HEALTH CARE FOR UNCOVERED IMMIGRANTS: IN THE SHADOW OF IMMIGRATION AND HEALTH CARE REFORM

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1 CALIFORNIA PROGRAM ON ACCESS TO CARE (CPAC) UC BERKELEY SCHOOL OF PUBLIC HEALTH IN COOPERATION WITH THE LATINO LEGISLATIVE CAUCUS, THE CALIFORNIA PRIMARY CARE ASSOCIATION, AND THE HEALTH INITIATIVE OF THE AMERICAS HEALTH CARE FOR UNCOVERED IMMIGRANTS: IN THE SHADOW OF IMMIGRATION AND HEALTH CARE REFORM WEDNESDAY, MAY 22, :00 AM TO 12:30 PM STATE CAPITOL, ROOM 126 SACRAMENTO, CALIFORNIA AGENDA WELCOME AND OVERVIEW 10:00 AM Moderator: Gil Ojeda, Director, CPAC, UC Berkeley School of Public Health 10:10 AM Keynote: Assemblyman V. Manuel Pérez (D- Coachella), Vice Chair, Latino Legislative Caucus IMMIGRATION REFORM IN CALIFORNIA: STATUS AND PROSPECTS 10:20 AM Alvaro Huerta, Esq., Skadden Fellow and Staff Attorney, National Immigration Law Center (Los Angeles) DEMOGRAPHICS OF NEED AND DEMAND FOR CALIFORNIA S UNCOVERED IMMIGRANTS 10:40 AM Nadereh Pourat, PhD, Director of Research, Center for Health Policy Research, UCLA COVERAGE APPROACHES 11:00 AM Status and Prospects for State-only Programs under the Brown Administration Ron Coleman, Director, Governmental Affairs, California Immigrant Policy Center 11:15 AM A Proposed County Model for Uninsured, Uncovered Immigrants under Health Care Reform Anthony Wright, Executive Director, Health Access California 11:30 AM Establishing Statewide Trust Fund to Cover Healthcare Services to California s Uncovered Workers after ACA Implementation Maximiliano Cuevas, MD, CEO, Clínicas del Valle de Salinas LUNCH WILL BE PROVIDED

2 11:45 AM Safety Net and Issues of Access in Rural California Noe Paramo, Project Director, Central Valley Partnership for Citizenship California Rural Legal Assistance Foundation (Fresno) RESPONDENTS NOON Deborah Ortiz, Vice President, Governmental Affairs, California Primary Care Association Xavier Morales, PhD, Executive Director, Latino Coalition for a Healthy California 12:20 PM CONCLUDING QUESTIONS AND ANSWERS 12:30 PM Adjourn LUNCH WILL BE PROVIDED

3 Immigration Reform, Health Care Access, and California Alvaro M. Huerta, Esq. National Immigration Law Center May 22, 2013 Sacramento, CA

4 Roadmap Immigrant Access to Health Care Overview of Senate s Immigration Reform Proposal Access to Health Care after Immigration Reform California s Role

5 A Historic Moment Immigration Reform being debated in Congress, including a pathway to citizenship for up to 11 million living in U.S. Health Reform (ACA) about to be implemented; debates about coverage continue in the states. Even with the ACA and immigration reform, barriers to health coverage will remain for many immigrants. Changing demographics make it imperative to address the needs of immigrant families in both systems.

6 Immigrants and the ACA Lawfully Present Immigrants Medicaid/CHIP Qualified immigrants 5-year bar Exchange Lawfully present No 5-year bar Eligible for tax credits and cost-sharing reductions Subject to individual mandate Undocumented Emergency Medicaid No Exchange access No ACA subsidies Exempt from individual mandate Remain eligible for FQHCs

7 Health Coverage of Immigrants More likely to be uninsured: 46% of non-citizens are uninsured, compared to 15% of U.S. born citizens 71% of undocumented adults are uninsured. But citizens make up the bulk of the uninsured (80%). Children of Immigrants Lack Coverage: 45-55% of low-income immigrant children in the US are uninsured. 17% of low-income citizen children lack coverage. Use Less Health Care: Immigrants use less health care, Per capita, immigrant use of health services costs less than half the cost for average citizen.

