Californians will suffer under ACA repeal

Californians will suffer under ACA repeal

If the Affordable Care Act is repealed, Californians will suffer. Members of the United States Congress need to know that before they vote. Millions of lives will be impacted. The actions of the congressional majority will have real consequences affecting the health of their constituents.

If Congress repeals the Affordable Care Act without a viable, simultaneous replacement, five million Californians will lose their insurance coverage. California’s uninsured rate will likely double, returning to rates not seen since 2013.

Nearly four million low-income, uninsured and uninsurable Californians, who are covered under the Medicaid expansion, will be left out in the cold. Covered California’s 1.2 million consumers, who are empowered by the ACA to shop for affordable healthcare plans that offer comprehensive coverage in the state run exchange, will be left alone to navigate a commercial marketplace in turmoil.

The impact on jobs and the economy is just as bad. According to a University of California Berkeley Labor Center Report, it is estimated that 209,000 California jobs would be lost if the ACA were repealed. Financially, California’s gross domestic product would take a $20 billion hit along with a $1.5 billion reduction in tax revenue.

Many of those jobs, which pay well and offer employee benefits, would be located in the low-income communities served by community health centers. Fresno, Kern, San Bernardino, San Joaquin, Stanislaus, and Tulare Counties would be especially harmed due to their community’s high level of reliance on Medicaid expansion and above-average unemployment rates.

Additionally, 800,000 mostly low-income women will lose their ability to pick the healthcare provider of their choice if Planned Parenthood, which provides myriad of primary care services to women and men, is defunded.

If Congress doesn’t address the expiration of key health center funding by this September, community health centers in California will lose up to 70 percent of the federal grant which helps keep our doors open and preserves our ability to serve everyone who is need.

People covered by private insurance or employer-sponsored insurance are not immune. The chaos in the insurance marketplace caused by all of these disruptions will drive premiums up.

If the path to ACA repeal cannot be reversed, the replacement plan must address three key issues.

First is ensuring access to care through the preservation of California’s healthcare safety-net. Community health centers serve 1 in 7 Californians, 57 percent of whom are on Medicaid. Our patients are among the states most vulnerable and include more than 400,000 agricultural workers, nearly 300,000 people experiencing homelessness, and more than 28,000 veterans. Thirty six percent of our patients don’t speak English and 32 percent of our patients are children. We cannot abandon them.

Protecting the safety-net requires broad healthcare coverage programs like the Medicaid expansion and protecting federal health center funding. Ensuring access to care also includes the preservation of Planned Parenthood, which makes up a significant portion of the state’s primary care network for low-income communities.

Second is affordability and clarity. Covered California, which is our state-run healthcare exchange, built a competitive marketplace that for the first time put consumers in the driver’s seat by giving them a clear picture of the coverage plans from which to choose. They also kept the plans affordable. In December 2016, Covered California reported that 60 percent of consumers receiving tax credits could get a Bronze plan for less than $10 per month that provides free preventive care and protection for high-cost medical events.

Third and last is a commitment to healthcare workforce. This might not seem as obvious in the healthcare debate as coverage and affordability, but it is just as important. California is experiencing a primary care workforce crisis that is limiting access to care for everyone, not just people who are low-income. The ACA addressed workforce issues by creating Teaching Health Center Graduate Medical Education Program, among others. In California, the legislature and Governor need to recommit to the $100 million healthcare workforce investment that was promised in last year’s budget, but eliminated in this year’s budget proposal.

If Congress repeals the ACA without a viable, simultaneous replacement that addresses these key issues, Californians will suffer. Californians will be sicker. We cannot allow that to happen. We cannot go backwards. The consequences in our local communities are dire and Congress needs to know that when they vote.

Don’t Be Misled: HSAs and Tax Credits Are Not the Answer for Low-Income People

Don’t Be Misled: HSAs and Tax Credits Are Not the Answer for Low-Income People

In House Republican Leader Kevin McCarthy’s words, the care and coverage provided under the Affordable Care Act is akin to the federal government giving some people cars, but those cars are missing two tires, leak gas, and have a busted transmission. Other people are being forced to buy cars they don’t want.

