Source: https://healthlaw.org/resource/californias-safety-net-law-and-low-income-health-programs/
Timestamp: 2019-04-26 12:37:42+00:00

Document:
 In 2010, the Federal Department of Health & Human Services approved an 1115 Medicaid Waiver for California that allows California counties to receive federal reimbursement for health services they provide to certain low-income people. The waiver services are provided through the Low Income Health Programs (LIHPs) and are for many of the same ñchildless adultsî who have historically been served by CaliforniaÍs safety net health care providers under state law that requires counties to provide basic subsistence health services to indigent individuals. This brief compares the obligations created by CaliforniaÍs safety net statute and the LIHP waiver, including the remaining obligations of counties that implement a LIHP to comply with the state safety net law. It also describes some of the possible lessons that are being learned from the LIHPs to prepare for CaliforniaÍs implementation of the Affordable Care Act in 2014.
For more than 100 years, California?s counties have been charged with providing basic medical care to their low-income residents. Over time, Federal and state health programs, like Medicaid (called Medi-Cal in California), Medicare, and the Children?s Health Insurance Program (called Healthy Families in California) have stepped in to provide care for many low-income and vulnerable people in our state. But one population has been left out of those programs?low income adults without disabilities and without minor children living at home. This group, often referred to as the ?childless adults,? have continued to rely on county safety net programs to obtain basic health care services.
Then, in 2010, the Federal Department of Health & Human Services approved a Medicaid Waiver for California pursuant to § 1115 of the Social Security Act. That waiver allows California counties to receive federal reimbursement for health services they provide to certain low-income people, starting in 2011. The waiver services are provided through the Low Income Health Programs (LIHPs). The LIHPs have begun to serve many of the same ?childless adults? who have historically been served by California?s safety net health care providers under state law that requires counties to provide basic subsistence health services to indigent individuals.
This brief compares the obligations created by California?s safety net statute and the LIHP waiver, including the remaining obligations of counties that implement a LIHP to comply with the state safety net law. It also describes some of the possible lessons that are being learned from the LIHPs to prepare for California?s implementation of the Affordable Care Act in 2014.
II. California counties have a legal obligation to provide medical care to certain low-income residents.
Section 17000 ensures that low-income childless adults who are not eligible for Medi- Cal or other public programs have access to a minimum safety net to meet their health care needs.
A. Section 17000 imposes a mandatory duty upon counties.
The statutory language limits eligibility for health care services under § 17000 to individuals who are residents in the county where they are applying for aid. Residence is defined in the law as ?the place where one remains.?6 In general, the residence provisions that apply to eligibility for health care services under § 17000 seem to require both physical location and intent to stay in a place.7 These provisions are very similar to those that generally govern residency in California, which are encoded at Government Code § 244.
III. Through CA?s 1115 Medicaid Waiver, California counties now have the ability to obtain federal funding to help pay for many medical services provided to low-income residents through the Low Income Health Program (LIHP).
The LIHPs are California?s early Medicaid expansion (at county option) through the § 1115 waiver. The waiver built upon an earlier program, called the Coverage Initiative, that was available in ten counties from 2007 to 2011 pursuant to an earlier iteration of the § 1115 waiver. But while those programs were quite limited in scope, the passage of the Affordable Care Act (ACA) in the time since the earlier § 1115 waiver was approved paved the way to make the LIHPs more expansive.
IV. When a county implements a LIHP, it is subject to both § 17000 and the terms and conditions of the Medicaid Waiver.
When a county chooses to implement a LIHP, its residual obligations under state law do not go away. While a LIHP may partly fulfill a county?s obligations under § 17000, it likely will not fulfill them entirely. Further, a county that chooses not to implement a LIHP (as Fresno and San Luis Obispo counties have done) is clearly still fully subject to § 17000 obligations.
For example, some counties have implemented LIHPs only for persons whose incomes are extremely low. Those counties still have a residual obligation under § 17000, however, to provide services to county residents whose income is over the LIHP eligibility level, but who are unable to afford the basic necessities of life in the county.
V. What we can learn from the LIHPs about counties? continuing residual legal obligation when Medi-Cal Expansion and the Exchange are implemented in 2014.
