Approximately 81,000 to 90,000 Alameda County children and parents are uninsured. This fact puts them at risk. Having health insurance is a vital link to health access and, eventually, to health status. Why? Because people without health insurance are more likely to delay or forego seeking medical treatment. As a result, people without health insurance are more likely to have serious health problems when they are finally treated and long-lasting negative effects on overall health status.

More than 70% of the County’s uninsured are people of color; more than 50% of the uninsured are immigrants-major factors not to be forgotten as the County tackles the complex issues of improving health access for its residents. The relationship between ethnicity and health access is documented. Ethnic and racial groups continue to “bear a disproportionate burden of mortality and morbidity across a wide range of health conditions,” according to a Kaiser Family Foundation report just published. Health insurance could reduce health disparities among ethnic and racial groups.

It was with this picture in mind that the Board of Supervisors’ Health Committee convened the Alameda County Children and Families Health Insurance Task Force. It was charged with finding ways to expand health coverage for Alameda County residents, with children and families as its primary focus. While the ultimate goal is universal health coverage, the specific charge of the Task Force was the development of a policy framework for the County’s health insurance initiatives.

A broad array of organizations participated in the Task Force providing information and experience invaluable to molding the end product. The organizations participating in the Task Force represented the County’s safety net providers, community physicians, hospitals, unions, health insurance plans, community advocacy groups, and a variety of County agencies. Over a short four-month period and with over 1,000 hours of individual meeting time, the Task Force and its three Work Groups have fulfilled the Health Committee’s charge.

Approximately 13 to 15 percent of uninsured children and families are ineligible for any public health insurance programs. However, the greater number (over 68%) of uninsured are eligible but not enrolled in Medi-Cal or Healthy Families. With this in mind, the Task Force identified two strategic objectives:

1. Find ways the County can provide health insurance coverage for the County residents who are ineligible for any existing public health insurance programs.
2. Maximize enrollment of eligible children and families in Medi-Cal and Healthy Families.

Ahieving these strategic objectives involves both long and short-term changes. To create long-lasting changes that will make health care accessible to all Alameda residents will take time. Changes in federal, state, and local policies are needed as well as fundamental infrastructure changes in complicated County agency processes. None of these changes can occur overnight.

The Task Force believes there are a number of things that can begin immediate to make a difference for those who are uninsured. While it is important to address the children and families without ANY source of health insurance, it is clear the larger problem is getting eligible children and families enrolled in Medi-Cal or Healthy Families. It holds the promise of health access to a great number of the uninsured in the County.

The primary recommendations of the Task Force are listed below:

1. A high degree of coordination and organizational accountability is needed to achieve better results from the existing outreach and enrollment activities. The County should establish a SINGLE point of accountability for the County’s Health Insurance initiatives. The SINGLE point of accountability would coordinate the widely dispersed outreach efforts in the County to address the uninsured issues and would work with both the Social Services Agency and the Alameda County Health Care Services Agency. It could report to the Board of Supervisors.
2. Existing enrollment processes present a significant barrier to County residents. Getting and retaining health insurance must be easy for clients. The County should implement a “no wrong door,” single point of service enrollment process with application assistance based in the community and application processing accomplished “behind the curtain.” Because the uninsured tend to be people of color and immigrants, effectively reaching these residents will rely heavily on community organizations with which there is an existing trust relationship.
3. The County should subsidize a “gap” health insurance product for children and families with incomes at or below 300% of the Federal Poverty Level who are ineligible for other public health insurance programs. The County should utilize Family Care as the “gap” health insurance product, as it is the only existing program in the County covering the target population. The County should continue its efforts to expand coverage through partnerships with Kaiser and other interested organizations.
4. The County should implement immediate short term improvements that can leverage Medi-Cal federal matched dollars: screening EVERY application for Medi-Cal; begin using the state-approved short joint application; and utilize SCHIP outreach funds to pilot specific enrollment strategies recommended by the Task Force.

The Task Force attempted to identify costs for implementing recommendations 1 and 2. This analysis is complex involving numerous inter-related factors. The Task Force felt this analysis was beyond the scope of the Task Force and that it is a task more appropriate for the next planning phase. The Task Force sought information from Santa Clara County’s Children Health Initiative, but the data are not yet available. The SCHIP outreach funds will allow the County to pilot some of the enrollment activities recommended by the Task Force. The pilot results, together with data from Santa Clara, will provide baseline data to estimate the financial impact of the recommendations.

Some County’s residents already purchase Family Care, the Alameda Alliance for Health’s health insurance plan for children and families with incomes at or less than 300% FPL, regardless of documentation status. Current financing available is $5.9 to $7.4 million comprised contributions from the Alameda Alliance for Health and County Tobacco Settlement funds.

For the County to provide such a health insurance product for the target population, additional funds will be needed to to cover the County’s 4,600 uninsured children and 7,100 uninsured families. The Alameda County Health Access Collaborative staff provided the following estimates of what the deficit might be:

1. Scenario One: Healthy Families expansion is not approved.
             $18.7 to $73.7 million additional funds needed over 4-years.
2. Scenario Two: Healthy Families expansion is approved for families up to 200% FPL.
             $16.5 to $45.4 million additional funds needed over 4-years.
3. Scenario Three: Healthy Families expansion is approved for families up to 250% FPL.
             $4.4 to 26 million additional funds needed over 4-years.

This analysis is very preliminary and depends on the accuracy of a number of assumptions. The wide range in these estimates is due primarily to the range in the per member per month which reflects variables such as age, sex, health status. The costs of subsidizing “gap” health insurance will need further refinement through actuarial analysis.

A number of funding opportunities will be pursued, if the Board of Supervisors approves the Task Force recommendations.

The Task Force is strongly committed to the core values and principles articulated in the report to the Board of Supervisors. It recognizes the recommendations need further definition and detail as to how each can be implemented. The Task Force strongly urges the Board of Supervisors to establish an Implementation Planning Group to take the recommendations to the next level of analysis and planning. The Implementation Planning Group should be a smaller executive planning group of no more than 7-9 members. The membership is as follows: 2 representatives from the Board of Supervisors, the Director of the Alameda County Health Care Services Agency, the Director of the Alameda County Social Services Agency, and three members representing providers, health plans, and community advocacy groups selected by the Task Force to represent it.

Responsibilities would include:

1. Outline implementation options for the Board of Supervisors to consider. Activities include:
   • Conduct an actuarial analysis
   • Develop cost models and financial projections
   • Structure the Single Point of Accountability concept
   • Design a pilot project for the “no wrong door” enrollment strategy.
   • Develop a funding strategy and plan.
   • Address provider network adequacy issues.
2. Act as a coordinating body to review funding opportunities to ensure the proposed responses are consistent with Task Force recommendations.
3. Oversee the implementation immediate short term improvements that can leverage Medi-Cal federal matched dollars.

The Task Force believes its recommendations provide a high level roadmap with specific actions the Board of Supervisors can take to increase the effectiveness of those efforts. There are many dedicated efforts in the County to reach and enroll uninsured children and families in existing public health insurance programs. In the course of its work, the Task Force found that many organizations join the Board in its efforts to forge more effective strategies to reduce the number of uninsured in Alameda County.

The Task Force recommendations are just a starting point and first step towards reducing health disparities The Board of Supervisors is urged to continue its commitment to making the dream of universal health coverage a reality for Alameda County residents.

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