 It works. Good afternoon, everyone. My name is Maria Bellino and we're going to get started. I'm with the New America Foundation and it's such a pleasure today to welcome you to our fall health wealth speaker series. We were in Los Angeles on Tuesday and yesterday we were in Oakland and today we're in Fresno. And along with our partners the United Way of Fresno County and the Economic Department here at Fresno State University, we're so pleased to be having this conversation here in Fresno. Because a lot of the health and wealth disparities that we'll be discussing in detail today, we know are amplified here in the Central Valley and the need is great and the challenges are great. And so we've been working to advance a health wealth agenda and we want to continue to have these various conversations throughout the state because we know that not one organization can do this alone. We need to work together among established partnerships and raise awareness about the various initiatives that are taking place, the programs that are now in place and ensure that we also build broad support for a lot of these ideas. So I'm going to begin just briefly sharing a few words about the New America Foundation. We are a national nonprofit, US and Policy Institute. We're based in Washington D.C. and we're also in Sacramento. And in Sacramento our asset building program and our health program stepped up to the challenge that I had the pleasure of actually hearing Dr. Tony Eitman from the California Endowment and just put out there for us in the asset building space. Those of us that are working on financial empowerment initiatives to say that poverty drives health outcomes. And we also know because of the research that our colleague Barbara Covina and Likazi have been doing that many Californians Americans across the country are just one medical emergency from financial ruin because of inadequate health coverage. And so with that we wanted to take advantage of the passage of the Affordable Care Act and know that within the act there are various provisions that enable families to become more financially secure that millions of Californians will now have coverage. But even with insurance folks are still going to have to be responsible for out of pocket costs which is why it's so important for us to create opportunities for folks to build their savings throughout their lifetime and have that emergency fund to be able to absorb emergencies. And so the New America Foundation we developed policy initiative proposals through research and legislative advocacy and advanced these goals. So with that I'm going to begin by introducing our moderator today Chet Hewitt. He's the president and CEO of the Sierra Health Foundation and he joined the foundation in 2007. Before joining the foundation he was the director of the Alameda County agency social service agency and prior to that he was the associate director of the Rockefeller Foundation in New York and San Francisco and has been nationally recognized for his work. He sits on a array of boards and it's such a pleasure to have him here today to moderate our discussion. He'll introduce all of our panelists and then everyone will come up and present and we'll open up for discussion. So with that will you please join me in welcoming Chet Hewitt. Welcome all of you here today and although it's not an extraordinarily large group I think that's the real point. Great thing to sometimes start with a few folks. Before we get started we'll just deputize you all and let you know that you're all now emissaries for this conversation. Back to your communities and have it with folks you know who are interested and particularly with folks who should be interested in issues that we're going to discuss here today. I also want to thank CSU for hosting this event of course the New America Foundation of the Union. As Olivia said the third three conversations have taken place across the state. I have two tasks here today. First is to kind of briefly introduce you to the social determinants of health. Interesting that I have become very kind of interested in over the past 15 years I must admit that I'm not an expert in this. I am a lawyer by law and a lot of work in criminal justice and justice in an early part of my career. But I'm really going to realize that was a downstream intervention and what got many people to the point that I was defending the court was because of poverty and other kind of life circumstances that often pushed them. It's not to in some ways some might eliminate responsibility for behavior but pushed them to activities that were often not good for themselves as well as the communities in which they lived. And so you started thinking about what would be a different intervention other than trying to suppress the evidence so someone could walk back out the door. It's got to be something else. My second role will be serve as a moderator which I will deal with by introducing the members on the panel here today. We just start by saying that the social determinants field is a field of study that looks to understand often dramatic variations in health status among groups of individuals that are closely linked to the groups of social backgrounds. Sometimes the World Health Organization's kind of description of the social determinants of health. And these variables often include access to care, poverty, education, living conditions, and even leisure. The short and easier to recite version of this for me is understanding the health implications of where and how we live, learn, work. That's how I'll see in a few minutes as I try to move through this quickly that there are profound implications to these things. As most folks say to me why these back is important. One thing that we know in health to be true. This is agreed upon by health researchers regardless of their ideological orientation. Not as only about 15% of your health is really determined by your access to health. That 85% of your health is the 85-15% is really largely dependent on your impact. Some of which you decide whether you eat what you eat, how much you smoke over the use of it, how much alcohol or other things that you might consume which may or may not impede on your ability to be healthy. But it's not all about health care. To be most effective health care defined broadly, I must not only think about treating illness, I must also think about promotion and wellness. That's the cost is making people healthy. And this is where they understand the link between health and wealth connection becomes essential to the development of policy and practice to really support efforts to achieve this goal which is the elimination of a reduction of disparities in health and the control of health. When one was degrading of health the poorer you are the more likely it is that you will live a shorter, less healthy life. And there are a few in any developed country in the world where health disparities are more pronounced than they are in America. Despite the fact that we spend more than any other country on health care, $2.5 million in 2009, or about $7,500 for every person in the system. You would think that that kind of expenditure we'd be doing a lot better than we are in health outcomes. For males, we have 32nd in the world, and for women we have 40. In terms of full term, top 10. One community that we actually looked at was in Montgomery County where we were rather fluent in the community where larger black and white community, where folks are doing pretty well. Although there are some disparities in those groups in that community as well. And in that particular county, life expectancy for whites is 80 years. About an American 63. 22% difference in life. So a whole lot of it. Your immediate fourth county region is by no means immune from this reality. I think no community. Once this conversation is part corrected, in fact this is a national challenge. Consider another example, in Bay Area a large health plan is actually mapped health outcomes in a Bay Area, East Bay. And their disparities actually follow poverty maps. So in some ways folks are not surprised. They look at East Oakland, West Oakland, Richmond. So of course health outcomes. What's surprising about this particular map is that it is a map of health plan participants. All of whom have the exact same access to health care. It's a map of some kind. So despite having higher coverage and one assuming that there's nothing in the lower communities to get that someone in the more fluid community can get. Based on that point. This isn't about old residents. It's just mirrors the old residents map. There is still extraordinary kind of respect. In your four county community, look at the UCL Center for Health Policy. You're one of the least affluent areas in California with per capita income well below the national average. Valley is some of the lowest per capita personal income. For a year, 42,000 is the state average. Highest rates of unemployment, 15.6%, about 12% for California. More residents below the federal poverty level, 21%, 15% for California. Higher rates of not only uninsured, 29% as opposed to state, 23%. And more residents over 25 are out of high school diploma, 29% as opposed to 19% statewide. And if you think about education in particular, which many would argue is the pathway to reducing health disparities. And that was actually discussed in a recently released national prevention step, which was put out in June by the office of the Surgeon General, which says that education is one of the most important interventions we can take to address health disparities. Education actually is a primary determinant of your socioeconomic status. The more money you will make on average over the course of your life. And many of you are probably familiar with the million dollar difference between someone who graduates from college and someone who only has others. If you look at mortality in education linked to US citizens 25 to 64, these are really mortality rates per 100,000. For those who have or have earned or moved beyond a high school diploma, it's about 206 per 100,000 annually. You only have a high performance, about 477, twice as high. And if you haven't finished high school, 650 per 100,000. And that is simply predicated. So we know that you will not only live a shorter life, you will have more health problems, or likely to have poor health over time. Of the 56 counties rated in University of Wisconsin's national study on county health status, all counties in the country. So that's actually not true, because two in California didn't make it to the ranking, so 56 are actually listed in the ranking. King's County actually ranked 40. The 56, Fresno 43rd, Tulare 46, and Madeira 49. You lose more residents to cardiovascular and respiratory diseases than do other counties. You've had an 8% reduction over the past decade. The rest of California's reduction, 22%. So some good news, but you're still lagging behind. You have more deaths from motor vehicle accidents, homicide and suicides in California as well. You have higher rates of asthma, Tulare's exception for folks over the age of 25, and high potential in California as well. And our high potential is called the silent killer. Because we know it's related to things like renal healing, heart healing, stroke as well. So it's one of those really predatory illnesses that you've really got to get a handle on if you want to deal with these kinds of things as well. And Latino's experience of hiding straights of diabetes and more hospitalization for illness, as well as greater mortality for African Americans, higher death rates for cancer, cardiovascular disease, and diabetes in California as well. So with respect to years of central life