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L.A. County’s Remaining Uninsured Bound for a Medical Home

LOS ANGELES – Even with more than three million Californians newly enrolled in health insurance through Covered California and the expanded Medi-Cal program, the number of people in Los Angeles County who will remain uninsured could be as high as 1.2 million. Medi-Cal is California’s Medicaid program.

That’s too many, say advocates who support a system in which everyone — regardless of income, immigration status and other factors — is covered. They say cases like that of Jose Ramirez illustrate the need for 100% coverage.

Ramirez, 27, developed a severe staphylococcus infection in 2013 that resulted in back-to-back brain and heart surgeries at a county safety-net hospital. While Ramirez, an undocumented immigrant, says he is “doing well,” he requires ongoing care. 

Ramirez is expected to be eligible for a “new and improved” version of Healthy Way L.A., a retooled version of the county’s Low-Income Health Program through the county’s Department of Health Services. Re-launching in September, the program follows the Affordable Care Act’s lead and supports the medical home model of patient-centered care.

“Not everyone in L.A. County will benefit from the ACA coverage expansion,” said Michael Wilson, communications officer for the county’s Department of Health Services. “The Healthy Way L.A. Unmatched program will continue to provide a coordinated and comprehensive care program for those who don’t qualify for other coverage options and meet the program’s eligibility criteria. The challenge is to develop a care program that meets the needs of a very diverse population.”

The program will cover uninsured residents of L.A. County with incomes up to 138% of the federal poverty level who are ineligible for other coverage programs, including Medi-Cal and Covered California.

The newly insured represent “mission advanced” but not “mission accomplished,” said Anthony Wright, executive director of Health Access. “Although the Affordable Care Act has made substantial progress that we acknowledge and celebrate, it’s up to cities and counties like Los Angeles to complete the job. The ACA still doesn’t extend health coverage to everybody who needs it, including those who are undocumented or have other special circumstances. That leaves them living sicker, dying younger and one emergency away from financial ruin.”

Reasons why an individual would remain uninsured include:

Being unable to afford coverage, even when subsidized; Being homeless with no address (an address is needed to complete enrollment application); Having employer-sponsored coverage that excludes families of the employed; and Simply lacking awareness about available opportunities.

Eyes on L.A. Health Care

The county is considered ground zero for the uninsured nationally, Wright said. “If L.A. were its own state, it would have the highest uninsured population in the nation. We think it is more effective and efficient to get people the care they need ahead of time, both primary and preventive, rather than doing so at the [emergency department].”

The medical home, “one place for all needs” seamless approach, has gained momentum under the ACA, aided by the accessibility of electronic health records for health care providers to share. The model offers the opportunity for patients to deal with one primary care doctor — the norm for some patients and providers, but something of a new concept for the public system.

“Patients can use a medical home for a primary care issue or preventive needs,” said Tangerine Brigham, director of managed care for the county’s DHS. Brigham, longtime deputy director of policy and planning for San Francisco’s Public Health Department, took the L.A. job last year after her former boss in San Francisco, Mitchell Katz, became director of Los Angeles County DHS in 2011.

“It’s a place where providers know their patients and their health history, and can help them not only manage their care but refer them to a specialist if they need it,” Brigham said.

Unlike LIHP, Healthy Way L.A. enrollees will be able to select providers instead of being assigned and have the ability to make appointments, she noted.

“They may choose a clinic based upon geography, their language capacity, or because a friend got good results there,” she said. “They’re more inclined to go to a place they select themselves, and that makes it easier to provide them care that’s less episodic or requires urgent or emergency care.”  

To achieve its goals, L.A. County — which has one of the largest urban communities in the nation — must provide clear communication, she said.

“We want to disseminate sufficient knowledge across this community about what the program is, how people enroll and what services are available,” said Brigham. “You can’t expect people to use the health care delivery system appropriately if they have no information. We understand that someone might think the easiest thing to do is go to the ER because they haven’t previously had other options that allowed them to use additional resources.”

Program Plans in the Works

As a result of the ACA, approximately 300,000 Healthy Way L.A. patients were transitioned into Medi-Cal on Jan. 1 via the “bridge to reform,” California’s pre-ACA arrangement with CMS.

These individuals were assigned to a medical home at either a county-run clinic or private, not-for-profit community clinic. The first of two “prongs,” Healthy Way L.A. Matched was originally part of the state’s Low-Income Health Program under California waiver 1115, implemented in 2011 and ending Dec. 31, 2013. The program received 50 cents on the dollar in federal funds for every enrollee, who had to be a citizen or resident.

The second prong, the former public/private partnership begun in 1995, was renamed Healthy Way Unmatched, and is still in effect. Not matched by federal funds, it is currently funded by the county board of supervisors who agreed to use county funds to reimburse community clinics for care for approximately 100,000 patients and will re-launch with a capitated payment model.

“We don’t really need to differentiate about Matched and Unmatched when it comes to the public,” said Louise McCarthy, president and CEO of the county’s Community Clinic Association. “They just want to know that the program will take care of them. We knew who was getting put on the matched waiver side and who wasn’t, and the goal is really one effective county-wide program.”

The county is currently assessing potential provider interest, and is piloting enrollment efforts for the new program, said McCarthy. Contract negotiations should begin this summer, she said.

 “Funding determined how many people enrolled in the program previously. Now we need to determine what the costs per person will be,” McCarthy said. I have confirmation that at a minimum, funding won’t shrink. What happens next — whether we can grow it — remains a big question.”

At an April 16 rally, supporters of the remaining uninsured called for three times the current funding, or $165 million for Healthy Way L.A., said Wright.

“Fifty-five million dollars is a great first step, but not a great last step,” he said. “We want to see those funds augmented, because current funds won’t meet the needs of L.A.’s remaining uninsured.”

Enrollment must also continue to target the undocumented, said Wright, because they deserve the next opportunity to be included fully in the “life of California.”

“Immigrants are such an important part of the L.A. economy and the community,” he said. “They’ve been paying their taxes and they should also be part of the health system.”

Proposed legislation could potentially make that easier. The Health for All Act, SB 1005 by Sen. Ricardo Lara (D-Long Beach), would extend the same ACA benefits to all California residents regardless of immigration. 

The Senate health committee this week unanimously approved Lara’s bill while supporters rallied in Sacramento.

“Medical care needs to be provided to all sectors of the community, regardless of how much money they have, their zip code or legal status,” said Vanessa Aramayo, director of the California Partnership group of anti-poverty coalitions. “The bill offers a statewide solution that can also set an example for the rest of the country.”

At the local level last week, Los Angeles City Council member Gilbert Cedillo of District 1 introduced a resolution in support of SB 1005.

For Jose Ramirez — and more than a million other uninsured Los Angeles residents — health coverage by whatever means would be welcome.

“After what I went through, I’m using the system a lot more than I used to,” said Ramirez, who is taking blood thinners and requires frequent, ongoing oversight. “I need lots of check-ups, and having care that’s within my budget would really be great.”