1. THE PPACAAND SFFC:
GETTING READY FOR
2014
Angela Liu
August 2013

2. Outline
• Three main takeaways:
1) Major changes ACA brings about
2) The predicted effects of these changes
3) What’s our role?

3. WHAT’S COMING AHEAD?
State of the union on healthcare reform:

4. Quick Recap of the ACA
• In 2014, Obama’s health care law goes into full
effect.
1. No denial of coverage for pre-existing conditions
2. No annual limits
3. Large employers to offer coverage (delayed to 2015)
4. Individual mandate + tax penalty
• Exemptions: members of certain religious groups and Native
American tribes, undocumented immigrants, people with
incomes below tax filing threshold, people for whom insurance
premiums exceed 8% of family income, and others
5. Medicaid (Medi-Cal) expansion
6. Exchange-purchased insurance coverage begins
• Subsidies for Exchange-purchased insurance

5. California specifically…
• ACA and the recent Supreme Court ruling gives
states the right to decide
• Whether to expand Medicaid or not
• Whether to establish a state exchange (insurance
marketplace) or default to a federally-run exchange

6. California on Medicaid expansion
• CA among states that will expand Medicaid

7. California on Medicaid expansion
• Medi-Cal currently only covers certain groups
of low-income Americans (families, children,
pregnant women, people with disabilities)
• Expansion of Medicaid to cover low-income
Americans up to 138% of the FPL
( ~15k/individual, ~31k/family of four)
• Federal funding for first five years
• Evidence that Medicaid expansion will have
wide ranging benefits (better health
outcomes, economy)

8. CA’s Exchange: Covered California
• CA first state to establish exchange

9. CA’s Exchange: Covered California
• Online “health insurance marketplace” where consumers
can shop/compare their options; competitive model
expected to drive down premium prices
• Covered CA to offer 13 plans by “name-brand” insurance
companies that cover at least 60% of medical costs
• More expensive premiums = more medical cost covered
• All plans must cover a set of ten Essential Health
Benefits
• State-run exchanges = more autonomy/decision making
by states than those defaulting to federal exchange
• Tax subsidies for insurance purchased through the
Exchange for those making 139%-400% of FPL

10. Timeline
• October 1, 2013: open enrollment opens for the health
insurance exchanges
• January 1, 2014: coverage under Covered California
begins
• Insurance premium subsidies for low- and middle-class income
families take effect
• Medi-Cal expansion
• March 31, 2014: Covered California open enrollment
closes for 2014

11. PREDICTING THE IMPACT
Who will be covered, who will be left behind, and why?

12. Impact on uninsured in CA
• About 7 million uninsured in 2011
• 1.8 to 2.7 million uninsured to newly gain
coverage in 2014
• These are the people whose jobs don’t offer
insurance benefits, those who couldn’t afford it
previously
• More people having insurance = more people
getting the care they need before getting
seriously ill

13. Many to still remain uninsured
• This still leaves 3.1 to 4 million Californians
without insurance (projected numbers for 2019),
with roughly 1.4 million (40%) uninsured
predicted to still lack affordable coverage
• Remaining uninsured fall into two categories:
1. Those that are not eligible (excluded from ACA)
• Undocumented immigrants
• Incarcerated individuals
2. Those that are eligible, but do not enroll
• About 2 million (50%) will be eligible, but remain
uninsured
• 1.1 million (28%) uninsured will pay tax penalty

14. Who will be left behind?
• Demographic groups most likely to be
uninsured after ACA (in CA):
• Latinos
• 66% of uninsured
• Non-English speakers
• 3 out of 5 uninsured
• People with incomes < 200% FPL
• 57% of uninsured

15. Why will they be left behind?
1. Not eligible
• Immigration status
2. Eligible, but do not enroll
• Insurance will still be unaffordable for many
• Majority of remaining uninsured Californians predicted
to be exempt from tax penalties
• Barriers to enrollment
• Difficult enrollment procedures (confusing
applications, language barriers, unfriendly eligibility
staff)
• Awareness of programs and eligibility
• One in five Americans unaware of health exchange marketplaces

