So when the 57-year-old from Fairfield, California, needed routine follow-up surgery after a mastectomy, she did her homework. “I looked up on my insurer’s network and made sure the outpatient facility that I was being referred to was in my network,” Ray said.

A month later, she received an unwelcome surprise: a $580 bill for an out-of-network anesthesiologist.

“I called the facility back, and at first, I felt like, this has to be a mistake. They’ll fix it,” Ray said.

The unexpected charges come when patients are treated by an out-of-network provider at an in-network facility.

After several failed attempts in recent years, the California legislature passedÌý, which aims to protect patients’ pocketbooks when they’re hit by these surprise bills. Gov. Jerry Brown has until the end of September to sign or veto the legislation. He is expected to sign it into law.

A 2015 Consumers Union suggests the surprise bill phenomenon is fairly common. It found nearly 1 in 4 Californians who’d had hospital visits or surgery in the prior two years reported receiving an unexpected bill from an out-of-network provider.

“They can range in price from a hundred dollars to many thousands,” saidÌý, special projects director for Consumers Union. “So it’s a big financial burden on consumers.”

In Ray’s case, she said she tried to speak with a manager at the outpatient clinic, but no one returned her repeated calls. Then the bills stopped coming, so she figured all was resolved. Soon after, however, her bill was sent to collections.

“I was so frustrated,” she recalled. “I was just in tears as I was dealing with it.”

Ray said it took about seven months of wrangling before her insurance company finally paid the bill and she was able to clean up her credit rating.

“My immediate response was, there does need to be a law to fix this,” said Ray. “This is so wrong.”

The legislation, by Assemblyman Rob Bonta (D-Oakland) and six colleagues, would limit a patient’s financial obligation to no more than what he would have owed if the provider had been in-network.

While agreeing that “patients should never have surprise bills,” Dr. Karen Sibert, president-elect of the California Society of Anesthesiologists, said her organization and a number of other specialty medical groups oppose AB-72.

At issue, Sibert said, is the bill’s formula for paying doctors who fill the gap left when insurance companies don’t have enough providers in their networks. The legislation would set the payment rate at either the amount the insurer normally pays a doctor on contract for such services or 125 percent of the Medicare rate, whichever is greater.

That’s insufficient, argued Sibert. “It’s a problem because it removes any incentive for insurance companies to reach fair contracts with physicians.”

Without such an incentive, she said, insurance companies will continue to haveÌýinadequate provider networks.

The powerful agrees with Sibert about the bill’s payment formula, but it has shifted its position on AB-72 from opposed to neutral, said Janus Norman, the Association’s vice president of governmental affairs.

There are a few reasons for the change of heart, he said. First, the bill would create stricter oversight of how in-patient services are delivered, and it would allow for tougher regulations on insurers if the state finds their provider networks to be inadequate.

The provision regarding tougher regulations, “is one improvement that AB-72 included that prior legislation did not,” he said.

In addition, the measure would give out-of-network doctors the chance to appeal payment disputes with insurers through an independent third party, and the decision would be binding, another important change from previous versions of the bill, Norman said.

The California Association of Health Plans and the Association of California Life and Health Insurance Companies don’t have a formal position on AB-72, according to an analysis by the Assembly Health Committee. Instead, they have expressed “concerns” about the measure, the committee said.

“While they laud the authors’ efforts to protect consumers from balance billing,” the analysis said, the insurer groups worry that the legislation might lead to higher premiums and cost-sharing, and that the bill’s dispute resolution process might spark more lawsuits between providers and health insurance firms.

Anthony Wright, executive director of Health Access California, a consumer health care advocacy coalition, said Gov. Brown took an interest in the legislation.

“The governor’s office did provide input during the negotiation process and we are hopeful that he will sign it,” he said.

Consumers Union’s Imholz said the California Medical Association’s neutral position on the legislation was key in getting AB-72 across the finish line.

She predicts that if Brown signs the measure, a number of other states now considering similar protections against surprise bills will likely follow suit next year.

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Five decades ago, two brothers helped start Medicare. Their father inspired them and they, in turn, have inspired the next generation.

To mark the anniversary of President Lyndon Johnson signing Medicare into law on July 30, 1965, three Lees sat down to reflect on the U.S. health care system.

It can be hard now to imagine a time when Medicare met serious opposition. But 92-year-old Dr. Peter Lee, a founder of the family medicine department at the University of Southern California, remembers that time well.

