 schedule so we appreciate you taking the afternoon to join us today. For those of you who are not familiar with the New America Foundation, we're a national nonprofit, nonpartisan policy institute. We're based in Sacramento and in Washington DC and and this year because of the passage of the Affordable Care Act and in the various provisions in the act that we believe helped to financially empower Californians by providing millions of uninsured residents with health insurance but also key provisions within the care act itself that they help to eliminate disincentives and silly rules that keep families from savings. Our asset building program and our health program partnered together through research and policy development and legislative advocacy to advance a health wealth agenda that we'll be talking about in detail this afternoon but but in our asset building program we traditionally advance assets in all policies in the area of banking in the area of taxation in the area of education and in the area of health now this year and and we we we decided because of the of the release of a report on medical debt that that our partners at the access project Mark Rukavina who's traveled all the way to Boston to be here with us today in partnership with Lee Pauzy and our health program co-wrote but that it would be a brilliant opportunity to go on the road and basically take Sacramento out of the bubble the Sacramento is and and travel to Los Angeles Fresno in Oakland and have this conversation with real people that get it and they'd want to know about the various policies that are moving forward in Sacramento because when it comes to for example legislation session ended in the beginning of September and the governor has up until October the 9th to sign any of these bills into law and so it would be an opportunity for all of you also to hear about what could potentially become law and will impact all folks we care about in the beginning of 2012 and so with that I just want to thank our partners the Urban Strategies Council and Alameda County Department of Public Health for joining us to convene this health wealth conversation and specifically explore the areas of medical debt and how medical debt impacts Californians ability to build savings and be financially secure so I want to introduce Lisa Forty from the Urban Strategies Council who I'm sure all of you in the room know she's an incredible leader in this space and in this field and actually it was about a year ago that she invited us to join her at the California Endowment to to be a part of this conversation and just want to build on this discussion that's where I actually met Mark Rucavina so these convenings do help to create these synergistic opportunities so with that thank you so much and let's get started Lisa. Thank you Olivia. As Olivia said I'm Lisa Forty I'm with the Urban Strategies Council here in Oakland and I staffed the Alameda County Community Asset Network a collaborative some of our members are here today we've been working together since 2007 on income and asset building strategies in the county and regionally and we're really proud to coagulate this conversation and also really proud that one of our founding member organizations the Fremont Family Resource Center Arnie Becker is on the panel today to talk about what he sees on the ground with the families that he serves as we think that that local perspective is really important as a part of these policy conversations. We've been really interested in the connection between health and wealth and as such we were one of the co-founders of the health wealth connection collaborative with the public health department and some other partners and last year as Olivia mentioned we hosted this health wealth symposium really trying to bring together the fields of economic justice and public health because we know how close health equity and income and asset building wealth opportunities and communities are. We're still continuing those conversations we're still strategizing and working together locally and there's a lot of exciting projects that are being incubated so if anyone's interested in getting involved in what's happening locally around the health wealth connection please come and see me I'd be happy to talk to you after the panel. Now I have the honor of presenting a very close partner I need to sequel is the director of the Alameda County Public Health Department and I can honestly say that the we are so lucky in this county because we have a national leader in terms of the health wealth connection in our public health department they get it they understand that economic justice and public health are so closely correlated in length and they don't just understand it they're acting on it they're looking at income protection strategies they're looking at how foreclosure and health are linked they're looking at how the well-being of communities has all these other social factors and what they as a health department can do about it. So she has a brilliant staff and I'm privileged to work with she's an amazingly energetic and committed partner in this in this conversation and I'm just really pleased that we have this helpful partnership with please I want to introduce I need to say that to my mother. So I'm I have the privilege of being the director of Alameda County Public Health Department and we are a very progressive department that's looking at the determinants of health and working very hard at it. So with our partners the America Foundation with Urban Strategies and the Select Committee on Financial Empowerment I want to welcome everyone to today's conversation and as I look over the audience and see the partners that are here I know that we have an opportunity for a great conversation around medical debt. So we're here for part of the new America Foundation and their solutions based report on medical debt an issue which has profound health consequences and I want to tell a little story about myself unfortunately over the last few years I have to deal with the medical world we're dealing with a medical problem and I am so blessed to have full coverage through my work because when I look at the bills for every single treatment that my husband is going through it's astounding and I know that if we had to pay a portion of it we probably would not be we wouldn't have a house we might be ready at this point and I know that a lot of Americans because of medical debt either lose their home or actually go into bankruptcy and that is that is so sad in this country. So every day my husband and I are blessed and we thank we give thanks for that blessing of having great medical coverage. So we're here to discuss medical debt and its implications on financial sustainability and the larger context of health and wealth and we know that health is very tied to well and we know that in this county in this community that there are great disparities that there are communities where people don't live as long as they they should. Infants don't celebrate their first birthday. Schools aren't as good in some of our neighborhoods and it's all tied to wealth. So wealth determines whether we live in a safe neighborhood, whether the home we live in has good air to breathe, whether there's fresh fruits and vegetables in our neighborhood and whether or not we can take a child to the doctor when it's sick. So regardless of income debt the dots from wealth and wealth seriously impacts health. Medical debt may lead to short term trade-offs preventing people from seeking much needed care. Medical debt also packs the ability of families to accumulate wealth and we know that this has profound effects on how well children do in our community. Even with the passing of the Affordable Care Act rising health care costs and inadequate coverage continue to have a profound impact on some of our most vulnerable populations and I know I have my husband and I are living through this and like I said we are so thankful that we have great health coverage. The health implications of wealth are the same as lacking income. We know that right now in this country we have a 12 percent unemployment rate. Nationally African Americans have an unemployment rate of almost 18 percent. In Alameda County the unemployment rate among African Americans is 20 percent and we know that this greatly affects our income and our ability to accumulate wealth. And medical debt threats to be enforced with this widening gap in families among racial lives. So in Alameda County, like Lisa said before, we are working in partnership with the community to try and bring health equity to all the residents of Alameda County. And health equity implies that there is equity in education, equity in health, equity in the way we live. And to achieve our mission we have to look at all these broader issues. Access to power, resources and opportunities. We are well acquainted with the compounding effects of economic stability of health. Opportunities to accumulate savings, acquire credit, develop assets that are not equitably distributed. In Alameda County where we experience significant disparities in wealth along racial and ethnic lines, rising medical costs and loss of income threaten to perpetuate health inequity. In our most recent health equity report we found that African American citizens living in Alameda County were three times more likely to be living in poverty than a white resident. The work that we're doing and the partners that we're partnering with include urban strategies, east open