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

BFDBFD

Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment

States Have To: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 CA’s inclusion of legal immigrants

including DACA students

Fulfilling the Promise 2014:Fulfilling the Promise 2014:Medi-Cal & Covered CA Medi-Cal & Covered CA

Expansion:Expansion:The Year One ChallengeThe Year One Challenge

Outreach & education, eligibility and mass enrollment is Outreach & education, eligibility and mass enrollment is a moral, public health, and financial imperativea moral, public health, and financial imperative

Major reforms Major reforms made it easier to get on and stay on made it easier to get on and stay on coverage:coverage:

– Streamlined and simplified enrollment in Medicaid, Covered Streamlined and simplified enrollment in Medicaid, Covered California and elsewhere; no wrong doors..California and elsewhere; no wrong doors..

– Expand integrated and funded system of enrollment Expand integrated and funded system of enrollment assistance and “navigation”: Call center employees, county assistance and “navigation”: Call center employees, county workers, brokers/agents, community enrollment counselors, workers, brokers/agents, community enrollment counselors, etc.etc.

– Goal to get millions of Californians covered in Year One and Goal to get millions of Californians covered in Year One and California gets all the federal help available.California gets all the federal help available.

– More to do: Smoother enrollment systems, online and More to do: Smoother enrollment systems, online and otherwise; more trained enrollment counselors on-the-otherwise; more trained enrollment counselors on-the-ground; More targeted outreach, in CA’s diverse ground; More targeted outreach, in CA’s diverse communities, in multiple languagescommunities, in multiple languages

– If successful, we will cover over half—maybe ultimately 2/3 If successful, we will cover over half—maybe ultimately 2/3 of California’s 7 million uninsured.of California’s 7 million uninsured.

California to Have 3 Million California to Have 3 Million Remaining UninsuredRemaining Uninsured

Who are the Remaining Who are the Remaining Uninsured?Uninsured?

800,000 undocumented and uninsured 800,000 undocumented and uninsured Californians—now 20% of the uninsured, will be Californians—now 20% of the uninsured, will be 27-33% of the remaining uninsured.27-33% of the remaining uninsured.– Even with immigration reform, many may be on a Even with immigration reform, many may be on a

long “path to citizenship.”long “path to citizenship.” Majority of remaining uninsured will be citizens Majority of remaining uninsured will be citizens

or legal residentsor legal residents Some frozen between “open enrollment” Some frozen between “open enrollment”

periodsperiods Affordability issues: i.e., workers with employer Affordability issues: i.e., workers with employer

based coverage for themselves but not family.based coverage for themselves but not family. Immigrants and communities of color:Immigrants and communities of color:

– Disproportionately benefit from coverage expansion. Disproportionately benefit from coverage expansion. Disproportionately part of the remaining uninsured.Disproportionately part of the remaining uninsured.

Who Needs More Help?Who Needs More Help?ACA has millions of “winners,” who have new coverage, ACA has millions of “winners,” who have new coverage, new access, and/or new financial help to afford coverage. new access, and/or new financial help to afford coverage. •And everyone wins with a health system more humane, And everyone wins with a health system more humane, more rational, more transparent, with a stronger safety-net, more rational, more transparent, with a stronger safety-net, new consumer protections and incentives aligned for new consumer protections and incentives aligned for improved quality and reduced cost.improved quality and reduced cost.

But But 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.

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.

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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.

County Low-Income Health County Low-Income Health Programs (LIHPs)Programs (LIHPs)

Early expansion of Medi-CalEarly expansion of Medi-Cal– 53 of 58 counties covered over 650,000 53 of 58 counties covered over 650,000

Californians with preventative and primary careCalifornians with preventative and primary care– Early care; Federal match; Relationship with Early care; Federal match; Relationship with

safety-net; Addressed pent-up demandsafety-net; Addressed pent-up demand– Transitioned to new Medi-Cal coverage Jan 1Transitioned to new Medi-Cal coverage Jan 1

Bridge to ReformBridge to Reform– No LIHP at all: Fresno, Merced, SLO, Santa No LIHP at all: Fresno, Merced, SLO, Santa

Barbara, Stanislaus.Barbara, Stanislaus.– Still under 133% eligibility: CMSP, Sacramento, Still under 133% eligibility: CMSP, Sacramento,

San Bernardino, Santa Cruz, Tulare.San Bernardino, Santa Cruz, Tulare.– What safety-net exists for those not What safety-net exists for those not

transitioned?transitioned?Maximizing Enrollment StrategiesMaximizing Enrollment Strategies

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)

#Health4All

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Health Dollars Health Dollars ReallocatedReallocated

As condition of Medi-Cal expansion, Gov As condition of Medi-Cal expansion, Gov Brown reallocated $1.4 billion in funds for Brown reallocated $1.4 billion in funds for counties for public health and indigent counties for public health and indigent care:care:

– $300 million in year one (Jan-June 2014)$300 million in year one (Jan-June 2014)– Counties to give back $ based on two formulas:Counties to give back $ based on two formulas:

60/40, where state takes back 60% of county 60/40, where state takes back 60% of county allocation, orallocation, or

““Cost based formula,” where county keeps $, gives Cost based formula,” where county keeps $, gives back up 80% of revenues/savings, up to a % based on back up 80% of revenues/savings, up to a % based on historical costs. historical costs.

