1
National Health Reform and Major Issues for Los Angeles County
Issue
DSH Hospital
Payments1
State of California and L.A.
County Implications
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Homeless
Population2
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i
Senate Finance Committee
With 130 DSH hospitals
statewide, there are 35 DSH
hospitals in L.A. County.
County DHS estimated that
hospitals will receive $412
million in federal Medicaid DSH
payments in federal fiscal year
(FFY) 2009.i
County DHS estimated that
hospitals will receive $18 million
in Medicare DSH revenue in
FFY 2009.
Annual Medicaid and Medicare
DSH revenue will be reduced by
25% nationally by FFY 2019.
The impact on California will be
determined by how Federal HHS
Secretary decides to apply
Medicaid DSH reductions to the
states and how the state allocates
DSH funds to hospitals.
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Nationally, 70% of the homeless
are uninsured.
25% of the homeless are eligible
for Medicaid throughout the
county but are not yet enrolled.
L.A. County is the epicenter of
homelessness, with 254,000
people reportedly homeless
during some part of the year and
82,000 chronically homeless.
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$40 to $50 billion of the
$155 billion in hospitals
savings would come from
cuts in Medicare and
Medicaid DSH hospital
payments.
Cuts would begin in 2015
and occur over duration of
10 years.
Assesses new DSH
payment levels to reflect
more people being insured.
Senate HELP Committee
“Affordable Health
Choices Act”
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The CBO estimates this
proposal will cost $615
billion over 10 years, but
the Senate HELP
Committee does not have
jurisdiction over the
Medicare and Medicaid
programs. The finances of
the proposal will be
developed in conjunction
with the Senate Finance
Committee.
Establishes new
competitive grants for
innovative programs
within hospitals and
clinics.
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Expand Medicaid to all
individuals up to 115% FPL
Higher expansion % FPL
possible for parents,
pregnant women, and
children.
Does not change 2 year
waiting time for Medicare
through Social Security
Disability Insurance.
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Expand Medicaid to all
individuals with incomes
up to 150% FPL.
Does not change 2 year
waiting time for Medicare
through Social Security
Disability Insurance.
The amount L.A. County would receive in FFY 2009 is about 4.5% of the total estimated nationwide DSH payments of $9.1 billion.
Created by LA Health Action: August 2009
H.R. 3200 “America’s
Affordable Health Choice Act of
2009”
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In FFY 2017, reduce total
Medicaid DSH payments by $1.5
billion, in FFY 2018, reduce
payments by $2.5 billion, and in
FFY 2019, reduce payments by
$6 billion.
Federal HHS Secretary will apply
the largest percentage of DSH
reductions to states with a low
number of uninsured persons,
hospitals with low volumes of
Medicaid inpatients, and hospitals
with high levels of
uncompensated care.
Between FFY 2017 and 2019,
reduce Medicare DSH payments
by an estimated total of $10
billion if rate of uninsured under
age of 65 years of age drops 8%
between 2012 and 2014.
Gives clinics preference for
competitive grant programs.
Expand Medicaid to all
individuals with incomes up to
133% FPL.
Newly eligible childless adults
can enroll in the Exchange with
conditions.
Does not change 2 year waiting
time for Medicare through Social
Security Disability Insurance.
2
Issue
State of California and L.A.
County Implications
Undocumented 
Immigrants3
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Approximately 2.2 million
undocumented residents in
California comprise about 30%
of the total undocumented
population in the country and 6%
of the state’s population.
L.A. County has about 1.1
million undocumented residents.
L.A. County has 2.1 million
uninsured residents who utilize
the safety-net system, and
800,000 are estimated to be
undocumented residents.
Senate Finance Committee
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Senate HELP Committee
“Affordable Health
Choices Act”
The Gateway is open to any 
legal immigrants.
No subsidies for
undocumented immigrants 
The consideration for the
state option to remove the 5 
year bar on Medicaid for
immigrants may be
cancelled.
The Exchange is open to
any lawful immigrants
regardless of status
No subsidies for
undocumented immigrants
Does not remove the 5
year bar on Medicaid.
