Faced with possible cuts in federal spending that could mess with health coverage and decreasing childhood vaccination rates, Monica Soni, the big boss medical officer of Covered California, has a ton on her plate — and on her mind. The health insurance exchange for California’s Affordable Care Act looks after nearly 2 million residents, with about 89% of them getting federal subsidies to cut down their premiums. Some middle-income households got subsidies for the first time in 2021, thanks to Congress expanding them, leading to a surge in enrollment in ACA exchanges nationwide.
From the original and improved subsidies, folks signed up with Covered California are currently enjoying an average of $563 a month, bringing the typical monthly out-of-pocket premium down from $698 to $135, according to info from Covered California. The 2021 subsidies are set to expire by the end of this year unless Congress decides to renew them. If they don’t, enrollees would have to fork out an average of $101 a month more for their health insurance — not even counting any premium hikes in 2026 and beyond. And those middle-income earners who weren’t eligible for subsidies before would lose all financial aid — about $384 a month, on average — which Soni worries could make them bail out.
At the same time, the vaccination rates for children 2 and under took a hit in 7 out of the 10 Covered California health plans that had to follow new quality-of-care rules. Soni, a Los Angeles native who joined Covered California in May 2023, manages that program, where health plans need to hit performance targets on things like blood pressure control, diabetes management, colorectal cancer screening, and childhood vaccinations — or pay a fine. The lack of access to these key aspects of care hits underserved communities harder, making Covered California’s initiative one of health equity. Soni, a primary care doctor trained at Harvard who sees patients once a week at an urgent care clinic in the public safety net health system in Los Angeles County, knows the struggles these communities face.
Covered California said last November that its health plans got better on three out of the four measures in the first year of the program. But childhood immunizations for those under 2 dropped by 4%. This drop matches a national trend, which Soni blames on post-pandemic vaccine mistrust and “more skepticism of the entire medical industry.” Most parents have heard at least one false statement about measles or the vaccine for it, and many don’t know what to believe, according to an April KFF poll.
Health plans did better on the other three measures, but not enough to avoid penalties, which raked in $15 million. The exchange is using that money to fund another effort Soni is in charge of, which helps 6,900 Covered California homes buy groceries and adds to over 250 savings accounts for kids who go for regular checkups and vaccines. Some of the penalty money will also help support primary care practices around California.
Aside from her two-faced professional roles, Soni is a mom to two kids, ages 4 and 7. KFF Health News senior correspondent Bernard J. Wolfson chatted with Soni about the impact of potential federal cuts and the exchange’s move to enhance care for its enrollees. This chat has been trimmed for length and clarity.
Q: Covered California’s enrollment is at an all-time high of nearly 2 million, thanks to the beefed-up federal subsidies passed under Biden, which are on their way out after this year. What if Congress doesn’t renew them? A: Our estimates say about 400,000 Californians might drop coverage right away. We hear from our peeps every day about how they’re basically living on the edge. Before they got some of those subsidies, they couldn’t even think about affording coverage. As a primary care doctor, I’m the one who deals with folks showing up with preventable cancers because they were too scared to think about what their out-of-pocket costs would be. I don’t want to regress to those days.
Q: Congress is thinking about cutting billions in Medicaid. How would that hit Covered California and the state’s population in general, given that more than a third of Californians are on Medi-Cal, the state’s Medicaid version? A: Those are our neighbors, our pals. They’re the ones working in the joints we chow down at. Earlier cancer screenings, better chronic disease control, lower maternal mortality, more substance use disorder treatment: We know Medicaid saves lives. We know it helps people live longer and better. As a doc, I’d have a hard time arguing to roll back anything that saves lives. It would be pretty upsetting to see that hit California.
Q: Why did Covered California launch the Quality Transformation Initiative? A: We did super well covering nearly 2 million, but honestly, we didn’t see quality improvements, and there are still gaps for some groups in terms of outcomes. So, the big question was: Are we getting bang for our buck with this coverage? Are we making sure people are living longer and better, and if not, how do we step up to make sure they are?
Q: There’s a penalty for not meeting the targets, but no bonuses for hitting them: It’s meet the goals or else, right? A: We don’t put it like that, but yeah, that’s the deal. And we didn’t complicate it. It’s just four measures. They’re things that, as a primary care doctor, I know are important and handle when I see folks in my practice. We said, get to the 66th percentile on these four measures, and you won’t have to shell out any cash. If you don’t, then we’re collecting those funds.
Q: And you’re using the penalty money to back the grocery help and child savings accounts. A: Yup, that’s the plan. We had a chance to think about what to do with those dollars and how to actually make a difference in people’s lives. So, we hit up a ton of folks, sent out surveys to thousands, and what we heard loud and clear was how pricey it is to live in California; folks are stuck making trade-offs between food and transportation, between child care and food — impossible choices.
Q: You’ll put up to $1,000 per kid into those savings accounts, right? A: That’s the idea. It’s tied to doing those healthy habits, going for child well visits, and getting recommended vaccines. We checked out the research, and once you hit even just $500 in an account, the chances of a kid going to a two- or four-year school go up by a lot. It’s all about them being hopeful about their future, and it shifts their path to moving up, which we know affects their health results.
Q: With the surge in vaccine doubt, are you afraid the recent measles outbreak could blow up? A: I’m really worried about that. I was looking at some posts from a doc buddy who trained way back and was talking about all the diseases my generation of docs have never seen. We don’t know how to diagnose and deal with a bunch of infectious diseases because they’ve mostly been wiped out or outbreaks have been contained. So, yeah, I’m concerned. I’ve been dusting off my old textbooks.
Wolfson writes for KFF Health News, a national newsroom that comes up with in-depth stories about health issues and is a core program at KFF — a standalone source for health policy research, polling, and journalism.
