Protecting the Safety Net and Providing Medical Protecting the Safety Net and Providing Medical Home Coverage, Including for Our Immigrant Home Coverage, Including for Our Immigrant

CommunitiesCommunities

Anthony Wright, Executive DirectorAnthony Wright, Executive Director

Fulfilling the Promise:Fulfilling the Promise:Finishing the Job of Covering Finishing the Job of Covering

the Remaining Uninsuredthe Remaining Uninsured

www.health-access.org

www.facebook.com/healthaccess

www.twitter.com/healthaccess

CALIFORNIA IMPLEMENTSMillions with new consumer protections; financial assistance3.5+ million Californians with new coverage already

CALIFORNIA IMPROVESEARLY:* Low-Income Health Programs* Children with pre-existing conditions* Maternity coverageBETTER:* Exchange that negotiates & standardizes* Medi-Cal express lane enrollment options* Continuing CA’s inclusion of legal immigrants

including DACA students

California May Have 3 California May Have 3 Million Remaining Million Remaining

UninsuredUninsured

Who Needs More Help?Who Needs More Help?ACA has millions of “winners,” who have new coverage, new ACA has millions of “winners,” who have new coverage, new access, and/or new financial help to afford coverage. access, and/or new financial help to afford coverage. Everyone wins with a health system more humane, more Everyone wins with a health system more humane, more rational, more transparent, with new consumer protections rational, more transparent, with new consumer protections and incentives aligned for improved quality & reduced cost. and incentives aligned for improved quality & reduced cost. Issues remain:Issues remain:•Medi-Cal year-round, but can be frozen out of Covered CAMedi-Cal year-round, but can be frozen out of Covered CA•No mandate if coverage is more than 8%No mandate if coverage is more than 8%

And And on affordability, some folks will need more helpon affordability, some folks will need more help::•Uninsured undocumented immigrantsUninsured undocumented immigrants•Those in “family glitch”: family members for workers with Those in “family glitch”: family members for workers with employer based coverage affordable for just themselvesemployer based coverage affordable for just themselves•Some over 400% federal poverty level (typically older, in Some over 400% federal poverty level (typically older, in high-cost areas) who don’t have affordability guarantee.high-cost areas) who don’t have affordability guarantee.•Those in Exchange who find monthly premiums/cost Those in Exchange who find monthly premiums/cost sharing still a burden, and may/may not decline coverage.sharing still a burden, and may/may not decline coverage.

Making #Health4All History Making #Health4All History *This Year**This Year*

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Continuing California’s Coverage of “Deferred Continuing California’s Coverage of “Deferred Action” Immigrants: Action” Immigrants: The President’s executive action The President’s executive action had the impact of expanding the category of immigrants had the impact of expanding the category of immigrants covered by state-funded Medi-Cal. covered by state-funded Medi-Cal. We need to defend We need to defend and secure this major victory. Also: and secure this major victory. Also:

Secure and Expand our County Safety-Net Secure and Expand our County Safety-Net Programs: Programs: Counties are the last resort of coverage. Counties are the last resort of coverage. Some counties are enhancing their safety-net for the Some counties are enhancing their safety-net for the remaining uninsured, with programs like My Health LA. remaining uninsured, with programs like My Health LA. We need to encourage more counties to care for the We need to encourage more counties to care for the undocumented.undocumented.

Making Progress to a Statewide Solution for Making Progress to a Statewide Solution for #Health4All:#Health4All: An effort now in its third year, we can An effort now in its third year, we can take another step to Health4All, expanding Medi-Cal to take another step to Health4All, expanding Medi-Cal to more immigrants, and setting up the structure for a more immigrants, and setting up the structure for a mirror marketplace so everyone can seek coverage.mirror marketplace so everyone can seek coverage.

Our Current Safety-NetOur Current Safety-Net Uninsured live sicker, die younger, one Uninsured live sicker, die younger, one

emergency from the financial ruin.emergency from the financial ruin. Emergency Rooms: But only to stabilize Emergency Rooms: But only to stabilize

emergencies; Bill and debt afterwards emergencies; Bill and debt afterwards – 2006 Fair Hospital Pricing Law 2006 Fair Hospital Pricing Law

www.hospitalbillhelp.org Private providers: clinics, hospital charity Private providers: clinics, hospital charity

carecare Counties. Counties.