building healthy communities, building blocks and place matters. And all of these different partners are helping us to work on social determinants of health and also wealth issues. So with the New America Foundation has been a champion for increasing the income and assets for Californians who suffer disproportionately from the worst health outcomes. And we are so grateful to have such an amazing partner. So we're proud to be promoting this. So at this point I've said enough and it's my pleasure to introduce my friend and my colleague, a real leader of public health and the vice president for Public Health Institute, Carmen Navarres. Good afternoon, everybody. Each of our speakers will come up one after another and share their ideas and hesitations with you. I want you to think of the questions that you think are particularly good and at the end we'll start to have a conversation and see if we can we can carry ourselves through that. And stay a little bit longer if you need to, but let's try to sort of shoot for that time. Okay. We all know that health care expenditures and see 16% of our gross national product. We don't really know enough about the other impacts of our nation's generally for health status. As we think about medical debt, health care expenditures and how to turn this massive ship around, I want to remind everybody that probably 85% of the things that cause poor health in this country are preventable. A lot of you guys are working on this stuff. You're working on anything from changing where the roads go and changing the quality of housing that people have and changing the level of education that people can access. But we have a long way to go. And until we actually make it somewhere in preventing ill health, I'd like to start this conversation on one of the very important sequela of poor health and that's what poor health does to our pocketbooks and to the economy in this country. So let me introduce you to this amazing group of people. We're going to start with Mark Lithovina, who's the executive director of the Access Project, whose efforts provide local initiatives with research and policy assistance. He's a nationally recognized expert on issues related to health access and medical debt, especially as they pertain to low and moderate income Americans. And after Mark will have Leith Wellington-Hoss, who's the California based senior fellow in the health policy program of the New American Foundation. He is a leading author and researcher on US health care system reform, insurance company, and controlling health care costs. After Leith will be Olivia Caberon, who is the California legislative director for the New American Foundation. She's based in Sacramento and helps policymakers to really hammer out the laws that improve the welfare of its residents. Finally, we'll end with Artie Becker, who has a very, very interesting background and that we serve as a photojournalist. So he looks deeply at this and tries to convey what they mean to people in a way that's different than most of us do in our daily work. He is serving as a volunteer at Life Log Medical Clinic in Berkeley in East Oakland, Charlotte Maxwell Complementary Cancer Clinic in Oakland, and has been both a paid and volunteer financial counselor at Fremont Family Resource Center, and is a volunteer income tax assistance program with restructuring approach in all of the county. Now that is a truly diverse and well, well distributed in terms of talents panel. Let me call Mark up to start with his presentation. Good afternoon. I should thank you for the opportunity to be here today. I want to thank the New America Foundation and the East Oakland Center of Health and Strategy and all of you who are part of this health wealth work, and it's such a pleasure to be here in California among the most forward thinking, progressive forces across the entire country. I'm wondering if we can just have a show up answer and try to understand who's in the room. And I know it's arbitrary to ask whether you work on health related issues or asset wealth issues, but you can just bear with me on that simple kind of view. How many of you are public health or health care people? How many of you do work around economic justice issues or asset wealth issues? Others? Okay, thanks. I'm just going to give up a, there are slides in the packet that you can see. My presentation will be hopefully brief. Under 10 minutes, we did a presentation yesterday in LA and all of us were convinced that when we each of us had to have a 60 minute mark, there was something wrong with the time. But I'll give kind of a broad overview of health care costs, talk about some of the medical debt data that's already been mentioned, explore a little bit this health, the health wealth connection and talk about some opportunities for mitigating medical health in this new policy environment. Health expenditures $2.5 trillion in 2009, actually a little more than 16% 17.6% of the gross domestic product. With that amount of money spent still 49 million people uninsured. Last year, in 2010, new census data came out recently, increasing the number of uninsured from 49 to 40, nearly a million additional uninsured. Fortunately, for about a million young adults, they had coverage, they were going to be covered under their family health plans. And otherwise, that number would have been even greater. But the number on our quality of attention is the projected cost of health care is going to go from $2.5 trillion, or slightly more than that today, to more than $4.5 trillion, nearly 20% of the gross domestic product. So clearly, work needs to be done around health care affordability. And I want to congratulate Carmen and folks in California broadly and the Public Health Institute for the award that you received, the Community Transformation Grants, because I think that is going to be necessary work to try and do something about health care costs and really try to bend this cost. So a little bit on affordable health care costs. And these are from the Commonwealth Fund. About 73 million Americans had troubles paying medical bills in 2010. And those were people who said that they wanted to pay bills, struggle to pay bills with the content of our collection agency for unpaid medical bills, had to change their way of life, or had medical bills that they were paying off over time, of people who had incurred medical debt. That medical debt figures a little smaller than the overall figure, but still about one in four Americans has medical debt bills they're paying off over time. That's from 2010 data. There's been some data from the California Health interview survey. And we had a colleague yesterday, Shane, who said there's going to be some new data coming out, I think it will be 2009 or maybe released soon. But those data, these data here are from prior to, from before the recession, two and a half million residents in California had medical debt. Some of this is previously mentioned, the issue with medical debt, people with medical debt insurance have care seeking patterns that are very similar to the uninsured, the Kaiser Family Foundation has some research on medical debt. And medical debt in and of itself as a risk factor, as was mentioned previously, we were kind of dealing with this health wealth cycle, people with low wealth, low income, greater health problems, which do reinforce issues related to poverty. So these are some data in terms of people with medical debt and their, their access of health care. Again, this kind of cycle that we see health, poor health can lead to issues of debt, which contribute to poor health can venture this from not having financial resources to have a healthy living place matters. I love, I love that, that being the word, because it clearly does. But we're seeing this cycle of medical debt contributing to the wealth problems and exacerbating health. So some of the financial difficulties that people experience with medical debt, they're unable to pay basic expenses. 40% of the people with medical debt to plead their savings, that second bullet there should actually be 29 million Americans use up savings to pay the medical bills. We're seeing similar trends in California in terms of the way medical debt first eats people's short term savings. But it goes beyond that. And as was mentioned, many people roll medical bills into home mortgages. And many people enter into risky financial arrangements, trying to pay off these medical bills, credit cards, taking on paying loans, etc. Trying to pay medical bills. I want to spend some time talking about the issues related to medical bills in the credit reports and in the credit area. And I'll be speaking after me about some of the health issues, the Affordable Care Act and how the Affordable Care Act will address some of the medical debt concerns. Again, for Commonwealth data, about 30 million Americans had were contacted by collection agencies for medical bills that they had a study that was published in the Federal Reserve Post on that half of accounts on credit reports that were in collection for medical nature. Once bill is sent to collection and on a credit report, it's actually quite difficult to get it removed from the credit report doesn't really matter why it was sent to collection. And I'm sure that some of you in the room today have had experiences with health insurance, where there's been some confusion around bills, uncertainty as to whether or not you're supposed to pay it. And if there's too long a delay on that, oftentimes, it ends