laws, which is really a measure of premature mortality, which is death before the age of 65, the Fort County Regents saw a 7% increase in the years of productive life potential laws, while California the whole experienced a 5%. And we look at the WHO and they say the poor health of the poor has more to do with the unequal distribution of power, income, goods, and services. This unequal distribution is not a natural phenomenon, but a result of the toxic combination of poor social policy, unfair economic arrangements, and death problems. This is not a political conversation. This is the data and this is what it actually said. You can come in it in different ways, but we know in this country, given how much we're spending, we could do a heck of a lot better than we're doing it. We have to get smarter and be more honest about what we're doing. I hope my remarks are not meant to demonize individuals and institutions. I know many people are working hard to address these issues. And as I said, the health goals challenge is a national one. You find national states and local interventions. One of which has to be the health wealth divide in this country. I hope that it was kind of a call to action. And I know this community is very interested in this work. I know that two days ago you received notice that Fresno had actually received a community transformation grant which is really focused on reducing chronic disease and illness prevalence of those illnesses in your community in this country. I encourage you all to get active and engaged in that particular work as well. But I also know it's kind of a call to action. And with the expectation that the conversations you will hear today from this knowledge-building age panel will offer specific ideas for how you can go about supporting and growing your community. So that a community as healthy, economically, socially, civically as it could possibly be. Distribution of those attributes are fair and equal and not dependent on where you live where you play or where and whether you work. So I'm not there and introduce the panel and I will do this in order of... I will introduce them and I will do it in order that they want to be presented. First up is going to be Mark Ruckermania who is the director of the Access Project and offered the report that you're going to see today. That's a health wealth divide report that you're going to see today. I'll leave you a call around with directly the California Asset Ability Programs and the American Foundation. Then some local expertise, Norman Forbes who's the executive director of Fresno Healthy Community's Access and all Michael Alexander who's the president and CEO of the United Way, who I know is doing some wonderful work here as health disparities as well. So with that I will call to the podium Mark. Afternoon everyone. So just before I begin just to get a better sense of who's in the room here today how many of you are doing work in healthcare or public health and how many of you are doing sort of economic justice or anti-poverty work and raise your hand more than once. And how many of you, anybody here from a financial institution? Great. And others. That's helpful. Thank you for doing that. I want to thank Olivia and the New America Foundation and the local partners and all of you for being here today. I appreciate the opportunity to speak on this issue of medical data. Talk a little bit about this health-wealth connection coming at it from a slightly different angle. I think as Chet said poverty drives ill health and ill health oftentimes drives people further into poverty. So I'm going to be talking about issues related to medical debt, how medical debt leads to other problems for people who have it and wrap up with some opportunities to address the medical debt side of this that hopefully will help relieve some of that pressure that people face, especially low and moderate income people who have, who experience illness or injury. So there's slides in the packet I'm going to go, I'm not going to go over these every slide here. I'll talk broadly about health plans, issues related to medical debt, explore a little bit this health-wealth connection look more closely at some socioeconomic demographic data to medical debt and then talk about these opportunities. So big picture I guess Chet said, two and a half trillion dollars spent in 2009 on health nationally, a little less than two and a half trillion projected that it was a little more than two and a half trillion in 2010 that represented more than 17% of our gross domestic product. But the trend here I think is really interesting and I want to draw your attention to the projections for 2020 that we will spend more than four and a half trillion dollars on health care costs and that will be the equivalent of just under 20% of our gross domestic product. In spite of what we spent in 2009 and 2010 there were nearly 50 million people with no health insurance in this country that number for 2010 represented as an increase but just under a million people. It would have been greater than that if not for some of the provisions of the Affordable Care Act that have already gotten to effect in particular a provision that enables young adults to get coverage under their parents' plans. So that's what we've covered. It's about a million people. There's also some provisions for people with pre-existing conditions who were invited to the full-time buying insurance otherwise. There was just an article in the paper yesterday from Pfizer, Family Foundation, Employer Survey of Health Care Costs. They've been tracking this for the past 13 years and they said workers' contributions over that 13 year time frame increased 168% while wages increased at about 50% and the inflation rate during that time period was 38%. So the result of that is that health care costs are more and more increasing burden in terms of family budgets. This is information from the Commonwealth fund 73 million Americans in 2010 experienced some type of bill problem, a problem paying for a medical bill contacted by collection agencies for bills that they received said that they had to change their way of life in order to pay medical bills or had bills that they incurred medical debt, bills they were paying off over time. The figures for medical debt are about one in five people across the country have medical bills that are paying off over time in California and these are older data, data from 2007 so that's prior to the recession about 13% representing more than 2 million in California had medical debt and the distribution of that varies by county and I think as was previously mentioned I think it's probably a greater percentage in this area here. So what are the consequences of medical debt? Some are obvious, some may be less so but I think the Kaiser information that was mentioned previously is telling their health access problems for people with medical debt even insured people who have medical bills there's a rich body of literature that shows that people without insurance have very different care seeking patterns than people with insurance but even people with insurance who have medical debt they have care patterns very similar to the uninsured so this in and of itself is a risk factor medical debt in and of itself is a risk factor it takes a toll on families and individuals who have it stress, depression, anxiety and it spills over so there are access problems there are a lot of people with medical debt but then once it does spill over there are also other problems that happen that result and credit problems result for people who come back to that again access problems there's national data on this and California data people with medical debt are much more likely to poor go care than those without it again poverty leads to ill health ill health leads to debt which reinforces this gap a growing gap for people who are struggling to pay these bills nationally 22 million Americans in 2010 were unable to pay for other expenses basic expenses food housing 29 million people used up savings and actually that bullet is incorrect it didn't take out a loan they exhausted their savings about 40% of the people with medical debt exhausted their savings trying to pay it off California numbers are similar about a half a million California's were unable to pay for their basic expenses because of medical bills and three quarters of a million used up savings trying to pay off those bills once you complete savings you go to other assets that you may have or do something possibly risky to predicate these bills people are barring against homes trying to pay medical bills or putting things on plastic incurring additional credit card debt or taking out payday loans trying to pay off the bills that they incurred I want to focus less on health and more on wealth and talk about the effect medical debt has on people's credit about 30 million Americans in 2010 again are unable to pay for contact by collection agencies for medical bills studies published in the Federal Reserve Bulletin have found that half of the accounts in collection half of the accounts in collection are medical in nature once a bill is sent to collection it is on a path that really is a path to financial ruin for the person that is built for collection these go into the credit history section of a credit report which is weighed most heavily in terms of determining somebody's credit score these are considered accounts in arrears and even small dollar balances and I have a couple of highlights from stories that appeared in the Wall Street Journal in the New York Times on this slide and we're talking accounts of bills of $15, several hundred dollars have a huge effect on one's credit score and their ability to access affordable loans whether it's for an automobile or the rate of interest charged on a credit card in the case of these stories here people's ability to refinance or get mortgages so the effect that a $15 bill or a $200 bill that has been paid off this is a bill that's been paid off but it's still lingering on credit report it can cost tens of thousands of dollars over the life of a mortgage again creating problems for people disproportionate problems and you know other work indicates that people are at risk studies that work done through the national foreclosure mitigation counseling program found that about 6% of the people counseling through that program were at risk of losing their home because of default but 6% of them said that the primary reason for their mortgage default was medical and this was greater than an increase in the interest rate charged on their mortgage here's some data there's not a lot of racial ethnic breakdowns of medical debt but this is something it's older from an older Commonwealth study 2005 but you can see an African American population had a much higher percentage of people with medical debt I don't think I am just looking ahead here to see if I have a slide on what is on a credit report and actually the incidence of medical accounts in collection appearing on credit reports among the African American population and Hispanic population is 2 or 3 times greater than the general population or whites so I know there's been some discussion about disparities in credit scores maybe part of it is being driven by this issue and you know income, wealth, math so again applaud the work of the new American foundation in terms of trying to build a belt you can see here the percentage of people at or below 133% of the poverty level about half of them are spending more than 10% of their household income on health care premiums and auto pocket costs at the highest income levels more than 4 times the rate of poverty still 20% of the population is spending more