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Reflections and Recommendations on Building Coverage for California's Uninsured

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California has a high percentage of its population uninsured. The uninsured are predominantly young, low wage working families. Children's uninsured rates are falling while uninsured rates for young working adults are growing at the fastest rates. In California and nationally, the rates of increase in health costs and premiums are the prime cause of the growth in the uninsured.

California has made important progress in covering the uninsured including: expanded coverage for children and parents, underwriting reforms and purchasing pools for small employers and a growing momentum for change at state and local levels. There are many state and
local leaders of good will seeking both immediate and long term, far-reaching solutions.

Major legislation is being proposed to reduce California's high rate of uninsured; these proposals include mandating employer and individual coverage, coverage for all children and enacting a Canadian style single payer system. Universal coverage could be incrementally achieved in California sequenced as follows: first, all children, second Healthy Families parents, third low wage working adults, finally universal coverage (via mandates, pay or play or taxes) if linked to cost controls. The missing ingredients for success are stakeholder statesmanship.

An increasing number of counties, regions and local initiatives are developing innovative pilots to increase coverage of the uninsured. Most cover children; some cover adults and parents. Some test new forms of coverage such as managed care for the county indigent or purchasing pools and premium subsidies for low wage workforces. Local efforts build on the strengths and needs of local communities: 1) Local Initiatives, County Organized Health Systems and Community Health Plans who are willing and able to lead experiments, commit financing and take risk, 2) public hospitals and community clinics who treat Medi-Cal, county indigent and uninsured patients without discriminating based on the patient's payor source, and 3) strong and cohesive local leaderships. The biggest challenge to local innovation is the frozen, fragmented and often incomprehensible thicket of federal and state programs and funding streams on which they rely. California is unique in that local government with the least access to funding shows the greatest leadership and creativity in covering the uninsured.