visit is needed, and what information, such as lab tests, might be needed prior to the encounter, so that the physician time is optimized.

Ron Yee, of the National Association of Community Health Centers, says the group has shifted from outreach efforts to enrollment. One great advantage of the ACA, said Yee, is that the increase in Medicare beneficiaries allows them to expand their budget for patients without insurance who pay on a sliding fee scale. “The budget is still not adequate, “said Yee, “but we can now stretch it a little bit further.”

The report detailed several challenges for people newly enrolled:

• A lack of a connection for many to health care providers.
• High premiums, deductibles and copay costs relative to income and limited understanding of benefits both before and after signing up for coverage.
• Uninsured adults in California are generally in low-income, working families who have significant health care needs.
• Half of uninsured adults in California are Hispanic, many of whom may be ineligible for ACA assistance because of their immigration status.
• Many low-income (or below 138 percent of the Federal Poverty Level (FPL) uninsured California adults have a family connection to a social services program, the majority of moderate-income (who have incomes of 139% to 400% of the FPL) uninsured adults do not.
• Paperwork and plan selection challenges for enrollees
• Barriers to seeking care, such as difficulty traveling to a provider’s office. A suggestion in the report is that beneficiary education may be needed to link the newly insured to a regular provider and help them establish a pattern of regular preventive care.
• Changes in insurance coverage may lead people to use new or different providers, but clinics and health centers will continue to serve many of California’s vulnerable populations.

*The Blue Shield Foundation of California is a funder of the California Health Report.