than 10% these are the medical debt figures similar trend line here so what are the opportunities to deal with this crushing problem well Leaves is going to talk more about some of the opportunities for important care so health insurance and programs like Medicaid, Medi-Cal are really anti-poverty programs very important programs I want to talk just briefly about some other opportunities there are provisions in the Affordable Care Act around charity care of non-profit providers the billing collection practices of non-profit providers whether or not bills are sent to collection agencies and reported to the credit bureaus can have an enormous effect on a family's long term economic stability and those are things that can be addressed locally can be addressed at the state level in some states there are proposals to limit the rate of interest that can be charged on medical bills that discourage medical providers from using or their collection agencies from reporting to the credit bureaus and there's an act in congress right now the medical care responsibility act that would require the removal this is pretty simple solution to a huge problem require the removal of medical bills that have been fully paid or set from a credit report so that they don't linger for 7 years and drive down on the credit score that once that balance is zero that those accounts must be removed from a credit report within 45 days of that account being cleared out so what we have today is millions of people who have bills that were sent to collection maybe because of confusion maybe because they were struggling to pay off this bill that was a surprise to them something that wasn't anticipated but they did the right thing and they paid it up well again that can stay in a credit report for years and drive down on the credit score I think there are numerous solutions to the problem, affordable care is going to bring relief to many for people at the lowest income level medicaid is going to be expanded, Lee's going to talk more about this in the middle income level there are going to be some public subsidies for private insurance coverage and at the higher income levels and for those who have private insurance the rules of the game are going to change so that coverage is more comprehensive and it's less likely that people with insurance will experience medical debt problems because of the inadequacy of insurance coverage that we have so with that said I'll hand the mic over to my colleague Lee can you see the screen? I'm thinking it all out getting my orientation well I'm purely speculating here but I think that when Kevin Costner and in high school in Central Valley this might have gotten the inspiration for that memorable line in field of dreams if you build it they will come and for the Affordable Care Act the federal health reformists they all know passed Congress last year the jury is still out on whether this is true contrary to the hopes of many as some of them in this room who worked to pass the bill health reformists remain a political litmus test media attention is focused on repeal and on provisions that aren't even in the legislation such as death panels rather than the practical consequences of implementation of Americans who know that the legislation is passed over one quarter of them think it's been repealed and even here in California based on calling more than 30% of low income Californians those who be held post by the provisions in the act think it would actually make their situation worse so for a few minutes here today we leave the world of ideology and legend and return to the facts the ACA is neither perfect nor the cure for all the ills of our broken health care system but taken as a whole health reform should greatly improve the financial security of low and middle income Californians illegalize access to affordable quality insurance coverage make it easier to avoid the medical debt problems that Marx just laid out lower the hassle involved in enrolling in public programs and give individuals and communities the tools to reverse health disparities in their own neighborhoods and again getting to the theme of this particular conversation if it works as intended I think the ACA can be a bridge between folks who work principally on health care and health policy issues and those who work principally on poverty financial security and social welfare issues just to look back and refer a couple of slides of why the ACA was needed so much. This is an international comparative study done by the Commonwealth on the number of folks, percentage of folks who went without medical care because of cost by income and you can see here that even middle and high income people in the United States had this problem as much as had this problem more than all the folks in other countries in the world and for low income individuals it's pushing 40 percent similarly a decade of real income gains have been wiped out for the average American family by rising health care costs especially devastating to working Americans and the uninsured what would have happened if we hadn't done anything the number of uninsured would have gone up to over 60 million employer health spending probably would have increased by 100 percent and uncompensated care the charity care that's given in hospitals probably by a similar amount so just to put a little bit of respect on why we had to have this bill the heart of the ACA of course is expanding insurance coverage and improving the quality of that coverage it's also an issue of financial security we know from many comparative studies of the uninsured and the insured that coverage results in better access to care improved health status lower on the pocket costs and reduced mortality and the expansion of coverage is expected to take place as most of you know in two major ways changes in eligibility for Medicaid, Medi-Cal and California which is historically the health insurance program for some but not all low income Americans and by offering a refundable tax credit for the purchase of private insurance on newly established health care markets or exchanges and when this process is complete 32 million Americans are expected to gain coverage between 4 and 5 million in California alone and that will include over 3 million Latinos, 2 million Asian Americans or actually 1 million Asian Americans and almost half a million African Americans and what this slide shows and I won't go into great detail is that it accomplished this intended expansion and other changes that changes were made to transform the health insurance market and also the ways in which health care is actually delivered the most important features are the individual mandate which requires the purchase of coverage by adults who have the means to do so and a variety of demonstration programs aimed at strengthening primary care and reducing excess spending on medical treatments so to look first at Medicaid and Medi-Cal I titled the slide Medicaid is health insurance and the reason I do that is because Medicaid is a program that has its roots and welfare in category of eligibility you wouldn't qualify for an adult and poor adult in a camp unless you have pen and shoulder or this kind of thing one of the most important things the ACA does is to get rid of Medicare as well as Medicaid's welfare roots at least and to make it a true health insurance program for all Americans under 133% of poverty without asset tests for adult Americans who fit that bill and Medi-Cal expansion will play a huge role in improving the financial bottom line of California's low income populations. John Gruber the MIT economist in fact has estimated that the household budgets of those between 133 and 200% of poverty in California will be improved by a combined $5.5 billion after health reform is fully enacted and also in California thanks to a federal waiver that's unique to this state the state could get as much as $10 million to enroll into 100,000 low income Californians in all our counties these will be folks who can have their coverage continued or newly enrolled and public hospitals will have the opportunity to revamp their operations and their facilities so they're more likely to become after the passage of the act places that individuals with either public or commercial coverage will seek out and so far so good but here's the problem which all of you I think in this room know. Medi-Cal is the target of $1.7 million of budget cuts in the most recent state budget. There's little or no low hanging fruit there. California has the lowest per capita Medicaid cost among the lowest rates paid for providers in the country and if the budget cuts are made in Sacramento or approved at the federal level there'll be 10% cuts in those already low rates, limits in the number of doctor visits, and unprecedented co-payments so there's reasonable concern here that the breaks are being applied even as we want to actually push in the accelerator and get more folks covered with good benefits and then if you look at the final line of the slide even after the Affordable Care Act is implemented even if everything goes well there's still going to be over a million Californians who won't have insurance coverage and those are mostly immigrants without legal status so another thing that the ACA does for this and other states it's really tried to continue to net to provide money to federally qualified health centers and community health centers, $11 billion worth in the original plan about $1 million of that for California and the folks who go to these community health centers as you know mostly people of color, uninsured, medically indigent and folks who are paid for by the counties. The rub here as well is that a lot of that money is maybe pulled back by any cuts and possibly deaths of cuts before it actually reaches these health centers and the second piece of this foundation are really health insurance exchanges and what are they? They're nothing more or less in some ways than an insurance store with standardized health care products health insurance and subsidies that go up to 400% of the federal property level which is about $88,000 for a family of four so in many ways it's a link between the coverage programs for low income populations and those that are for the working middle class. There are examples of these in place in Massachusetts and Utah for instance, very different kinds of things and as you probably know California was the first state in the nation to pass enabling legislation creating the California Health Benefit Exchange after the passage of the ACA. It's actually two one for individuals, two exchanges for small business and the exchange will be the sole place through which individuals and small businesses will be able to get the federal subsidies so that people can pay for affordable coverage and this raises a lot of questions with the exchanges. It's again back to that field of dreams point. Will enough people enroll in the exchanges so that insurers will offer reasonably priced products so that you get that sort of reasonably priced coverage and then it becomes a self perpetuating cycle. Are the products going to be comprehensible? Will they be standardized? What will minimum benefits be at each level of coverage and these are things I'd love to talk about more in the Q&A if that's of interest. So I'm going to finish up by pointing out a couple of bills that are on the Governor's desk right now in Sacramento that are needed to actually keep the wheels rolling and get the Affordable Care Act not to run it. And one of these SB 1296 is particularly critical because it sets a framework for the ACA by establishing a single standardized application form for Medi-Cal healthy families, the exchange and