8 2013 Immigration Reform Why Now? Change in political climate after November 2012 election Changing demographics Majority of Americans support road to citizenship Lessons Learned Last big immigration reform effort in Perfect cannot be the enemy of the good Enforcement traded off for legalization Mandatory E-Verify program NO access to health/benefits Due to fear of costs & associated myths

9 Immigration Reform Bills Senate Bipartisan Gang of 8 Senators introduced Border Security, Economic Opportunity, and Immigration Modernization Act (S. 744) on April 16, 2013 Senate Judiciary Committee markup of S May 2013 (including Sen. Feinstein) Senate floor - mid June and July (60 votes required)

10 Immigration Reform Bills House Bipartisan Gang of 8 still working on bill (including Reps. Lofgren & Becerra) Timing? any day now Unclear if there will be a road to citizenship (but likely) Piecemeal approach possible (but unlikely)

11 General Terms S. 744 Border Security, Economic Opportunity, and Immigration Modernization Act RPI Registered Provisional Immigrant LPR Blue Card Lawful Permanent Resident (also known as a green card holder) Visas for Agricultural Workers

12 Road to Citizenship Key Provisions in S New Statuses: 1) Registered Provisional Immigrant (RPI) 2) Blue card 3) Family V visas 4) W non-immigrant visas Mandatory E-Verify Improves current paths: Fixes family backlog BUT eliminates sponsoring siblings (in future) Eliminates diversity visas Increases limits of U-Visas from 10,000 to 18,000 Future flow

13 REGISTERED PROVISIONAL IMMIGRANT STATUS (RPI)

14 Registered Provisional Immigrant Status (RPI) ELIGIBILITY: 1. Be physically in the U.S. on or before December 31, Maintain continuous presence up until the date of application 3. Settle any unpaid taxes; AND 4. Not have certain offenses such as: Felony Aggravated Felony 3 or more misdemeanors (other than minor traffic violations) Gang activity Certain foreign offenses Unlawful voting Limited waiver available for some offenses

15 The S. 744 Road Map to Citizenship RPI application Year 1 $500 fine + fees RPI renewal Year 6 $500 fine + fees Total: 13 years $ fees Green card application Year 10 $1000 fine $1070 fees U.S. citizen Year 13 $680 fees

16 Rights with RPI Status Are authorized to work while in RPI status (will be issued SSN and RPI card) Are considered admitted and lawfully present when in RPI status (BUT not under the ACA) Are authorized to travel outside of the US for up to 180 days

17 May apply for RPI DREAM Timeline At the end of 5 years in RPI status: DREAMers can apply for LPR status AND immediately apply for citizenship (time in RPI status counts toward naturalization)

18 BLUE CARDS

19 ELIGIBILITY: Blue Card Holders (Agricultural Workers) 1. Individual without status must demonstrate a minimum of 100 work days (or 564 hours) in the two years prior to the date of enactment 2. Remain in Blue Card status for 5 years 3. To be eligible for LPR status (after 5 years): Must have worked at least 100 days/year for 5 of 8 years OR 150 days/year for 3 of 5 years Have paid all taxes Pay $400 fine + fees Not be convicted of serious crimes 4. Apply for citizenship in 5 years (under current procedure)

20 ACCESS TO HEALTH CARE AFTER IMMIGRATION REFORM

21 Access to Health Care After Immigration Reform RPIs/Blue Card/V Visas Medicaid/CHIP Not eligible during status 5-year wait after LPR Exchange Not eligible for ACA subsidies during status Excluded even though lawfully present Eligible after LPR (with no waiting period) Exempt from individual mandate During Status Emergency Medicaid Can buy full price insurance in Exchange No ACA subsidies Exempt from individual mandate Remain eligible for FQHCs

22 Potential Additional Restrictions Health/Benefits Public Charge test for RPI s at time of application Add new 5-year waiting period for ACA (after LPR) Barred permanently for benefits if previously undocumented Require W visas to have proof of non-government subsidized insurance as condition of status Restrictions to FQHCs, emergency care Reporting of immigration status of patients

23 What Now? Protect existing access (Do No Harm) Eliminate 5-year bar (after LPR) Additional funding for safety-net Ensure employers comply with ACA mandate Encourage small business employers to participate in Small-business Health Options Program (SHOP)

24 Immigrants in the U.S million foreign born (13% of total population) 18.1 million are naturalized citizens (45% of immigrants) 11.1 million are undocumented. Foreign born comprise about 17% of labor force. 24.3% of children and 30.5% of low-income children in U.S. have an immigrant parent. 87% of children of immigrants are US citizens.

25 Immigrants in California Highest Share in US: 10.3 million foreign born (27% of pop.) 4.8 million naturalized citizens (47% of immigrants) ~2.6 million undocumented (7% of pop.) Economic Engine: 34.3% of the labor force. 9.7% of work force undocumented $2.7 billion in state and local taxes paid in 2010 by undocumented immigrants In Families with Citizens: Half of the children and 60% of the low-income children in California have an immigrant parent (and 13% have at least one undocumented parent) 90.4 % of these kids are citizens.