– Counties have a “17000” obligation to provide basic care Counties have a “17000” obligation to provide basic care – Counties vary widely on their service to the uninsured:Counties vary widely on their service to the uninsured:– Amidst 58 counties, 12 have public hospitals;Amidst 58 counties, 12 have public hospitals;– 12 “Article 13” counties just have clinics, or contract with 12 “Article 13” counties just have clinics, or contract with

private providers; or are a hybridprivate providers; or are a hybrid– 36 small rural counties in County Medical Service 36 small rural counties in County Medical Service

ProgramProgram– Some serve the undocumented; others do not.Some serve the undocumented; others do not.

3 Flavors of Counties3 Flavors of CountiesPUBLIC HOSPITALPUBLIC HOSPITAL•AlamedaAlameda•Contra CostaContra Costa•KernKern•Los AngelesLos Angeles•MontereyMonterey•RiversideRiverside•San BernardinoSan Bernardino•San FranciscoSan Francisco•San JoaquinSan Joaquin•San MateoSan Mateo•Santa ClaraSanta Clara•VenturaVentura

““ARTICLE 13” ARTICLE 13” FresnoFresnoMerced Merced OrangeOrangePlacerPlacerSacramentoSacramentoSan DiegoSan DiegoSan Luis ObispoSan Luis ObispoSanta BarbaraSanta BarbaraSanta CruzSanta CruzStanislausStanislausTulareTulareYolo*Yolo*

Others are part of CMSPOthers are part of CMSP(County Medical Services Program)(County Medical Services Program) 99

1010

Surveying California’s Surveying California’s Commitment to the Remaining Commitment to the Remaining

UninsuredUninsured Working with community partner organizations, we Working with community partner organizations, we surveyed what counties currently do for the remaining surveyed what counties currently do for the remaining uninsured—and what their plans are in this transition.uninsured—and what their plans are in this transition.

Initial findings: In some counties, Initial findings: In some counties, remarkable and remarkable and innovative progressinnovative progress in providing a medical home for all in providing a medical home for all Californians.Californians. In other counties, a In other counties, a thin safety-net may get thinnerthin safety-net may get thinner..

An An uneven safety-net uneven safety-net across the state: Different across the state: Different eligibility with regard to income levels, age, immigration, eligibility with regard to income levels, age, immigration, and medical need, different benefits, services, and and medical need, different benefits, services, and infrastructure.infrastructure.

How to have a safety-net that survives and thrives; and How to have a safety-net that survives and thrives; and provide a medical home for those who don’t qualify for provide a medical home for those who don’t qualify for ACA. ACA.

Which Which County County

Safety-Nets Safety-Nets Serve Serve

Patients Not Patients Not Legally Legally

Present?Present?AlamedaAlameda

Contra Costa (only children)Contra Costa (only children)Fresno (<67% FPL)Fresno (<67% FPL)

KernKernLos Angeles (<133% FPL)Los Angeles (<133% FPL)

Riverside Riverside San FranciscoSan Francisco

San MateoSan MateoSanta ClaraSanta Clara

Santa Cruz (<100%FPL)Santa Cruz (<100%FPL)

(Most to 200% FPL or more)(Most to 200% FPL or more)

Some County Health $ Some County Health $ ReallocatedReallocatedCounties had

2 optionsfor determining the redirected amount.

Each county must inform DHCS of tentative decision

by 11/1/13Must adopt a resolution by

1/22/14

60% of 1991 Health Realignment Funds

+60% of Maintenance of

Effort Maintenance of Effort is capped at 14.6% of the total value of each county’s 10-11

allocation.

