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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. Fulfilling the Promise: Finishing the Job of Covering the Remaining Uninsured. www.health-access.org www.facebook.com/healthaccess

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

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  1. Protecting the Safety Net and Providing Medical Home Coverage, Including for Our Immigrant Communities Anthony Wright, Executive Director Fulfilling the Promise:Finishing the Job of Covering the Remaining Uninsured www.health-access.org www.facebook.com/healthaccess www.twitter.com/healthaccess

  2. BFD! BFD Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment

  3. States Have To:

  4. CALIFORNIA IMPLEMENTS Millions with new consumer protections; financial assistance 1.5+ million Californians with new coverage already CALIFORNIA IMPROVES EARLY: * Low-Income Health Programs * Children with pre-existing conditions * Maternity coverage BETTER: * Exchange that negotiates & standardizes * Medi-Cal express lane enrollment options * Continuing CA’s inclusion of legal immigrants including DACA students

  5. 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.

  6. WHAT’S NEXT?

  7. California to Have 3 Million Remaining Uninsured

  8. 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.

  9. 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 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.

  10. 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 www.hospitalbillhelp.org Private providers: clinics, hospital charity care Counties. 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.

  11. Surveying California’s Commitment to the Remaining Uninsured 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 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 don’t qualify for ACA.

  12. 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 safety-net; Addressed pent-up demand Transitioned to new Medi-Cal coverage Jan 1 Bridge to Reform No 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

  13. Which County Safety-Nets Serve Patients Not Legally Present?AlamedaContra Costa (only children)Fresno (<67% FPL)KernLos Angeles (<133% FPL)Riverside San FranciscoSan MateoSanta ClaraSanta Cruz (<100%FPL)(Most to 200% FPL or more)

  14. #Health4All

  15. 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

  16. Overview Counties have 2 options 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 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. 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) • 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. Article 13 Counties

  17. Steps Backward? Facing State & Federal Cuts & Uncertainty Retrenchment in Some Counties CMSP: 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 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

  18. Steps Forward ACA Provides Significant Savings to State/Counties 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.

  19. 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. 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 doesn’t provide, state can go on its own.

  20. Continuing California’s 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 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 Exchanges.

  21. LEGISLATIVE CAMPAIGN BEGINS NEWS State senator wants health care for all immigrants By ROXANA KOPETMAN / ORANGE COUNTY REGISTER Published: Jan. 10, 2014 Updated: 6:04 p.m. 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.

  22. Core Messages • Investing in California: Undocumented Californians are an 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. • Prevention Makes Economic Sense: Emergency room treatment 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. • Increasing Access to Affordable Care is the Responsible Thing to do:Everyone—regardless of ability to pay or legal status—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.

  23. Strategy & Tactics Focused Attention: Counties Supervisors Administrator Health Departments State Governor State Legislative Leaders Legislative Process Budget Process Obstacles: Money, Messaging, Priorities, Politics

  24. Organizing and Communications

  25. 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

  26. 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 1127 11th Street, Suite 234, Sacramento, CA 95814 916-497-0923 414 13th Street, Suite 450, Oakland, CA 95612 510-873-8787 1930 Wilshire Blvd., Suite 916, Los Angeles, CA 90057 213-413-3587

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