Orientation
David Alexander
Introduction to the system in California. It's a real microcosm of the country. If you can make a system work in California you can make it work anywhere.
There are a number of services at a county level that make things confusing. Title V has been implemented in California largely through California Children’s Services. CCS started before Title V. You qualify based on diagnosis and income level. There is a list that qualifies you for CCS services.
Counties pay for part of the program so you have to live in the county where you apply.
If you move you have to re-establish eligibility.
The diagnosis is pretty broad. There are 175,000 children on the program right now; 75% on Medicaid. 15% are in the chip program; 10% have no insurance or some insurance part of the year. They are all earning under $40,000 per year; in 1983 before CCS was formed it was $120,000 income to be eligible for CCS. Prop 13 changed things to $40,000 but they haven't done a cost of living increase in all these years.
Sufficient income in the Bay Area is $44,000. You have to be really poor to qualify for this program.
CCS is a supplemental payer for sub-specialty care. It's allowing the sub-specialty care to exist in the state. California Medical payments are the lowest or second lowest in the country.
If you are a child on Medicaid, CCS pays for the care related to the CCS eligible condition, and Medical pays for the rest of your care.
Medical is a mix of managed care and fee for service.
Even though there is a carve out for certain kids their primary care is in the health plan and the CCS care is outside of that. The money reimbursing the physician is Medical money.
It's carved out because the health plans don't have to pay.
There are four counties where it is carved back in for Medical.
The majority of the children with Chronic conditions in California are not covered by CCS. If there is a child in an HMO it covers all their services. It's fairly broad. We probably have the widest range to qualify.
This 180,000 kids or so costs $2B per year to the state. There is an interest in reforming the CCS program. There is a project in state government going on to reform CCS. They are the biggest single payer in the state for kids in this population.
Chip Kids aren't even reached. If they are in Chip they are automatically eligible. $40,000 limit are for those that are non-Medical and non-Chip. There is a small exception - a family over $40,000 can pay out of pocket 20% of the care and be eligible.
If you were going to design a system from scratch it would look just like this. [laughter]
One of the things that CCS has done very effectively is to create quality standards for specialty care in California. That's been good in California. Those standards have translated in practice to all kids.
There are a whole range of standards for hospitals - facilities, and special care center standards; the standards go beyond JACO. It's elevated care for everyone as long as they get to those hospitals.
They are more likely to get to the right place for care if you are poor in California.
The other thing is something called the Regional Centers System. They have been around 42 years. They are a 501c3 and there are 21 regional centers covering all 58 counties. They are private not for profits initially serving mental retardation. It's all done through advocacy. To have some other option other then state institutionalization. There were about 12,000 people at that time the centers were created.
They have added other handicapping conditions- autism, cerebral palsy and anything that resembles that throughout their whole life; case management, diagnosis, built in to educational law includes special ed and the educational plan. We're involved in transition as well.
One of the service groups has increased disproportionately and that's autism.
In population alone Los Angeles is covered by 7 regional centers.
There are no financial eligibility requirements to be cared for in these centers.
There is some cost for case management based on family income. When you see the formula it's very generous.
Independent living centers - certified Type S - purchase of service; case management translates into purchase of services (not purchased by some other agency). We purchase no educational services by mandate. We purchase early intervention services.
The updating budget has some changes in it that affect the regional centers.
We need to put California's budget in perspective for folks. The financial underpinnings don't work. Because of Prop 13 we are dependent on personal income taxes; property tax is fixed based on the purchase price of your home. We are more susceptible to the economy and with personal income going down we're in a world of hurt. The budget is 40% less than it was a year ago. Social services, education, health have all taken great cuts in the last several years.
There have been special sessions where the legislature has been asked to cut expenses. State employees are on a 4 day work week.
The challenge - children with chronic illnesses - we try to identify a provider in the community or a medical home.
If you look at the national survey of kids nationally we don't do well on the medical home.
LA County is the most urban county - Medicaid has qualifications in many languages - there are 11 threshold languages there. That's pretty typical. There is a level of diversity in California.