Marking a Milestone

“I was one of the people who was supporting the idea,” he says. “And in response to that some people from the USC alumni association wanted me fired because they thought that was socialized medicine.”

The Los Angeles County Medical Association, too, called for Lee’s ouster. While Lee didn’t get fired, he did get called a lot of names. The same thing happened to his now 91-year-old brother, , who helped implement Medicare in the Johnson administration.

“They called me a socialist more often than a communist, but occasionally they referred to me as a communist,” he recalls.

Among those who did that, he says, was former President Ronald Reagan, who lent his voice to an ad by one of Medicare’s biggest opponents, the American Medical Association.

“One of the traditional methods of imposing state-ism or socialism on a people has been by way of medicine,” Reagan says in the ad.

The AMA opposed Medicare out of fear the government would become too deeply involved in the practice of medicine. But that didn’t sway the Lee brothers. Their work as ardent foot soldiers for Medicare, was borne in part from family legacy of health policy started by their father, Dr. Russell Lee, says his grandson Peter Lee.

“Desegregation was critical,” says Philip Lee. “You couldn’t have a segregated medical care system.”

Philip Lee was sent to the South to make sure hospitals didn’t discriminate. He says it took the threatened loss of federal Medicare dollars to overcome resistance by many hospitals that ultimately integrated. And integration meant everyone and everything — from patients and staff all the way to the blood supply.

“And we made a lot of progress, even if it wasn’t perfect,” he says.

Today, both of the elder Lees say the biggest issues facing the nation’s health care system is making sure everyone gets medical care.

It’s a job that the younger Peter Lee says he’s taken on with inspiration from his family legacy and support from his father and uncle. And, he says, they set a high bar.

“It take persistence. It takes hard work. But change happens,” he says.

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“At our age, with some preexisting medical conditions, it would have been very costly to buy insurance on the open market – about $3,000 a month,” he says.

But the Affordable Care Act changed that. The federal health law bars insurance companies from charging higher premiums to those with preexisting conditions, so the Smiths have been able to find a plan they can afford. The couple pays $200 a month for a subsidized health insurance policy they bought through California’s state-run marketplace, Covered California.

And that’s brought a big change to Smith’s household: ÌýHe’s joined Laura in early retirement. That means more time for him to help Laura care for his elderly in-laws as well as more down time to pursue some budding passions, namely playing his guitar and cooking new recipes.

But early retirees aren’t the only people benefitting from the federal health law.

A Ìýby Georgetown University and the Urban Institute predicts the ACA will enable up to 1.5 million Americans to leave unfulfilling jobs and become self-employed or start new businesses. It’s a finding that runs counter toÌýÌýby ACA critics, who contend the federal health law will cost the nation jobs and cripple America’s small business economy.

It will take years to know for certain how the health law will change the work landscape broadly, but already the law has changed life for Rebecca Murray.

Last year, the Chicago resident says, her husband — a freelance IT worker — was diagnosed with chronic spinal arthritis. He needed good health insurance, which he received through Murray’s job as a social worker for a dialysis corporation. But Murray didn’t like her job.

Murray and her husband are both 31, with a 20-month-old daughter and a second child on the way. Before the Affordable Care Act, they couldn’t get insurance on the individual market market because of hisÌý.

But under the federal health law, they now qualify for a subsidized policy that will cost $535 a month for the whole family. Not inexpensive by any means, she says, but it does allow her to quit her job and launch an online business to help young women, like her, take care of sick loved ones.

“It’s thrilling. It’s exciting. It’s kind of like taking a leap into the unknown, and I know it’s a big risk,” she says of her new venture. “But this really is allowing me to finally step into what I feel is truly satisfying for the soul,” she says, adding that just a year ago, “I was convinced I would be a renal social worker for the next 30-something years and just raise my kids and hope they could live out their dreams instead.”

This story is part of a partnership that includesÌý,ÌýÌýand Kaiser Health News.

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About 100,000 people signed up during the first two weeks of February, almost exactly matching , said Covered California and the

In January, 28 percent of those who enrolled were Latino, a “marked improvement” compared with the first three months of signups, said. From Oct. 1st to Dec. 31st, only about 18 percent of enrollees identified themselves as Latino.

“We’re very excited to note significant growth in enrollment of the numbers of people from California’s Latino population,” Lee told reporters.

