live / 2014

Health Care for 1 Million Uninsured Los Angeles Residents

Idea submitted in the My LA2050 Maker Challenge by Western Center on Law & Poverty (WCLP)

WCLP will help the state and county expand health care to the 1 million LA residents who remain uninsured after the Affordable Care Act.


Please describe yourself.

Collaboration (partners are signed up and ready to hit the ground running!)

In one sentence, please describe your idea or project.

Western Center advocates and litigates to secure housing, health care and a strong safety net for all Californians living in poverty.

Which area(s) of LA does your project benefit?

  • Central LA
  • East LA
  • South LA
  • San Gabriel Valley
  • San Fernando Valley
  • South Bay
  • Westside

What is your idea/project in more detail?

A healthy community means health care for all. Despite the Affordable Care Act’s progress in expanding health coverage, an estimated 1 million people in LA remain uninsured. They include undocumented residents (≈40%); families caught in the family “glitch,” that makes family coverage unaffordable for low wage workers (≈30%-40%); and individuals eligible for but not enrolled in Medi-Cal or Covered CA (≈20%-30%). Western Center will work with health care stakeholders to repair broken systems and amend policies and procedures to ensure that L.A. residents access the best health services available to them.

What will you do to implement this idea/project?

Western Center will help the County of Los Angeles and the State of California develop and implement specific and sweeping policy solutions to ensure health care access for the remaining uninsured.

For nearly five decades, Western Center has successfully blended effective policy advocacy and strategic impact litigation to achieve major system-wide victories for poor Californians. With offices in Los Angeles, Sacramento and Oakland, we are able to work with state and local governments and stakeholders throughout the state to achieve policy changes on behalf of millions of poor families and individuals.

To address the eligible but unenrolled, we will engage in a collaborative process to create pathways that make it easier for LA residents to enroll in coverage. We will conduct detailed program analysis of Medi-Cal and Covered CA; identify procedural enrollment obstacles and inefficiencies; review enabling regulations, All County Welfare Directors Letters, notices to consumers, website designs, training materials and marketing materials; deliver detailed recommendations to policymakers and advocate for their adoption. Beyond internal systems, we will work with stakeholders who are developing media savvy messaging aimed at persuading “young invincibles” to enroll in affordable health care programs .

We will engage in local, state and national advocacy to address and resolve the family glitch issue. The most likely “fix” involves a reasonable and simple change in the definition of affordability within the Affordable Care Act to permit family members who can’t obtain affordable employer sponsored insurance coverage to access subsidies in the Exchange (Covered CA).

We will educate policymakers about the remaining uninsured, including undocumented people. We will develop helpful tips informing advocates and consumers of how to maximize underutilized resources for the remaining uninsured including county indigent care mandates under Section 17000 of the CA Welfare & Institutions the Ability to Pay program, Healthy Way LA Unmatched, Medi-Cal for DACA eligible youth, the Kaiser Permanente Child Health Program, selected Medi-Cal services, community health clinics and emergency rooms, and the Hospital Fair Pricing Act. We will simultaneously seek a system-wide solution to ensure coverage for all Angelenos, regardless of immigration status.

How will your idea/project help make LA the healthiest place to LIVE today? In 2050?

Healthy communities offer quality, affordable and available health care to all of its residents. Families and individuals can take advantage of preventative and primary care, rather than relying on costly emergency rooms. People have health insurance and patients don’t “fall through the cracks.” The entire community is broadly committed to expanding access and improving the quality of health care services and systems.

Quite simply, Los Angeles falls short. The Robert Wood Johnson Foundation, which ranks counties within states by the quality of the clinical care available to residents reported that in 2014 Los Angeles ranked 49th among California’s 58 counties. The Foundation cites access to care as one of the principal pathways to improve health outcomes.

By helping the state and county expand health care access, Western Center will have a direct positive effect on 1 million people in Los Angeles and simultaneously improve the health of the community at large.

Expanding coverage and access makes also sound financial sense. The UCLA Center for Health Policy Research notes in their May 2014 study, A Little Investment Goes a Long Way: Modest Cost to Expand Preventive and Routine Health Services to All Low-Income Californians, that expanding coverage to those who are uninsured would cost about 2% of the state’s Medi-Cal spending and would be substantially offset by increased sales tax revenue and reduced county spending.