26 States and Counties Provide Services to Immigrants Almost all states take advantage of federal funds available to serve immigrants. Over half the states cover at least some immigrants ineligible for federal Medicaid or elect federal options to cover children or pregnant women. Several states and counties invest in coverage for all children or pregnant women, or in other efforts to integrate immigrants. But significant gaps remain, and shifts in coverage are likely when ACA implemented

27 CA Programs Available Regardless of Status Emergency Medi-Cal Prenatal care (Medi-Cal) Access for Infants and Mothers (AIM) Long-term care Early Breast Cancer Detection and Breast and Cervical Cancer Treatment California Children s Services (CCS) Healthy Kids (Children s Health Initiatives) Health Programs in some counties (Healthy SF) Community clinics Child Health and Disability Prevention Program (CHDP) and CHDP Gateway Family PACT Minor consent services Mental health services Regional Center Services Women Infants and Children (WIC) School lunch and breakfast

28 Address Barriers for Eligible Families Education to clarify eligibility rules and address immigrant-specific concerns, such as public charge Outreach strategies to reach eligible but not enrolled families Limiting inquiries and documents requested from applicants, privacy messages Practical strategies for ensuring access for individuals with limited English proficiency

29 Resources on Immigrants and Benefits National Immigration Law Center: National Council of La Raza: National Health Law Program: Center on Budget and Policy Priorities: California Immigrant Policy Center:

30 Alvaro M. Huerta Skadden Fellow & Staff Attorney National Immigration Law Center (213)

31 Protecting the Safety Net and State-Only Programs for Immigrant Families Ronald Coleman Government Affairs Manager California Immigrant Policy Center May 22, 2013

32 Founded in 1996, CIPC is a non-partisan, nonprofit statewide organization that seeks to inform public debate and policy decisions on issues affecting the state s immigrants and their families in order to improve the quality of life for all Californians. CIPC engages in legislative advocacy, and also provides technical assistance, training and education on immigrant issues.

33 Coverage Options Available to Immigrants and Their Families California Health Benefit Exchange Expansions of Medi-Cal Other Safety Net Programs

34 Even with new coverage options, it will be important to protect the safety net Protect funding for Public Hospitals Protect funding for Community Health Centers: Federally Qualified Health Centers Community Health Centers Migrant Health Centers Rural Health Centers Protect access to emergency rooms under EMTALA Protect funding for public health programs

35 Emergency Medical Treatment and Active Labor Act (EMTALA) Passed in 1986 to prevent hospital emergency rooms to treat people who need emergency medical assistance but have no health insurance or other means to pay the bill

36 Restricted or Emergency Medi-Cal Emergency Medical Condition a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient s health in serious jeopardy Serious impairment to bodily functions Serious dysfunction to any bodily organ or part of it

37 California s State-Only Health Programs

38 Access to Care Regardless of Immigration Status

39 Pregnancy Only Medi-Cal Pregnancy-related services which include prenatal care, labor, delivery, and up to 60- days post partum care Pregnant Women Under 200% FPL Pregnant women qualify for any pregnancy-related services, including office visits, lab tests, prescription medicine, anesthesia, labor and delivery, other hospital care, etc. This is true for women who are citizens or qualified legal immigrants and women with restricted coverage

40 Breast and Cervical Cancer Treatment Programs (BCCTP) 2 programs: 1 receives federal match, 1 state funded Qualifications for state funded program: Be diagnosed with breast of cervical cancer Be underinsured or not have any other creditable health insurance Be a California resident, and found to be ineligible for federally funded BCCTP Monthly income at or below 200% FPL

41 Other Programs Long-Term Care and Kidney Dialysis: Initially created as a result of a court decision Family Planning, Access, Care and Treatment (Family PACT): Provides family planning, including emergency contraception, screening and treatment for sexually transmitted diseases to women to age 55, men to age 60, and some adolescents Minor Consent Services: Substance Abuse Treatment, Mental Health Services, Family Planning, STD screening and treatment, sex assault and rape treatment

42 Other Programs Child Health and Disability Prevention Program (CHDP): Provides for the early detection and prevention of disease and disabilities for low-income children under age 20 whose income is 200% FPL or below, regardless of immigration status Program pays for regular infant and child health assessments or check-ups, immunizations, nutrition screening, lead screening, vision and hearing tests, lab tests, dental assessments, outreach and educational services, and referrals for further diagnosis and treatment if necessary, but not hospital care

43 Other Programs Access to Infants and Mothers (AIM) Program: Provides health care to women and children to focus attention on the need for more efficient system of care which includes hospital services, physician services, clinical services, preventive and primary care, case management, outreach, immunizations, nutrition, and substance abuse services

44 Gov. Brown s Proposal and State- Only Programs Eligibility and Enrollment Restrictions Currently Eligible, but not Enrolled by January 1, 2014; new applicants must apply to Exchange first If an individual is not eligible for the Exchange, they would still have be eligible and have access to the state-only program Undocumented and PRUCOL would still have access