“I couldn’t be happier … that Latino and Spanish-speaking enrollment has increased,” said Rep. Loretta Sanchez (D-Anaheim) in a written statement. She indicated that more progress is needed, noting that “Latinos make up more than half of California’s uninsured population.” In January, Sanchez joined 15 of her California congressional colleagues in sending saying Covered California needed to do more to boost Latino enrollment.

Despite the stronger January numbers, only 21.4 percent of those who signed up for health insurance from Oct. 1st-Jan. 31st were Latino.

Lee acknowledged that his agency needs to step up its outreach to Latinos. He said Covered California has embarked on new efforts to do soÌý— including more community outreach and new Spanish-language advertisements.

“We will be spending $8.2 million dollars in Spanish language media in the first quarter of this year,” Lee said. “That’s a 73 percent increase over what we spent in the final quarter of 2013.”

Overall, more than 1.6 million Californians have signed up so far either for a private health insurance plan through Covered California,Ìýor for according to the Wednesday data release.

From Oct. 1-Feb. 15, 828,000 Californians enrolled in a health plan, Lee said. What’s more, he said,Ìýabout 80 percent have paid their premiums and now have coverage.

During that same period, another 877,000 Californians were determined eligible for Medi-Cal, California’s Medicaid program Ìýfor individuals with incomes at or below $15,850 a year and a family of four that earns $32,500 or less.

Lee went on to say that of the Ìý728,000 Californians who selected a private health policy by Jan. 31, 626,000 were eligible for subsidies to help offset the cost of monthly premiums and other insurance expenses.

Covered California wanted to enroll between 500,000 and 700,000 subsidy-eligible customers by the end of open enrollment on March 31.

“We’veÌýÌýalready exceeded the base enrollment projections… and we’re well on the way to surpassing the enhanced projections,” Lee said. “This shows how strongly Californians are stepping up and are interested in taking advantage of the Affordable Care Act coverage opportunities.”

The numbers released Wednesday include only those who signed up through Covered California and do not include those who bought insurance plans directly from health insurance companies.

Wednesday’s numbers also don’t include information about how many of those who have signed up for coverage were previously uninsured, which is a key factor in determining how well the law is working.

“We don’t have good numbers on how much we’ve reduced the uninsured,” Lee said. Ìý“We’re going to do follow up on this, but we’re confident we have had a very dramatic impact on reducing the number of uninsured in California,” he added.

Lee said enrollment in another key group – Ìýyoung adults – is also improving, if only slightly.

Lee told reporters that ÌýJanuary saw a slight uptick in As of January 31, about 26 percent of those who enrolled in a health plan fell into this coveted age group. They had made up 25 percent of enrollees through the end of December.

This group of young adults makes up about 25 percent of the overall state population, but economists believe it needs to constitute closer to 40 percent of enrollees to keep overall costs down.

Under the Affordable Care Act, nearly every American must be covered by health insurance by March 31 or face a tax penalty that starts out small and grows over time.

This story is part of a partnership among , andÌýKaiser Health News.

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But Neff, a 46-year-old self-employed writer, isn’t outraged. She’s relieved. Even though she makes too much money to receive a subsidy to buy insurance under the Affordable Care Act, the policy cancellation was good news for her.

Neff says she’s been stuck in a bad plan because treatment for a back problem years ago red-flagged her with a preexisting condition.

“The deductible has ranged anywhere from $3,000 to as high as $5,000, which means I have to spend that much each year before the insurance even kicks in,” she says. “I was rejected [from a more affordable policy] because I’d had a bout of sciatica five years previously that has never returned.”

On Jan. 1, the federal health law prohibits insurers from denying coverage or charging more for such preexisting problems. That’s opened an array of options for Neff, who has enrolled in a new plan through California’s state-run insurance marketplace, Covered California. On Thursday, the exchange board voted unanimously that it would not extend canceled policies, rejecting the president’s proposed fix for the problem.Ìý

Neff’s policy has a $2,000 deductible and her premium will go up by $24 a month. Under the federal law, she’ll no longer have to pay for preventive care, and she figures that alone will more than make up for the additional premium costs.

“I’ve been paying for my mammograms out of pocket and that’s $400 to $450 per year,” says Neff. “That type of care is 100 percent covered under this new policy.”Ìý

Huge deductibles have been the norm for Tim Wilsbach, a 40-year-old TV editor who lives in Culver City with his family. Like Neff, Wilsbach also makes too much to qualify for federal subsidies, so when he received his cancellation notice a few weeks ago, he was worried his premium would go up.