up down a path that's difficult to retrieve that bill from, or it's sent to collection, once it's sent to collection, it's reported to the credit bureau. And once that happens, other problems result in terms of one's credit. These accounts are considered accounts in the years. So the derogatory accounts, they go into the credit history section of the credit report, which is the most heavily weighted section of the credit report. And driving on through the credit source. And that happens, it increases the cost of any loan that one is going to access, whether it's a field loan, interest rate, you pay on credit card, it's a home mortgage that the examples here come from some articles that were written in the Lawson Journal in the New York Times of people that very small medical bills that created disproportionate, large problems in these stories here are about people who have difficulty accessing the foreign mortgages because of pretty small balanced medical bills that they have. In fact, once a medical bill ends up on a credit report, it stays there even if the balance is zero. And the more recent that account is, even with a zero balance due, the more recent that account is, the more heavily it's weighted on a credit score. So you can have people with who have had some, yeah, there's no medical bills, small bills, coping, it's 15, 20, $50 bills, three or four of them whose scores will be decreased by 100 points because they appear on a credit report because they're considered derogatory accounts in this credit history section of the report. Again, you know, some people borrow against their homes, some people struggle to maintain their mortgages. The top bullet here is from the National Foreclosure Religation Counseling Program that served over a million people at this point in time in the last couple of years as we were struggling with this foreclosure crisis. But I thought this was really interesting because 6% of the people served by that program cited medical debt medical issues as the primary reason for their mortgage default. And that actually was greater than the number of people whose rates were resetting and the interest rates and the mortgages were increasing. Obviously, this is a problem that's been largely driven by people's loss of jobs, reduction in income. But the third greatest factor was medical debt. I just, again, want to spend some time looking at the burden of health care costs by income category. And you see here that nearly half of people out of below 133% of poverty spent more than 10% of their household income on premiums and out-of-pocket costs. Though the number is much less among higher income populations, it's still pretty dramatic, one in five individuals. Fortunately, the Affordable Care Act is going to, for those people under 133% of poverty, expand Medicaid to get to the category of eligibility for Medicaid so that people with incomes below that figure will qualify for Medicaid. People between 133% and 400% of poverty will be eligible for subsidies for private health insurance. That will reduce some of the pressure. And I think for many of the people over 400% of poverty have substandard insurance right now. Policies that don't adequately cover them for the medical expenses they have are losing some changes to those policies as well under the Affordable Care Act. But I want to talk about briefly, we're just going to speak in more detail about the Affordable Care Act, so I don't want to spend any time on that. I want to talk about a couple of provisions that I think are one provision of the Affordable Care Act that I think is going to be crucially important going forward and an opportunity to really address medical debt. And that is charity care standards and transparency around charity. There are some provisions, especially for non-profit hospitals in the Affordable Care Act, that they have clear and transparent policies around charity care. They can reduce the fees, they can charge the insured for the services that they receive that they not pursue aggressive collection actions against uninsured people and people struggling financially. There's also provision in there that I think will be of interest to the public health people that requires hospitals to regular community needs assessments. And again, I think this is not going to bring together health and wealth in the hospitals that these non-profit hospitals and the needs assessments and ensure they'll be partnering with public health departments across the country to do this. But the way that medical bills are treated, the way the collection actions are taken to get payment from people for the medical debt that they have, it's going to be very important. I think there are examples out there and examples in this state of systems that have very good charity care policies in place. It's going to be important to do the education to inform people of those policies so that people aren't billed for services and aggressive collection actions not taken against them that hopefully will reduce the amount that we're expected to repay for the services they receive and won't put them in that spiral in terms of credit. I know I'm out of time, but I just want to say that there have been actions at the state level and other states around the reporting of medical bills and issues related to credit for health care bills and there's a bill that's been introduced in Congress, H.R. 2086, and then with the responsibility act. That would do something that's pretty straightforward, pretty reasonable proposal. It would require that medical collection accounts that have a zero balance due. You remove from a report within 40 days. So this only requires the removal as a result of then fully paid or fully settled. So I encourage you all to take a look at that. These are a couple of provisions that would be enormously helpful to people struggling with medical bills. It could make a real difference in terms of people's lives on this health welfare team. And I will end there. Turn this over to Lee. He's going to cover more details around issues where it would be important to have. Thank you. Well, it's a great pleasure to be here today. And it's especially a pleasure to see out there the audience of a number of friends and colleagues who are active in health care reform back to the year of health care reform in California and then the passage of the Affordable Care Act. With the twists and turns that that took in March of last year. And I was reflecting on that and realizing that now that I'm on the panel with a photojournalist. You realize very much that in photojournalism and photography that how you see a photo that comes a lot of the frame and where it's taken and how it's presented. And in the same way, probably the impact of the desirability of the Affordable Care Act is very much in the eye of the beholder. I'm contrary to the hopes of many who work past the bill, some of them in this room. On health care reform has really remained something of a Orzac test. But all you either like it or you hate it. The bulk of media attention is focused on the appeal and provisions that maybe aren't even in the bill, like death panels, rather than the practical consequences of implementation. Misconceptions abound. Even if the Americans who know that the bill was passed, 25% of them think it's already been repealed. And all the shows of 30 to 40% of low income folks in California think the bill will do the more harm than good. And so for a few minutes today I want to leave the world of ideology and myth and return to the facts on the ground. I'm going to try to convince you that the ACA can be a bridge between folks who concentrate on health care and health policy and those who work principally on poverty and financial security and social welfare issues. And I'd argue that taken as a whole, the ACA should greatly improve the financial security of low and middle income Californians and legalize access to affordable health coverage. It'll make it easier to avoid the medical bed issues that Marx just laid out and lower the hassle of avoiding the enrollee either in public programs or in private coverage. And it will give very importantly, and I'll get to this at the end, individuals at least in preliminary tools to try to reverse health care disparities in their own communities. And let's look for a minute at just a couple of slides about why the ACA was needed. If you see here it's a comparative international study done by the Commonwealth Fund in New York. Essentially, even high income folks in the U.S. went because of medical care, without medical care because of income, at a rate pretty much even low income people in other countries. And for low income folks in this country, the figure is pretty staggering. Similarly, if we hadn't had the form number of uninsured would reach nearly 70 million, employer health spending could have gone up as much as 100 percent. And uncompensated care, the care that hospitals or doctors give you there, paid for, is paid for either by charity or not at all, would have grown again by as much as 75 to 120 percent. So just to think back as you, you know, as the debate over the Affordable Care Act goes on, it's worthwhile just stepping back a few minutes and thinking what the trajectory of health costs and insurance would have been otherwise. And the heart of the ACA, as you know, is expanding insurance coverage and improving quality of this coverage. And it's also an issue of wealth preservation and financial security. We know from many, many comparative