45 What programs would be affected under Governor Brown s Proposal? Pregnancy Only Medi-Cal Genetically Handicapped Persons Program (GHPP) Breast and Cervical Cancer Treatment Program Prostate Cancer Screening Every Woman Counts AIDS DRUG Assistance Program (ADAP) State-Only Medi-Cal for Recent Qualified Immigrants

46 State-Funded Medi-Cal - Protecting Access for Recent Immigrants 76,260 Qualified Immigrants subject to the 5-year bar 26,000 Permanently Residing Under Color of Law (PRUCOLs)

47 Concerns Related to Brown s Proposal for State Funded Medi-Cal Affordability Wrap Benefits Wrap Language Access Due Process Keeping Families Together

48 Next Steps Short Timeline Working With Leadership Working With the Brown Administration

49 Future Budget Issues to Look Out For. Cuts to or elimination of funding to safety net programs at federal and state level, including public health programs in CA available regardless of immigration status Restrictions to eligibility for health programs Cuts to community clinics or hospitals that serve low-income populations

50 Additional Resources California Immigrant Policy Center ( National Immigration Law Center ( Health Access ( California Pan-Ethnic Health Network (CPEHN)(

51 For Additional Information: Ronald Coleman Government Affairs Manager California Immigrant Policy Center Sacramento, CA Phone: (916)

52 Continuing California s Commitment to the Remaining Uninsured: Protecting the Safety Net and Extending Low-Income Health Programs May 2012 Anthony Wright, Executive Director

53 California s Implementation of the Affordable Care Act California is at a pivotal moment in the next few weeks: * California will soon make decisions how to expand Medi- Cal, part of the largest expansion of coverage in 45 years, a historic reduction of uninsurance by 1/2 to 2/3. Medi-Cal now covers low-income children, parents, seniors and people with disabilities. Expansion now covers childless adults, too. Decisions include eligibility and enrollment issues, online vs. paper verification, benefits, and reforms of existing state-only programs, other issues. Key decisions to expand Medi-Cal fully and urgently. * California will soon make decisions about how we care for Californians who remain uninsured. Governor Jerry Brown has tied the Medi-Cal expansion to taking funds that go to support the county safety-net. Will we maintain public hospitals, clinics, and other safety-net providers? Do we continue California s commitment to the uninsured?

54 California to Have 3-4 Million Remaining Uninsured

55 Who are the Remaining Uninsured? One million undocumented and uninsured Californians now 20% of the uninsured, will be 27-33% of the remaining uninsured. Many may be on a long path to citizenship. Majority of the remaining uninsured will be citizens or legal residents Some frozen between open enrollment periods Affordability issues: i.e., workers with employer based coverage for themselves but not family. Immigrants and communities of color: Disproportionately benefit from coverage expansion. Disproportionately part of the remaining uninsured.

56 California Must Lead California must lead in implementing the Affordable Care Act, in covering the newly eligible and showing the way among states with significant uninsured populations and in addressing the needs of the remaining uninsured.

57 Our Current Safety-Net Around $1.4 billion of vehicle license fee money goes to the state but is earmarked to fund county health services, including public health and medically indigent care. Counties have a obligation to provide basic care Counties vary widely on their service to the uninsured: Savings goes back to the state. Amidst 58 counties, twelve have public hospitals; Others just have clinics, some contract with private providers; Some serve the undocumented; others do not.

58 Governor s Proposal Progress from January: State-based Medi-Cal expansion Governor ties Medi-Cal expansion to state-county realignment, and the state getting savings from people becoming insured. Governor proposes mechanism based on county costs of historical experience. Estimate of savings claimed: Year one: $300 million. Year two: $900 million Year three: $1.3 billion Cuts more than 75% of state funds, at same time of public hospital cuts at federal level Too much, too soon

59 Too Much, Too Soon, and.. Counties: State shouldn t take money for first few years, at most uncertainty, peak demand, and when federal government is paying for 100% of newly eligible. LAO: Why tie to complicate programmatic realignment of human services? Proposal takes into account county costs, but includes cost containment cap that locks counties into recessionlevel spending, into decisions that can t be revisited. Equity issues within populations, within counties. Formula is based on historical costs, not future needs: post-health reform, changing demographics, different health market, emergencies, etc. No incentives for improved and more efficient and costeffective care, including providing a medical home for the uninsured.

60 Another Vision: LIHPs A California success story: 53 of 58 counties covering nearly 600,000 Californians who will become Medi-Cal eligible in January The biggest early expansion of coverage in the nation. Learned to do the safety-net better: Providing not just episodic or emergency care, but providing a medical home, with primary and preventative care. More efficient and effective use of scarce dollars, providing coverage and better health outcomes. Evolved over two waivers and multiple years, the LIHPs expire at the end of the year without legislative action. **Rather than losing LIHPs and their lessons and infrastructure, California should encourage counties to re-direct and extend LIHPs to the remaining uninsured.