18. Why will they be left behind?
• Gap between eligibility and enrollment (in CA)
• Medi-Cal:
• 880,000 uninsured already eligible for Medi-Cal
• 880,000 to be newly eligible for Medi-Cal
• Only 640k - 1 million to newly enroll in Medi-Cal
• Exchange:
• 1.59 million uninsured eligible for subsidies with
the Exchange
• 790k - 1.2 million predicted to enroll in Exchange
with subsidies

19. Reform’s success depends
hugely on awareness of and
enrollment into programs

20. Making enrollment accessible
• Marketing and outreach campaigns, geared towards groups
most at risk of remaining uninsured
• Existing programs to provide enrollment assistance (HSF,
SF Path)
• Streamlined eligibility, enrollment, and renewal policies for
both Covered CA and Medi-Cal to make getting insurance
coverage as easy as possible
• Multiple languages
• Multiple ways to enroll (mail, in-person, online)
• Covered CA Assisters Program: community organizations
(including nonprofits, religious organizations, labor unions, clinics,
schools, etc) can directly help people enroll into Covered CA
• More on this later!

21. Making enrollment accessible
• “No Wrong Door” Policy
• A system in which “no matter where and with what
knowledge people apply for coverage, they get full
access to all public health coverage programs and are
enrolled into the most beneficial program.”

22. WHAT’S OUR ROLE?
“What’s going to happen to SFFC after Obamacare?”

23. Yes,
we’ll still be
needed!

24. SFFC’s role
• Two-fold:
1. Continue providing the “safety-net” care
for remaining uninsured
• Health care “safety nets” crucial as ever after reform
• HSF program will continue on after 2014: ~20k of current 40k
will continue to be enrolled
• 3-4 million Californians to remain uninsured
• Our patient base will change with the uninsured
population
• Focus on immigrant community: two of the big “at-risk”
groups are undocumented immigrants and non-English
speakers

25. SFFC’s role
2. Educate and encourage existing patients to
get coverage through these new avenues
• “The safety net…that provides health services to
vulnerable populations is crucial in caring for the
uninsured population; however, such services are unable
to fully substitute for the access to care that insurance
provides.”
- KFF, Primer on the Uninsured
• Encourage patients reluctant to get coverage for a variety
of reasons (stigma, seems unaffordable, satisfied with
care they get here etc.)
• People with insurance experience better health
• Reduce risk of bankruptcy from high medical bills

26. Educating our patient base (and
ourselves)
• We’re in a great position to do this!
• Direct access to the relevant population (the uninsured)
• Trusted, reputable clinic
• Clinics and doctors are preferred sources of information
for programs like Medicaid
• Importance of getting familiar with health reform
ourselves
• The more we know, the better we can help our patients

27. Recommendations
• Get the word out at SFFC
• Mentioning upcoming changes to patients
• Having outreach materials (such as handouts) and
application materials available
• Webpage on SFFC website with video, links to more
information and resources regarding ACA
• Group sessions/workshops on new programs and
eligibility
• Others ways?

28. Recommendations
• Become a certified Assister Enrollment Entity with
Covered California
• Provide in-person assistance to patients wanting to
apply for Covered CA programs
• The good: directly help patients get insurance (thus
access to better care!), contribute to higher enrollment
rates by providing one-on-one assistance, monetary
compensation for successful applications
• The not so good: red tape (background checks),
intensive training, more responsibility taken on by clinic

29. Recommendations
• Build/maintain relationships with other
organizations to which we can refer the patients
that we can’t help ourselves
• Clinics/specialists providing health services that we
don’t
• Other Assister Enrollment Entities
• Organizations serving undocumented immigrants,
immigrant communities, and other medically
underserved
• The California Endowment “Health for All” campaign to find
a solution for uninsured undocumented immigrants

30. Looking forward
• Still have to wait for the actual effects of ACA
• How will our patient base change in reality? Will it align
with these projections/predictions?
• Will we have enough patients to see?
• If not, investigate costs of participating in local/federal
health programs
• Be prepared to adapt!

