1. ACA Coverage Expansions and the Future of County Indigent Programs Shannon McConville

2. 2 ACA Coverage Expansions Raise Questions for State-County Relationship Many medically indigent served by counties could gain Medi-Cal or Exchange coverage Need to finance costs of Medi-Cal expansion – Mostly federal dollars, particularly in early years Future of county indigent care programs – Differences across county delivery types – Implications for county-based public hospital and clinic systems – Continued need and responsibility for safety net services for remaining uninsured

3. Considerable Variation Across Existing County Indigent Programs Medically indigent services programs County medical services programs Provider counties Payer countiesHybrid counties Number of counties 12 counties5 counties6 counties35 counties % of California uninsured adults 642088 County program descriptions Income requirement Up to 100%FPL 012-- Up to 200% FPL 52335 Up to 300% FPL 321-- Above 300% FPL 400-- Services for unauthorized immigrants None 445-- Emergency Only 00135 Full Services 810-- Ages served All ages 501-- Adults, 19–64 300-- Adults, 21–64 45535 Covered services Limited inpatient/outpatient 325-- No limits on basic medical services 93135 SOURCES: CHCF County Indigent Care Profiles, October 2009; U.S. Census Bureau, American Community Survey, 2011, 3 year estimates.

4. Current Funding Sources for Indigent Programs State 1991 Realignment Funding Tobacco Settlement County Funds – Realignment Maintenance of Effort (MOE) – General Funds – Local initiatives Federal Funds – 1115 Waiver (LIHP, DSRIP, SNCP), DSH

5. If state assumes responsibility for Medi-Cal expansion population Should reduce county indigent costs and could relieve some counties of indigent obligation Difficult to estimate potential savings – LAO - $800M – $1.2B Re-assessment of 1991 realignment health financing from state – Declining revenue source in recession – Historic allocation of funds across counties – not necessarily tied to need

6. 1991* Realignment Funding SOURCE: California State Controller’s Office, Health and Welfare Realignment Allocation, New Base *

7. Health Realignment by County Indigent Delivery Structure 7 SOURCE: California State Controller’s Office, Health and Welfare Realignment Allocation, New Base

8. Considerations for changes to realignment financing VLF is constitutionally protected source of funding for local government – Bulk of health realignment funding – Program ‘swaps’ ie. child care, CalWORKs Counties retain responsibility for providing care to remaining uninsured – Will vary considerably across counties Health realignment funds support other county health programs and functions

9. Counties still projected to have sizable uninsured populations Estimated Uninsured Californians in 2019 by county and region SOURCE: UC Berkeley-UCLA CalSIM Model, version 1.7 from Remaining Uninsured in California under the Affordable Care Act: Regional and County Estimates.

10. Counties have other health program responsibilities County public health programs County share of California Children Services (CCS) for HFP and state-only caseload Non-federal match for Medi-Cal funding – Inpatient FFS Medi-Cal – Waiver programs: LIHP, DSRIP, SNCP – DSH

11. Potential sources of information on county spending and financing UCLA LIHP/CI evaluations State controller local government county reports County administrative and financial records Public hospital systems Others??

12. Moving Forward Many unknowns, but research is being done. – Current county spending and financing – Eligibility, take up, and enrollment – Health needs and costs of coverage for expansion population – Impacts of other funding changes ie. DSH reductions Ongoing dialogue between state and counties Phase-in approach as expansions ramp-up and more data is available

13. ACA Coverage Expansions and the Future of County Indigent Programs Shannon McConville

14. Notes on the use of these slides These slides were created to accompany a presentation. They do not include full documentation of sources, data samples, methods, and interpretations. To avoid misinterpretations, please contact: Shannon McConville: 415-291-4481, mcconville@ppic.org mcconville@ppic.org Thank you for your interest in this work. 14