Health Access California presents an update on efforts to protect the safety net and provide medical homes and coverage for the state's immigrant community, including the undocumented--at both the county and state level.

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

2. CALIFORNIA IMPLEMENTS
Millions with new consumer protections; financial assistance
3.5+ 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

4. California May Have 3 MillionCalifornia May Have 3 Million
Remaining UninsuredRemaining Uninsured

5. Who Needs More Help?Who Needs More Help?
ACA has millions of “winners,” who have new coverage, newACA has millions of “winners,” who have new coverage, new
access, and/or new financial help to afford coverage. Everyoneaccess, and/or new financial help to afford coverage. Everyone
wins with a health system more humane, more rational, morewins with a health system more humane, more rational, more
transparent, with new consumer protections and incentivestransparent, with new consumer protections and incentives
aligned for improved quality & reduced cost.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%
AndAnd 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 withThose 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 high-Some over 400% federal poverty level (typically older, in high-
cost areas) who don’t have affordability guarantee.cost areas) who don’t have affordability guarantee.
•Those in Exchange who find monthly premiums/cost sharing stillThose in Exchange who find monthly premiums/cost sharing still
a burden, and may/may not decline coverage.a burden, and may/may not decline coverage.

7. Making #Health4All History *ThisMaking #Health4All History *This
Year*Year*
77
 Continuing California’s Coverage of “Deferred Action”Continuing California’s Coverage of “Deferred Action”
Immigrants:Immigrants: The President’s executive action had the impactThe President’s executive action had the impact
of expanding the category of immigrants covered by state-of expanding the category of immigrants covered by state-
funded Medi-Cal.funded Medi-Cal. We need to defend and secure thisWe need to defend and secure this
major victory. Also:major victory. Also:
 Secure and Expand our County Safety-Net Programs:Secure and Expand our County Safety-Net Programs:
Counties are the last resort of coverage. Some counties areCounties are the last resort of coverage. Some counties are
enhancing their safety-net for the remaining uninsured, withenhancing their safety-net for the remaining uninsured, with
programs like My Health LA. We need to encourage moreprograms like My Health LA. We need to encourage more
counties to care for the undocumented.counties to care for the undocumented.
 Making Progress to a Statewide Solution forMaking Progress to a Statewide Solution for
#Health4All:#Health4All: An effort now in its third year, we can takeAn effort now in its third year, we can take
another step to Health4All, expanding Medi-Cal to moreanother step to Health4All, expanding Medi-Cal to more
immigrants, and setting up the structure for a mirrorimmigrants, and setting up the structure for a mirror
marketplace so everyone can seek coverage.marketplace so everyone can seek coverage.

8. Our Current Safety-NetOur Current Safety-Net
 Uninsured live sicker, die younger, oneUninsured live sicker, die younger, one
emergency from the financial ruin.emergency from the financial ruin.
 Emergency Rooms: But only to stabilizeEmergency Rooms: But only to stabilize
emergencies; Bill and debt afterwardsemergencies; Bill and debt afterwards
– 2006 Fair Hospital Pricing Law2006 Fair Hospital Pricing Law
www.hospitalbillhelp.orgwww.hospitalbillhelp.org
 Private providers: clinics, hospital charity carePrivate providers: clinics, hospital charity care
 Counties.Counties.
– Counties have a “17000” obligation to provide basic careCounties 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 with12 “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 Program36 small rural counties in County Medical Service Program
– Some serve the undocumented; others do not.Some serve the undocumented; others do not.

9. 3 Flavors of Counties3 Flavors of Counties
PUBLIC 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”
FresnoFresno
MercedMerced
OrangeOrange
PlacerPlacer
SacramentoSacramento
San DiegoSan Diego
San Luis ObispoSan Luis Obispo
Santa BarbaraSanta Barbara
Santa CruzSanta Cruz
StanislausStanislaus
TulareTulare
Yolo*Yolo*
Others are part of CMSPOthers are part of CMSP
(County Medical Services Program)(County Medical Services Program) 99

10. 1010

11. Surveying California’sSurveying California’s
Commitment to the RemainingCommitment to the Remaining
UninsuredUninsured
 Working with community partner organizations, weWorking with community partner organizations, we
surveyed what counties currently do for the remainingsurveyed 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 andremarkable and
innovative progressinnovative progress in providing a medical home for allin providing a medical home for all
Californians.Californians.
 In other counties, aIn other counties, a thin safety-net may get thinnerthin safety-net may get thinner ..
 AnAn uneven safety-netuneven safety-net across the state: Differentacross the state: Different
eligibility with regard to income levels, age, immigration, andeligibility with regard to income levels, age, immigration, and
medical need, different benefits, services, and infrastructure.medical need, different benefits, services, and infrastructure.
 How to have a safety-net that survives and thrives; andHow to have a safety-net that survives and thrives; and
provide a medical home for those who don’t qualify for ACA.provide a medical home for those who don’t qualify for ACA.