The expansion of health care to all Los Angeles residents will not simply help people today but will establish the programs and systems that will be able to deliver high quality health care services to our community for years to come.

Whom will your project benefit?

The project will directly benefit the 1 million people who do not currently have health care coverage. For these families and individuals, it will improve their health; limit preventable, early deaths; and reduce financial and emotional stress. As noted above they include:

  1. Undocumented residents (≈40%) who are not eligible for coverage under the Affordable Care Act.
  2. Families caught in the family “glitch,” that makes family coverage unaffordable for low wage workers (≈30%-40%). This means families with one or both parents working at low paid jobs and receiving individual, but not family health insurance through their employment. The current Affordable Care Act regulations provide that even if the uncovered spouse and children are financially eligible for ACA insurance and subsidies, they may not take advantage of that opportunity. Their only choice is to pay for prohibitively expensive family coverage through the employed parent’s work.
  3. Individuals eligible for but not enrolled in Medi-Cal or Covered CA (≈20%-30%). These people fall into two sub-categories: those who are eligible for free care via Medi-Cal or subsidized care through Covered CA and those who simply refuse to purchase health insurance, often believing that they don’t need it. The latter group has been dubbed “the young invincibles”, young healthy people who don’t believe they will get sick or need medical care.

The project will also benefit the broader community. It will minimize uncompensated care; reduce reliance on overstretched emergency rooms, increase the health care system delivery capacity; strengthen the local economy; and improve public health.

Please identify any partners or collaborators who will work with you on this project.

Western Center’s partnerships with California’s 95 legal aid organizations, including 20 in Los Angeles, are well known. We deliver in-depth legal support, including technical assistance by email and phone, on-site trainings, conferences, webinars, publications and litigation support to 700 legal aid attorneys in the state.

Equally important are our longstanding, working partnerships with virtually every significant policy organization working on health care issues. This includes organizations such as Health Access, Consumers Union, California Pan-Ethnic Health Network, California Immigrant Policy Center, Insure the Uninsured, Tenants Together, Los Angeles Community Action Network, and CA Partnership. Our work is recognized and supported by the California Endowment, the California Wellness Foundation and other philanthropic organizations dedicated to improving the health of Californians.

In addition, we maintain strong relationships with local, state and federal public sector stakeholders, including Covered California; the California Departments of Health Care Services, Managed Health Care, Housing and Community Development, and Social Services; County Welfare Directors Association, California State Association of Counties along with legislators and legislative staff. We are a unique highly effective voice in Sacramento representing the health care needs of low-income Californians, and collaboration is part of the fabric of our work.

Three factors critical to Western Center’s collaborative success are: 1) This is a winnable but immensely complicated project with many moving parts. 2) There are distinct yet intertwined roles for each of the partners that must be appropriately woven together. 3) The partners will need to maintain a nimble and flexible strategy that fluidly adjusts to shifting policy currents.

How will your project impact the LA2050 “Live” metrics?

  • Healthcare access
  • Rates of mental illnesses
  • Prevalence of adverse childhood experience (Dream Metric)
  • Percentage of residents receiving coordinated healthcare services (Dream Metric)

Please elaborate on how your project will impact the above metrics.

The project is precisely designed to address the LA2050 metrics that “Every family will be able to afford quality healthcare…”and that “our region’s residents will have the economic means and cultural capital to lead active, healthy lives.”

Simply put, the project’s aim is ensure that every child, women and man in Los Angeles has quality health care. Western Center will accomplish this by vastly expanding health care access, health insurance enrollment, services for people with mental illness and the overall system-wide capacity to deliver health care services in Los Angeles.

Please explain how you will evaluate your project.

The project will establish both interim and final goals. Interim goals may include items such as increased media outreach to eligible but unenrolled individuals; changes in the application that streamline and ease the process; translation of application and related materials into new, needed languages; removal of bureaucratic barriers to application and enrollment; expansion of the health care delivery system; and changes in regulations and policies that prevent access to health care services. Final goals are described below and include both quantitative and qualitative measures. The evaluation will be conducted by attorneys, who will assess on a monthly basis the progress made towards both incremental and final goals. They will utilize state and county data, documents and reports; assessments by collaborative partners and other stakeholders; and reports from potential beneficiaries of the project.