61 Our Proposal Expand Medi-Cal: Reduce the number of uninsured dramatically. Aggressive outreach, enrollment in Medi-Cal/Covered California as primary Capacity Building: Use the first three years to build capacity. Peak demand from newly insured; When feds are funding at 100% Maintenance of Effort for Health: for both the State and Counties. Redirecting the Low-Income Health Programs to Cover the Remaining Uninsured Ensuring a Portion of Funds for Public Health Guarantee counties at least half for public health and base responsibilities. Linking Funding to LIHP Enrollment: Providing a metric for state savings and county continuation of funding. A capitated rate per person per month for the county up to their allotment A metric that show the demand and their commitment to meet it Ensuring Basic Support for the Safety-Net Statewide. If a county doesn t want to serve their residents, a portion of state savings should go to support the safety-net in their area. Accountability and Transparency.

62 Support Support from the editorial boards: The Sacramento Bee The Los Angeles Times AARP Health Access PICO California SEIU California Latino Coalition for a Healthy California California Labor Federation California Immigrant Policy Center California Pan-Ethnic Health Network Western Center on Law & Poverty AFSCME

63 Better Health Outcomes New University of California brief: The post-reform uninsured population in California would greatly benefit from strengthened safety net care Medicaid expansions & LIHP-like programs have consistently been found to significantly improve the health and well-being of vulnerable populations. The robust research literature described above that extending the LIHP program after 2014 to serve California s remaining uninsured would yield valuable health benefits indeed, reducing avoidable hospitalizations, improving both mental and physical health, and ultimately preventing premature deaths.

64 Key Reasons California is stronger when every person has access to care and coverage, creating healthier and more financially stable families and communities. California can, and should, fully expand the coverage options in the Affordable Care Act *and* ensure access to care and coverage to the remaining uninsured, including those following a roadmap to citizenship, We've learned to provide safety-net services in a better way through these Low-Income Health Programs, but we could lose that infrastructure if we don't act this year. These Low-Income Health Programs have been a national success story, and we need them to continue to serve the remaining uninsured. Folks who are left uninsured will eventually, by age or accident, find themselves in our emergency rooms and health system. California has an interest in providing primary and preventative care early, rather than more expensive and intrusive care when it is too late. California has always seen immigration as a source of strength and pride and accordingly has made investments in our future. A portion of the remaining uninsured will be new American immigrants who will be on a roadmap to citizenship. California has a stake in their health and success. Including immigrants in safety-net care and coverage is an investment in the future of California.

65 LIHP Proposal Summary Builds on existing programs and institutions; Supports the county safety new of both public hospitals, clinics, and other types of counties. The remaining uninsured have better and more effective care than just the ER. Willing counties have the roadmap to get continued dollars to support their safety-net services. California gets a health system more inclusive and responsive to the needs of all Californians.

66 For more information Website: Blog: Facebook: Twitter: Health Access California th Street, Suite 234, Sacramento, CA th Street, Suite 450, Oakland, CA Wilshire Blvd., Suite 916, Los Angeles, CA

67 Presentation Establishing Statewide Trust Fund to Cover Healthcare Services to California s Uncovered Workers after ACA Implementation BY MAXIMILIANO CUEVAS, MD Chief Executive Officer Clinica del Valle de Salinas (CSVS) Sponsored by California Program on Access to Care (CPAC) UC Berkeley School of Public Health In Cooperation with the Latino Legislative Caucus & the California Primary Care Association Wednesday, May 22, 2013 State Capitol Sacramento, California

68 I have submitted a power point presentation entitled 2013: Health Needs of Undocumented Workers which presents you with the data on the number of undocumented workers in the U.S. and the numbers and challenges we face locally in Monterey County while working to address their health care needs. I would like to make sure that the power point presentation is made part of the record and will address these issues and others in this oral presentation dealing with an initiative that we have proposed to address the health care needs of the remaining millions of California residents and workers who will not be covered by the federal Affordable Care Act (ACA) and/or the expansion of the Medicaid program known as Medi-Cal in California. I want to begin my presentation by emphasizing what many in this room have known from their own personal experiences---community health centers were created for the purpose of serving working poor and uninsured communities of people throughout California. We went into this work with our eyes usually quite open and aware of the problems and barriers we were confronting. Those of us who have worked in and directed community health centers have made a long-term commitment to serving this population. We have worked in health centers located in rural areas, urban centers, or farm worker communities in the state. We have always sought new approaches, policies to increase access and services to the populations we serve. Despite the growth many health centers have experienced over the last 20 years, there remain many working poor who go without vital preventive health, dental and mental health services. PREVIOUS EFFORTS TO ADDRESS ACCESS TO HEALTH CARE FOR WORKING POOR UNINSURED POPULATIONS As a member of the California Hispanic Health Care Association, CSVS along with other clinics serving non-english speaking populations crafted legislation carried by Assemblyman Marco Antonio Firebaugh on two major issues addressing improvements in creating greater access to preventive health care services for working poor communities throughout California: AB authored by Assemblyman Marco Antonio Firebaugh-signed by Governor Gray Davis September 28, 2000: Established the Task Force on Culturally and Linguistically Competent Physicians and Dentists to address the feasibility of establishing a pilot program to that would allow Mexican and Caribbean licensed physicians and dentists to practice in 2

