1. Medi-Cal Expansions and 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 counties6 counties 34 counties % of California uninsured adults 642088 County program descriptions Income requirement Up to 100%FPL 012-- Up to 200% FPL 52334 Up to 300% FPL 331-- Above 300% FPL 400-- Services for unauthorized immigrants None 455-- Emergency Only 00134 Full Services 810-- Ages served All ages 501-- Adults, 19–64 300-- Adults, 21–64 46534 Covered services Limited inpatient/outpatient 335-- No limits on basic medical services 93134 SOURCES: CHCF County Indigent Care Profiles, October 2009; U.S. Census Bureau, American Community Survey, 2011, 3 year estimates.

4. 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

5. 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

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

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

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

9. 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 17000 – Costs? State funding source? Health realignment funds support other county health programs and functions

10. 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

11. 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

12. 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??

13. 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

14. Medi-Cal Expansions and County Indigent Programs Shannon McConville

15. 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 720 360 CPE 360 County 1,410 705 subtotal 2,130 1,065 Safety Net Care Pool (SNCP) UC 100 50 CPE 50 County 780 390 subtotal 880 440 DSH CPE UC 220 110 CPE 110 County 840 420 subtotal 1,060 530 DSH IGT UC 150 75 IGT 75 County 1,030 515 subtotal 1,180 590 Delivery System Reform Incentive Pool (DSRIP) UC 220 110 IGT 110 County 1,080 540 subtotal 1,300 650 Excess CPE/SNCP Rollover UC/County 400 200 CPE 200 LIHP County 1,210 605 CPE 605 Total 8,160 4,080 Estimated Non-Federal Claiming by Public Hospitals and LIHP Counties, FY 2011-12 SOURCE: California Department of Health Care Services.