Formula Decisions Due January 22, Formula Decisions Due January 22, 20142014

Other Actions Likely ConcurrentOther Actions Likely Concurrent

OverviewOverviewCounties 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 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)

If the counties do not adopt a resolution or fail to If the counties do not adopt a resolution or fail to inform DHCS of their chosen option, then the inform DHCS of their chosen option, then the calculation is 62.5% of County Realignment funds calculation is 62.5% of County Realignment funds and 62.5% of the MOE.and 62.5% of the MOE.

Counties that select the 60%/40% option may later Counties that select the 60%/40% option may later petition the Health Care Funding Resolution Committee petition the Health Care Funding Resolution Committee to elect the formula option.to elect the formula option.

Article 13 CountiesArticle 13 Counties 1818

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: In court seeking to get out of court order Fresno: In court seeking to get out of court order and to eliminate MISP: Hearing February 26thand to eliminate MISP: Hearing February 26th

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 Medical The Lessons of LIHP: Primary/Preventative Medical

Home, rather than episodic/emergency careHome, rather than episodic/emergency care– 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, Santa Los Angeles, Alameda, San Francisco, Santa

Clara, San Mateo, Etc.Clara, San Mateo, Etc.Advocacy:Advocacy:

– Counties That Cut Undocumented Care in 2009: Counties That Cut Undocumented Care in 2009: Sacramento, Contra Costa, YoloSacramento, Contra Costa, Yolo

– Public Hospital Counties have incentives to be Public Hospital Counties have incentives to be efficient: San Bernardino, Monterey, San Joaquin, efficient: San Bernardino, Monterey, San Joaquin, etc.etc.

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

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); including DACA Dream Act students. including DACA Dream Act students.

Potential complementary proposals to mirror ACA:Potential complementary proposals to mirror ACA: Maintaining existing state-specific programs and Maintaining existing state-specific programs and servicesservices

State-only Medi-Cal for those not legally present, similar State-only Medi-Cal for those not legally present, similar to other non-federally covered populationsto other non-federally covered populations

–Building off emergency Medi-CalBuilding off emergency Medi-Cal

Mirror Exchange, a 3rd exchange operated by Covered California board, funded by state funds/premiums paid by enrollees, for all not eligible for federally approved Exchanges.

                                                                                                                                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 LEGISLATIVE CAMPAIGN BEGINSBEGINS

Core MessagesCore Messages

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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.

Strategy & Strategy & TacticsTactics

Focused Attention:Focused Attention: CountiesCounties

– SupervisorsSupervisors– AdministratorAdministrator– Health DepartmentsHealth Departments

StateState– GovernorGovernor– State Legislative LeadersState Legislative Leaders– Legislative ProcessLegislative Process– Budget ProcessBudget Process

Obstacles: Money, Messaging, Priorities, Obstacles: Money, Messaging, Priorities, PoliticsPolitics

Organizing and Organizing and CommunicationsCommunications

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Next Steps: Fulfilling the Full Next Steps: Fulfilling the Full Promise of Health ReformPromise of Health Reform

““What we are getting here is not a mansion but a starter home. What we are getting here is not a mansion but a starter home. It’s got a good foundation: 30 million Americans are covered. It’s It’s got a good foundation: 30 million Americans are covered. It’s got a good roof: A lot of protections from abuses by insurance got a good roof: A lot of protections from abuses by insurance companies. It’s got a lot of nice stuff in there for prevention and companies. It’s got a lot of nice stuff in there for prevention and wellness. But, we can build additions as we go along in the wellness. But, we can build additions as we go along in the future” –Senator Tom Harkinfuture” –Senator Tom Harkin

Including the Excluded/Covering the UndocumentedIncluding the Excluded/Covering the UndocumentedFixing the Flaws in the Law/Closing GapsFixing the Flaws in the Law/Closing GapsMore on Affordability & Cost ContainmentMore on Affordability & Cost ContainmentEmployer-Based Coverage [AB880(Gomez)]Employer-Based Coverage [AB880(Gomez)]Rate RegulationRate RegulationPublic Option/Single-PayerPublic Option/Single-Payer

A Platform For MoreA Platform For MoreOn Other IssuesOn Other Issues

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

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