county programs and for every one of you and I suspect most of you want to have another really involved in the rolling books and programs simplifying this process will be one of the most critical things toward making the whole system work otherwise the SB 922 improves the office of the patient advocates, the existing office, but it will make it much more capable of delivering good information, potential beneficiaries. And finally I'd like to talk for a second about the social determinants issue that Chet raised so well at the outset. Even though it's not the specific focus of the ACA there are a lot of provisions and there are green shoots, provisions that can serve as an entering wedge to start thinking about these critical social determinants. Everyone who works in public health and many or most of those who work in health care knows that it's the places and circumstances where people live, work and play, not access to acute medical care that determines for the most part whether people are healthy. There's also growing evidence from studies that financial security itself is an important tribute to good health. And as we've heard before one of the elements of the ACA is community transformation grants and both Norma and Chet were an organization which received these happily in the last few days to move this good work forward on tobacco control of these chronic illness. So they are living examples of the sort of transformation that the ACA is going to bring about. And so I'm conclude by saying that with this focus on helping people keep their resources in place as well as all the other things in the ACA we're very hopeful that the ACA can be in fact what we're always looking for, not dissing me. Thank you very much. It's an incredible job of helping folks understand again the connection and the need. Again hearing California 2 million folks are struggling with medical debt and many of these individuals have insurance but it's inadequate. And we have this incredible opportunity with the ACA but we know that folks are going to need to build their own personal savings. And I want to begin by sharing a personal story of how I was introduced into this space and why it just resonated with me instantly. See I am the child of immigrants. I'm the first generation I was born in Los Angeles and my father's from El Salvador and my mother's from Mexico. And my dad he came to this country like many immigrants do because of that desire to want to tap into his own potential and build savings and build wealth, build assets. And so he actually was working in a shoe factory and he realized quickly that he was not going to be able to make it working in the shoe factory. And he made a friend on the bus one day who had shiny shoes. He asked him what do you do for a living? And the guy says I sell plastic pants. My dad said oh you must speak English really well to do so. And he said well no actually I sell to Latinos because they're the ones that cook for their families at home. And my dad said well how do you make this happen? And he said well in various parts of Los Angeles but also on weekends I go up the 5 and I head over to the 99 and I go into migrant communities and I sell in migrant communities. So my dad says can I join you? The guy says yes. So he starts doing this on the side and that's how he met my mother in Narva California. He knocked on my mother's door and my grandmother opened the door and of course my father is gorgeous. And so she bought everything he was selling and my father saw my mother. And they met and he brought her with him to Los Angeles selling these plastic pants that he proudly says are manufactured in West Bend, Wisconsin since 1911. His ability to be able to do so, to be able to have ownership and go in and start selling this product and have built small savings. Allow him to then purchase the first home, qualify for a loan, a loan that did not blow up in their face and then raise us in this house, a stable place for me and my sister to then be proud of where we live, be a part of a community. And it was this way that we would join my father knocking towards the door and he was proud and had ownership over his trade. We then were always told if you work really really hard and you do your part then you can achieve your dream. You can do anything you want to do. At the time there was a lot of being violence in Los Angeles and they actually, in my mother's wisdom, she was like let's go back to the valley. And they took us to my safety in California and we headed across to graduate upon that in high school. And they took us to my safety in California and that's where I graduated from both of us high school. My dad likes to believe that he kind of picks himself up by his bootstraps and he did this all alone because they worked really hard. I quickly understood that that was not true, that there have been investment policies in place and opportunities created for those to be able to tap into the potential and those are those asset-building policies, those opportunities for an individual throughout the lifespan to be able to build these assets. And when I was introducing this field I thought, aha absolutely, that's right. And when we see the great need across the state and across this country we know that these investments have been quickly disappearing and been detrimental, particularly in communities of color. When the census numbers recently broke and showed that 6 million California were struggling with poverty, that's really just the tip of the iceberg. What we should really be thinking about is asset poverty. Here in California we know that 30% of households are asset poor, meaning they don't have enough savings to be able to survive at the poverty level for three months if they were to have a medical emergency or lose their job. And so at the New America Foundation and our asset-building program we advance assets in all policies, in education, in banking, in taxation, and in health. And challenge our colleagues to break out of their silos so that we can advance in our mutual goals and endeavors and create these opportunities. And so for the past half-decade now in Sacramento we've been advancing developing policies and advancing them to the legislature and it created programs that now are just at the state level. So the first for example was the bank on program at the state level and this of course was inspired by what was happening in San Francisco and at the time Mayor Nusam and Treasurer Cisneros brought research to them to show that over half of Latinos in Blacks in the city were unbanked. 50,000 residents were unbanked meaning they didn't have a basic checking or savings account. And with that one it's going to be nearly impossible for you to begin to build your savings. And so they partnered with financial institutions, with banks and with credit unions to understand that this is an untapped market and if you develop products and services that are tailored to the needs of this market then it's a win-win situation. And so we developed starter accounts for folks there in San Francisco and it worked so well that we quickly took this idea to Governor Schwarzenegger and he created the states by program so the cities could start sharing as practices. And so now you have six cities throughout the state including Fresno that have bank on programs but bank on programs work really, really well when you have a bank and a credit union to partner with. But what happens in communities where you have no financial institutions to partner with? We believe we need to continue to build on bank on through a banking development district program where states and credit unions would be eligible for state and local deposits if they agreed to open up a community where there is clear need and develop the products and services that are tailored to the needs of the community. And so we have been advancing this idea for some time now and this year in our health health agenda that you all have there before you a 38 is now in the Governor's desk and he supports this legislation that would require the Department of Financial Institutions in partnership with the Office of Consumer Affairs to go out there and map the state of California and identify where those communities are so that the legislators can have a very clear roadmap of where they need is that we can have strategic investments into these communities and bring these financial institutions to these communities because in the state of New York it's worked really well since 2002 and we know that we can work here in California as well. In addition to that we know the tax time is the ideal time to get folks to start saving and so we passed legislation in 2006 to require the French House tax board to use the tax form is that easy place, automatic place where folks could save. And so we amended the state of the tax form to allow folks to split their refunds into a checking or a savings account right on tax form. But of course this was just the beginning, an incremental approach to start introducing a franchise tax form and get them to be more innovative not just out there collecting our taxes but also financially empowering California taxpayers. And so in addition to that what we were working on is how do we get families to save for college from the very beginning. Because Chet said that education is key, it's one of the key determinants that will enable us to be out there be competitive and earn more money and have that money to be able to save. And so we have legislation moving forward that would have amended the state income tax form to allow taxpayers to roll a refund into a college savings account. Our scholarship program that is housed in the treasurer's office and make it automatic for someone to be able to do so. Now what we found is in moving this legislation forward that the franchise tax board could do this administratively. And so we are working with the franchise tax board to do this administratively and make this change on our tax form to allow families to do so. In addition to that we've introduced asset building into the Department of Social Services. We know that low income families need to have the ability to save and shouldn't be decent centralized or penalized for doing so. And so looking at our social programs and looking at those rules and trying to change them is something that we think and we love it. And so the asset development comes for example to our welfare to work program, the CalWorks program that was created to help people become self-sufficient and enter the workforce and get temporary assistance to do so. There is this silly asset rule. You can have one in $2,000 in savings to be eligible for the program or to stay on the program. And you can have a car with more than $4,650. And we believe the car is the tool in welfare to work especially in California and especially in rural communities where you need to have a car to get to and from work. And so we in 2006 again have legislation that was signed by Governor Schoeniger that created savings explosions so that someone's their 401k or their kids college savings account wouldn't have to be completed to get temporary assistance or their individual development accounts. Restricted savings accounts for low income families wouldn't be completed for temporary assistance. And in addition to that made financial education allow families to be able to go like a community college or to go to an on profit and certified to offer financial counseling and education to make that a work-level activity and allow families to get credit for that. And so we've been building on trying to eliminate these rules and there's legislation now on the Governor's desk, AB 1182 that will eliminate the vehicle asset test