County Savings Determination Process

(Formula)Lesser of:

(Revenues-Costs) x .80(.70 in 13/14)

Or County Indigent Care Health Realignment

Amount(=Health Realignment

Amount x Health Realignment Indigent Care Percentage)

With the Medi-Cal With the Medi-Cal expansion, AB85 expansion, AB85 reallocated up toreallocated up to$900 million of $1.4 $900 million of $1.4 billion in funds for billion in funds for countiescountiesfor public health and for public health and indigent careindigent care

Article 13 CountiesArticle 13 Counties 1313

Steps Backward?Steps Backward?

Facing State & Federal Cuts & UncertaintyFacing State & Federal Cuts & Uncertainty Retrenchment in Some CountiesRetrenchment in Some Counties

– CMSP: Eliminated optometry, mental health, CMSP: Eliminated optometry, mental health, substance abuse; reduced dental; shortened substance abuse; reduced dental; shortened certification to 3 months.certification to 3 months.

– Fresno: Preliminary vote to eliminate MISP: Fresno: Preliminary vote to eliminate MISP: Effort to change safety-net program from Effort to change safety-net program from hospital contracthospital contract

Many Other Counties in “Wait and See” Many Other Counties in “Wait and See” ModeMode

Nothing in Funding Formula Requires Cuts Nothing in Funding Formula Requires Cuts in Eligibility—Allows Full Reimbursement of in Eligibility—Allows Full Reimbursement of Services for What Counties Provide NowServices for What Counties Provide Now– Limits Are On Use of State $ For Going FurtherLimits Are On Use of State $ For Going Further

Steps ForwardSteps Forward

ACA Provides Significant Savings to ACA Provides Significant Savings to State/CountiesState/CountiesWith Many Covered, Time to:With Many Covered, Time to:

– Re-Orient Safety-Net, Do It BetterRe-Orient Safety-Net, Do It Better– The Lessons of LIHP: Primary/Preventative The Lessons of LIHP: Primary/Preventative

Medical Home, rather than episodic/emergency Medical Home, rather than episodic/emergency carecare

– Extending Eligibility to the Remaining Uninsured Extending Eligibility to the Remaining Uninsured ““Now We Can Say Yes”Now We Can Say Yes”

– Los Angeles, Alameda, San Francisco, Los Angeles, Alameda, San Francisco, Santa Clara, San Mateo, Etc.Santa Clara, San Mateo, Etc.

Bridges to a Statewide SolutionBridges to a Statewide Solution

SACRAMENTO COUNTYSACRAMENTO COUNTYOpportunities to Expand Access for Opportunities to Expand Access for UndocumentedUndocumentedCounties that Cut Undocumented Care in 2009:Counties that Cut Undocumented Care in 2009:

– Sacramento, Yolo, Contra CostaSacramento, Yolo, Contra CostaOthers, including Public Hospital Counties have Others, including Public Hospital Counties have incentives to coordinate care: San Bernardino, incentives to coordinate care: San Bernardino, Monterey, San Joaquin, etMonterey, San Joaquin, et

In Sacramento & Elsewhere, New SupervisorsIn Sacramento & Elsewhere, New SupervisorsIssues:Issues:

– Political WillPolitical Will– FundingFunding– Administering/Providers/LogisticsAdministering/Providers/Logistics– Interplay Between Supervisors & County Interplay Between Supervisors & County

AdministrationAdministration

Statewide SolutionsStatewide Solutions

Undocumented explicitly excluded from federal help;Undocumented explicitly excluded from federal help; even even under immigration reform, many aspiring citizens will be on a under immigration reform, many aspiring citizens will be on a “path to citizenship” of over a decade, restricted from federal “path to citizenship” of over a decade, restricted from federal help with health care. So even with immigration reform, help with health care. So even with immigration reform, this this issue remains for local policymakers, states, counties, and issue remains for local policymakers, states, counties, and private providers. private providers.

MAXIMIZE ENROLLMENT: MAXIMIZE ENROLLMENT: Continue efforts to maximize enrollment of those who are eligible but not enrolled.

EMPLOYER-BASED COVERAGE: EMPLOYER-BASED COVERAGE: Most undocumented Most undocumented residents are working, and some are covered through on-the-job residents are working, and some are covered through on-the-job benefits. The more we promote employer-based coverage, the benefits. The more we promote employer-based coverage, the more we cover. (i.e. AB880)more we cover. (i.e. AB880)

SAFETY-NET FUNDING: SAFETY-NET FUNDING: From the county safety-net and public From the county safety-net and public hospital dollars to funding for community clinics (like restoring hospital dollars to funding for community clinics (like restoring EAPC).EAPC).