69 nonprofit community health centers in areas with provider shortages with knowledge of Spanish language and culture, AB authored by Assemblyman Marco Antonio Firebaugh signed by Governor Gray Davis September 30, 2002: Created the Licensed Physicians and Dentists from Mexico Pilot Program that would have allowed up to 30 primary care physicians and dentists from Mexico to practice in medically underserved communities with medical provider shortages, AB 801 authored by Assemblyman Manny Diaz Signed by Governor Gray Davis September 25, Enacted the Cultural and Linguistic Competency of Physicians Act of 2003 where local medical societies of the California Medical Association would operate a voluntary competency program for physicians and established for the first time in the United States the definition for cultural and linguistic competency. California was the first state to establish this definition. AB Authored by Assemblyman Dean Flores ( ) passed the Assembly died in Senate Health Committee: Would have established the Farm Worker Health Trust Fund within the State Department of Health Care Services (DHCS). This trust fund would have accepted contributions from private employers in the agricultural industry that would have been allocated to community health centers in agricultural producing counties of California to provide comprehensive preventive health care services (including dental and mental health) to designated farm worker employees for a specific period of time. This legislation was supported by the California Farm Bureau which was the first time in history that the leading agricultural industry representative in California had gone on record as supporting growers and employers contributing to the health care of their workforce regardless of status in the U.S. and without regard to length of time employed. This legislation was very promising but encountered opposition from non-agricultural interests that caused the bill to die in the Senate Health Committee. These are some of the highlights of the legislative efforts that I and several of my clinic colleagues including Clinicas del Camino Real, Borrego Springs Health Foundation (formerly Clinicas del Desierto de Coachella) took that were aimed at creating greater access for perennially uninsured populations to comprehensive preventive health care services and improving the delivery of care to populations whose culture and language were not mainstream in California medical schools or in health care institutions. 3

70 CURRENT INITIATIVE DESIGNED TO ADDRESS POPULATIONS OF WORKERS IN CALIFORNIA NOT QUALIFYING FOR HEALTH CARE SERVICES UNDER MEDI-CAID EXPANSION AND/OR THE FEDERAL AFFORDABLE CARE ACT (ACA) Continued Barriers to Access Over the last two years we have initiated several studies that speak to the continued barriers these populations have to preventive health care services. The Central Coast Health Network issued two policy briefs---the Status of California Farm Workers Since 1990: Progress or Retrenchment/March 2011 and The Patient Protection and Affordable Care Act: Impact on Farm Worker Access to Health/September These policy briefs make the argument that despite the attention and media visibility that has been given to farm workers in a political context very little has improved for a significant percentage of farm workers in California. And despite the many benefits that will be provided under the ACA, many legal residents and citizens of California and the US will not be afforded health insurance under the new law and some 2 to 3 million Californians will remain uninsured and without consistent access to comprehensive preventive health care services. Contrary to the positive intentions of the ACA many workers in California will not qualify for the ACA because: They are employed in temporary positions, They work for an employer who has less than 50 employees and thus is not covered by the federal law, The premiums under Covered California will continue to be a financial challenge for them to afford. Many such workers are employed in two major industries in California that present real problematic issues for qualifying for ACA---they work in the agricultural and service industries that employ hundreds of thousands of workers on a part-time, temporary, seasonal basis. There can be no doubt that this will present major problems for employers and employees in these industries when it comes to determining compliance with this new federal law. Furthermore, the ACA prohibits undocumented workers from participating in this program in any capacity including purchasing their own insurance from the state health care exchange. Should an undocumented person be found participating in the ACA and 4