from our state's CalWorks program. And it's received a overwhelming bipartisan support because a lot of Republican members are generally in rural districts. What they've been witnessing is something that's been happening across the country which is to say that we have folks that are going and seeking out for the first time ever unemployment is at 12% in rural communities it's much higher than that it's double that. And so they know that you have these families that might have a car the car might not even be worth the over the $5,000, $10,000 because they might be upside down on those car loans. For regardless that it's a silly rule that needs to be eliminated because when we look at data it only keeps out one tenth, one percent of people that actually apply for the program and it costs millions and administrative dollars because our county workers are then having to go through a county group and try to figure out how much their cars work. So the Governor's now we're hoping that he signs this bill and it makes it again that helps this program actually work for working people. Leif mentioned the health bills but again we've been having this conversation throughout the state because we want to raise awareness and build support. The Governor hasn't over the night designed many of these bills and the time is now to weigh in and if your organization wants to support happy to have a conversation with you about who to contact and how to make that happen. But again what I said earlier that we can't do it alone I want to stress that again and I'm thrilled to be a part of the California EITC and Asset Building Coalition and the chair of this coalition that was created by five organizations, City Bank AARP, Catholic Charities is also on board, the San Francisco Office of Financial Empowerment in San Francisco and many others. But the coalition is growing and it's ready to partner and if you want to be a part of the coalition we invite you to do so. The second one is going to happen on November 15th in Los Angeles and the registration is open. So with that I know my time is up and I'm going to pass this on to Norma Ford. I'm not going to actually mess with the slides because we aren't slow on time here, we're out of time. But we should all have a copy of them in your packets. So I'm just going to talk to the five, I only have five slides, I can't talk as fast as Olivia so we're actually going to really talk for a second later. Fresno HCAP, Healthy Communities Access Partners, we were a nonprofit coalition of healthcare delivery systems, safety net organizations and healthcare leaders, community leaders. I'm going to list some of these organizations so you can get an idea of who is with HCAP. Community Medical Centers, the largest medical center here in Fresno, Central Faculty Medical Group, Central College Faculty Medical Group those are the physicians who teach the residents at community medical centers. They're the ones who are caring for the immediate patients in Fresno County. I'm bringing that up because we talked about low income health program which was turned down here in Fresno County and in terms of the delivery system connections it means now that our resident program is at risk because the hospital is now saying that they want out of primary care while teaching medical residents. This is a mess, my message is not a happy message, my message is healthcare in the Central Valley is at a crisis we have clinical services, we have all three of the federally qualified health centers here in Fresno County on our board and they are under stress, the hospitals are under stress. Affordable Care Act is wonderful and it's provided great opportunities but we've got a gap to be able to get there which is a real challenge in the Central Valley. We have Federal Medical Ministry our faith-based organization. We have St. Agnes, the large Catholic hospital, Central Valley Health Policy Institute, Fresno County Department of Community Health, UC San Francisco Medical Education program, Children's Hospital, Central California, Fresno-Vendera Medical Society and Kaiser Permanente. Those are the literally system safety net organizations in Fresno County that I'm working with every single day. Our goal is access to healthcare. We're all about access to healthcare and it's for low income and underserved populations. We believe that access to healthcare has many barriers and obstacles. We're talking here about medical debt being a huge one, transportation, language, culture, but we believe strongly that the first critical step that opens the door to healthcare is health insurance coverage which we have three focus areas, an H-PAP which is health coverage we have simplifying the enrollment and application program for adults and public programs that's using a tool called 1AMP and we work on policy change and coordination of changes at the local, state, and federal level. Unique challenges in the Central Valley, I'm just going to attach on these there's a growing racial and ethnically diverse population we have a 40% Latino population and a Hmong population that is nearly half of the total U.S. Hmong population it's nearly 50,000, nearly 50,000. We have four county threshold languages, Spanish, Lao, Hmong, and Cambodian plus additional languages, Russian, Armenian, many, many, many others we work with community-based organizations we're all about collaboration and I'm going to list some of them that we work with because some of them are here in the audience I'm willing to add to say. Some of them are here and they are serving the Hispanic population proud to be a partner with them, they leave the way in strengthening families and getting them able to be able to get into health care Fresno Center for New Americans, that's our Hmong population the Oaxaca population, I can't pronounce their name I need you to be able to say it but it has a long name I call it C-B-D-I-O we work with Clovis Unified School District, very glad to have a health clinic in a school district that enrolls children into health care programs, health coverage programs Cedric Aciravista, one of the FQHCs, the largest one which is here in Fresno County, Inferno County, and West Fresno Health Care Coalition who's here. Obviously the challenges are ethnic and racial disparities have a negative impact on access and quality of care what that does in the valley, let me see I had a little slide here that I think I messed up since I didn't show the slides there are lots, you've seen a lot of data so I'm not going to actually run through all that data but we have higher rates of persons without adequate health insurance or ongoing relationship with a medical home less use of pre-nail care, the worst outcomes and high prevalence of asthma and diabetes and everyone who lives here in the valley really knows that. That results obviously in this reduced life expectancy and the quality of life. You add however to those statistical data the valley challenges, our public health funding deficit, our public health system is crumbling we have a stress healthcare delivery system we have a change impact going in both our hospital and our clinics of technology impact, the ARA funds have provided a wonderful opportunity to access health technology funds but change of technology is disruptive. They're wonderful once you get through the change but all of these organizations it's unusual, it's hitting everybody at the same time the clinics and hospitals, everybody. On top of that you put a state budget crisis, you put a local county crisis, the county board of supervisors, their lack of funding and you add the federal political party stalemates, what do we have? We have confusion and we have inertia. People do not know what to do how to work their way through this confusion. There's a leadership deficit because people are kind of in a whole pattern however but there are opportunities and possibilities to step up on a local level at a regional basis I think and really take control of this. I think we need to really work at the grassroots level and show that it doesn't make any difference to me to all of my partners who's a Democrat or who's a Republican we learned years ago how to work together. I think we can show on the local level we can solve some of these problems. So I think Fresno and Central Valley can turn this around to become a leader in this and really my message on this. We have wild enthusiasm over the passage of health reform. We're all excited about that you know, bruised about being able to do it but we're still learning about it. This program is great because when we've got this crisis going on in health care right now where people are getting discharged from the hospital we don't know why. I find my office across the street when people are walking around they've been discharged. They have no place to go. It's incredible. We're learning about health reform. We're talking about it. We're learning about the health benefits change. We're trying to understand it. It's not easy. When you're in the midst of crisis it's not easy to learn this. We're working with teaching our families what it means but the reality right now so far there's very little impact on health reform for low-income populations. They don't have health insurance so extending Medicaid has not really helped. We have so many people without health insurance. Down employment numbers are growing. We're seeing more and more middle income people without health insurance so it's still adding to the confusion and the mix that is making Affordable Care Act and health reform still look like it's far down the road. We were really hoping the low-income health program would really give us that bridge to get there and that opportunity would be $56 million with enrollment. The board of supervisors is too much risk. Fresno County has little money to draw out of a match. The low amount of money that they have, and it's true in all of the counties in the valley makes it riskier for them to commit that match. Agriculture workers unfortunately were left out of health reform. That's what we have in the valley. It's our biggest industry. When we're talking to our ad workers, the farm workers, what can we tell them? Well, maybe someday immigration will address this but that's been being discussed for a long time. The valley is very conservative. We're trying to move through our culture of coverage. We're working with our families to help them understand the opportunities here. We have found that a program we ran for the undocumented victim was two years for a family that has never had health insurance to be able to understand how to use it. Those of us who have employer health insurance we know how to work through the system. Our families don't know that. They have never had that opportunity. They think MediCal is a hodgepodge of services, reduced benefits, unstable, healthy families here in California has announced that they're going to have to enroll. People don't know what those are. Is that what health insurance is all about? You get furniture sometime and then you don't get it. You try to take your MediCal part and it doesn't work this time. They don't understand health insurance. It's a huge need for education. We work with these clinic-based organizations to try to be able to help people and help them navigate the system. We're very excited about the health benefits change in that. We think that's an opportunity for our certified application assistants that are working in the field to be at the grassroots level, literally in the field sometimes, to be able to get some funding to support these organizations. These organizations are in a crisis. Also, nonprofit community organizations don't have enough funding to help the families that they