STATE-ONLY/MIRROR PROGRAMS: STATE-ONLY/MIRROR PROGRAMS: Philosophically, all Philosophically, all Californians should be eligible for the level of benefits offered by Californians should be eligible for the level of benefits offered by the Affordable Care Act. If federal government doesn’t provide, the Affordable Care Act. If federal government doesn’t provide, state can go on its own.state can go on its own.

                                                                                                                                RICH PEDRONCELLI, ASSOCIATED PRESS

The chairman of the California Legislative Latino Caucus plans to propose a new law that would expand access to health insurance for all Californians, including those living in the country illegally.

State Sen. Ricardo Lara, D-Bell Gardens, is working with a broad coalition of organizations to map out the details of a bill that would cover undocumented immigrants, who are excluded from insurance coverage under the national Affordable Care Act, or ACA.

“Immigration status shouldn’t bar individuals from health coverage, especially since their taxes contribute to the growth of our economy,” Lara said in a news release.

NEWS

State senator wants health care for all immigrantsBy ROXANA KOPETMAN / ORANGE COUNTY REGISTERPublished: Jan. 10, 2014 Updated: 6:04 p.m.

LEGISLATIVE CAMPAIGN FOR A LEGISLATIVE CAMPAIGN FOR A STATEWIDE SOLUTIONSTATEWIDE SOLUTION

Continuing California’s Continuing California’s Commitment to Covering Commitment to Covering

ImmigrantsImmigrants Progress made on California-specific efforts to cover:Progress made on California-specific efforts to cover:

–legal immigrants, including recent immigrants here legal immigrants, including recent immigrants here less than 5 years;less than 5 years;–People Residing Under the Color of Law (PRUCOL); People Residing Under the Color of Law (PRUCOL); now including DACA Dream Act students!now including DACA Dream Act students!

Legislative proposal to mirror ACA: SB4(Lara)Legislative proposal to mirror ACA: SB4(Lara)formerly SB1005(Lara):formerly SB1005(Lara): Maintaining existing state-specific programs and Maintaining existing state-specific programs and servicesservices State-only Medi-Cal for those not legally present, State-only Medi-Cal for those not legally present, similar to other non-federally covered populationssimilar to other non-federally covered populations

–Building off emergency Medi-CalBuilding off emergency Medi-Cal Mirror Marketplace, a 3rd exchange operated by Covered California board, funded by state funds/premiums paid by enrollees, for those not eligible for federally approved Exchange subsidies.

Financing #Health4AllFinancing #Health4AllLOS ANGELES TIMES:LOS ANGELES TIMES:

““Study sees modest costs in Study sees modest costs in healthcare for immigrants here healthcare for immigrants here illegally”illegally”By Patrick McGreevy * May 21, 2014By Patrick McGreevy * May 21, 2014

Increased health of poor Californians could reduce Increased health of poor Californians could reduce costs down the road, study sayscosts down the road, study says

Extending healthcare to people in the country illegally would cost the state a modest Extending healthcare to people in the country illegally would cost the state a modest amount more but would significantly improve health while potentially saving money amount more but would significantly improve health while potentially saving money for taxpayers down the road, according to a study released Wednesday.for taxpayers down the road, according to a study released Wednesday.

The study by the UCLA Center for Health Policy Research estimates that the net The study by the UCLA Center for Health Policy Research estimates that the net increase in state spending would be equivalent to 2% of state Medi-Cal spending, or increase in state spending would be equivalent to 2% of state Medi-Cal spending, or between $353 million and $369 million next year, while the net increase in spending between $353 million and $369 million next year, while the net increase in spending would be up to $436 million in 2019. Enrollment in Medi-Cal would increase by up to would be up to $436 million in 2019. Enrollment in Medi-Cal would increase by up to 730,000 people next year and up to 790,000 in four years.730,000 people next year and up to 790,000 in four years.