McCarthy and the Republicans in Congress believe they can fix the proverbial “car crisis” and save our patients (I can’t in good conscious refer to our patients in automobile terms) through the judicious use of health savings accounts (HSA) and tax credits. In their view, HSAs and tax credits provide a broad-based, responsible foundation of healthcare reform.

If that was the case and these were viable solutions, I would be very supportive. But they’re not, so I’m not. HSAs and tax credits don’t work for low-income communities. Allow me to explain.

HSAs are tax-advantaged savings accounts that are normally tied to high-deductible health plans, which can be used to pay for certain medical expenses. People who use HSAs in high deductible plans can place a portion of their income, tax-free, into an HSA and then use that money, tax-free, to pay their medical bills. Because their high deductible plan would not start covering any medical expenses until they’ve spent at least a thousand or more dollars out of their own pocket (or their HSA), they would have a lot of medical bills to cover.

Current law requires an HSA-qualifying high deductible plan to have at least a $1,300 deductible for single coverage and $2,600 for families, along with a $6,550 out-of-pocket maximum for singles and $13,100 for families. This means that a family using a high deductible plan will spend $2,600 out of their HSA before their coverage kicks in and require that same family to potentially spend up to $13,100 in a single year, too.

For the low-income communities we serve, these out-of-pocket expenses are inconceivable and it is misleading to say they’re not. Our patients are struggling to provide their family with food and shelter, but now they have to come up with thousands of dollars to cover their share of medical expenses before their insurance even kicks in? That’s a plan for bankruptcy, not healthcare.

Republicans have discussed a refundable tax credit to offset these bankruptcy-inducing costs, but that is misleading as well. Under the Republican proposals that have been floated so far, flat-rate tax credits (that ignore family income) would be issued monthly to purchase healthcare coverage and anything left-over can go into an HSA.

While it sounds simple, it’s not. For low-income families, it can be disastrous. For example, if President Trump succeeds and allows people to buy insurance across state lines, out-of-state insurance plans may start manipulating the price point of insurance premiums to match or exceed the monthly tax credit amount, forcing families to spend one-hundred percent of the tax credit on premiums in a high deductible health plan, without any funding for the HSA that helps pay the plan’s high deductible.

In this situation, families will be forced to purchase bare-bones high deductible plans that don’t cover vital primary care needs and won’t have an HSA to help cover the high deductibles – they will have to pay out-of-pocket. Again, a plan for bankruptcy, not health care.

HSAs and tax credits may work for more affluent people, but they cannot be the foundation of the healthcare replacement plan for the low-income communities we serve. Quite simply, it diminishes the quality of coverage and dramatically increases financial risk for communities who are already struggling to make ends meet.

For these reasons, I cannot support them.

The Value of Community Health Centers

The Value of Community Health Centers

I just finished a webinar with more than 500 health center advocates and wanted to share with you, what I shared with them.

The value of community health centers is more apparent now than ever. Over the past five decades we have successfully built one of the finest patient-centered healthcare systems in the nation. Millions of Californians, in fact, one in seven, choose to come to us for care. They trust us, they believe in us.

Now, post-election, our future and the future of health care in the state of California seems uncertain. Speculation runs rampant but facts do not. What we do know is that change is certain. Health care coverage for our patient population and the health care financing that keeps our doors open are at stake. It is a very dynamic situation that does not instill a lot of confidence in the future.

But, as I thought about the history of our movement and what we have already accomplished, I am encouraged because I know that we will endure and ultimately prevail. It may be a different path than we expected, but we will continue forward. Our patients will still have somewhere to go for care, they will not be left out in the cold. Not only because we are good people committed to low-income communities, but because we have built a nation-wide system of care that forms the foundation of health in our local communities. We are efficient and effective. That cannot be ignored or abandoned.

