1. Healthcare for the Remaining Uninsured Merced Healthcare Consortium October 23, 2014 Merced Marisol Avi ñ a Marlon Cuellar The California Endowment

2. Who are the Remaining Uninsured? 1.4-1.5 million unauthorized and uninsured Californians— previously 20% of the uninsured, will compose almost 50% of the remaining uninsured. Majority of remaining uninsured will be citizens or legal residents Some frozen between “open enrollment” periods Affordability issues: e.g., workers with employer-based coverage for themselves but not family, choose not to enroll Immigrants and communities of color: – Disproportionately benefit from coverage expansion – Disproportionately part of the remaining uninsured

3. Beyond Obamacare We must use this window to find a statewide solution for access to care and services for the undocumented and remaining uninsured. Major public education campaign on the necessity for at least preventive services for everyone in California

4. #Health4All Campaign Communications Research Local & State: Capacity and Coalition Building Federal: Federal Immigration Reform

5. Communications

6. Messaging Prevention Makes Economic Sense: Emergency room treatment is an expensive substitute for preventive care. It makes economic sense to invest in preventive services that minimize the risk of chronic disease and more costly treatment later on. Access to health care is a basic human right and increasing access is the Right Thing to do: Everyone—regardless of ability to pay or legal status—should have access to affordable health care. Undocumented Californians are part of the fabric of our communities. They are our neighbors, friends, co-workers, and an integral part of our communities. They pay $2.7 billion in taxes every year. This includes sales and property taxes that fund schools, public safety, infrastructure, and other vital services. It’s only fair to expand access to include all California taxpayers regardless of immigration status.

7. Social Media

8. Bus Ads

9. TV Ads: I am California

10. Newspaper Ads

11. Community

12. Billboards

14. Other Resources and Engagement Integrating proper messaging for this population in our enrollment events Creating consumer friendly FAQ in Spanish and English Eligibility Grid Statewide Direct Mail Activation/Support Cards #Health4All listserve

15. #Health4All 15

16. Research

17. 17

18. Additional research UCLA Labor Center /Dream Resource Project statewide survey led by immigrant youth – Over 500 surveys – Preliminary results: many immigrant youth don’t have health insurance, many rely on community clinics, many have translated for family members in order to access care USC/Manuel Pastor – Will generate estimates and information regarding the number and characteristics of the unauthorized migrants residing in TCE's 14 Healthy Communities. UC Berkeley/Blue Shield Foundation study on DACA eligible population & health needs Opinion Research – Voter Polls

19. State & Local Capacity and Coalition Building

20. Capacity and Coalition Building Identify areas of collaboration and partnership between coalitions that could advance immigrant health at the local level and plug into statewide advocacy work Strengthen capacity of coalitions to engage in local campaigns through local sub-grants. Grassroots outreach through California Calls Youth engagement – Pre-Health Dreamers

21. Federal

22. Federal Immigration Reform: National Immigration Law Center Goals: Educate policymakers and advocate for federal immigration reform policies that allow aspiring citizens to have the same access to safety net programs, public services and economic supports as other lawfully present immigrants. Research and explore options for policies needed to help providers and localities protect and strengthen the safety net in California to ensure that undocumented immigrants and others left without affordable coverage to continue to have access to basic, affordable, non- emergency care.

23. Options to Addressing CA’s Remaining Uninsured & Undocumented Status of statewide policy efforts County - There is a successful track record for allowing underinsured and uninsured residents eligibility and full access to preventive health services and health homes through LIHP-like programs.

24. Voter Poll

25. California Voter Support for Providing Health Coverage for All 800 telephone interviews with registered voters statewide – Oversample of an additional 154 African-American voters, with data statistically weighted to reflect the true ethnic composition of the electorate – Interviews conducted August 24-31, 2014 – Interviews in English and Spanish and on landlines and wireless phones Margin of sampling error of +/- 3.5% Central Valley data is 8 counties and 84 interviews, margin of error is 11% Bipartisan research team of Fairbank, Maslin, Maullin, Metz & Associates (FM3) (D) and GS Strategy Group (R)

26. Policy Description Tested As you may know, federal health care reform – also known as Obamacare – was signed into law. As a result, a new state program called Covered California now offers individuals affordable private health care coverage for purchase, and also offers discounted rates to those who cannot afford to pay. In addition, Medi-Cal was expanded to cover over one million Californians who didn’t previously qualify. However, millions of Californians still are not offered health coverage through these changes – including undocumented immigrants. Currently, health care providers are required by law to provide emergency care to all Californians, including those who are undocumented, whether or not they have health insurance coverage. The costs of this care are currently passed on to other patients and taxpayers.

27. Most Californians in the state support the policy. Central Valley 25% 19% 18% 34% 4% To prevent costly emergency care, some people have proposed expanding access to affordable health coverage through Medi-Cal and Covered California to cover all low- income Californians – including those not currently eligible because of their immigration status. Does this proposal sound like something you would support or oppose? Total Support 44% Total Oppose 52% State

28. For many, support is guided by a conviction that it’s the “right thing to do.” Central Valley 49% 39% 12% State

29. Central Valley voters support various elements and impacts of the policy. Improving access to preventive care to reduce overall health costs and prevent the spread of disease Total Support: 75% Total Oppose: 19% Ensuring that working undocumented immigrants have the ability to purchase affordable health insurance 68% 30% Reducing the costs paid by patients and taxpayers to cover unpaid emergency room care for the uninsured 55%36% Expanding the state’s Medi-Cal health care program for low- income residents to provide preventive health services to undocumented residents who are not eligible for coverage under the current health care law 54%31% Ensuring that working, uninsured undocumented immigrants can be eligible for subsidized health coverage through Covered California 43%50%

30. Pro and Con Messages Tested Supporters say access to health care is a basic human right, and our economy and communities are stronger when everyone has health coverage. When people lack health coverage, they wait to get treated until their condition worsens and requires expensive emergency care. That’s passed on to the rest of us in a “hidden tax” of lowered productivity and higher medical expenses. In contrast, when people have access to preventive care like vaccines and annual checkups, they avoid expensive illness later on and are more productive on the job. It’s more cost-effective to make sure that ALL Californians have basic access to doctors, hospitals and health clinics, than to wait to treat them after they become sick. Opponents say that extending health coverage to those here illegally will force California to raise taxes, meaning more jobs leaving the state and more costs for all of us. Undocumented immigrants are breaking the law and should not be rewarded. Besides, the existing health care system is broken—there is a doctor shortage, emergency rooms are crowded, and health care costs continue to rise. The system should work first for those who have legal status before expanding it to others.

31. Messaging Moves Voters

32. Conclusions While Central Valley voters do not instinctively support the policy, when context and information is provided, they become more comfortable with the idea. Broad bipartisan consensus in favor of improving access to preventive care. The numbers are encouraging – with the right framing and messaging, voters across the political spectrum can be moved.

33. Join the conversation Health4all list serve – www.health4all.orgwww.health4all.org Follow us on Facebook – https://www.facebook.com/CalEndow https://www.facebook.com/CalEndow Follow us on Twitter – https://twitter.com/CalEndow https://twitter.com/CalEndow Follow us on Instagram – http://instagram.com/CalEndow http://instagram.com/CalEndow

34. Marisol Aviña Marlon Cuellar Program Managers, Healthy California The California Endowment Email: mavina@calendow.org mcuellar@calendow.org Phone: 916.558.6780 916.558.6764