In 2014, California will undertake an enormous expansion of coverage for low-income people as it implements the Affordable Care Act. Most low-income people with income below 133% FPL will become eligible for Medi-Cal expansion, and many other low- income people with be able to buy subsidized insurance through the Health Benefits Exchange. Like the LIHPs, these new programs will significantly reduce the burden of § 17000 obligations placed on counties, but they will not repeal it. The counties will have a continuing obligation to provide needed health care services to low-income residents who cannot access care through these new programs.
One lesson the LIHPs have taught us is that the coverage expansion programs under federal health reform will not fulfill all existing needs. For example, many lawfully present recent immigrants are not eligible for the LIHPs. To ensure that all individuals who need health coverage are able to get it, advocates in counties that implement LIHPs have had to closely monitor their counties? plans to ensure that lawfully present recent immigrants continue to have access to safety net health care services. Once the ACA is fully implemented, there will likely remain some county residents who are left out of the new coverage programs due to immigration status, temporary coverage gaps, or other factors. Advocates should work with their counties to make sure that those residents continue to have access to basic health care services.
Another lesson we?ve learned from the LIHPs is that new funding streams under the ACA can strengthen the safety net that has long served as the source of health care services for low-income people. Advocates should encourage the Exchange and Medi- Cal expansion program to invest in the safety net. Not only are many of those individuals newly eligible for these coverage sources already accustomed to receiving their care through safety net providers, but the investment will keep the safety net viable for others who will continue to need to access services through § 17000.
A final lesson learned from the LIHPs is that affordability is a key to coverage. LIHP enrollment has been successful in large part because the financial barriers to enrollment are so low?no program so far charges any premium, and the copayments are also very low or non-existent. The cost-sharing structure in most LIHPs is very similar to what we expect cost-sharing to look like in the Medi-Cal expansion program in 2014. Projections suggest that the cost of coverage in the Exchange, however, will be much higher?with premiums as high as $67 per month for a single adult with income at 150% FPL.56 If Exchange-subsidized insurance is not accessible to low-income Californians due to cost, counties could be required to offer them services under § 17000.57 Alternately, counties might consider subsidizing people?s cost to obtain coverage in the Exchange, which might be more cost-effective than providing the services directly at full county cost.
California has a rich history of providing basic health care to its lowest-income residents through a county safety net system. In 2014, fewer Californians will rely on their counties to provide them with subsistence health care services as they become eligible instead for federally funded health programs?the Medi-Cal expansion program or subsidized insurance in the Exchange. Nevertheless, § 17000 will remain as an important backstop to ensure that the most vulnerable individuals who cannot obtain full coverage through health reform do not fall through the cracks and continue to get the care they need. In order to achieve that, new programs must invest in the safety net infrastructure on which low-income Californians have come to rely.
1 This provision is also interpreted to require counties to pay cash aid, which takes the form of General Assistance or General Relief, to very poor residents. Mooney v. Pickett, 4 Cal.3d 669, 671 (1971). The cash aid requirement has been significantly curtailed by statute. See Welfare Rights v. Frank, 25 Cal. App. 4th 415, 420-21 (1994).
2 Id. (emphasis added) (describing the legislative history of these provisions).
3 County of San Diego v. State of California, 15 Cal. 4th 68, 104-05 (1997).
4 Boehm v. Superior Court, 178 Cal. App. 3d 494, 502 (1986).
5 Welf. & Inst. Code § 17107.
7 See Nelson v. San Diego County Bd. Of Supervisors, 190 Cal. App. 3d 25 (1987).
8 Khasminskaya v. Lum, 47 Cal. App. 4th 537, 543 (1996).
9 Welf. & Inst. Code § 17003.
10 See Khasminskaya, 47 Cal. App. 4th at 543.
11 Welf. & Inst. Code § 17030.
12 Cf. McCormick. v. County of Alameda, 193 Cal. App. 4th 201 (2011) (General Assistance, the cash aid counterpart to § 17000 health programs, must pay for services when CalWORKS provides no cash assistance).
13 See County of San Diego, 15 Cal. 4th at 101 (?[C]ounties have no discretion to refuse to provide medical care to ?indigent persons? within the meaning of section 17000 who do not receive it from other sources.?).
14 Nelson v. San Diego County Bd. Of Supervisors, 190 Cal. App. 3d 25 (1987). 15 Arenas v. San Diego County Bd. Of Supervisors, 93 Cal. App. 4th 210 (2001). 16 Hunt v. Superior Court, 21 Cal. 4th 984, 1012 (Cal. S. Ct. 1999).