In rural communities, we are some of the only healthcare providers available. In Lassen, Mariposa, and Yuba counties, which are all rural, we provide care to more than 70% of those counties’ Medicaid beneficiaries. In agricultural counties like Merced, Kern, and Tulare, where our nation’s food is grown, half the county is on Medicaid and come to our health centers for care. In urban communities, we are the healthcare backbone of low-wage industries that keep our cities moving. Highly vulnerable communities, like children living in poverty, people who are homeless, and people who are living with HIV, rely heavily on us as well.

The patients we serve in these communities are among the sickest and most medically complex as well. Working in these communities has forced us to overcome significant challenges while continuing to deliver excellent healthcare at the local level. We have been doing it for decades.

For example, we have been longtime champions of integrated care models and health homes. They are our day-to-day reality, not just buzz words. Team-based care, which utilizes a broad spectrum of providers to meet the individual needs of the patient, have been in place at community health centers since our founding. We do it because it makes sense and it works. The same goes for health information technology, community health workers, and developing new value based reimbursement models.

Our reputation for delivering excellent healthcare in an efficient and effective manner is the primary reason we have enjoyed support from both Republicans and Democrats for more than 50 years. They have seen the proven results of our work and know how we benefit patients and communities alike.

We can make the financial case for taxpayers too. Health centers save, on average, $2,371 (or 24 percent) in total spending per Medicaid patient when compared to other providers, according to a recent multistate study published in the American Journal of Public Health. According to a report by Capital Link, Federally Qualified Health Centers (FQHCs) in California produce savings of $4.4 billion annually.

The benefit to our local economy is even greater. Statewide, community health centers have an $8 billion annual economic impact including 58,234 direct and indirect jobs in low-income communities. Those are good jobs that allow hard-working families to put food on their table and be productive members of our communities.

Because of our reputation with our patients and communities, we have grown as more people became insured and sought the care they long delayed. Last year, 6.2 million patients walked through our doors, a 28% increase from 2010. More than a million of those patients were part of the Medicaid Expansion and Covered California, who for the first time had access to comprehensive primary care and preventive care in their local community. Medical, dental, mental health and more, we offer a one-stop shop for people in need. We also offer important wrap-around services like enrollment in nutrition programs, social services and disaster relief. Combined, we offer the most important thing of all – peace of mind.

They say that you can’t buy peace of mind and I would agree. Reducing our programs to dollars and cents on a balance sheet exponentially undervalues what we do in local communities. Our value is incalculable.

Our value lies in decades of experience that have enabled us to make things work just right. Our value lies in the communities who trust us with their care. Our value lies in our ability to adapt to changing circumstances and business models. Our value lies in the fact that we are already here, operating, and ready to go.

Our path forward will be difficult, but our value cannot be ignored and it certainly cannot be abandoned. Using our sincerest tone and our loudest voice, we will continue to make that point clear. We will be heard. We will endure. Ultimately, we will prevail. It is what we have always done.

Charting our own path – Creating our own destiny

Charting our own path – Creating our own destiny

Part of what keeps me going, outside of the work that I do each day, is pushing the envelope and striving to be bigger, bolder, and better in that work. A large part of how I do that is being one step ahead, always seeing the bigger picture – the end game – rather than getting caught up in the weeds and letting them hold me back. Which is why I have so enjoyed the work we are doing at the California Primary Care Association (CPCA) around our next strategic plan. It’s affording us the ability to look forward, get out of our own way, and mold the future we want for our organization and its members.

​Over my nearly 20 years of leading this amazing organization, I have seen tremendous strength and innovation from its members. They have never been afraid to take bold steps forward and blaze a trail for others to follow. Community health centers have grown to become a network of more than 1,150 sites across the state serving nearly six million patients each year. That’s one in every seven Californians. And community health center revenue has grown from $795 million in 1997 to over $3.7 billion in 2015.

This is amazing growth in a relatively short amount of time, and we were able to accomplish much of this by coming together and working toward the greater good for everyone. Since the passage of the Affordable Care Act (ACA), we have made great strides in defining our own destiny through the three bold steps in our last Strategic Plan. As called for in that plan, we are currently in the process of implementing our payment reform pilot, the largest in the nation, with the State and our health plan partners. This innovation will allow health centers to transform the way they deliver care in a post-ACA environment where outcomes are paramount. We have created a robust training and technical assistance program to get our members ready for our payment reform pilot, ensuring their readiness and overall success.

