New Report Shows Post-ACA Enrollment in County Indigent Programs

Thursday, March 12, 2015


* Counties Vary Widely: On Income, 43 Counties Provide Care Up To 200% of Federal Poverty Level; Six are Below, Nine Are Above That Medium Threshold; Twelve Run Public Hospital Systems; Only Ten Report Providing Services to Undocumented Immigrant Californians.

* New Health Access Report Shows Counties Successfully Enrolled Most In Their Indigent Care Programs in ACA. Counties With Broad Eligibility Showed Continued Need; Those With Restricted Eligibility Had Few If Any Enrollees.

* Momentum For the Remaining Uninsured, as My Health LA Now Covers 81,000 Californians, and Many Counties Currently Discussing Reforming Their Indigent Care Programs. As an Example, Sacramento County Starting to Discuss Restoring Care for Undocumented Immigrants at Workshop on March 18th

A new report released today by Health Access California, the statewide health care consumer advocacy coalition, shows the major impact of the Affordable Care Act on California’s safety-net programs, as well as dramatic differences by the counties in both their eligibility levels by income and immigration status, and especially in their enrollment. The study puts a spotlight both on counties that are refocusing their programs to serve the remaining uninsured including undocumented immigrants, and on counties starting to have that conversation.

The survey shows that the Affordable Care Act expanded coverage to many of those with limited care options through county indigent care programs. The survey also shows there is still a need for a safety-net that survives and thrives, as tens of thousands of Californians who remain uninsured are still using these services in each county with expanded eligibility. Howvever, many counties with restrictive eligibility requirements have few if any people getting care through their programs, and thus need to re-adjust their programs. Community and health advocates are urging counties and the state to reorient their safety-net programs to serve the need that continues to this day.

The survey of all 58 counties’ indigent care programs, a follow-up from an earlier November 2013 Health Access report, shows the impact of the dramatic expansion of health care coverage under the Affordable Care Act. In late fall of 2014, Health Access conducted a survey of California county health departments, asking about eligibility and enrollment in programs for the medically indigent. The survey found that:

** California counties continue to be dramatically different in how they care for the “medically indigent,” both in term of how they provide care, who is eligible due to income and immigration status, and other factors.

o Forty-three counties serve residents at twice the federal poverty level; six counties have income limits below that; nine counties have income levels above that.

o Only ten counties provide services beyond emergency care to the undocumented.

** The 2014 implementation of the Affordable Care Act significantly reduced the number of Californians in every county indigent care program in the state, as counties successfully enrolled their patients in Medi-Cal and Covered California.

** Counties with broad eligibility requirements are seeing strong continued need for their safety-net programs, with tens of thousands people enrolled in some counties. Some are adapting and augmenting their programs to be more comprehensive, focusing on primary and preventive care.

o Beyond programs like Healthy San Francisco and Alameda’s HealthPAC, the new My Health LA program launched in September 2014 and is already serving 81,000 Angelenos.

** Counties with restrictive eligibility requirements, especially those that exclude the undocumented, are finding few if anyone left in their indigent care programs—but not because there is not need.

** While some counties adjusted benefits, most counties generally did not change eligibility for their programs in the last two years, opting for a “wait and see” approach after both the ACA implementation and the state’s reallocation of some safety-net funds.

o Fresno was the main county that actively considered, and in fact voted on, rolling back eligibility significantly, but it is in the process of establishing a reformulated program, including for the undocumented.

o Other counties and advocates are looking to refocus and reform their programs to better meet community needs and the remaining uninsured including the undocumented.

o For example, Sacramento, one of three counties to stop serving the undocumented in 2009 (the others being Yolo and Contra Costa), is having a conversation, at a workshop on March 18th, about options for restoring such services, and in what form.

Based on this survey, Health Access recommendations urge counties to re-orient their programs to better serve the remaining uninsured, as many counties are starting to plan their 2015-16 budgets, which are set to start in July 2015. The President’s executive order on immigration also will spur these policy conversations, as immigrants with this expanded “deferred action” status become eligible for both state Medi-Cal or these county programs, depending on income.

With the Affordable Care Act successful enrolling many Californians, some counties are consdering reorienting their indigent care programs to meet the new needs of the remaining uninsured. Many community groups are working in many counties to make sure all Californians have basic access to the primary and preventive care they need. Much like the county Low-Income Health Programs were a bridge to health reform and the Medi-Cal expansion, these county efforts can ultimately be a bridge to a statewide solution, where all Californians can be covered regardless of immigration status.

For more information, read the report on the Health Access website at: