Medi-Cal Expansions and County Indigent Programs Shannon McConville

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

Considerable Variation Across Existing County Indigent Programs Medically indigent services programs County medical services programs Provider counties Payer countiesHybrid counties Number of counties 12 counties6 counties 34 counties % of California uninsured adults County program descriptions Income requirement Up to 100%FPL Up to 200% FPL Up to 300% FPL Above 300% FPL Services for unauthorized immigrants None Emergency Only Full Services Ages served All ages Adults, 19– Adults, 21– Covered services Limited inpatient/outpatient No limits on basic medical services SOURCES: CHCF County Indigent Care Profiles, October 2009; U.S. Census Bureau, American Community Survey, 2011, 3 year estimates.

Current Funding Sources for County Indigent Care 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

If state assumes responsibility for Medi-Cal expansion population Could relieve some counties of indigent obligation LIHP/MCE enrollees convert to Medi-Cal – County Savings = $800M – $1.2B (LAO) Re-assessment of health realignment funding from state – Total Funding Declining revenue source in recession – Distribution of funds across counties Historic allocation formula not necessarily based on need

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

Health Realignment - Vehicle License Fee (VLF) Revenue by County Type SOURCE: California State Controller’s Office, Health and Welfare Realignment Allocation, New Base *

Health Realignment - Sales Tax Revenue by County Type SOURCE: California State Controller’s Office, Health and Welfare Realignment Allocation, New Base *

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 under Section – Costs? State funding source? Health realignment funds support other county health programs and functions

Remaining Uninsured Counties still projected to have sizable uninsured populations – Some ineligible ie. unauthorized Medi-Cal retroactive eligibility protects counties to a certain degree financially Exchange-eligible population – open enrollment periods Churning between programs – “Bridge” programs between Medi-Cal and Covered California

Other county health responsibilities funded by realignment dollars 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

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

Moving Forward Many unknowns – Enrollment and take up – Current spending on county indigents; potential savings – 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

Medi-Cal Expansions and County Indigent Programs Shannon McConville

Medi-Cal and Waiver Programs Non-Federal Match 15 Total Funds Non-federal Share (NFS) Source of NFSFederal Funds Medi-Cal Inpatient Fee-For Services UC CPE 360 County 1, subtotal 2,130 1,065 Safety Net Care Pool (SNCP) UC CPE 50 County subtotal DSH CPE UC CPE 110 County subtotal 1, DSH IGT UC IGT 75 County 1, subtotal 1, Delivery System Reform Incentive Pool (DSRIP) UC IGT 110 County 1, subtotal 1, Excess CPE/SNCP Rollover UC/County CPE 200 LIHP County 1, CPE 605 Total 8,160 4,080 Estimated Non-Federal Claiming by Public Hospitals and LIHP Counties, FY SOURCE: California Department of Health Care Services.