What’s at stake for California under proposals to unwind federal health reform March 10, 2017 Shannon McConville

California fully embraced ACA, now faces uncertainty under federal reform efforts California experienced dramatic declines in its uninsured rate under the Affordable Care Act Medi-Cal expansion responsible for most gains in coverage The federal government provided the bulk of funds for coverage expansions Federal proposals – in particular funding reductions – will have major implications for state, counties, and individuals Still considerable uncertainty as to the scope and timing of proposed federal reforms

California’s uninsured rate declined substantially under ACA; particularly among people of color SOURCE: American Community Survey, 2014, 2015, 2016, 1-year Public Use Microdata Sample (PUMS).

Largest gains from Medi-Cal expansion; now covers 1/3 of state population SOURCE: California Department of Health Care Services, Research and Analytic Studies Division, Medi-Cal Summary Pivot Tables; California Department of Finance, County population estimates.

Nearly 4 million adults gained Medi-Cal under ACA; make-up nearly 30% of enrollees Total Enrollees: 13.3 million SOURCE: California Department of Health Care Services, Research and Analytic Studies Division, Medi-Cal Monthly Enrollment Fast Facts, September 2016

Federal government provides about 2/3 of total program funding in recent years SOURCE: California Department of Health Care Services, Medi-Cal Local Assistance Estimates

Opportunities (and now concerns) for enrolling correctional populations Jail inmates have more physical and behavioral health needs than the general population and most are uninsured National estimates suggest more than one-third of newly eligible for under ACA may have criminal justice contact Health coverage could be part of a comprehensive reentry strategy, improve public safety and public health outcomes State continues to move forward with expanded Medi-Cal program despite federal uncertainty Coverage options for correctional populations could change, but incentives for providing care and coverage are still present. First a brief introduction to what motivates our focus on the intersection between jails and health. The recent implementation of the Affordable Care Act – and in particular the expansion of California’s Medicaid program – Medi-Cal – to low-income single adults presents new opportunities for insurance coverage for much of California’s jail population. In addition, a new state law passed last year to complement the coverage expansions – has the potential to allow jail sites to become places where people moving through the jail systems can get connected/enrolled in available coverage options. This may be particularly beneficial for this group because available evidence indicates they have high health needs and insurance coverage post-release could facilitate better access to needed medical care – for both physical and behavioral health services. At the same time, health coverage and access to care for this population could help reduce county costs related to health care provision within jail systems as well as improvements in public health outcomes and reductions in recidivism.

Despite large reductions in uninsured, disadvantaged young men more likely to be uninsured post ACA SOURCE: Authors calculations from the American Community Survey, 1-year PUMS 2015; PPIC report “Expanding Health Coverage in California: County Jails as Sites of Enrollment” 2016.

Medi-Cal could be even more salutary to the correctional population than in the past Managed care plans are focused on better integrating physical and behavioral health Re-designed Drug Medi-Cal program provides substance use disorder services Other programs provide case management, social services to beneficiaries with high needs Whole Person Care pilot programs Health Homes for Patients with Complex Needs PRIME projects at public hospitals to target high-risk populations; incorporate alternative payment models

Looking forward With major federal changes on the horizon, policymakers likely to face difficult choices related to: Need for increased state funding support Size and scope of the program Repercussions of many more uninsured Californians, especially for counties and safety net providers Important to consider impacts on particularly vulnerable groups who gained coverage under ACA Correctional populations People with behavioral health issues, homeless

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: Your name (Shannon McConville @ppic.org; 415-291-4481) Thank you for your interest in this work.