studies of the insured and uninsured that coverage results in better access to care, improve health status, lower out of pocket costs, and reduce mortality. In this expansion of coverage, I'm going to focus on today, is taking place through two main vehicles. One is changes in eligibility to Medicaid, which is historically the health care program, federal health care, and also state health care program for most, but not all, of low income Americans. And secondly, offering a refundable tax credit for the purchase of private insurance on newly established health care markets or so-called exchanges. When this process is complete, 32 million Americans are expected to gain coverage between four and five million in California alone. In about 30, 16 million of those through Medicaid, and just put that in perspective, that's basically the same number of seniors who enrolled in Medicare in the mid to late 1960s when it was enacted. So just that one portion bill alone should lead to that increase in coverage. And to accomplish this, other changes were made, and that's what this sort of celestial navigation slide shows to transform the market for health insurance and down the line hopefully change the way we deliver medical care, the most important features of the individual mandate, which requires the purchase of health coverage by adults who have the means to do so, and a variety of pilot programs aimed at strengthening primary care and reducing excess spending on medical treatments. And so I've titled this side Medicaid is health insurance. And the reason I say that is because for many, many years Medicaid or Medi-Cal in California was filled with categorical eligibility requirements. You couldn't be just a working adult man, for instance, and get access to Medicaid even if you were poor. You'd have to have all sorts of dependent children or you have to be blind. One thing the Affordable Care Act does that's critically important, it makes Medicaid health insurance for anybody who makes 133% of poverty, practically speaking 138% of poverty or below. And that's a remarkable difference in the way things are treated. There'll be no more asset test, for instance, for adults in Medi-Cal and California. In 1.7 million low-income Californians are expected to gain coverage as a result of this change in the welfare groups. There's also something that's really unique to California. There's a federal waiver of Medicaid rules that could bring the state as much as $10 billion. California is the only state to get a waiver of this kind. And as many as 500,000 low-income Californians in 57 out of 58 counties, and you can ask a question about 58 if you like, will be eligible either to continue their current coverage or to become newly enrolled. And public hospitals will have an opportunity to revamp their operations so that they might be a provided choice and become places that individuals with either public or commercial coverage will seek out. And so far so good with this, but here's the problem that most of you know. Medi-Cal argues the target of $1.7 billion in cuts in the most recent state budget. There's really little or no low-hanging fruit in this program. We already have the lowest per capita Medicaid costs and among the lowest payments providers. And although the state intends to move most of those eligible for Medicaid and to manage care in order to save money, there's really no inclusive evidence, only a hope that it will do so. And budget cuts in Sacramento, if they're given the green light by the federal government, would put caps on the annual number of doctor visits, 10% payments to the already low provider payments, 10% cuts, and co-payments would be unprecedented in the program for emergency room visits and others. And this is on top of the elimination of adult dental care and other services that are already having a pretty ugly impact. So there's concern here, even as the Affordable Care Act gets implemented in 2014 and after, that the breaks are being applied even as we try to push on the accelerated to get better coverage. And then if you can see the bottom line of the slide, that leads to the next form, which is that even after the Affordable Care Act is in place, there'll still be over a million Californians, most immigrants without legal status, who won't be covered. And so one other critical feature of the Affordable Care Act anticipating us is about $11 million in funding for federally qualified health centers, many of which, of course, as you know, operate here in the East Bay and the Oakland area, such as La Planca. And three quarters of all visits to those clinics are made by people of color or the uninsured who are treated principally like counties. Unfortunately, again, there's some federal budget cuts that are actually taking away some of that money or offsetting of money even as it's coming down the pipe. And so the third and very important way to cover is being spent is through exchanges. And these are basically stores for insurance, a place where you can go out to prepare coverage. There are already some of these things up and running in Massachusetts, quite comprehensively, in Utah, which is more like an Expedia information comparison site for health care. But what are these? They're going to offer subsidies on a sliding scale, up to folks with 400 percent of the poverty levels, so about $88,000 for a family of poor. And it will gradually, the subsidy will pay as out as you get closer to the top end. It's politically quite critical to reform and also for getting people involved in coverage. And one of the things that's really important here is that California was the very first state in the country to set up an exchange in the afternoon passes of the Affordable Care Act. It's actually two exchanges. One's located in small businesses and other individuals. And this will be the only place that individuals in small businesses will be able to get access to these universities. But it's still raised a lot of questions. And the big ones are these. It's the field of dreams question. If you build it, will people come? Will people come? Will there be enough of them so that insurers will actually offer products at reasonable rates? Will the products be standardized so you can actually know how to choose between them? And what will the minimum benefits be, which will also make a pretty big difference? One other thing that the ACA offers, which you may have heard about, which is the Sacramento in the last session, is the basic health program, in which instead of having her in addition to having an exchange, the money that would go over folks to 100, 33 and 200% of poverty would go to the creation of this new program. And there's the possible advantages of this, for instance, one would be the continuity of coverage. If you were from 100, 33 to 200% of poverty, you'd probably be less likely to leave your current provider network. And it might lead to not necessarily the lower income by the state. However, it could leave the exchange without enough people in it to make it work and also need to hire prices for insurance products for people on the exchange. So that was a bill that went forward sponsored by the Chairman of the Health Committee. It's a two-year bill, though, maybe back next year. It didn't pass this year. It would be, I'd happen to talk about it a little more in Q&A. And I'm going to conclude by looking at a couple of other key features of the ACA. And one of the key ones that I think are really crucial to both those interested in health policy and in financial services and economic development as well. The ACA directs the exchanges to determine eligibility to public programs for anybody who enters. So it actually acts as a new way of steering people to public programs that they're eligible for. And a bill that's actually on the government's desk right now sets a very critical framework for the ACA by establishing a single standard application form for MedCal, for healthy families, for the exchange, and for county programs. So this is something, as you know, streamlining the process by which folks become eligible is very important for healthcare and it also can lead to parallel opportunities, I'd argue, in other areas in social service provision. And finally, as we've heard from Carmen Agarras and our partners sponsoring this panel, everyone who works in public health and many of those, most of those who work in healthcare generally knows it's the circumstances in which people work and live and play, not really access to high-tech medicine or acute medical care that determines for the most part where the people are healthy. Land use, availability of good food, jobs that minimize stress, these are all part of the key social determinants of health. And there's also growing evidence that financial security itself is an important attribute to good health as we've heard. And the Affordable Care Act recognizes this and offers a bit of an entering winch. By putting forward and incorporating a number of relatively small potentially important programs that could encourage the lessening of these improvements in social determinants of health. One is the prevention of public health funds. We've already spent 40 million of that in California and 750 million nationally. Although the President's plan for debt reduction has a path, there are requirements for chain restaurants and vendors to disclose nutritional content. And finally, the Public Health Institute, as you heard from Mark, has received one of these terrific community