have been serving for years. This is all, when health reform came in, the big foundation funding stopped supporting these local organizations because health reform was going to get everyone into health insurance. Why do we need to continue to fund local communities organizations throughout their health? The need is greater than ever for that. What we're looking for is we want to move forward with the Affordable Care Act. We totally agree and support it and we're 100% behind it. We just aren't sure how we're going to get there in the next two years. We want to see, we're working to expand workforce capacity, definitely strengthening the safety net, working to support primary and especially care, those areas where we're using some technology like telemedicine to try to be able to get access to doctors that we don't have here in the Valley and access to learning more so we can reduce the demand on specialists. We're looking about teaching health centers. Very excited about that opportunity to be able to get our residents trained in the rural clinics as opposed to the urban areas where they don't understand really what primary care means in our agricultural area west of Valley and we're looking at community based clinics and she has the weakest little sign what does it say, does it say time? I can't read most. Everyone's been ignoring it so I have to. I get my back. The teaching, the community based health centers is a wonderful opportunity where, the school based health centers, I'm sorry that's what I'm trying to say, where we have some of those not enough, not nearly enough. There are three funded programs here in the Valley that are going to be great where you can actually have a doctor at a school clinic. Many of our families think that their kids get covered, they get cared at a clinic and they think that's a medical home and they only have nurses there. So this new model, a lot of this leadership and opportunities are coming from these wonderful opportunities that we are really trying to take advantage of. The community transformation graphs, absolutely wonderful opportunities. But again, you've got to put that in perspective of we're in crisis. So it's hard to even get up the resources to fund, to try to apply for those competitive funds. And we believe the way to do that is collaborate, collaborate, collaborate. Work, we accomplish everything within HCAP. We can magnify our resources by working together and strengthen each other by sharing our resources, our commitment to the same goals. I think the Valley is strong in that and I think that we do have, because we haven't been able to go independently down past by ourselves, I think we believe more in our own collaboration and sharing the working together. Our regional approach is our next step. We have been funded, HCAP has been funded with the Center for Medicare and Medicaid Services grant, bringing in technology to a five county region in the Valley. And we're really excited about that opportunity. We do have one gap is an integrated one stop shop approach for taking applications in people in the health interest. We brought that into Fresno County. We've had a terrible time being expanded. But now we have federal funds to be able to dedicate it from Stanislaus through CURM. So really excited about that. Lots and lots of opportunities, hoping that we can dedicate, that we can keep our partnerships alive and funded long enough to get through the next couple of years to the first steps of the expanded Medicaid services that are going to be available for the families for serving. So that's where we're at. Being the last one out of this good panel, it's good back in the face shop, but they used up all the time. So I'll make this quick so we can get to some discussion. But again, United Way is really proud as we work with our community partners to really change the way our community looks. We have the building blocks alive of education, finance, and health. If you don't have a good education, you can't have a good financial well-being. You also can't have good health. We have a committee that we work with through our partners to really look at how do we advance the common good. And again, United Way doesn't exceed us without our great community partners that we have. We believe that education, financial, stability, health issues, as we partner with elected officials or partners, media clinics and others will really start to change what's going on that you've heard about, what's going on in our community. We have a United Way public policy called, once a month, to really work with our legislators, to work with our community partners to really make a difference in some of the laws that we're trying to get implemented or passed from the governor of the sign. We are very much a part of it throughout California and the United Way to make sure those initiatives get through the desk, get passed, and get the governor of the sign. We've heard about all the critical areas that we have. And again, it's the community coming together, and that's what's excited about it. I think in Fresno County, we're all working together. Also, we're now working with our community partners from Stockton to Stanislaus and the United Way, really working with, as our partners in the United Way, but our partners within the Valley to try and really be concise and bring those initiatives together because the Valley has different issues, as we know, than Northern California or Southern California. And sometimes we get forgotten because people think about Oakland and the Bay Area, they think about LA and San Diego, but we have a rich history here that we want to make sure we continue with by everybody working together. We're also working with the California Endowment, their 10-year Healthy Families Initiative, but we're excited about how we're going to move that through. We have a one-year through that process, and we have nine more years to really work on how do we make sure our families are doing well in our community. In the United Way with our partners, we use a lot of tools, so one of our tools is 2-1-1. If you haven't heard about it, the county information call center closed down because of budget cuts, and our call center or call volume over the last few months has gone up 60 percent because people have tremendous needs. Within the call center it's open seven days a week, 24 hours a day, and we have 170 languages that we can use through interpreters to help people who need it. And so if you have clients or families that really need some support the 2-1-1 call center is a unique opportunity. Sadly, the federal and state haven't seen the need to continue to budget like it's been in the past, give funding for it, but it's a huge need that saves the sheriff's departments and the police departments in our county from getting unnecessary calls to 9-1-1. But more importantly these call centers really work with those clients to get them right to the agency they need to be seen at and work to make sure that their problems are being identified, and the police and sheriff's departments just can't do that. It was also mentioned earlier about our spark point center. We have that's our financial center that we work with our community partners to really provide support to the families that are in need from housing to financial debt or whatever they need to get out of. Again, it's a collaboration of our community partners. It was also mentioned a little bit about bank in Oakland in San Francisco. We started our bank on Cresna as it was mentioned and we've done over 60,000 accounts that we've set up. The only one that's beat us is LA, but last we looked it was about 800 accounts because we have such a need in this community where people are going to the check cashing places and they're spending, they're taking money right off their income to pay for those check cashing where our financial institutions have come together to support them with low or no income or no interest to set up a checking savings account which then gets the families back on their feet. They start to save some money and then they can have a better life moving ahead. We've heard a lot about health. This whole issue with kids and individuals not getting health care is a huge initiative that we work with all of our partners and again it's to make sure people have access to health and so we continue to work with 30 members in a coalition in our community in our county and you've heard some of the significant issues that are facing us with families that don't have health care coverage to the debt that they get and you've heard from Norma just like people walking out because the hospitals and positions aren't getting paid like they need to and so they have to look at how do we continue to treat all these patients when we're not getting any funding to cover the minimum costs that they have. So it's a critical issue that we need to move ahead on. Some other things we worked successfully to educate the state legislators on our managed care organization assessment that helps the funds keep coming into our community and if that process didn't get quite funded like we wanted but if we didn't get that through with our partners in the county and in the state, 36,000 people would have lost their health care coverage and so that would just put more people in a pearl of what they're going to do when they get sick and how are they going to be able to take care of their needs. Financial stability as I mentioned is a critical one. You believe that that is a second sort of the building block. If you have a good education you can have finance. So we really work hard with people we have our VITA program that works with our community partners who are trained by their RAS. We did almost 6,000 tax returns this year by volunteers that brought back over $10 million back in the community, the county, where people were able to get their tax returns done at no cost and then they were able to get those EITC credits back that helped their families become more stable. We had people coming into the different areas that we did the tax returns and some people had three years of tax returns they had in five but again with our great volunteers working with the IRS we were able to get them situated so that they could move ahead and get their life back on track. Again, education is critical. We want our kids to be literate. We have a problem in our county 30% of our kids that go from third to fourth grade are literate to really continue to move ahead and that's why we have a high dropout rate that we heard earlier. So we're working with the county superintendent the county or the local superintendents of the school districts how do we get our kids working with their families to make sure that they have the skills necessary so they can graduate and we heard earlier if you graduate then you can have a better income and hopefully we can get them into training either technical training or college training so that they can have a better life. So these are some of the just quickly some of the examples that we have but a good example is we had 333,000 preventable hospitalizations occurred between 2005 and those they could have been prevented but they weren't and those are usually about $7,000 per hospitalization and that's about a $2.3 million bill put out onto the rest of the public so if we can get people with the right care, the right connections with that healthcare with physicians and institutions we can wipe out some of that debts there. More importantly they can get the right healthcare that they need and they can be healthy in that process. We also need to continue to work to make sure that families get into the exchanges that you've heard about so that they can in fact