We have also created a statewide brand, CaliforniaHealth+ to educate patients about the benefits of California’s community health centers. The “plus” represents all the services and support community health centers offer that go beyond primary care to encompass a whole health approach. The brand’s message is simple – “Whoever you are, we speak your language, honor your traditions and value your experiences. We treat everyone with respect and courtesy. We are a trusted friend and partner in your care.” We’ve had so much positive feedback on that messaging that we have also utilized the CaliforniaHealth+ name for our newly formed 501(c)(4) organization – CaliforniaHealth+ Advocates – which will advance the mission of community health centers through both state and federal advocacy and will provide more flexibility and capacity to advocate above and beyond what CPCA, a 501(c)(3) organization, is allowed to do.

​While we have achieved some important milestones over the past few years, we have seen our share of challenges. We are currently operating in a space in which we are measured on value but paid on volume. We are facing a growing primary care workforce shortage, coupled with an increase in patient demand. We have celebrated the great success of the implementation of the Affordable Care Act here in California and are now realizing, as we plan for our future, that we may be victims of that very success. The lack of workforce capacity is making it more difficult to provide needed services. The healthcare landscape is changing, both here in our state and nationally. Additional health care delivery innovation is needed to address a growing complex patient population; and increased competition over resources and patients has required us to shift the way we think about what we do. On top of all of this, the current political climate has made our future uncertain in many respects.

But, one thing I have learned by criss-crossing the state, meeting with our members in their communities during seven regional strategic planning meetings this summer and fall, is that our members are up to the task. Every region is different and has unique challenges, but they are all ready to confront those challenges. Quite frankly, sitting in those meeting rooms and listening to our state’s brightest leaders define their own destiny, I was in awe. They are ready. We are ready.

​For example, workforce issues were identified as the top challenge throughout the state. Health centers are ready to innovate in order to deal with this difficult challenge. They are embracing new payment models which will better incentivize team-based care in order to expand the types of providers available to serve their patients. The need to address social determinants of health is another issue we heard repeatedly. Health centers have a long track-record of being community-minded healthcare providers who are committed to the whole patient. Their commitment to food and housing security and addressing the non-health needs of their patients are second to none. But, listening to our members, they realize we must take these efforts to another level – we must address impacts of gentrification, violence, education inequities, and more. It was truly inspiring.

​Pushing the envelope and striving to be better in our work is not an easy task. But the fact of the matter is, our members are up for the challenge. As we wrap up our regional strategic planning meetings, where nearly half of our member organizations turned out to inform our process, I am excited for what the future will bring. I am so proud to see how far we have come and where the health center movement is going. We are charting our own path and creating our own destiny. Soon we will have a new strategic roadmap to guide our journey through new and unknown areas. I look forward to embracing the next set of bold steps the California Primary Care Association and our member health centers will embark upon as we continue to be a driving force behind health care delivery for diverse communities throughout California.

Our Civic Duty

Our Civic Duty

I grew up with a strong sense of social justice and civic duty.  As a young Latina, I understood from an early age that standing up for my rights was something I would do my entire life.  I wasn’t going to sit around and wait for someone else to fight for me.

My mom set a great example. I distinctly remember her being actively engaged in campaigns for the local Community College District Board of Governors. She was an Executive Secretary at San Jose City College.  She cared about the governance of the College.  She knew the decisions of the board of trustees had a great impact on the college’s employees, its students, and the community.  She couldn’t afford to make big campaign contributions like some, but she walked precincts, made phone calls and put her energy behind the candidates she supported. I asked my dad about it the other day.  He said she used to make him go knock on doors with her.  He couldn’t say no.  He supported her in everything that was important to her.

Seeing my mom involved in the political process at a young age had a strong influence on my career path and is one of the reasons I am such a passionate advocate today. Like my mom, I am highly engaged in the issues of the day and I fight for the causes I support.  Voting is one important way we have to make our voice heard – a way to stand up for what we believe in and to be counted!