transformation grants intended to reduce ethnic and racial disparities. And they're going to be operating in 42 counties in California. So a terrific, practical consequence of the Affordable Health Act. And so in conclusion, all these elements of the Affordable Care Act that ostensibly are directed mostly in health and health care policy as we've seen, also should have a big impact on the asset building and those of you who are working in financial services. So perhaps down the road when we've taken that picture and it's fully developed, the Affordable Care Act could be genuinely the missing link. Either that or not for our plastic services. Thank you so much. Can you all hear me? Perfect. Thank you for that, Leif. Again, Olivia, got it on. And I think Mark and Leif did a great job of showing the research and the data. Again, that helped link this health-wealth conversation. We know that Californians aren't just shown data that says $2 million are struggling with medical debt. And even with the passage of the Affordable Care Act, because many of these Californians have health insurance, even with the passage of the Affordable Care Act that's going to ensure about 5 million Californians, our residents are still going to have to deal with out-of-pocket costs and figure out a way to pay for those out-of-pocket costs, which is why we need to be advancing policies and initiatives that help Californians build savings and assets over their lifetime, which is why, together with our health program and partners in Sacramento, we started to advance this health-wealth legislative agenda and you have it there in your packets. This year, we worked on 11 bills. Six of these bills are currently on the governor's desk. All of them passed out on the legislature in the middle of September. And the governor has until October the 9th to sign many of these bills into law. I want to be very, very clear when I discuss what these initiatives are that we do not believe that any one of these bills will in and of itself solve poverty or help people permanently exit poverty. Many of these efforts are also been incremental because we've had to be very sensitive to the fact that there is no money at the state level and for our state lawmakers and for the governor are very sensitive about costs but believe that these efforts do lay the foundation and the framework for us to be visionary and to continue to move forward in a bipartisan way to help financially empower working families in our state. And so what we were able to do is think about, okay, what are the key opportunities within the ACA, within the Affordable Care Act that allow for us to make this clear connection. And so one of them we've mentioned that we're able to now kind of streamline the eligibility for various state programs, health programs, and other means tested programs. And so together with the Western Center on Law and Poverty, the California Welfare Directors Association, Health Access, and Food Policy Advocates we're able to advance efforts to do what AB6 does, which will help streamline eligibility for it, our state's food stamp and welfare to work program, CalFresh and CalWorks. It eliminates the finger printing imaging in these programs as well as deals with semi-annual reporting in addition to that, the Welfare Directors Association and Health Access also sponsored legislation to create an office of a patient advocate. There's going to be a lot of information out there and Californians are going to have to figure out how to maneuver through it. And so this office of patient advocate is going to be housed in the Health and Human Services Agency to provide Californians with accurate, up-to-date information on health insurance. And in addition to that, the Health and Human Services Agency has been directed to collaborate with all the various departments to figure out how they've said with the Assemblywoman Bonilla, Bill 1296, streamline the application process for all the various state programs out there. We know that Californians are in great need and they need to have access to these various services. I know that many of you heard the news in the census reported that about 6 million Californians are now living in poverty. It was reporting on income poverty. And we believe that income poverty is just the tip of the iceberg. What we should really be thinking about is asset poverty. About 30% of our state residents are living in asset poverty, meaning they don't have enough savings, enough assets to be able to survive at the poverty level for three months if they were to experience a medical emergency or lose their job or have already lost their job. And so we need to ensure, I mean, the safety net was created for these difficult times that folks are able to apply in a very, very easy way and create this one e-app so that folks can be able to tap into all the various resources that are available out there for them to provide this temporary assistance. And so when I talk about these struggling families, the most indigent among us, we know that the CalWORKS program, the Welfare to Work program was created to help folks transition back into the workforce, provide temporary assistance. And so there's another piece of legislation that's before the governor's desk. This is a bill that would eliminate the vehicle asset test in our CalWORKS program. It eliminates the vehicle test. There's a limit. You can have more than $4,650 worth of a car. And if your car's worth more than $650, then you're ineligible for CalWORKS and we think that that's really silly, especially in a state like California and in areas like in rural California where you need to have a car to get to and from work. And so this bill actually moved through the legislation with bipartisan support, which is an incredible victory in and of itself because the car has been such a contentious issue in our welfare programs. And so a lot of Republicans in rural districts, like I mentioned, stepped up and supported this effort to eliminate the vehicle asset test in CalWORKS. So now it's before the governor's desk. And we're hopeful that he'll sign it because what we were able to find is that really it's just keeping less than one-tenth of one percent of people out of the program. The folks that are applying for assistance, their car's not worth more than this amount. And our county workers are having to have to go through Kelly Blue Book to have to determine the value of someone's car, which is such a waste of administrative dollars and that's money that they could be otherwise spending, helping to get people back to work as opposed to looking at these silly rules. Then there were very traditional asset-building efforts. That our partners in the health community stepped up and helped support us. One specifically is banking development districts and the department here, Alameda County, has been a visionary leader and incredibly supportive of these efforts. We in 2008 helped Governor Schwarzenegger start Bank on California, which really started in San Francisco around 2006. It was a city effort to help the unbanked and underbanked residents there in San Francisco that didn't have a basic savings, a basic checking account, and without one, it's impossible for you to begin to build your savings. To challenge banks to develop these starter accounts, low-cost accounts for folks to enter the financial mainstream. It started in 2006 in San Francisco and it was so wildly successful that the state of California stepped up under the leadership of Governor Schwarzenegger and launched the statewide Bank on program to help the city of San Francisco really share its learnings and its practices with other cities and about six mayors launched similar initiatives in cities throughout the state of California. This program is now being replicated in about five state 7D cities across the country. But the reason it works really well is because there are existing banks and credit unions to partner with. But in communities and in areas where there are no banks, where all you see are check cashiers and payday lenders, we're not going to be able to spur Bank on initiatives. And so AB 38, Banking Development District Program, we believe should be incorporated into this Bank on statewide effort. What it would do initially, and this is before the governor as well, is it would require the Department of Financial Institutions to look out into the state basically and map it out and identify where are these communities, where are these cities that don't have these financial institutions that are necessary for all these various issues, not only to develop starter accounts, but also provide the credit that folks need to start their businesses, to provide home loans and so forth, and to just invest in the community, the visceral impact of having an actual bank. And many of these banks that have been participating in Banking Development District programs in the state of California, New York, are community banks, are small and mid-sized banks, that care about investing and being in the community. To be able to identify where are these communities and then provide the legislators with the roadmap of where these targeted incentives should be to help these banks develop and open up in these areas. And so the initial step is going to be mapping, and after that, it's going to be requiring that the state treasurer work with the Department of Financial Institutions to provide state deposits to these banks and credit unions that agree to open up in these communities and then