31. Selected References
1. www.kqed.org/news/health/obamacare/obamacare-guide.jsp
KQED radio station’s very helpful guide to Obamacare for Californians
2. http://www.coveredca.com/
Official site of California’s healthcare exchange, Covered California
3. https://www.healthcare.gov/
Federal government’s website regarding the Affordable Care Act
4. http://www.bcoe.org/admin/maa/docs/factsheet_getting-covered_english.pdf
Covered California Fact Sheet in English
5. http://tcenews.calendow.org/blog/san-franciscos-leg-up-on-the-affordable-care-act
Article by the director of the HSF program discussing HSF's role post-ACA in 2014.
6. http://laborcenter.berkeley.edu/healthcare/aca_uninsured12.pdf
UC Berkeley Labor Center report on who will get coverage and who will remain uninsured after 2014. Projections
of these numbers for 2019.
7. http://laborcenter.berkeley.edu/healthcare/medi-cal_expansion.shtml
UC Berkeley Labor Center report on the effects of Medi-Cal expansion on Californians
8. http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8445-key-lessons-from-medicaid-and-chip.pdf
Kaiser briefing on outreach and enrollment targets for the ACA using Medicaid/CHIP programs as models
9. http://blogs.kqed.org/stateofhealth/2013/03/04/hard-enough-understanding-health-law-in-english-try-in-
mongolian-khmer-or-even-spanish/
Article discussing minority representation groups' push for exchange/reform information availability in different
languages
10. http://blogs.kqed.org/stateofhealth/2012/03/01/how-big-a-barrier-is-language-to-enrolling-in-health-exchange/
Article with link to a report that shows that of those that will qualify for insurance through the exchange, those
with limited English skills will have lower enrollment rates than people with strong English skills.
11. http://www.healthycal.org/archives/11156
Article discussing outreach efforts regarding Covered CA: network of nonprofits, or through churches, employers
etc.
12. http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision
Information from the IRS about the guidelines and exceptions to the Individual Mandate of the ACA

32. Selected References
13. http://www.cahba.com/covered-california/assisters.htm
Website for entities and organizations interested in becoming Assister Organizations under Covered
California
14. http://kff.org/health-reform/poll-finding/march-2013-tracking-poll/
Kaiser tracking poll demonstrating the attitudes among Americans regarding the ACA
15. http://kff.org/medicaid/issue-brief/medicaid-a-primer/
The basics of the Medicaid program in the United States
16. http://kff.org/uninsured/issue-brief/the-uninsured-a-primer/
Primer on the state of the uninsured population in the United States
17. http://kff.org/medicaid/issue-brief/key-lessons-from-medicaid-and-chip-for-outreach-and-enrollment-
under-the-affordable-care-act/
Briefing covering strategies that have been historically successful for increasing enrollment under
Medicaid and CHIP, and could be applied to the ACA
18. http://cardenas.house.gov/sites/cardenas.house.gov/files/Assisters%20Program%20Phase%20I%20an
d%20II.pdf
Presentation from a seminar on the assisters program for Covered CA
19. http://www.dpc.senate.gov/healthreformbill/healthbill04.pdf
Executive summary of the Affordable Care Act from the Senate
20. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/R/PDF%20ReadyOrNotSafetyNetPrep
aredForReform.pdf
Issue brief by the California Healthcare Foundation with suggestions on how healthcare safety net
programs and organizations can prepare for the ACA
21. http://www.calendow.org/with_prevention.aspx
California Endowment’s website, promoting care for undocumented residents of California
22. http://www.coveredca.com/news/101-presentations/101-Region-4.pdf
Covered California presentation at the San Francisco Town Hall meeting August 9, 2013