Quantitatively, Western Center will measure:

  1. The number of undocumented people who obtain health care;
  2. The number of new enrollees among those eligible but not presently enrolled in Medi-Cal or Covered CA;
  3. Increased coverage flowing from changes in regulations that eliminate or mitigate the negative impacts of the kid/family glitch

Qualitatively, we will look at the lives of our clients – are they better off today than yesterday? We will hear the stories from those who benefit from the policy changes we secure.

What two lessons have informed your solution or project?

  1. SUCCESS: Solutions can be crafted to solve complex, system wide challenges. For 47 years, Western Center has led the charge for policy change on behalf of poor Californians. In 1971, we litigated Serrano v. Priest, which established the rule that school finance systems can’t discriminate against children from low income communities. In 1985, we eliminated mandatory county “poor houses”. In 1999, we established that the county must provide last resort medical care to those who can’t afford it. In 2004, we kept Rancho Los Amigos Hospital open, preserving residential services for thousands of severely disabled people. In 2012, we helped the state enroll over 500,000 people in the Low Income Health Program. We have a history of success.

  2. PERSEVERANCE: Policy problem solving is not a “one shot” affair. Western Center tackles big problems that often require strategic, staged solutions. There is no “magic wand” to change the way complicated public and private systems work. Policy change is often incremental, building upon past victories to construct new wins. Whether its civil rights, gay rights, civil liberties or expanding health care, the path to victory has been and is often twisting and indirect. Western Center understands that campaigns take time. The proposed project stands on the shoulders of our historic health care work that in 2014 helped millions of people in California obtain health coverage for the first time.

Explain how implementing your project within the next twelve months is an achievable goal.

There is a broad and deep coalition of likely and unlikely allies who support the continued expansion of health care reform in California, including elected officials, government health departments, the medical community, patient advocates and residents. Each group of stakeholders has much to gain from the provision of health care to an additional 1 million people in Los Angeles. Some stand to benefit financially while others simply need quality health care. All benefit from the overarching community advantages of expanded access to health care.

Given the intertwining agendas of the various power stakeholders, it is an opportune time to make significant policy changes to achieve our goal. The State and County stand to gain millions of dollars should the family glitch be addressed and fixed and they therefore stand shoulder to shoulder with advocates working on this issue. The medical community, along with Covered CA and the State insurance pool, will similarly benefit financially if those who are unenrolled but eligible for insurance sign up. As noted in the UCLA Center for Health Policy Research report, there is overwhelming and bi-partisan support among Californians for immigration law changes that improve conditions for undocumented immigrants and similarly support the state making its own policies apart from the federal government regarding undocumented persons. Twenty six state Senators and Assembly members are co-authoring legislation to expand coverage to undocumented people.

This is not to say that it will be easy or certain. However, there is already a great deal of momentum among the public and private sector towards full coverage…momentum that must be seized, nurtured and encouraged. Achieving the goal of health care access for 1 million people without coverage in Los Angeles is within our reach through the adept implementation of regulatory and policy change along with meaningful public education—all Western Center areas of expertise. It can be done.

Please list at least two major barriers/challenges you anticipate. What is your strategy for ensuring a successful implementation?

  1. Financial Barriers There are costs associated with covering 1 million uninsured Angelenos. For the 60% - 70% who fall in the family glitch and the eligible but not enrolled categories, those costs will be met through federal Affordable Care Act subsidies. Costs will be offset through decreased use of emergency rooms, reduced mortality, increased productivity in employment, and better risk sharing in the state insurance pool.

  2. Bureaucratic Barriers Developing the systems and infrastructure to cover and deliver health care to 1 million people is a complex project with many moving parts. Barriers to coverage include computer problems in determining eligibility; out of date policies that impede access to services; and misinformation regarding coverage availability. State and county government have undertaken similarly complex projects in the past and are able to appropriately create programs and systems to meet the challenge.

  3. Policy Barriers Expanding health care to people without documents raise passions that, as the UCLA Center for Health Policy Research says, “get in the way of good public policy design”. The Center’s report, Ensuring California’s Future by Insuring California’s Undocumented, describes how expanding coverage not only improves patient’s health and results in economic stability for undocumented Californians and their citizen children but also strengthens Covered CA by adding people who are generally younger and healthier to the insurance pool.

What resources does your project need?

  • Network/relationship support
  • Money (financial capital)
  • Volunteers/staff (human capital)
  • Publicity/awareness (social capital)