12. WhichWhich
CountyCounty
Safety-NetsSafety-Nets
ServeServe
Patients NotPatients Not
LegallyLegally
Present?Present?
AlamedaAlameda
Contra Costa (only children)Contra Costa (only children)
Fresno (<67% FPL)Fresno (<67% FPL)
KernKern
Los Angeles (<133% FPL)Los Angeles (<133% FPL)
RiversideRiverside
San FranciscoSan Francisco
San MateoSan Mateo
Santa ClaraSanta Clara
Santa Cruz (<100%FPL)Santa Cruz (<100%FPL)
(Most to 200% FPL or more)(Most to 200% FPL or more)

13. Some County Health $ ReallocatedSome County Health $ Reallocated
Counties had
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
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-CalWith the Medi-Cal
expansion, AB85expansion, AB85
reallocated up toreallocated up to
$900 million of $1.4 billion$900 million of $1.4 billion
in funds for countiesin funds for counties
for public health andfor public health and
indigent careindigent care
Article 13 CountiesArticle 13 Counties 1313

14. 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; shortenedsubstance abuse; reduced dental; shortened
certification to 3 months.certification to 3 months.
– Fresno: Preliminary vote to eliminate MISP: Effort toFresno: Preliminary vote to eliminate MISP: Effort to
change safety-net program from hospital contractchange safety-net program from hospital contract
 Many Other Counties in “Wait and See” ModeMany Other Counties in “Wait and See” Mode
 Nothing in Funding Formula Requires Cuts inNothing in Funding Formula Requires Cuts in
Eligibility—Allows Full Reimbursement ofEligibility—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

15. Steps ForwardSteps Forward
ACA Provides Significant Savings toACA Provides Significant Savings to
State/CountiesState/Counties
With 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 MedicalThe Lessons of LIHP: Primary/Preventative Medical
Home, rather than episodic/emergency careHome, rather than episodic/emergency care
– Extending Eligibility to the Remaining UninsuredExtending Eligibility to the Remaining Uninsured
““Now We Can Say Yes”Now We Can Say Yes”
– Los Angeles, Alameda, San Francisco, SantaLos Angeles, Alameda, San Francisco, Santa
Clara, San Mateo, Etc.Clara, San Mateo, Etc.
Bridges to a Statewide SolutionBridges to a Statewide Solution

16. SACRAMENTO COUNTYSACRAMENTO COUNTY
Opportunities to Expand Access for UndocumentedOpportunities to Expand Access for Undocumented
Counties that Cut Undocumented Care in 2009:Counties that Cut Undocumented Care in 2009:
– Sacramento, Yolo, Contra CostaSacramento, Yolo, Contra Costa
Others, including Public Hospital Counties haveOthers, 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 Supervisors
Issues:Issues:
– Political WillPolitical Will
– FundingFunding
– Administering/Providers/LogisticsAdministering/Providers/Logistics
– Interplay Between Supervisors & County AdministrationInterplay Between Supervisors & County Administration

17. Statewide SolutionsStatewide Solutions
 Undocumented explicitly excluded from federal help;Undocumented explicitly excluded from federal help; even undereven under
immigration reform, many aspiring citizens will be on a “path toimmigration reform, many aspiring citizens will be on a “path to
citizenship” of over a decade, restricted from federal help with healthcitizenship” of over a decade, restricted from federal help with health
care. So even with immigration reform,care. So even with immigration reform, this issue remains for localthis issue remains for local
policymakers, states, counties, and private providers.policymakers, states, counties, and 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 residentsMost undocumented residents
are working, and some are covered through on-the-job benefits. Theare working, and some are covered through on-the-job benefits. The
more we promote employer-based coverage, the more we cover. (i.e.more we promote employer-based coverage, the more we cover. (i.e.
AB880)AB880)
 SAFETY-NET FUNDING:SAFETY-NET FUNDING: From the county safety-net and publicFrom the county safety-net and public
hospital dollars to funding for community clinics (like restoring EAPC).hospital dollars to funding for community clinics (like restoring EAPC).
 STATE-ONLY/MIRROR PROGRAMS:STATE-ONLY/MIRROR PROGRAMS: Philosophically, allPhilosophically, all
Californians should be eligible for the level of benefits offered by theCalifornians should be eligible for the level of benefits offered by the
Affordable Care Act. If federal government doesn’t provide, state can goAffordable Care Act. If federal government doesn’t provide, state can go
on its own.on its own.

