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THE PPACA AND SFFC: GETTING READY FOR 2014Angela Liu
August 2013
Outline
• Three main takeaways:1) Major changes ACA brings about
2) The predicted effects of these changes
3) What’s our role?
WHAT’S COMING AHEAD?State of the union on healthcare reform:
Quick Recap of the ACA• In 2014, Obama’s health care law goes into full effect. 1. No denial of coverage for pre-existing conditions
2. No annual limits
3. Large employers to offer coverage (delayed to 2015)
4. Individual mandate + tax penalty• Exemptions: members of certain religious groups and Native
American tribes, undocumented immigrants, people with incomes below tax filing threshold, people for whom insurance premiums exceed 8% of family income, and others
5. Medicaid (Medi-Cal) expansion
6. Exchange-purchased insurance coverage begins• Subsidies for Exchange-purchased insurance
California specifically…• ACA and the recent Supreme Court ruling gives states the right to decide• Whether to expand Medicaid or not• Whether to establish a state exchange (insurance
marketplace) or default to a federally-run exchange
California on Medicaid expansion• CA among states that will expand Medicaid
California on Medicaid expansion
• Medi-Cal currently only covers certain groups of low-income Americans (families, children, pregnant women, people with disabilities)
• Expansion of Medicaid to cover low-income Americans up to 138% of the FPL ( ~15k/individual, ~31k/family of four)
• Federal funding for first five years• Evidence that Medicaid expansion will have wide ranging benefits (better health outcomes, economy)
CA’s Exchange: Covered California
• Online “health insurance marketplace” where consumers can shop/compare their options; competitive model expected to drive down premium prices
• Covered CA to offer 13 plans by “name-brand” insurance companies that cover at least 60% of medical costs • More expensive premiums = more medical cost covered
• All plans must cover a set of ten Essential Health Benefits
• State-run exchanges = more autonomy/decision making by states than those defaulting to federal exchange
• Tax subsidies for insurance purchased through the Exchange for those making 139%-400% of FPL
Timeline• October 1, 2013: open enrollment opens for the health
insurance exchanges• January 1, 2014: coverage under Covered California
begins• Insurance premium subsidies for low- and middle-class income
families take effect• Medi-Cal expansion
• March 31, 2014: Covered California open enrollment closes for 2014
PREDICTING THE IMPACTWho will be covered, who will be left behind, and why?
Impact on uninsured in CA• About 7 million uninsured in 2011• 1.8 to 2.7 million uninsured to newly gain coverage in 2014• These are the people whose jobs don’t offer insurance benefits, those who couldn’t afford it previously
• More people having insurance = more people getting the care they need before getting seriously ill
Many to still remain uninsured• This still leaves 3.1 to 4 million Californians without insurance (projected numbers for 2019), with roughly 1.4 million (40%) uninsured predicted to still lack affordable coverage
• Remaining uninsured fall into two categories:1. Those that are not eligible (excluded from ACA)
• Undocumented immigrants• Incarcerated individuals
2. Those that are eligible, but do not enroll• About 2 million (50%) will be eligible, but remain uninsured• 1.1 million (28%) uninsured will pay tax penalty
Who will be left behind?• Demographic groups most likely to be uninsured after ACA (in CA):• Latinos
• 66% of uninsured
• Non-English speakers• 3 out of 5 uninsured
• People with incomes < 200% FPL • 57% of uninsured
Why will they be left behind?1. Not eligible
• Immigration status
2. Eligible, but do not enroll• Insurance will still be unaffordable for many
• Majority of remaining uninsured Californians predicted to be exempt from tax penalties
• Barriers to enrollment• Difficult enrollment procedures (confusing
applications, language barriers, unfriendly eligibility staff)
• Awareness of programs and eligibility • One in five Americans unaware of health exchange marketplaces
Why will they be left behind?• Gap between eligibility and enrollment (in CA)
• Medi-Cal:• 880,000 uninsured already eligible for Medi-Cal• 880,000 to be newly eligible for Medi-Cal• Only 640k - 1 million to newly enroll in Medi-Cal
• Exchange:• 1.59 million uninsured eligible for subsidies with
the Exchange• 790k - 1.2 million predicted to enroll in Exchange
with subsidies
Reform’s success depends hugely on awareness of and enrollment into programs
Making enrollment accessible• Marketing and outreach campaigns, geared towards groups
most at risk of remaining uninsured
• Existing programs to provide enrollment assistance (HSF, SF Path)
• Streamlined eligibility, enrollment, and renewal policies for both Covered CA and Medi-Cal to make getting insurance coverage as easy as possible
• Multiple languages
• Multiple ways to enroll (mail, in-person, online)• Covered CA Assisters Program: community organizations (including
nonprofits, religious organizations, labor unions, clinics, schools, etc) can directly help people enroll into Covered CA • More on this later!