71 receiving a federal subsidy under this program they would be ruled ineligible for the legalization provisions of S. 744 in its current form. Immigration Reform Barriers In addition and also significantly adding to these concerns are the provisions of the Congressional comprehensive immigration reform legislation. The U.S. Senate bill S. 744 provides an opportunity for some agricultural workers who are in the U.S. without legal status to secure permanent resident alien status after five years but leaves this population without access to health care services during those five years. The potential House bill will not allow any workers including those in agriculture to access the ACA or any other program for up to 20 years. All eligible undocumented workers will be required to pay for health insurance with their own funds and no assistance or subsidy from the federal government. Furthermore, the Senate bill places a restriction on all other qualifying undocumented persons eligible for legalization of at least ten years before they would be allowed to access the ACA or other federally funded programs. Consultants whom we are working with on these issues who are nationally known experts on immigration inform us that public statements and discussions during mark-up by the Judiciary Committee in the Senate and in hearings held by the House Committee on the Judiciary indicate that any efforts to lift these time restrictions on health care coverage for undocumented workers or efforts to make it easier for them to secure health care services funded in part by the federal government, or even state governments, will be very difficult to accomplish. In the last two weeks this issue was a stumbling block for the House bi-partisan group drafting a comprehensive immigration reform package as the Senate has prepared. Democrats wanted the House bill to at least follow the Senate version while House Republicans in the group made it clear that they would not support any measure shorter than the 20 year ban of allowing states to make their own decisions on this issue. Politico publications of May 12, 2013 entitled A Volatile Mix: Health Care and Immigration Reform appears to make it very clear---- Politically, it s a no-brainer: People in the country illegally shouldn t get government health care benefits. It s such a nonstarter politically, in fact, that politicians don t even question whether it s smart policy to have millions of people remain uninsured for another decade or more, even if Congress does approve a pathway to their legalization. If anything, some in Congress want to make it tougher for people on that pathway to get government health benefits, and several senators have drafted amendments 5

72 to the immigration bill that would prolong waiting periods or reinforce other coverage restrictions. The article goes on to quote Senator Jay Rockefeller who is supporting the comprehensive immigration reform legislation who states that I think it would be a heavy lift politically for any push to cover them sooner or more easily. This is a reality that cannot be ignored when considering policy options in California. While every effort should be made to pursue funding alternatives such as expanding Low Income Health Plans at the county level there are many hurdles that need to be cleared before this option can come about including whether Congress will grant any flexibility to states to take such action with state funds that are made available due to the ACA and possible Medicaid expansion. State Funding for Health Care Services--- In the last twelve years we have seen a clear and consistent demise and decrease in funding of state funded health care programs in California. The last three Governors have reduced funding for Medi-Cal, have reduced services and then increased some only to have them decreased again. Categorical programs for migrant and seasonal farm workers have been eliminated altogether, the funding formula for Federally Qualified Health Centers (FQHC s) has been altered and continues to be in debate, and Medi-Cal provider rates have been steadily decreased including this year only to be protected by federal courts. In other words, dependency on public funding for any expansion of health care programs for the working poor in California have not been increasing but decreasing and eliminated since Any policy options that include a high dependency on state and/or federal funding cannot be viewed nor considered permanent. There are unintended consequences to having any policy options that begin with full funding by the federal and/or state government. Populations that desperately need access to health care services should not be placed in such situations of tenuous funding for such vital programs. These facts should not and cannot be ignored. The Uncovered Worker Health Trust Fund Initiative I am joined by my colleagues at Clinicas del Camino Real (CDCR) in Ventura County and 6

73 Borrego Springs Health Foundation in Riverside, San Diego, and Imperial Counties in developing our policy proposal for addressing the remaining populations that we have discussed today who will not be covered by the ACA or Medicaid expansion. This initiative the Uncovered Worker Health Trust Fund expands on the proposal we developed in AB 883 in 2001 with Assemblyman Dean Flores. We do not limit the program to the agricultural industry; we extend it to any employer in any industry in California who has workers who are not covered by the ACA or Medicaid expansion who wants to help cover the health care costs of their workers. The program is voluntary but we have heard from many employers who see this as a reasonable avenue to try and keep good workers from seeking employment elsewhere or dropping out of the work force. We have had discussions with several employer groups in the agricultural sector and some have indicated their support for the concept and objective. We will continue to have discussions with agricultural employer groups and other industries such as restaurants, janitorial, hotel and service. The program will be housed and administered by the Department of Health Care Services Primary Health Care Services Branch. This is the branch that administered the Seasonal and Migrant Health programs that no longer receive funding through the General Fund. However the authority for these two program was not deleted from state law and thus these programs are an excellent vehicle for administering the funds that would be donated by employers seeking to provide health care services to their workers who are not covered by the ACA or Medicaid. Funds from employers would be deposited into one of these yet to be determined programs with existing authority to operate the Uncovered Health Worker Trust Fund. These funds would then be distributed to community health centers that would be required to sign an MOU with contributing employers. Uncovered workers designated by contributing employer would be provided specific health care services for a specific period of time. Services to be provided to designated workers would be comprehensive preventive health care services including preventive dental and mental health services along with primary care. Only community health centers as defined in Health and Safety Code Section 1204 would be eligible to participate. This policy proposal is not the only option that should be pursued. It should be supported to provide another option/pathway for providing more sustainable and better access to health 7