develop the parts and services that are tailored to the needs of low-income consumers. Finally, one of our major state partners has been Comptroller John Chung. He has had a time after, year after year, he's had financial service fairs in the Capitol Park. This year we joined him again for the financial service fair that he provided. He wants to be able to have an advocate within the office of the Comptroller that would be there to work in partnership with banks throughout the state, nonprofits that are interested in consumer financial education and lift up and highlight those successful consumer financial programs that are taking place throughout the state. And so the bill that you see there before you would create a consumer financial education fund in the office of the treasurer and would allow the controller of the state then to manage those funds to be able to first and foremost create a state website that would be like a clearing house for all the various financial education efforts that are happening throughout the state and make it easy for California to maneuver through. You could put something as simple as your zip code in there and you could be searching for how do I go about getting a car loaner or I'm thinking about buying a house, where can I start to get some counseling and I need to fix my credit because there's this medical bill that I paid and it's still showing up on my credit report and it's making everything difficult for me. I'm thinking about going to college for the first time. How do I go about financing my college education that you would be able to go to this clearing house and we've been working with the controller to develop something even more visionary than that. What about if we had a financial service core, a core financial counselors, volunteers that would go out there to help low income consumers and really volunteer their time to help people do the most basic things like developing a budget to thinking about again planning for their retirement and developing an estate. So that's what the controller is doing. But I do want to say that again, these are incremental approaches. We of course believe in more visionary ideas. We know that the need out there is great and many times when we're working with our partners feel like it's daunting when we think about how our families are struggling. Carmen had mentioned and Anita mentioned the unemployment rate in our state. We know that in communities of color, ICN price here from the Insight Center, that the wealth disparities are even greater in communities of color. And we need to have, our approaches should be universal. They should be targeted to meet the needs of communities of color. And we can't do this work alone, which is why I'm so thrilled that this year the California EITC and Acid Building Coalition was launched. We at the New America Foundation, along with five other partners were founding members of this coalition. This coalition is going to be having its second annual symposium in Los Angeles on November 15th. So mark your calendars. Many of these policies will be highlighted at this symposium down in Los Angeles. Last year, the first lady, Maria Shriver, was our keynote and challenged us to continue to work together and break out of our silos because the need of a family is in siloed. And our fuel shouldn't be siloed either. We should all be working together to advance our mutual endeavors. And so with that, I'm going to pass the mic onto Arnie because one of the reasons why we've decided to go on the road and host these speaker series throughout the state of California is because whenever we're in communities and we hear the real life impact that the work has on struggling Californians, it helps to put a face on a lot of the work that we're doing in Sacramento and it's powerful in and of itself. So with that, Arnie. What I'd like to talk about this morning with Stephanie is the contact that I have with folks at medical clinics in Oklahoma and in Alameda and with what they're dealing with in terms of death and how it is affecting their lives and how it prevents them from getting to medical care that they really desperately need and in some cases is after shortening their lives and the lives of their children. I'm going to give you a couple concrete examples of folks I've been dealing with. There's a couple from Italy first generation immigrants about 75 years old who have a $10,000 CD. Because of that CD they don't qualify for Medi-Cal yet they both members of the family have major medical issues and what they've said is we want to give this money to our heirs we're not going to spend it down and they in fact now are not taking their medications not getting their medical treatment this has to change another family that I'm working with has a $900 share of cost but they have Medi-Cal so Medi-Cal in that particular case isn't really helping them because they have to spend $900 every month in order to get Medi-Cal to kick in beyond that so they're trapped in this situation where Medi-Cal exists it's there they've participated in it but it doesn't pay so now they're having to go out and buy supplementary insurance you know HMO, BPL something of that sort to actually fill the gap that Medi-Cal is not filling I've also got another single person who has probably $500 worth of bills from ambulance trips and medical treatments that he did not know was on his credit report when he went to get an apartment he couldn't get one because he has negative credit rating he went to get employment could not get employment for the same reason we now are checking credit reports credit history before they will actually offer a job if they have two people equal qualifications one with start credit one with less than start credit guess who gets the job and so it goes throughout society and goes beyond just the medical issues it goes to the issue of being able to actually have a livable wage things that are changing in at least one case not for the better is ineligible in terms of health insurance and this is going to affect a lot of folks who don't qualify for Medi-Cal who can't afford things like secure horizons or health net or Kaiser Anthem Blue Cross has been kind of a saver in many cases ineligible they offered a zero premium policy that policy covered with no deductible things like emergency room and primary care physician visits there is a deductible of $300 for other services that premium is now going from zero to $131 so the folks that were banking on that kind of policy that were shopping and what they're going to find is that there's nothing less than about $75 a month that $75 a month for many of these folks is the difference between living and existing is the difference between having food on the table being able to get transportation and many other items this also has to change because these folks are now getting depressed they are now needing mental health services and it just mushrooms it then affects the entire family not just those that need the medical care another big issue is the whole process of application which was mentioned before for people to understand what opportunities there are for help what help there is out there in terms of support for pharmaceuticals for doctor's visits and so on most people don't even have an idea as to what exists or how to apply for it or what the qualifications are and if you look at the MediCal application for example it's about four pages long the basic application and then there are about six additional forms that have to be filled out before they can even be considered for MediCal these things also are roadblocks for people to get any kind of supportive medical help also in-home services or in-home support services are tied in MediCal I've got another client who is in a wheelchair who doesn't have the ability to cook but because she has a stove and a refrigerator her funds are cut because it's assumed she can cook because she has a facility again it's these kinds of people who are suffering because of the way the system is set up many people don't know that there's something called LIS or low-income subsidy for medications administered by the Social Security Administration it actually drops the cost of their medication to about $1.10 for generics and $3.30 for brand names if you don't know about it you can't apply for it you don't have the help there are other programs such as that where again there isn't the knowledge and the counseling for these folks to understand what they have available the pharmaceutical industry itself has patient assistance programs but again most of the population either doesn't know they exist don't know the rules and they don't know how to access that benefit so that ties into the wealth side the asset building side in that these folks that are really medically indigenous medically very poor they don't have the money to create an account in the financial counseling that I'm doing I started with save a dollar a week save $5 a week save something start the plan start doing budgeting so that you can see where you're going in terms of having emergency money expenses or for whatever comes up so it's really I hope for me as a counselor both on financial side and the Medicare medical side should deal with these folks that have major medical issues no funds and extremely limited access to care and so again I think that this has to change and change fairly quickly we're going to have a large segment of the population that's going to suffer both in terms of living and then a shorter