19 Cooke v. Superior Court, 213 Cal. App. 3d 401, 404 (1989).
20 Fuchino v. Edwards-Buckley, 196 Cal. App. 4th 1128 (2011).
21 Hunt, 21 Cal. 4th at 1012.
22 See Id. at 1014.
23 Alford v. County of San Diego, 151 Cal. App. 4th 16, 33 (2007).
24 See Griffeth v. Detrich, 603 F. 2d 118, 122 (9th Cir. 1979). But cf. Zobriscky v. Los Angeles County, 28 Cal. App. 3d 930, 933 (Cal. Ct. App. 1972) (finding that applicants for § 17000 benefits are only entitled to judicial relief, not to administrative notices or hearings).
25 See Griffeth, 603 F. 2d.
26 See Goldberg, 397 U.S. at 270-71; Mathews, 424 U.S. at 333.
27 Boehm v. County of Merced, 163 Cal. App. 3d 447, 456 (1985); see also Brown v. Crandall, 198 Cal. App. 4th 1, 16 (2011) (suggesting that Humboldt County?s refusal to determine an applicant?s eligibility, to issue her any notice, to allow her to appeal, or to hold any hearing on the matter was improper).
28 Jennings v. Jones, 165 Cal. App. 3d 1083, 1089 (1985).
29 42 U.S.C. § 1396a(10)(A)(i)(VIII); 26 U.S.C. § 36B.
30 42 U.S.C. § 1396d(y).
32 CENTER FOR MEDICARE & MEDICAID SERVICES, SPECIAL TERMS AND CONDITIONS, AMENDED APRIL 1, 2012, CALIFORNIA BRIDGE TO REFORM DEMONSTRATION ¶¶ 42-47 [hereinafter STC], available at http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/Publications/California%20STCs%20(3- 30-12).pdf; see also CAL. DEP?T OF HEALTH CARE SERV. LOW INCOME HEALTH PROGRAM BRANCH, REVISED PROGRAM REQUIREMENTS AND APPLICATION PROCESS LOW INCOME HEALTH PROGRAM (LIHP) (2011), available at http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/Applications/ProgramRequirementsandA pplicationProcessREV01-25-11.pdf.
35 Id. ¶ 58(b)(ii), (c).
39 SANTA CRUZ COUNTY HEALTH SERV. AGENCY, MEDICRUZ ADVANTAGE POLICIES AND PROCEDURES MANUAL 7 (2011), available at http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/Deliv/SantaCruz/Deliv18.pdf. 40 STC ¶ 48(a).
41 8 U.S.C. § 1613.
42 STC ¶¶ 48, 58.
51 Id. ¶ 70(a); 42 U.S.C. § 1396o.
53 Id. ¶ 76; Cal. DEP?T OF HEALTH CARE SERV., CALIFORNIA BRIDGE TO REFORM DEMONSTRATION HEARINGS AND APPEALS PROCESS FOR LOW INCOME HEALTH PROGRAMS (LIHP) (2011), available at http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/Hearings-Appeals/Hearing- Appeals_Process_062911.pdf.
54 See sources cited supra note 53.
55 Hunt, 21 Cal. 4th at 1012.
56 UC BERKELEY CTR. FOR LABOR RESEARCH & EDUC. & UCLA CTR. FOR HEALTH POLICY RESEARCH, ESTIMATING THE CHANGE IN COVERAGE IN CALIFORNIA WITH A BASIC HEALTH PROGRAM 3 (2012), available at http://www.healthexchange.ca.gov/StakeHolders/Documents/UCB- UCLA%20BHP%20Memo%20Final%208-9-12.pdf; see also MERCER, STATE OF CALIFORNIA FINANCIAL FEASIBILITY OF A BASIC HEALTH PROGRAM 14 (2011), available at http://www.mercer-government.mercer.com/basic-health-program/feasibility (estimating the premium for an individual with income at 150% FPL at $61 per month).
57 Cf McCormick. v. County of Alameda, 193 Cal. App. 4th 201 (2011) (General Assistance, the cash aid counterpart to § 17000 health programs, must pay for services when CalWORKS provides no cash assistance).

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