H.R. 3200 “America’s
Affordable Health Choice Act of
2009”
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Undocumented 
Children4
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In 2001, it was estimated that
300,000 undocumented children
were enrolled in County schools.
In news reports, President
Obama expressed willingness to
provide undocumented children
with coverage. However, detailed
information is unavailable.
Created by LA Health Action: August 2009
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Undocumented children are
not eligible for Medicaid.
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Undocumented children
are not eligible for
Medicaid.
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Sec. 242 and 246 explicitly state
that only individuals who are
lawfully present in the US will
receive any benefits from the bill.
Gateway is open to any lawful
immigrants regardless of status
No subsidies for undocumented
immigrants
Does not remove the 5 year bar on
Medicaid
U.S. Rep. Steve King, R-Iowa,
estimates the bill would allow
about 5.6 million illegal
immigrants coverage because he
said “the bill does not include any
requirements to verify the
citizenship or immigration status
of those receiving taxpayerfunded health benefits.”
CBO found the measure would
provide health coverage to 37
million people, estimating that
97% of all citizens would be
covered by some health care. The
plan leaves 17 million people
within the U.S. uninsured, nearly
half would be illegal immigrants
who would not receive coverage.
Undocumented children are not
eligible for Medicaid.
3
1
DSH Hospitals:
1. County of Los Angeles Chief Executive Office “Washington, D.C. Update.” June 16, 2009, July 8, 2009, and July 16, 2009.
2
Homeless Population:
1. Mostrous, Alexi. “HUD Chief: Health Reform Will Help Homeless.” The Washington Post. July 31, 2009.
2. “Letter to the Senate”. National Health Care for the Homeless Council. July 15, 2009. Accessed at: http://www.nhchc.org/HealthreformlettertoSenate.pdf
3. “Homelessness in Los Angeles County.” Los Angeles Almanac. Accessed on: August 4, 2009. Accessed at: http://www.laalmanac.com/social/so14.htm
3
Undocumented Immigrants:
1. “Illegal Immigrants in California.” Los Angeles Almanac. Accessed on: August 4, 2009. Accessed at: http://www.laalmanac.com/immigration/im04a.htm
2. “Health Care Expenditures for Immigrants are Lower than for Citizens.” National Immigration Law Center. May 2009. Accessed on: August 4, 2009.
Accessed at: http://www.nilc.org/immspbs/health/costs-less-than-citz-2009-05-26.pdf
3. Ludden, Jennifer. “Health Care Overhaul Ignores Illegal Immigrants.” NPR. Morning Edition. July 8, 2009. Accessed on: August 4, 2009. Accessed at:
http://www.npr.org/templates/story/story.php?storyId=106376595
4. “Sharing the Costs, Sharing the Benefits: Inclusion is the Best Medicine.” Immigration Policy Center. July 22, 2009. Accessed on: August 4, 2009.
Accessed at: http://www.immigrationpolicy.org/images/File/factcheck/Sharing%20the%20Costs%20Sharing%20the%20Benefits%202009.pdf
5. “Analysis of 2009 National Health Care Reform Proposals.” Having Our Say! Communities of Color Stake in Health Care Reform.
6. Montopoli, Brian. “Obama: No Health Care for Illegal Immigrants.” CBS NEWS Political Hotsheet. July 21, 2009. Accessed at:
http://www.cbsnews.com/blogs/2009/07/21/politics/politicalhotsheet/entry5178652.shtml
7. “Should Health Care Reform cover the Undocumented?”. Houston Chronicle. July 22, 2009. Accessed at:
http://blogs.chron.com/immigration/archives/2009/07/should_health_c.html
4
Undocumented Children:
1. “Congressional Health Reform Proposals: How Do Children Fare?” First Focus. July 2009. Accessed on: August 4, 2009. Accessed at:
http://www.firstfocus.net/Download/SidebySide_HealthReform.pdf
2. “Analysis of 2009 National Health Care Reform Proposals.” Having Our Say! Communities of Color Stake in Health Care Reform.
Created by LA Health Action: August 2009