life span so thank you very much first I'm going to ask you all to thank the panel for these very very well thought out and detailed presentations and questions yes please hi my name is Jessica Rothard I'm a health access counselor I just wanted to make sure that everybody knew and ensure the panelists know that California actually has a law a state law passed in 2006 that goes beyond the Affordable Care Act in terms of protections for uninsured and low income hospital patients and it's one of those programs that people don't know about there are flyers, bilingual flyers on the table and there's a website where we're trying to get information out but the hospital fair pricing Act of 2006 in California says that if you're uninsured and at 350% of the federal poverty level or below that a hospital cannot charge you more than they could get from MediCal or Medicare for hospital care which ends up to be a discount of at least two thirds and usually around 75% it doesn't mean free care but it also protects people from being sent to collections while they are applying for the discount or trying in good faith to come up with a payment plan and it says that the payment plan has to be reasonable so if a hospital is trying to get a low income person to pay $400 a month that person as long as they are applying or have agreed on a principle has in principle the right to continue to negotiate until the hospital comes up with an amount that is actually sustainable for them and a huge the law has a tremendous amount of power but we've got to get it out there people just don't know about it so I hope that you will take the posters, flyers put them up in bullet boards if you work with people who are uninsured technically it's supposed to help people who are underinsured as in spend more than 10% of their income on health care it's much harder to get hospitals to know about that, advocacy is still needed and many hospitals actually offer the discount to people above 350% for example Tenet and Sutter typically go to 4 and 500% and there are some hospitals that go up to 1,000% of the federal poverty level so Any questions? Thanks Jessica, that's great we've said Medicaid is health insurance it's also wealth protection and I just want to invite the people doing work on the wealth on the assets into the health discussion and implementation process, it's going to be very important and I think that the issues related to streamlining the eligibility enrollment it's going to be crucial and the wisdom of those in the asset field and the public health field and the foundation of public health work it's going to be very important to insert that wisdom into the process of implementing affordable care act and your example just now of this pricing act is a perfect example of protections that exist that too few people are aware of and I think there's a real opportunity to knit together these various safety net programs what Jessica's raised we've already talked about some of the programs we've already talked about and make sure that they're all part of that package that's going to be screened, people will be screened for eligibility for those programs and to streamline the enrollment into those programs as much as possible I think that's going to be very important quick follow-up to Jessica relative to mine was discharged from the emergency room at Alton Bates with Southern Hospital they actually received notification of is that a requirement under the law that they need to receive that notification or not? It is a requirement and Sutter does very well at it as superintendent because they got sued for overcharging uninsured patients which is how we got money to do this project most hospitals in California are doing a very bad job and we actually so there is on the website a file a complaint button and anytime anybody who is uninsured is billed by a hospital and has not been notified about this send them to the website and the first thing they should do is a file a complaint about non-compliance Thank you very much I want to just ask that if you're going to speak that you have the microphone in your hand because we are trying to record this so we have another question over here Hi Michael Weinberg I run healthcare for a group called the Barrier Council former colleague of Lincoln it's great to see you guys what a wonderful presentation so much information but then our presentation really grounded it in the reality of people's experience so what I wanted to have you guys address a little bit is the issue of complexity there is a bit of a catch 22 in a lot of these situations where we want to pass some law that helps some people do something a law that will help under ensure people with their health bills and so on and so forth and all those sort of laws are inherently valuable but we create a system in which there are a thousand different programs that you may or may not qualify for and that ultimately complexity favors the powerful because the powerful have lawyers and financial planners and think tanks to think through this for them but complexity is really difficult for people with limited means and this is true in the sort of asset sector as it is in the health sector we create these enormously complex systems so how do you wrestle with trying to kind of put band-aids on a very complex system versus try to create systems that really maybe work in a more simple and equitable way so legislatively my on can you hear me my mic on that's right Lincoln we've tried to legislatively figure out how do we help low-income Californians middle-income Californians maneuver through the ACA as well as the other health programs and state benefits that they might be eligible for and so AB 1296 the voting bill that we've mentioned helps to again to streamline this effort and also the legislation that creates this office of a patient advocate that will help to house all these various programs in a single place and then and then partner with all the various organizations out there to help to get this information to the communities but it also helps to reinforce by having these conversations about the state and public forums is that they're going to have to partner in the community they're going to have to know about this and they're the ones that are working on the ground with folks that have community trust that have all the various partnerships and they're going to have to go out there as well and get the information out to folks that are in place now and how folks can take advantage of that but you were asked a similar question in Los Angeles you just want to fill it up on that yes I think that the general philosophy then gives some specific examples the general philosophy is of course the no wrong nor approach that basically wherever you enter the system even if you're not aware you end up being moved to the right place for you and I think that both the Affordable Care Act and the companion bill in California you're seeing evidence of understanding of this sort of issue so that you can be taken to the right place even if you don't know the right access going in but there's a lot of real life examples of this one was in the Massachusetts exchange and so called Connector they started out in the unsubsidized portion of the Connector having many many different plans all of which differed from each other only by a little bit and they've been encouraged to do that by folks in the health policy who wanted people to have precise choices and options I mean you'll see this of course in social security privatization there are a lot of people and they're well-meaning people who really feel that choice is the principal value and then when this Massachusetts plan was put into effect after about two years it was quickly realized that people didn't actually want this choice and the head of the Connector said basically we're going to limit this, we're going to standardize it limit it to three and people are a lot happier Medicare and drug benefit same sort of thing started out with lots of choices and even if they were tiny differences of the narcissism of small differences and now there are a lot of choices but not nearly as many as in the start so basically I wouldn't say it's almost non-American to say that choice is an overvalued virtue in public programs probably you want to have a few clear differences differentials and then open there absolutely and to give a little context you show us right research that when you have all these options you're probably not going to take advantage of any of them because it's just so complicated and convoluted and you're just like where do I even start which is why in the asset building field we've been trying to figure out how do we simplify it how do we make it easy, how do we make it automatic how do we create like a very simple option so that folks will take advantage I think there are a couple of other examples in the Affordable Care Act and one is Medicaid the Medicaid program in making it simpler in terms of who qualifies for Medicaid so they see that on income and not on particular composition of family and the other is I think around private health insurance and you know in California because you have many problems especially in the non-group market here the rules of the game are going to change dramatically under private insurance going forward and I think many of the tricks and traps that are part of the private insurance market in particular for non-group and small group insurance products will be addressed going forward so there's some