Wilsbach has two plans for his family. The one being cancelled is a bare bones policy with an $11,000 deductible that he has for himself and his four-year-old son.

“It was not a great policy,” he says, “which is essentially why we had a second plan for my wife which we paid a little more for.”

Wilsbach and his wife are planning to have a second baby, so they bought a policy for her with better coverage and a $5,000 deductible.

After getting the cancellation notice, Wilsbach checked out plans on the Covered California website and he was pleasantly surprised. He found a plan for the whole family that offers broader coverage, a much lower $4,000 deductible and a more affordable monthly premium.Ìý

“Our premium went down, not quite 100 bucks, and just looking through what the plan covers versus what used to be covered, yeah, I’m quite happy about it,” Wilsbach says.

Jane Bradford, 52, is a stay-at-home mom in Pasadena. She’s losing the HMO insurance she has for herself and her three kids, who are 16, 21 and 23. Her policy offers low co-pays for doctor visits and a relatively low $3,000 family deductible, but she’ll shed no tears to see it go. Bradford says that’s because she’s found several plans that will cost hundreds less in monthly premiums – even though her husband’s income is too high for the family to qualify for a federal subsidy.Ìý

“Saving possibly $400 or more a month is awesome, so I’m not sad at all,” Bradford says.Ìý

None of this comes as a surprise to Micah Weinberg, a senior researcher at the Bay Area Council Economic Institute in San Francisco.Ìý

“A lot of the anecdotes about people having policies cancelled and gigantic increases are real but not representative of what’s happening more broadly in the marketplace,” Weinberg says.

Weinberg predicts many people who are losing their policies will come out ahead — even if their premiums go up — because of lower deductibles, full coverage of preventive care and no penalties for preexisting conditions. What’s more, he says, health insurance will almost certainly be cheaper for those who qualify for subsidies – in California, that’s an estimated .

This story is part of a partnership that includes , , and Kaiser Health News.

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This story is part of a reporting partnership that includes , NPR and Kaiser Health News.

Ìý

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Officials at Covered California — the Golden State’s health insurance marketplace Ìý— are placing a big bet on advertising to lure people to get health insurance. WithÌýa campaign boosted by $80 million from the federal government, they’ll tell peopleÌýabout theÌýAffordable CareÌýAct and encourageÌýuninsured citizens to buy health insurance.

Officials see the 15-month-long campaign —Ìýusing highway signs, ordinary people and stories to engage the viewer in English and Spanish — as a goodÌýway toÌýinspire the estimated 5.2 million uninsured Californians who will qualify to buy insurance on the state-run exchange beginning Jan. 1.

“You won’t be seeing movie stars,” says Covered California Executive Director Peter Lee. “You won’t be seeing rock stars. You’ll be seeing real people.”

The campaign of radio and television commercials begins on Labor Day with a month-long, three-city trial in San Diego, Sacramento and the Chico-Redding area of the northern Central Valley.

The first phase:Ìýhighway signs welcoming the viewer toÌý “a new state of health” (see above). Another “welcome” ad is in Spanish (below). More will roll out, including some focused on .”

“You’ll see people in their everyday lives doing things that could end up making them need health insurance,” says Covered California spokesmanÌýDana Howard.

This no-nonsense approach to promoting California’s insurance marketplace is a departure from ad campaigns in the nation.

Oregon, for instance, launched a $20 million media campaign with who croon not about the health law, per se, but rather about the virtues of living healthy in Oregon.

And in Minnesota, the state’s $9 million ad campaign for its MNsure state-run exchange relies on humor by employing and his blue ox Babe in a series of painful, yet pretty funny, mishaps.

Officials at Covered California said they’re stayingÌýserious with their ads, becauseÌýhealth insurance is not something to joke about.

“Things happen, and when these things do happen to you, it can mean the difference in whether you keep your job or you don’t,” HowardÌýsays. “Whether you keep your house or you don’t. It’s serious business.”

The ad campaign will expand statewide on Oct. 1, the same day that Covered California opens for enrollment, though consumers can sign up until the end of March to avoid the health law’s penalty for not having health insurance.

This story is part of a partnership that includes , , and Kaiser Health News..