1. CSAC Institute: Realignment Workshop Health Services June 4, 2010 Judith Reigel, CHEAC Executive Director Margaret Szczepaniak, Assistant Director, Health Care Services San Joaquin County

2. Realignment Health Account  Public Health  Indigent Health Care (Former AB 8 and MISP/CMSP Programs) County Health Executives Association of CA2

3. History of County Health Funding Leading up to 1991 Realignment  1971 – Creation of state only MIA Medi-Cal category  1978/79 – Aftermath of Prop 13: AB 8  MOE Requirement  1982/83 – Transfer of MIA’s to counties (MISP/CMSP)  1991/92 – Realignment  AB 8  MISP/CMSP  Local Health Services  SLIAG County Health Executives Association of CA3

4. Health Allocations Chart County Health Executives Association of CA4

5. How are Health Realignment Funds Used?  Public Health  Health and Safety Code Section 101025 “The board of supervisors of each county shall take measures as may be necessary to preserve and protect the public health in the unincorporated territory of the county, including, if indicated, the adoption of ordinances, regulations and orders not in conflict with general laws, and provide for the payment of all expenses incurred in enforcing them.”  Though mandate precedes Realignment, it is the primary funding source for county public health  Used to pull down federal matching funds (e.g. MAA/TCM) County Health Executives Association of CA5

6. 6  Indigent Health Care  Helps meet Welfare and Institutions Section 17000 mandate  Supports County Hospitals and clinics  Medi-Cal waiver: Non-federal share of hospital inpatient How are Health Realignment Funds Used?

7. California Children’s Services (CCS)  Serves children with serious illness or traumatic injury through Medi-Cal, Healthy Families and the CCS- only program  Realignment changed state/county sharing ratio for non-Medi-Cal diagnosis/treatment/therapy from 75/25 to 50/50  Placed in Social Services Account since it is a caseload driven program County Health Executives Association of CA7

8. Local Revenue Fund Social Services Account Health Account Mental Health Account Social Services Account Health Account County Allocations CMSP General Growth Account Social Services Account Health Account Mental Health Account VLF Base Account

9. Revenue Sources AccountSales TaxVLF Health15%74% Mental Health29%22% Social Services56%4% Percentages by Revenue Source 08/09 Base Distribution Percentages by Account 08/09 Base Distribution AccountHealthMental HealthSocial Services Sales Tax25%69%96% VLF75%31%4%  Percentages change yearly due to Growth Distribution

10. Sales Tax Revenue History County Health Executives Association of CA10

11. Vehicle License Fee Revenue History County Health Executives Association of CA11

12. Maintenance of Effort (MOE)  In order to be eligible for the receipt of Realignment Sales Tax Funds each month, a county must:  Deposit into its health account an amount of general funds which is equal to 1/12 of the amount specified in section 17608.10 of the Welfare & Institutions code for the county.  Note: Section 17608.10 refers to old AB 8 MOE.  Deposit an amount of county general funds at least equal to the Vehicle License Fee (VLF) amount of funds transferred by the State Controller’s Office (SCO) each month.  Deposit local matching funds each month that are sufficient to permit local Health and Welfare trust fund disbursements that are equivalent to the growth of revenues in Sales Tax and VLF allocated to the county.  Constitutionally, VLF is considered county general funds; therefore, MOE’s were created to assure that VLF Health Realignment funds are actually spent on health. County Health Executives Association of CA12

13. MOE Chart County Health Executives Association of CA13

14. Benefits of Realignment to County Health Services  Stable, relatively predictable (until recently) funding source has allowed counties to plan across fiscal years  Flexibility has allowed local health departments to target resources as needed to address local community health needs  Realignment funds have been used to supplement categorical grant funding that has not kept up with need County Health Executives Association of CA14

15. Challenges  No Sales Tax growth since FY 05/06; no VLF growth since FY 06/07  VLF has been extremely volatile past two years  Demand for local health services has increased at same time revenues have decreased County Health Executives Association of CA15

16. What Will Health Care Reform Bring?  2014: Medi-Cal expansion to childless adults to 133% FPL (100% federally funded first 3 years)  State likely to want to recoup Health Realignment funds as early as 2014  Need to preserve public health funding  Section 17000 – Not likely to go away  County hospitals and clinics will still have uninsured to serve  Health Care Reform does not serve the undocumented County Health Executives Association of CA16