74 care services for historically medically underserved populations. It also provides benefits that are essential for the future. Having funding from employers for their workforce is vital to maintaining a broader system of health care for all residents of California. Employers can have a degree of responsibility for financially covering the health care costs for their workers. This would greatly lessen the expectations of public funding which is the trend that we have seen for the last 15 years and is expected to remain for the future. We recognize that the program is voluntary but we believe that employers will utilize the program because of its simplicity and accountability. An employer knows what services they are paying for, employers are familiar in most instances with the community health centers that have been in the same community as the employer has been, if not longer. The provider network is in place, the provider is audited annually by federal government standards and requirements, and health centers have proven their quality of care through various certifications and reviews by quality care standards and measuring institutions. Lastly, we firmly believe that this approach is sound for the future of health care funding. Good and financially sound community health centers have established a good sustainable diversity of funding. They have a mix of funds from private health insurance, public funding, philanthropic contributions and patient contributions. The Uncovered Worker Health Trust Fund can develop into having the same sustainable funding mix for the future. This can only aid perennially uninsured and populations that will not be covered under the ACA and as a result of federal immigration reform policy. This proposal deserves to be included in any and all discussions about policy options for providing health care services to these vulnerable populations that remain without health insurance or access to health care services. 8

75 Safety Net and Issues of Access in Rural California 1 Noe Paramo, JD Project Director, Central Valley Partnership at California Rural Legal Assistance Foundation Chair, Regional Advisory Council, Central Valley Health Policy Institute May 22, 2013

76 California Rural Legal Assistance Foundation Since 1981, we have been advocates for justice working in geographically isolated communities 2 Policy Advocacy; Impact Litigation; Technical Assistance; Representation regardless of legal status. Our staff includes former farm workers and children of immigrants.

77 Community Residents Are Asking What is the ACA? Is that the same as Obamacare? Who is eligible? What if I am undocumented? When will medical coverage start? Does the ACA help immigrants? As a DACA recipient, can I qualify for healthcare coverage? Can I qualify for health coverage if CIR is achieved? Do farm workers benefit from the ACA? 3

78 Education/Outreach The gap: A lack of knowledge among rural communities about ACA 4 The opportunity: Since the inception of CRLAF s citizenship project in 1993, 40,000 applicants in rural California have been assisted with the naturalization process on a pro bono basis. Seizing the opportunity: CRLAF has been working to increase knowledge of the ACA by incorporating ACA information into our Naturalization Clinics

79 HealthCare Coverage for All? 5 2/3 of the remaining uninsured have legal status; Prevention versus emergency room services; Why exclude healthy and young populations like DACA beneficiaries?

80 Geographic Isolation 6 Poor land use planning; Lack of reliable, accessible, affordable, and equitable public transit services

81 Limited English Proficient 7 Fresno includes communities that speak Mixteco, Spanish, Hmong, and other languages

82 Unscrupulous Actors 8 Lack of regulation over notarios combined with a lack of access to pro bono services providers who can serve all regardless of legal status

83 Summary of Current Challenges San Joaquin Valley faces higher mortality and morbidity than other regions 9 High prevalence of undocumented adults and children, and children in mixed status families Valley counties do not mount comprehensive health care programs for undocumented Even with ACA Undocumented persons and children in mixed status families continue to face barriers to coverage and care

84 Four Key Facts about SJV Higher mortality and morbidity than California Complex patterns link cause-specific mortality and morbidity to race/ethnicity, immigration status, and economic well-being 10 Huge differences across Valley communities in mortality and morbidity are linked to neighborhood demographics, exposures, and resources Excess rates of ambulatory care sensitive hospitalizations pinpoint need for primary prevention through health sector and non-health sector initiatives

85 11

86 Valley County Programs for Indigent Care 12

87 ACA and the San Joaquin Valley Projected Program Eligibility 13 Assuming improvement in economy to 2007 levels: At least 628,684 will be newly insured (including 194,247 new on Medi-Cal) 353,487 or 9% will be excluded from new coverage or unable to afford (including 303,487 undocumented, and 50,000 who can t afford even with subsidies)

88 Lack of Data 14 There is little detailed data on the demographic, health status, and utilization features of undocumented population Lack of data on the public costs for emergency health care that could be avoided or real costs for comprehensive coverage for undocumented Lack of programmatic experience (except through CHI) in outreach and enrollment for this population

89 Implications of Federal Immigration Reform on Health Care Access 15 Current proposals may continue the exclusion of undocumented immigrants from publicly subsidized health insurance. The approximately 350,000 undocumented or mixed status family residents would continue to be excluded from coverage California and counties need to find ways to finance comprehensive care