Crossing the VoidUnderstanding Contra Costa’s Newly Uninsured Patients

Kali Stanger, MDPGY1December 28, 2009

Project ObjectivesProject Objectives Describe health care access for undocumented immigrants

in Contra Costa County, in light of BHC eligibility cuts enacted in June

Understand current outpatient primary care resources available for uninsured patients in Contra Costa County

Identify and realize strategies for connecting undocumented patients to outpatient follow-up services upon hospital discharge

Explain basic differences between types of insurance coverage in Contra Costa County

Brainstorm methods for increasing communication between financial counselors and medical providers at CCRMC

Goals of this Goals of this PresentationPresentation

Provide a bit of information gleaned during my 2 weeks on Community Medicine

Share experiences, corrections, arguments, thoughts, ideas…..

Foster conversation

Case 1Case 1 37 yo Spanish-speaking man with shortness

of breath

Case 2Case 2 27 yo woman w/AML still in hospital after

being discharged by her primary team earlier in the morning…..

Who are the insured in Who are the insured in our county?our county?

State MediCal

Medicare

Basic Health Care

Veterans

Healthy Families

Who are the uninsured Who are the uninsured in our county?in our county?

Visitors to the county

Wealthy uninsured (assets too high to qualify for MediCal or BHC)

Undocumented (as of June 2009)

Pausing for some Pausing for some definitions….definitions….

Immigrant: foreign-born individual

Legal non-citizen

Naturalized citizens

Undocumented immigrants

Undocumented Undocumented Immigrants in the USImmigrants in the US

39 million immigrants in US make up 13% of our population 7 in 10 of these are naturalized citizens or legal non-citizens

46% of ALL immigrants are uninsured; 59% of undocumented immigrants are uninsured Non-citizens make-up 20% of total US uninsured pts Undocumented immigrants are prohibited from Medicaid and CHIP Non-citizens are also prohibited from Medicaid and CHIP for their 1st 5 years in the US

Pregnant women and children in this category = state dependent

In 2005, Medicaid began requiring proof of citizenship which led to a decrease in coverage, largely due to loss of coverage in US citizens This new requirement cost $28 million in administrative costs 6 states combined spent $8 million to identify total 8 undocumented immigrants

US immigrants are healthier than the general population (thought 2/2 self-selection of who is healthy enough to immigrate)

sdf

What happens now What happens now with undocumented with undocumented

pts?pts? County writes off costs accrued during

inpatient stays

30 day override available for specially identified pts requiring specialty care Pts requiring longer care must be approved by

CEO

RN for specialty care acts as check/balance

New administrative costs?

Undocumented KidsUndocumented Kids

Undocumented Clinic Undocumented Clinic AccessAccess

Specialty AccessSpecialty Access

Basic Health CareBasic Health Care County Residents with limited assets

Do not qualify for MediCal or MediCare

Needs to be renewed frequently (every 6 months) but can be immediately approved (as opposed to MediCal, needs 4-6 months)

AO, AN, AT, AZ

Requires: proof of source of support (ie quarterly statement, pay stub); list of assets; proof of residence (PG&E, water bill); ID; proof of US citizenship Invited refugees ok (political asylum not qualified) Permanent residents ok Work authorization not qualified (work, religious, or student visas)

MediCareMediCare Open enrollment period each year

Ages 65 and older; renal failure

MediCalMediCal Age under 21 or over 65 are not eligible

Eligible: adults responsible for a deprived minor child; disabled greater than 1 year; pregnant women

4-6 months to get approved

Financial Counselors Financial Counselors and CCRMCand CCRMC

Every inpatient has a financial folder – either pending, PO, or BHC

All PO or BHC patients are seen by FCs during hospitalization to attempt to qualify them for better coverage

FCs make notes in E2Search (SW/case mgrs have access)

What’s the problem with BHC? Not really insurance – doesn’t cover pts outside of the county

even in emergencies MediCal reimburses better No ambulance coverage

What’s next?What’s next?

In ConclusionIn Conclusion

Give me your tired, your poor,

Your huddled masses yearning to breathe free,

The wretched refuse of your teeming shore.

Send these, the homeless, tempest-tost to me,

I lift my lamp beside the golden door!