get the healthcare that they need. We need to make sure we streamline the eligibility process so there's not all these the ways of people getting their healthcare coverage and we also need to make sure there's good public education because as you heard earlier if people aren't educated about the process and if we're going to lose maybe funding for the residency program here at the University Medical Center what are we going to do as far as making sure we have the right people here to provide the healthcare people need. So in conclusion I just want to say it's great to be a part of this organization in the sense that we're providing a community resource but we do it because of our partners. The United Way of President County doesn't provide any services it's our partners to do but the funding we get through all the campaigns both federal and state we are able to then give the money back to our community partners so that they can do the jobs that they need to. So with that it was a quick one but I'll stop so we can have some discussion. I'll take that as our round of applause for all of our families that we won't waste any time. Let me quickly summarize. Mark talked us a lot about our policy in trying to particularly issue around the day to exacerbate the wealth gap while also both gaps also exacerbate the health outcomes. But it is a critical component of that. Something that we do have the ability to thought through policy and practice actually. At least it was a good overview of the ACA and this was not perfect because pretty far down the road a lot of us don't believe in health disparities but pretty great access to healthcare. And raise some concern around the state support and cuts and some of the things that you seem to be trying to walk in two directions and say you know that's really not possible. You can't cut any growth at very no same time. I think I'm going to mention that in terms of some of the work that's used, something that seems to be happening in Fresno as well. I love your talk I think I was only thinking about the deficit side of this but around the massive cuts and how the ability to have savings is really one of the safeties that you own personally. A lot of you deal with the traumas that might go with all of us but you have some resources in the bank and it makes it a lot easier to deal with one of those challenges due before a family or an individual. Norma admitted that her story was not any more. Talked about the systemic crisis and the big need is to really try to figure out how we get from here to 2014 and do that without creating a deep hole in the wounds that we're in now. But I said that she admitted that it's not a happy story but I think you can also see that her fashion report was undeterred by the fact that things aren't going as well as she thinks they could. It could be better. It could be improved definitely. And then of course, our Michael really talked about the other side of the coin in terms of what's happening and, for example, some of the unique coalitions focusing on education, health, financial stability and literacy as well as the kind of world economy around the human development side, the human capital side. So the second half of the development in the day is around human capital development as well. That's where we are now as well. You can't simply retreat to the future. Think about how you groan for the future as well. That's the fourth one. So I'm going to stop there and we're going to have questions for you now. But I think that given the size of the story, do you think this kind of stand-up question is whether you would like to and do it as quickly as possible? Yes. Hi, I'd like to thank you all. I'm aware of all the mental health department for the county in Clarey County and I really don't want to sound political but I'm really concerned about how would you recommend that some of us who are citizens could keep some momentum going, in fact really get it rolling faster at the federal level because I'm really afraid that what I'm hearing is the Tea Party agenda is to make sure that President Obama doesn't have a second term and that scares me because I believe that President Obama is the one who has really reignited a passion in a lot of hearts about working at the grassroots level and what that means. And so I'm wondering if we need to be working at the federal level to make sure that he gets re-elected so that we have more opportunities to grow things and put together more bipartisan kinds of collaboratives. I'll walk in that attention line view. Well, without giving anything away about where I am and how you should contribute something, I think there is one thing I would recommend is involvement with Dave Jess, for instance, regionally. I mean, Herb Schultz up there in San Francisco used to work for Governor Schwarzenegger. He's out pushing the features of the Affordable Care Act going into communities and doing things in a healthcare focus in a really quite remarkable way. So I think there are people like Herb and we can talk later about a number of others so we can also talk about the political question. I think there are a lot of people out there who are deeply committed to making this work of the clinical side of the foundation world and there's maybe a little more activity there that we might worry about. So that's my opinion. I recommend that you also get involved, look at organizations like Health Access covering kids and families. There are advocacy groups that are out there that will deal with mental health issues and you can join them and they're pretty strong, very impressive organizations that have been out for a long time and they're dealing with federal state and public issues. Health Access was just here in Fresno helping us to fight the losing the LHP which had mental health funds in that. So they're a good group knowledgeable and operate across the California states. I just also respond to that. When it comes to acid building policy there is tremendous bipartisan work that's happening in this space. From a democratic perspective they support this work because for them it's about personal responsibility and folks being thrifty and saving and from a democratic perspective folks are very supportive of this because you're creating those opportunities for individual particularly low income people to be able to build their savings over their lifetime. At the national level there are organizations that are doing this work. The New America Foundation CFEDS, Aspen Institute DC and building bipartisan partnerships but we do have extremes and it does tend to be the moderates and particularly in the central valley that are the leaders in supporting much of this work. I would also like to say that for a lot of these visionary ideas I'll tell you when I was out there talking about these legislative pieces I just wanted to be clear that we do not believe that any one of these ideas or bills are going to help people permanently exit poverty and grow the middle class and deal with our asset poverty rate but that we need to think ahead like Chet said and be visionary and start from the very very beginning. At the national level there's this idea, this aspire act that every single child should be a savior and an investor from the moment that they're born and that this account should be an acid building account that kids can use when they graduate from high school to purchase their first home, to roll into a retirement account, to start their first business and we've been trying to advance this idea and it was Rick Santorum actually who introduced the aspire act that he used to be in Congress and when he moved on and it was Hillary Clinton who took over and started supporting this idea in Congress here in California in San Francisco which is really exciting it's not the first thing in the entire country that's testing this idea on the ground every single kindergarten that starts kindergarten in San Francisco is starting kindergarten with a college savings account it's open by the city, it's seated by the city it's progressive and that low income kids get their savings matched and the teachers union agreed to have it integrated into K through 12 financial education so now every single kid in San Francisco what are they being told, the expectations are high this is just the beginning, we're going to see this for you, we're going to invest in you you're going to go to college and they're learning about money management in a very concrete way but these ideas are bipartisan ideas. and you are, and you've been deputized in San Francisco and one of the things that people need to know about is the facts around these sets of issues as well and that may not seem like a direct engagement at the federal level but all politics really are and that aggregates up to federal policies and politics when people are engaged in a lot of that sort of thing can you introduce yourself to me? My name is Larry Hodges I'm the U.S. President of the U.K. Education Development and Vulnerability Community Policy Research in America I applaud you Larry, thanks for inviting me and I agree that education is key and I agree that the way to reframe the data should be pure and not biased one way or the other. My question is this most of the states do not have a mandate for financial literacy taught in the schools. What are you doing as advocates of asset building to facilitate that process? We have introduced legislation as sponsors throughout the years to mandate financial education be taught in our schools and a founded cost has been a major barrier. Legislation has been detailed time and time again because of cost, because schools will say not another mandate and how are you going to pay for this and when are you going to buy the time during the school date to teach this? What we said is look at states like Texas for example in Texas and high school they have now integrated into the math curriculum and so they're teaching high school students about what is an APR and how do you set up a budget and making math time that ideal time to be able to connect them with and they will know how but we have been involved in those efforts and continue to be involved in those efforts to create financial education and integrate it into the case of all financial education in our state. One of the things that we're dealing with is that we're trying to partner with these schools totally education in terms of you know whatever happened to you know it's not mandated that they have health nurses anymore. They can pay if they have busy children and not the tenants. So I mentioned that we have an electronic application tool and we're encouraging enrollments in the schools in terms of getting children and families into health coverage. I want to stress on this application tool because it's not well known. There's a mic behind you. I have a rolling chair here. It's called one EF, one electronic application and it is all of the rules for eligibility of any sort of program you can possibly imagine. All social service programs, we take applications for every week. At one stock shop, one application, we take applications. I have a list here to make sure that I have them correctly. We do not own the insurance coverage of medical health for adults and children, but food stamps, CHDP for disability. We have presumptive eligibility to give people immediate coverage. WIC programs, Medi-Cal for children and pregnant women, Healthy Families, Kaiser Child Health Plan. We are the only program in the state that has interface already into commercial health plans. So when we talk about the health benefit exchange, one EF already has much of the ACA requirements built into it, which is available here in Fresno County. We also have