Financing #Health4AllFinancing #Health4All These Californians already in our health system today, These Californians already in our health system today,

getting care in the most expensive, least efficient way.getting care in the most expensive, least efficient way. More effectiively use existing dollars & revenue More effectiively use existing dollars & revenue

streams:streams:– Maintaining funds for restricted scope Medi-Cal for emergency Maintaining funds for restricted scope Medi-Cal for emergency

carecare– Savings from existing programs that serve this populationSavings from existing programs that serve this population– Natural recoupment from county realignment formulaNatural recoupment from county realignment formula– Leverage existing MCO and hospital provider feeLeverage existing MCO and hospital provider fee– More effectively use existing state-only Medi-CalMore effectively use existing state-only Medi-Cal– Opportunities under the Medi-Cal waiverOpportunities under the Medi-Cal waiver

President Obama’s executive action and deferred actionPresident Obama’s executive action and deferred action Decisions to deal with the remaining costs:Decisions to deal with the remaining costs:

– Additional revenues face a 2/3 voteAdditional revenues face a 2/3 vote– Making this a budget priorityMaking this a budget priority, against other priorities, against other priorities– Phasing in/starting with a down payment with aPhasing in/starting with a down payment with a proposal proposal

under a certain dollar amount.under a certain dollar amount.

#Health4All

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Core MessagesCore Messages

2323

Investing in California: Investing in California: Undocumented Californians are an Undocumented Californians are an economic engine for the state. An overwhelming percentage economic engine for the state. An overwhelming percentage work and pay taxes. They are an economic asset. Investing in work and pay taxes. They are an economic asset. Investing in them is investing in our state.them is investing in our state.

Prevention Makes Economic Sense: Prevention Makes Economic Sense: Emergency room Emergency room treatment is an expensive substitute for preventive care. It treatment is an expensive substitute for preventive care. It makes economic sense to invest in preventive services that makes economic sense to invest in preventive services that minimize the risk of chronic disease and more chronic minimize the risk of chronic disease and more chronic treatment later on.treatment later on.

Increasing Access to Affordable Care is the Responsible Increasing Access to Affordable Care is the Responsible Thing to do:Thing to do: Everyone—regardless of ability to pay or legal Everyone—regardless of ability to pay or legal status—should have access to affordable health care. After status—should have access to affordable health care. After Obamacare, the remaining uninsured, including the Obamacare, the remaining uninsured, including the undocumented, should have access to affordable care, undocumented, should have access to affordable care, including a comprehensive set of preventive services and a including a comprehensive set of preventive services and a health home.health home.

Organizing and Organizing and Communications: We Need Communications: We Need Action & Stories!Action & Stories!

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Opportunities Opportunities This YearThis Year

Focused Attention:Focused Attention:Now-JuneNow-June CountiesCounties

– SupervisorsSupervisors– AdministratorAdministrator– Health DepartmentsHealth Departments

StateState– GovernorGovernor– State Legislative LeadersState Legislative Leaders– Legislative ProcessLegislative Process– Budget ProcessBudget ProcessObstacles: Money, Messaging, Priorities, Obstacles: Money, Messaging, Priorities,

PoliticsPolitics

For more informationFor more informationWebsite: http://www.health-access.orgWebsite: http://www.health-access.orgBlog: http://blog.health-access.org Blog: http://blog.health-access.org

Facebook: www.facebook.com/healthaccessFacebook: www.facebook.com/healthaccessTwitter: www.twitter.com/healthaccessTwitter: www.twitter.com/healthaccess

Health Access CaliforniaHealth Access California1127 111127 11thth Street, Suite 234, Street, Suite 234, SacramentoSacramento, CA 95814, CA 95814916-497-0923916-497-0923

414 13414 13thth Street, Suite 450, Street, Suite 450, OaklandOakland, CA 95612, CA 95612510-873-8787510-873-8787

1930 Wilshire Blvd., Suite 916, 1930 Wilshire Blvd., Suite 916, Los AngelesLos Angeles, CA 90057, CA 90057213-413-3587213-413-3587