Protecting the Safety Net and Providing Medical Home Coverage, Including for Our Immigrant Communities
Anthony Wright, Executive DirectorFulfilling the Promise:Finishing the Job of Covering the Remaining Uninsured
BFDBiggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment
States Have To:
CALIFORNIA IMPLEMENTSMillions with new consumer protections; financial assistance1.5+ 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 CAs inclusion of legal immigrantsincluding DACA students
Fulfilling the Promise 2014:Medi-Cal & Covered CA Expansion:The Year One Challenge
Outreach & education, eligibility and mass enrollment is a moral, public health, and financial imperative Major reforms made it easier to get on and stay on coverage:Streamlined and simplified enrollment in Medicaid, Covered California and elsewhere; no wrong doors..Expand integrated and funded system of enrollment assistance and navigation: Call center employees, county workers, brokers/agents, community enrollment counselors, etc.Goal to get millions of Californians covered in Year One and California gets all the federal help available.More to do: Smoother enrollment systems, online and otherwise; more trained enrollment counselors on-the-ground; More targeted outreach, in CAs diverse communities, in multiple languagesIf successful, we will cover over halfmaybe ultimately 2/3 of Californias 7 million uninsured.
California to Have 3 Million Remaining Uninsured
Not eligible due to immigration status
No offer of affordable coverage (>8% income)
Eligible for Medi-Cal
Other (has an affordable coverage offer from Exchange or Employer)
Remaining Uninsured, 2019Not eligible due to immigration statusNo offer of affordable coverage (>8% income)Eligible for Medi-CalOther (has an affordable coverage offer from Exchange or Employer)Total
Who are the Remaining Uninsured?800,000 undocumented and uninsured Californiansnow 20% of the uninsured, will be 27-33% of the remaining uninsured.Even with immigration reform, many may be on a long path to citizenship.Majority of remaining uninsured will be citizens or legal residentsSome frozen between open enrollment periodsAffordability issues: i.e., workers with employer based coverage for themselves but not family.Immigrants and communities of color:Disproportionately benefit from coverage expansion. Disproportionately part of the remaining uninsured.
Who Needs More Help?ACA has millions of winners, who have new coverage, new access, and/or new financial help to afford coverage. And everyone wins with a health system more humane, more rational, more transparent, with a stronger safety-net, new consumer protections and incentives aligned for improved quality and reduced cost.But on affordability, some folks will need more help:Uninsured undocumented immigrantsThose in family glitch: family members for workers with employer based coverage affordable for just themselvesSome over 400% federal poverty level (typically older, in high-cost areas) who dont have affordability guarantee.Those in Exchange who find monthly premiums/cost sharing still a burden, and may/may not decline coverage.
Our Current Safety-NetUninsured live sicker, die younger, one emergency from the financial ruin.Emergency Rooms: But only to stabilize emergencies; Bill and debt afterwards 2006 Fair Hospital Pricing Law www.hospitalbillhelp.orgPrivate providers: clinics, hospital charity careCounties. Counties have a 17000 obligation to provide basic care Counties vary widely on their service to the uninsured:Amidst 58 counties, 12 have public hospitals;12 Article 13 counties just have clinics, or contract with private providers; or are a hybrid36 small rural counties in County Medical Service ProgramSome serve the undocumented; others do not.
Surveying Californias Commitment to the Remaining Uninsured
Working with community partner organizations, we surveyed what counties currently do for the remaining uninsuredand what their plans are in this transition.
Initial findings: In some counties, remarkable and innovative progress in providing a medical home for all Californians. In other counties, a thin safety-net may get thinner.
An uneven safety-net across the state: Different eligibility with regard to income levels, age, immigration, and medical need, different benefits, services, and infrastructure.
How to have a safety-net that survives and thrives; and provide a medical home for those who dont qualify for ACA.
County Low-Income Health Programs (LIHPs)
Early expansion of Medi-Cal53 of 58 counties covered over 650,000 Californians with preventative and primary careEarly care; Federal match; Relationship with safety-net; Addressed pent-up demandTransitioned to new Medi-Cal coverage Jan 1Bridge to ReformNo LIHP at all: Fresno, Merced, SLO, Santa Barbara, Stanislaus.Still under 133% eligibility: CMSP, Sacramento, San Bernardino, Santa Cruz, Tulare.What safety-net exists for those not transitioned?Maximizing Enrollment Strategies
Which County Safety-Nets Serve Patients Not Legally Present?
AlamedaContra Costa (only children)Fresno (
Health Dollars Reallocated
As condition of Medi-Cal expansion, Gov Brown reallocated $1.4 billion in funds for counties for public health and indigent care:
$300 million in year one (Jan-June 2014)Counties to give back $ based on two formulas:60/40, where state takes back 60% of county allocation, orCost based formula, where county keeps $, gives back up 80% of revenues/savings, up to a % based on historical costs.
Formula Decisions Due January 22, 2014Other Actions Likely Concurrent
OverviewCounties have 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 countys 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)If the counties do not adopt a resolution or fail to inform DHCS of their chosen option, then the calculation is 62.5% of County Realignment funds and 62.5% of the MOE.
Counties that select the 60%/40% option may later petition the Health Care Funding Resolution Committee to elect the formula option.Article 13 Counties*
Article 13 Counties
Facing State & Federal Cuts & UncertaintyRetrenchment in Some CountiesCMSP: Eliminated optometry, mental health, substance abuse; reduced dental; shortened certification to 3 months.Fresno: In court seeking to get out of court order and to eliminate MISP: Hearing February 26thMany Other Counties in Wait and See ModeNothing in Funding Formula Requires Cuts in EligibilityAllows Full Reimbursement of Services for What Counties Provide NowLimits Are On Use of State $ For Going Further
ACA Provides Significant Savings to State/CountiesWith Many Covered, Time to:Re-Orient Safety-Net, Do It BetterThe Lessons of LIHP: Primary/Preventative Medical Home, rather than episodic/emergency careExtending Eligibility to the Remaining Uninsured Now We Can Say YesLos Angeles, Alameda, San Francisco, Santa Clara, San Mateo, Etc.Advocacy:Counties That Cut Undocumented Care in 2009: Sacramento, Contra Costa, YoloPublic Hospital Counties have incentives to be efficient: San Bernardino, Monterey, San Joaquin, etc.
Undocumented explicitly excluded from federal help; even under immigration reform, many aspiring citizens will be on a path to citizenship of over a decade, restricted from federal help with health care. So even with immigration reform, this issue remains for local policymakers, states, counties, and private providers.
MAXIMIZE ENROLLMENT: Continue efforts to maximize enrollment of those who are eligible but not enrolled.
EMPLOYER-BASED COVERAGE: Most undocumented residents are working, and some are covered through on-the-job benefits. The more we promote employer-based coverage, the more we cover. (i.e. AB880)
SAFETY-NET FUNDING: From the county safety-net and public hospital dollars to funding for community clinics (like restoring EAPC).
STATE-ONLY/MIRROR PROGRAMS: Philosophically, all Californians should be eligible for the level of benefits offered by the Affordable Care Act. If federal government doesnt provide, state can go on its own.
Continuing Californias Commitment to Covering Immigrants
Progress made on California-specific efforts to cover:legal immigrants, including recent immigrants here less than 5 years;People Residing Under the Color of Law (PRUCOL); including DACA Dream Act students.
Potential complementary proposals to mirror ACA: Maintaining existing state-specific programs and services