I am keenly aware that not everyone gets involved the way I do, and many Americans take a much more passive role in the political process and choose not to participate. They think their vote doesn’t matter. It is unfortunate that they make this choice and leave the decision-making process in the hands of others.

My concern is for the people who want to vote but can’t – people who have been disenfranchised by a complicated and opaque process that is at best unwelcoming to the uninitiated.  All across the country there are headlines about processes that are causing the exclusion of voters – particularly Black and Latino voters.  These draconian barriers, such as the absurdly strict voter identification laws being adopted in some states, are a stain on our democratic process and an unfortunate violation of people’s civil rights.

Thankfully, California’s Secretary of State Alex Padilla has taken significant steps to make the voting process easier and more welcoming to all Californians.  We are fortunate to live in a state where our leaders are seeking to make the process more accessible, and where significant barriers to voting have been removed.

First, Secretary Padilla has championed a new online voter registration process. Californians are no longer relegated to filling out a voter registration form on a clip board in front of their local grocery store. Instead, you can visit to register. All you need are the last four digits of your social security number and your driver’s license number.  You can complete the process in a matter of minutes.

Second, Secretary Padilla supported a new vote-by-mail law that allows your vote to be counted if your mail-in ballot is post-marked on or before Election Day. This is a change from past elections when mail-in ballots had a different deadline than traditional in-person voting, resulting in tens of thousands of ballots being thrown out. Now, everyone has the same deadline to vote – Election Day.

Third is the new Motor Voter law – only the second of its kind in the country.  This progressive law will register to vote every eligible California citizen who goes to a Department of Motor Vehicles (DMV) office to get a driver’s license or renew one. Sponsored by Secretary Padilla and jointly authored by Assemblymembers Lorena Gonzalez (D-San Diego), Luis Alejo (D-Salinas), and Kevin McCarty (D-Sacramento), the bill was signed into law in 2015 and is being rolled out now by the DMV. According to a press release published upon its passage, the new Motor Voter law will help the 6.6 million Californians who are eligible to vote but are not registered. In its first year of operation, experts’ forecast that we will add two million new voters to the election rolls. Many of these new voters come from low-income families, are young, Latino/people of color.

Secretary Padilla has shown tremendous leadership by advancing the voting rights of millions of Californians.  I greatly admire his commitment to the people of our great state, especially those who are most likely to be marginalized by the process.

One of the things I am very pleased about is the efforts of my own constituency -community health centers- and the leadership role they are playing in getting their communities registered to vote. Health centers have a long history of civic engagement that has been bolstered by federal requirements to offer voter registration when we enroll our patients into the Medi-Cal and Covered California Programs. Additionally, and in partnership with Community Health Vote and NonProfit Vote, CaliforniaHealth+ Advocates continues to support voter registration drives in community health centers this year.  Our efforts include a campaign launching on National Voter Registration Day and runs through the last day to register before the general election (Sept. 27-Oct. 24).  Through this campaign we hope to register thousands of voters who will advance the issues important to our communities.

Approximately two-thirds of the six million health center patients are eligible to vote based on their age.  While some of our patients lack citizenship and are not eligible, many more are.  Health centers are uniquely positioned to support efforts to increase not only voter registration but also voter turnout. Health centers are familiar and trusted sources of care in their communities, and they also provide additional supportive services, education, and outreach to their patients – often in a language other than English.

These are all exciting innovations that empower disenfranchised communities like those I have dedicated my life to serving. Unlike other states, California is breaking down barriers to voting so that everyone has the opportunity to have their voice heard.  Community health centers are stepping up and doing their part to support the community’s right to vote.

We cannot afford to be silent and we must participate in the democratic process if we want our issues to be heard. Like my mom, we have to stand up and do our part to advance the causes of justice that are so important to our community. We have to engage – we have to fight – we have to vote!

It is our civic duty.