18.
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
immigrants
By ROXANA KOPETMAN / ORANGE COUNTY REGISTER
Published: Jan. 10, 2014 Updated: 6:04 p.m.
LEGISLATIVE CAMPAIGN FOR ALEGISLATIVE CAMPAIGN FOR A
STATEWIDE SOLUTIONSTATEWIDE SOLUTION

19. Continuing California’sContinuing California’s
Commitment to CoveringCommitment 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 lesslegal immigrants, including recent immigrants here less
than 5 years;than 5 years;
–People Residing Under the Color of Law (PRUCOL); nowPeople Residing Under the Color of Law (PRUCOL); now
including DACA Dream Act students!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 servicesMaintaining existing state-specific programs and services
 State-only Medi-Cal for those not legally present, similar toState-only Medi-Cal for those not legally present, similar to
other non-federally covered populationsother 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.

20. Financing #Health4AllFinancing #Health4All
LOS ANGELES TIMES:LOS ANGELES TIMES:
““Study sees modest costs inStudy sees modest costs in
healthcare for immigrants herehealthcare for immigrants here
illegally”illegally”
By Patrick McGreevy * May 21, 2014By Patrick McGreevy * May 21, 2014
Increased health of poor Californians could reduce costsIncreased health of poor Californians could reduce costs
down the road, study saysdown the road, study says
Extending healthcare to people in the country illegally would cost the state a modestExtending healthcare to people in the country illegally would cost the state a modest
amount more but would significantly improve health while potentially saving money foramount more but would significantly improve health while potentially saving money for
taxpayers down the road, according to a study released Wednesday.taxpayers down the road, according to a study released Wednesday.
The study by the UCLA Center for Health Policy Research estimates that the net increase inThe 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 between $353state 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 would be up to $436million 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 730,000 people next yearmillion in 2019. Enrollment in Medi-Cal would increase by up to 730,000 people next year
and up to 790,000 in four years.and up to 790,000 in four years.

21. 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 streams:More effectiively use existing dollars & revenue streams:
– Maintaining funds for restricted scope Medi-Cal for emergencyMaintaining 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 proposalproposal

22. #Health4All
2222

23. Core MessagesCore Messages
2323
 Investing in California:Investing in California: Undocumented Californians are anUndocumented Californians are an
economic engine for the state. An overwhelming percentage workeconomic engine for the state. An overwhelming percentage work
and pay taxes. They are an economic asset. Investing in them isand pay taxes. They are an economic asset. Investing in them is
investing in our state.investing in our state.
 Prevention Makes Economic Sense:Prevention Makes Economic Sense: Emergency roomEmergency room
treatment is an expensive substitute for preventive care. It makestreatment is an expensive substitute for preventive care. It makes
economic sense to invest in preventive services that minimize theeconomic sense to invest in preventive services that minimize the
risk of chronic disease and more chronic treatment later on.risk of chronic disease and more chronic treatment later on.
 Increasing Access to Affordable Care is the ResponsibleIncreasing Access to Affordable Care is the Responsible
Thing to do:Thing to do: Everyone—regardless of ability to pay or legal statusEveryone—regardless of ability to pay or legal status
—should have access to affordable health care. After Obamacare,—should have access to affordable health care. After Obamacare,
the remaining uninsured, including the undocumented, should havethe remaining uninsured, including the undocumented, should have
access to affordable care, including a comprehensive set ofaccess to affordable care, including a comprehensive set of
preventive services and a health home.preventive services and a health home.

24. Organizing and Communications:Organizing and Communications:
We Need Action & Stories!We Need Action & Stories!
2424

25. OpportunitiesOpportunities
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 Process
Obstacles: Money, Messaging, Priorities,Obstacles: Money, Messaging, Priorities,

26. For more informationFor more information
Website: http://www.health-access.orgWebsite: http://www.health-access.org
Blog: http://blog.health-access.orgBlog: http://blog.health-access.org
Facebook: www.facebook.com/healthaccessFacebook: www.facebook.com/healthaccess
Twitter: www.twitter.com/healthaccessTwitter: www.twitter.com/healthaccess
Health Access CaliforniaHealth Access California
1127 111127 11thth
Street, Suite 234,Street, Suite 234, SacramentoSacramento, CA 95814, CA 95814
916-497-0923916-497-0923
414 13414 13thth
Street, Suite 450,Street, Suite 450, OaklandOakland, CA 95612, CA 95612
510-873-8787510-873-8787
1930 Wilshire Blvd., Suite 916,1930 Wilshire Blvd., Suite 916, Los AngelesLos Angeles, CA 90057, CA 90057
213-413-3587213-413-3587