Recommendations for Delivery System Reforms and Financing Care for the Remaining Uninsured Henry Tuttle Chief Executive Director San Diego, CA ITUP Conference | February 17, 2015

Remaining Uninsured Data Pre ACA Post ACA San Diego22% 14% Riverside 34% 20% Imperial 34% 21% Pre ACA Post ACA San Diego 9% 5% Riverside 9% 7% Imperial 12% 8% Adults (19- 64) Youth (0-18)

Enrollment Issues In addition to policy considerations, not all of those eligible for medical coverage have enrolled into the available programs. Of the adult population in San Diego, 14% of the population is uninsured. Of this group, 45% are eligible for Medi-Cal or Covered California with subsidies. Factors for non enrollment include: cost, concerns, fears of government programs, and being uninformed As of late 2014, 27% of the those uninsured adults in San Diego County who remain uninsured are undocumented. This increases to 28% in Riverside County, and 30% in Imperial County.

2019 Remaining Uninsured Projections CALIFORNIANS UNDER AGE 65 PROJECTED TO REMAIN UNINSURED - HIGH SIGN-UP SCENARIO California San Diego County – 2019 ELIGIBLE FOR MEDI-CAL 550,00040,000 ELIGIBLE FOR COVERED CA SUBSIDIES 380,00030,000 NON-SUBSIDY ELIGIBLE CITIZENS & LEGAL IMMIGRANTS 440,00040,000 NOT ELIGIBLE DUE TO STATUS 1,350,000100,000 TOTALS 2,720,000210,000

Policy Considerations SB 4 (proposed) - Lara Bill would provide access to health coverage to all Californians, regardless of immigration status. The Lara Bill is pending before the California Senate Rules Committee as of Jan Federal Actions (DAPA/DACA) – recent executive action should qualify some additional undocumented for Medicare.

Medicare Shift & Transformation In President Obama’s February 4, 2015 budget proposal, there are a number of health related changes to Medicare reimbursements, no longer based exclusively on patient load. Proposed federal budget reductions as proposed in the Obama budget to Medicare would impact health care providers and result in structural reforms to Medicare, and likely to Medi-Cal as well. A funding source as a result of Medicare changes - Cadillac premium tax issues.

Potential Funding Options Undocumented drivers’ license fee Money orders to Mexico & other countries’ fees California medical device tax Hospital tax Medical provider tax

Potential Funding Options… Pharmacy tax - both prescription & non prescription medication Increase criminal background check fees Excess earnings on Health Savings Accounts or 529 college plans Tobacco settlement County General Fund - can be used to cover costs of unfunded health coverage for the undocumented

Potential Funding Options… Tax deductible contributions, through crowd source funding or other mechanism Marijuana sale additional tax Medical marijuana dispensary tax Increased cigarette tax Medical provider license fee taxes

For additional information, or copies of referenced documents, please contact: Henry Tuttle (619)