current income tax referral. We have the low income energy assistance, auto insurance, utility assistance, tax credit programs for the families to strengthen them financially with one stock shop. So when they go to these community-based organizations they can take an application and refer people not only into health care but financial assistance at the same time. And we are encouraging the people to use this and be aware of this program in California in Fresno that's available for low income families. I got it. One of the things we're doing briefly here with our partners is the whole Spartan 20 Center. You're one of our partners, of course, and it's to make sure that people have financial education so they can be financial stable. One of the things we proceed through the Mayor's Council that actually came from Bank America from their grant process is we were able to set up 150 accounts with 150 students were able to go through this financial education. If they completed the course then they got $25 to set up a check in your savings account. And so, again, it's our partners that are providing this education, but then your bank and the institution providing the funding through the Mayor's Council to be able to provide that statement for those students who then got through that process. I know. It's great to hear all the work that's happening at the local level, but again at the state level there's another bill that you have there before you in 597 where the controller has been a leader in the field of financial education, particularly consumer financial education and it means creating a fund. If the Governor Brown supports this in the Treasurer's Office then it would allow the controller to partner with banks with credit unions and other nonprofits to create this financial education fund. The idea would be that in the Controller's Office they would create a clearing house, a website where consumers could then go and search really quickly by putting in their zip code to say, you know, I live at the 95814 area code and I want to know how do I start thinking about getting from my retirement what should I be doing that you would be able to go there and find all the programs that are near me that are providing these kind of services. So that's one step. But also I have to again stress that this idea is being tested in San Francisco. This K to C program where every single child is now learning about financial education we hope that again that this will be the model that's replicated statewide so that all kids not just San Franciscans are learning about money management when they start school. I was kind of curious in regards to the role of applications, the one-stop shop and then the spark place would be interesting. My experiences with people who have actually tried to enroll in that account is that it's a, you know, besides the long list that you have to do initially that it's happening to do it on a regular basis and it's not just every three months. On top of that it's every time you get a new social worker and it's the babies to turn over like there's no tomorrow. So every single time, every three months you have to submit the same information you did at the application point and then when you get a new social worker you have to do it again. If by chance you have to be sick during any of those points and you can't get that paperwork in then you lose it. And there should be some kind of a guarantee that if you're using it you don't have to be applied. You're absolutely right. I mean those are the obstacles that exist even, you know, that have, that's a screen-lining that process because that training that goes on with MedCal is unbelievable. But in the electronic application tool that we have, that pilot project we're doing with Center for Medicaid and Medicare Services is that we are electronically interfaced into the state MedCal systems so that they will give back to us. It's a two-way interface. They will give back to us applications that are enrolled and then we will know the computer builds in the flag as to whether it's new rules are due so that we have, then we can notice the family and we can have the application with the sister who will help them contact them and say this is the renewal time. At the same time though all of those barriers to access that we are working in terms of our advocacy groups to eliminate those barriers. So why do we have to have those? Why don't we have eligibility? If you're using it exactly what you said, why do we have to go back in and prove that you need it again? We don't have to do that with insurance, right? Regular insurance, no one has to do that. I call it regular insurance. And even though I know, you know, if you said that MedCal is insurance, it's not handled by regular insurance so it has to be restructured to make it the same equitable for everybody. Can I just add to that? Is this really important with 1EF? The health arena is going to be changing dramatically the next couple of years. So someone who might not be eligible today, may be eligible in the future. So with a tool like what with 1EF, you know, there's the opportunity for people to get those benefits in spite of the fact that they may not today so I think that's really an important tool. And acknowledging that there are problems with it but the other thing I wanted to say is that, you know, this health wall of connection is really clear and I just want to invite those working around the economic justice issues in the room into the healthcare discussion and to raise exactly the point that you're raising in terms of the barriers to these programs and continuing the coverage under these programs but to bring those of you working around and probably work in economic justice into the health discussion because this health coverage is going to be so vitally important for people and the opportunities are enormous. The challenges are as well but the fact that there are funds coming from the federal government and to the state in spite of the fact that the state has budget crisis and many states do, but the federal funds and the flow of those federal funds and talking to your local Congress people and those in Washington is going to be very important for those who are health care advocates and those of us who are working on wealth creation and doing any quality work in general. We have two questions here. I'm going to ask I'm going to ask We won't be looking there I'll ask for shorter responses My name is very young with the Valley Latino Environmental Investment Project and I think the nail was hit on the head earlier with the issue of agriculture industry I mean some of the known facts is that we have the poorest counties in the state while they are at the same time the states or the counties with the highest aggregate in the nation. There's a big disconnect and if we pay attention it's a quarter of the state's revenue 1.3 trillion it's about 25 billion ag industry who works in that industry? You'll notice it's Latinos over 80% I think closer to 97% and when you look at the workers within this industry it's minimum wage they get overtime after 10 hours they don't get a pension plan they don't get health insurance no benefits you miss work one day you're gone and so there's a huge economic injustice issue taking place which is also creating a huge gap in health and one of the reasons why also the measure of America Human Development report has identified the region as being the population of the West and we're going to have a conversation on the 18th of October with the measure of America Human Development authors here in Fresno talking about what are we going to do in respect to the initiatives that we have to bring to the valley including smart valley places including SC2 building healthy communities Fresno's one of the places how do we leverage those assets and how do we make something that is going to be sustainable because it needs to be sustainable but at the legislative level of California we really need to resolve that overtime issue of farm workers and that health care issue because industry is banking they're getting subsidies but they're not putting anything back and what happens there's elders in my community at 70 something years old still working in the fields they cannot retire they retire they get $500 a month social security huge problem decades of work and it's terrible because they cannot retire at 55 years old go back to their communities be volunteers in the community action committee or whatever it may be to ensure that education equity is being respected the small businesses are being able to advance their economic well to also provide another option in terms of economic development for that farm worker community they can't do that they got to die in the fields so it's a serious issue and at the federal level it's existed since FDR even the new deal it excluded farm workers and again during the 60s so what are we going to do about it I'll take it as a statement more than a question No, what are we going to do about it? That's a question I'm so thrilled Mr. Laum that you shut up today because I think that your remarks helped to reinforce why we're all here that is to say that we I consider myself a financial empowerment expert and then we have health experts and then you have a housing expert and a banking expert but that we need to break out of our silos because individuals' needs are not siloed and that if we partner together and start making these connections we'll be more powerful, we'll have a greater impact and we'll be able to make the challenges that you expressed today Hello my name is Alicia I'm on siloed and I'm with the Central Learning Health Colleges Institute part of the state and thank you for asking that question I also have a question for my next question similar is how will the ACA or efforts of the ACA that you know of raise awareness about expanded safety net services of the federally qualified health centers in order to reduce their fear because immigrants undocumented especially are fearful of even seeking or asking so how are we going to minimize their fear in order for them to come and finally get services which are supposedly going to be offered to them I'm less familiar with the committee health centers here in Fresno but I'm very familiar with the company at Aldermen and LA the leaders of those institutions are excited by the money they expect to come in although the federal budget cuts in the interim are hamstringing their opportunity to plan among other things but they are all of these institutions that I know that I have outreach programs internally which they're going to add more money to to deal with precisely that issue and of course the existing folks who attend the company clinics are the best ambassadors and they have Jane Garcia at the clinic that said that exactly to me that we have people who are telling what a good job we do and what a community field this has and how you get really all social services are talked about here not only health care work and so they are actively thinking about that issue of peer and they have internal you know they work internally to make sure that persons immigration status for instance is not disclosed or that is certainly something on their mind as far as the ACA I mean I think that the ACA gives the money and then these very good local institutions I think are going to take that baton and run over there. There's one other opportunity for populations that don't have coverage under the ACA and that's through the provision of ACA. I think that there is one provision in the ACA that could extend some protection to these populations that don't have coverage under the ACA and that's the provision around charity care for...