Fulfilling the Promise:
Finishing the Job of Covering
the Remaining Uninsured
Protecting the Safety Net and Providing Medical Home
Coverage, Including for Our Immigrant Communities
Anthony Wright, Executive Director
Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment
States Have To:
Millions with new consumer protections; financial assistance
1.5+ million Californians with new coverage already
* Low-Income Health Programs
* Children with pre-existing conditions
* Maternity coverage
* Exchange that negotiates & standardizes
* Medi-Cal express lane enrollment options
* Continuing CA’s inclusion of legal immigrants
including 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 CA’s diverse communities, in multiple languages
If successful, we will cover over half—maybe ultimately 2/3 of
California’s 7 million uninsured.
California to Have 3 Million
Remaining Uninsured
Who are the Remaining Uninsured?
800,000 undocumented and uninsured
Californians—now 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 residents
 Some frozen between “open enrollment” periods
 Affordability 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 safetynet, new consumer protections and incentives aligned for
improved quality and reduced cost.
But on affordability, some folks will need more help:
• Uninsured undocumented immigrants
• Those in “family glitch”: family members for workers with
employer based coverage affordable for just themselves
• Some over 400% federal poverty level (typically older, in
high-cost areas) who don’t have affordability guarantee.
• Those in Exchange who find monthly premiums/cost
sharing still a burden, and may/may not decline coverage.
Our Current Safety-Net
Uninsured 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
Private providers: clinics, hospital charity care
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 hybrid
– 36 small rural counties in County Medical Service Program
– Some serve the undocumented; others do not.
Surveying California’s
Commitment to the Remaining
Working with community partner organizations, we
surveyed what counties currently do for the remaining
uninsured—and what their plans are in this transition.
Initial findings: In some counties, remarkable and
innovative progress in providing a medical home for all
 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 don’t qualify for ACA.
County Low-Income Health
Programs (LIHPs)
Early expansion of Medi-Cal
– 53 of 58 counties covered over 650,000 Californians
with preventative and primary care
– Early care; Federal match; Relationship with safetynet; Addressed pent-up demand
– Transitioned to new Medi-Cal coverage Jan 1
Bridge to Reform
– No LIHP at all: Fresno, Merced, SLO, Santa Barbara,
– Still under 133% eligibility: CMSP, Sacramento, San
Bernardino, Santa Cruz, Tulare.
– What safety-net exists for those not transitioned?
Maximizing Enrollment Strategies
Which County
Patients Not
Contra Costa (only children)
Fresno (<67% FPL)
Los Angeles (<133% FPL)
San Francisco
San Mateo
Santa Clara
Santa Cruz (<100%FPL)
(Most to 200% FPL or more)
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, or
 “Cost based formula,” where county keeps $, gives back up
80% of revenues/savings, up to a % based on historical costs.
Formula Decisions Due January 22, 2014
Other Actions Likely Concurrent
Counties have 2
for determining the
redirected amount.
Each county must inform DHCS of
tentative decision by 11/1/13
Must 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.
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.
County Savings Determination
Process (Formula)
Lesser of:
(Revenues-Costs) x .80
(.70 in 13/14)
County Indigent Care Health
Realignment Amount
(=Health Realignment Amount x
Health Realignment Indigent Care
Counties that select the 60%/40% option may later petition the
Health Care Funding Resolution Committee to elect the formula
Article 13 Counties
Steps Backward?
Facing State & Federal Cuts & Uncertainty
Retrenchment in Some Counties
– CMSP: Eliminated optometry, mental health, substance
abuse; reduced dental; shortened certification to 3
– Fresno: In court seeking to get out of court order and
to eliminate MISP: Hearing February 26th
Many Other Counties in “Wait and See” Mode
Nothing in Funding Formula Requires Cuts in
Eligibility—Allows Full Reimbursement of Services
for What Counties Provide Now
– Limits Are On Use of State $ For Going Further
Steps Forward
ACA Provides Significant Savings to
 With Many Covered, Time to:
– Re-Orient Safety-Net, Do It Better
– The Lessons of LIHP: Primary/Preventative Medical
Home, rather than episodic/emergency care
– Extending Eligibility to the Remaining Uninsured
“Now We Can Say Yes”
– Los Angeles, Alameda, San Francisco, Santa
Clara, San Mateo, Etc.
 Advocacy:
– Counties That Cut Undocumented Care in 2009:
Sacramento, Contra Costa, Yolo
– Public Hospital Counties have incentives to be efficient:
San Bernardino, Monterey, San Joaquin, etc.
Statewide Solutions
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.
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 doesn’t provide, state can go on its own.
Continuing California’s
Commitment to Covering
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
State-only Medi-Cal for those not legally present, similar to
other non-federally covered populations
–Building 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
State senator wants
health care for all
Published: Jan. 10, 2014 Updated: 6:04 p.m.
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
“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.
Core Messages
Investing in California: Undocumented Californians are an
Prevention Makes Economic Sense: Emergency room treatment
Increasing Access to Affordable Care is the Responsible
Thing to do: Everyone—regardless of ability to pay or legal status—
economic engine for the state. An overwhelming percentage work
and pay taxes. They are an economic asset. Investing in them is
investing in our state.
is an expensive substitute for preventive care. It makes economic
sense to invest in preventive services that minimize the risk of
chronic disease and more chronic treatment later on.
should have access to affordable health care. After Obamacare, the
remaining uninsured, including the undocumented, should have
access to affordable care, including a comprehensive set of
preventive services and a health home.
Strategy &
Focused Attention:
 Counties
– Supervisors
– Administrator
– Health Departments
State Legislative Leaders
Legislative Process
Budget Process
Obstacles: Money, Messaging, Priorities, Politics
Organizing and Communications
Next Steps: Fulfilling the Full
Promise of Health Reform
“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 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 wellness. But, we can build additions
as we go along in the future” –Senator Tom Harkin
Including the Excluded/Covering the Undocumented
Fixing the Flaws in the Law/Closing Gaps
More on Affordability & Cost Containment
Employer-Based Coverage [AB880(Gomez)]
Rate Regulation
Public Option/Single-Payer
A Platform For More
On Other Issues
For more information
Website: http://www.health-access.org
Blog: http://blog.health-access.org
Facebook: www.facebook.com/healthaccess
Twitter: www.twitter.com/healthaccess
Health Access California
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