Honoring my dad and all of California’s farmworkers today

Honoring my dad and all of California’s farmworkers today

I am attending the San Benito Health Foundation (SBHF) open house today in Hollister to celebrate the great work our migrant health centers do in their communities.  I am so pleased to be joined by my parents, Alcario and Carmen Castellano.  It is also a homecoming of sorts, as Hollister is the town my father grew up in.  My dad was born in Artesia, New Mexico and his family headed west when he was nine years old to join other family members in the Central Valley.  After spending time as a migrant worker in San Joaquin County, his family settled in Hollister in 1945 where they continued to work in the fields. 

My father picked cotton, apricots, prunes, tomatoes and garlic alongside his siblings and parents during his youth. Later, he joined the armed services and then worked in other industries including aerospace, ultimately retiring from Safeway in San Jose.  He went on to win the lottery and established the Castellano Family Foundation which supports non-profits serving the Latino community of Santa Clara County.  My dad has been very successful in his life due to his hard work and dedication to his family and community.  I believe he was greatly influenced by the years he spent working on the farms of San Benito County.  It’s not often that I get back to the area, but when I do, I can’t help but think of my father, his heritage, and his roots.

My dad has told me stories about what a hard life it was back then for farmworkers.  He recalls there were no social services for the farmworkers or their families whatsoever.  There was no health care, no social support services, terrible housing and awful work conditions.  While conditions are still very difficult for farmworkers, organizations such as the San Benito Health Foundation have brought very critical health care services to these communities.  I am extremely honored to represent migrant health centers in California, as they have a tremendous positive impact on the lives of agricultural workers throughout the state.

The open house at SBHF, part of a weeklong celebration of National Health Center Week, highlighted the important work our health centers do in the communities they serve. This event in particular celebrated the work of San Benito Health Foundation as a migrant health center – a vital part of our agricultural system in the state. In California, there are 340 migrant health center sites providing care the state’s migrant agricultural population, many of whom are undocumented immigrants. In fact, as many as 38 percent of the 2.6 million undocumented residents of California work in agriculture. Migrant health centers play a vital role in agricultural workers’ health since these workers experience higher incidences of work-related injuries as well as respiratory problems, musculoskeletal ailments, eye problems, hypertension, diabetes, and pesticide-related illnesses. The state’s recent drought has only exacerbated these health issues. Combined with low wages and limited time off, these workers endure tremendous hardship.

Community health centers provide care to anyone in the communities they serve – no matter their immigration or insurance status. They were born out of a need to provide primary and preventative care to our underserved populations, a mission they are committed to and uphold each and every day. In California, our community health centers serve nearly 500,000 migrant workers and their families each year. Migrant health centers, including SBHF, coordinate care for agricultural workers and their families, who often migrate throughout California as they follow the growing season and help cultivate crops nearly year-round. These migrant health centers understand the challenges of frequent moves and adapt to provide the preventative and primary health care these families need. The centers also provide dental, pharmacy, behavioral health, outreach, and support services specifically tailored to these migrant communities. Without our migrant health centers, the health of our agricultural community would worsen until injuries and illnesses became so severe that they would require the costly services of an emergency department.

Agriculture continues to be one of California’s largest economic drivers. According to the California Department of Farm and Agriculture, more than a third of the country’s vegetables and two-thirds of the country’s fruits and nuts were grown and harvested here. Given the vital role agriculture plays in our state’s economy, the health of agricultural workers is critical. Our migrant health center program is an important investment, both in the sustainability of our state’s economy and our nation’s food supply. It keeps patients healthy and healthcare costs down by treating illnesses and injuries early, before they become debilitating, thus preventing costly emergency room care. Delivering high quality, affordable health care to California’s agricultural workers benefits all Californians by reducing healthcare costs and improving health outcomes.

As the President and CEO of the California Primary Care Association, and as the daughter of a former farmworker who spent his youth on the fields of San Benito county, it was such a pleasure to be a part of the San Benito Health Foundation celebration today, especially with my father by my side.  It was an opportunity to pay tribute to the health center, its leadership, its patient population, and all farmworkers who are making a tremendous contribution to our great state.  And, it was an opportunity to honor and appreciate my dad and his example of what can be accomplished when you don’t forget where you came from.