simplification yet at the same time you're right there's going to be an array of programs and I think that I think technology can help and it solves all problems but I'm hopeful that with the use of some of these web-based platforms to help ease enrollment programs and address some of these challenges there's something else that's going to be taking place too you know in the county we're starting a spark point center in Fremont there's one in Oakland and this is actually a center point for anybody coming in and seeking any kind of assistance whether it's food stamps cow works whatever it is they come in really with a financial review and then from there they're filtered out to whatever agency will best serve their needs any other questions out here questions did you have this question did you raise your hand there you go okay I am Stephen Watkins I'm with the Mission Economic Development Agency in San Francisco and I work on financial education I'm the program leader and I'm in the middle of trying to assess my options first of all I guess to back up a little bit I would underline what Olivia said about narrowing the field of choice and in that spirit what I'm faced with right now is narrowing the field of choice in terms of how do I train my staff in what options are available for me in training my staff as financial educators and what the question specifically for you Olivia would be what if anything New America is doing to sort of standardize the field of community based financial education I mean there's a lot of stuff out there there's not a lot from what I can tell that not a lot of it is actually applicable it's not standardized a lot of different places to choose from but I'm just wondering I'd like to hear your thoughts on so that we can address the health wealth connection what are your thoughts about sort of standardizing a maybe what I've envisioned is maybe a professional some professional standardization not making much sense right now but I hope you understand what I'm saying so I'm a huge fan of the development agency to say I'm on board and actually on October the 4th the select committee on financial empowerment you have information on this committee in your packets it's the first committee in any state house at the state level it's focused specifically on wealth building and wealth preservation it's a bipartisan committee and it's made up of members from throughout the state of California they had a hearing in Los Angeles they're meeting in San Francisco and are going to be visiting Placer Atlantic because it's such a fabulous model where it houses a bunch of nonprofits that are providing much needed services to the folks there in the mission district but in terms of financial education one of the things that we've been focused on in America is trying to advance K through 12 financial education think that we need to start from the beginning with our kids that when we looked at what was happening prior to the foreclosure crisis Californians were saving Americans were not saving the lowest savings rate was during the Great Depression it was all credit credit debt we need to have a cultural shift if we're going to actually have an impact we need to start with our kids which is why we're so excited that the city of San Francisco has been a leader and every single kindergartener in San Francisco is starting kindergarten with a college savings account it's open by the city and it's progressive in that it helps low income kids it matches their savings and think that having models this way the talent that's actually with you that's growing with you is a powerful way to have this kind of cultural shift again but in terms of the community and having standards across the field there hasn't been any movements in that space in Sacramento but again the controller as I mentioned his efforts he has to of course be very sensitive to cost and I think that's what's been the challenge over the past half decade in Sacramento is that a lot of these ideas are visionary to make a dent in a different we have to invest in these ideas and in these policies but there are great models out there that can be replicated the SF-ERN in San Francisco they offer financial counseling they had at the beginning of the year training for other nonprofit leaders to join them and go through courses and we're also providing it for free from any of the nonprofit leaders and so I'm happy to connect you with them after today's discussion Opportunity Fund is also done and so there are nonprofits out there that do have programs that work the FDIC also has MoneySmartz and you could go online and you could order MoneySmartz and it's creative age-appropriate financial education well it's from kids it's for like children and also adults and people online and they'll mail it to you for free you can get the CDs, you can get the material and so there are programs out there where you're right there are so many options right that you don't know where to start but there haven't been that effort policy-wise to try to create a statewide standard I just want to mention they've parallel or been a cognate in the healthcare side now one of the provisions of the ACA in respect to helping to exchange is the health market so is the navigators they're going to have to be navigators now who will actually educate the navigators who the navigators like former insurance brokers others is itself an endlessly interesting question but it is a little bit unusual that the scope of these specific guidance counselors as it were are stipulated in the end and I also want to say financial education is one piece of it we also need to look at asset protection and look at the products that are out there and think about this banking development district idea where we're telling banks and credit unions will deposit the state deposits into your institution but you have to be a community partner and you have to develop products and services that are tailored to the needs of consumers and not gouge low income consumers with exorbitant fees but to make sure that our mortgages are not going up in our faces so we also need to look at the product in and of itself and if there's a clear linkage and there are friends in the asset protection space like the Center for Responsible Lending and the California Reinvestment Coalition and Consumers Union they're working in that space to make sure that the financial products are not so complicated and convoluted it doesn't matter if you really know right, if you're educated and you just don't know how to maneuver because it's just the product in and of itself is flawed like the payday product we know the fees are 300-400% you take out this two week long and then you get stuck in the debt trap and the payday lender will say but it's so easy that somebody shopped and look the fees are right there you know it's straightforward no hidden fees we know that people get stuck in the debt trap because when you're living paycheck to paycheck two weeks later you're not going to have those 300 bucks to pay back and I think as it relates to medical debt it's really important that people not get into this risky financial situations and take a problem and make it even more sample by that problem due to penalties and late fees particularly there are some protections in place hopefully there are others that can be implemented going forward and I think one of the takeover messages hopefully today for everybody because in particular working with individuals or asset building and for the wealth protection is to really discourage people from taking out credit cards putting things on credit credit cards or taking out a payday loan to pay off a healthcare provider because it's very likely that there are other protections in place so we're getting to the end of our time and I want to invite the audience to come up and have maybe a little bit less formal conversation with our presenters who I think did an absolutely excellent job one of the things that occurs to me in thinking about everything that's been said today is this going to be a tremendous challenge and really thinking through a very thoughtful way how to distribute information about the kinds of solutions and options that you talked about today and one thing that I didn't hear talked about that I want to just inject into the conversation perhaps at some other point we need to think about the fact that among poor people poor people of color in this country some of the fastest growth in cell phone use has happened in that sector now people may not have individual personal computers in their homes but they have a software and one of the things that we want to think about is how might we help people to access the kind of information and linkages that they might access through the cell phones from the thing they already have in their pocket people in other countries have already figured out how to do this in Africa so we should be able to think this one through and I think we have the kind of assets that we need to make those connections and linkages but let me just say I learned a great deal from the incredible support and leadership that the Alameda County Department of Public Health had and helping to put this together along with the Urban Strategies Council thank you again and also the New America Foundation you guys did a great job this was very, very, very, very methoding thanks for connecting the dots I guess it just all goes to show that health is way more complicated than we even knew so thank you very much everybody