Making enrollment accessible• “No Wrong Door” Policy
• A system in which “no matter where and with what knowledge people apply for coverage, they get full access to all public health coverage programs and are enrolled into the most beneficial program.”
WHAT’S OUR ROLE?“What’s going to happen to SFFC after Obamacare?”
Yes, we’ll still be
needed!
SFFC’s role• Two-fold:
1. Continue providing the “safety-net” care for remaining uninsured
• Health care “safety nets” crucial as ever after reform• HSF program will continue on after 2014: ~20k of current
40k will continue to be enrolled
• 3-4 million Californians to remain uninsured• Our patient base will change with the uninsured
population • Focus on immigrant community: two of the big “at-risk”
groups are undocumented immigrants and non-English speakers
SFFC’s role
2. Educate and encourage existing patients to get coverage through these new avenues
• “The safety net…that provides health services to vulnerable populations is crucial in caring for the uninsured population; however, such services are unable to fully substitute for the access to care that insurance provides.”
- KFF, Primer on the Uninsured
• Encourage patients reluctant to get coverage for a variety of reasons (stigma, seems unaffordable, satisfied with care they get here etc.) • People with insurance experience better health• Reduce risk of bankruptcy from high medical bills
Educating our patient base (and ourselves)
• We’re in a great position to do this!• Direct access to the relevant population (the uninsured)• Trusted, reputable clinic • Clinics and doctors are preferred sources of information
for programs like Medicaid
• Importance of getting familiar with health reform ourselves• The more we know, the better we can help our patients
Recommendations• Get the word out at SFFC
• Mentioning upcoming changes to patients• Having outreach materials (such as handouts) and
application materials available• Webpage on SFFC website with video, links to more
information and resources regarding ACA• Group sessions/workshops on new programs and
eligibility• Others ways?
Recommendations• Become a certified Assister Enrollment Entity with Covered California• Provide in-person assistance to patients wanting to
apply for Covered CA programs• The good: directly help patients get insurance (thus
access to better care!), contribute to higher enrollment rates by providing one-on-one assistance, monetary compensation for successful applications
• The not so good: red tape (background checks), intensive training, more responsibility taken on by clinic
Recommendations• Build/maintain relationships with other organizations to which we can refer the patients that we can’t help ourselves• Clinics/specialists providing health services that we
don’t• Other Assister Enrollment Entities• Organizations serving undocumented immigrants,
immigrant communities, and other medically underserved • The California Endowment “Health for All” campaign to find
a solution for uninsured undocumented immigrants
Looking forward• Still have to wait for the actual effects of ACA
• How will our patient base change in reality? Will it align with these projections/predictions?
• Will we have enough patients to see?• If not, investigate costs of participating in local/federal
health programs
• Be prepared to adapt!
Selected References 1. www.kqed.org/news/health/obamacare/obamacare-guide.jsp
KQED radio station’s very helpful guide to Obamacare for Californians
2. http://www.coveredca.com/Official site of California’s healthcare exchange, Covered California
3. https://www.healthcare.gov/Federal government’s website regarding the Affordable Care Act
4. http://www.bcoe.org/admin/maa/docs/factsheet_getting-covered_english.pdfCovered California Fact Sheet in English
5. http://tcenews.calendow.org/blog/san-franciscos-leg-up-on-the-affordable-care-actArticle by the director of the HSF program discussing HSF's role post-ACA in 2014.
6. http://laborcenter.berkeley.edu/healthcare/aca_uninsured12.pdfUC Berkeley Labor Center report on who will get coverage and who will remain uninsured after 2014. Projections of these numbers for 2019.
7. http://laborcenter.berkeley.edu/healthcare/medi-cal_expansion.shtmlUC Berkeley Labor Center report on the effects of Medi-Cal expansion on Californians
8. http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8445-key-lessons-from-medicaid-and-chip.pdfKaiser briefing on outreach and enrollment targets for the ACA using Medicaid/CHIP programs as models
9. http://blogs.kqed.org/stateofhealth/2013/03/04/hard-enough-understanding-health-law-in-english-try-in-mongolian-khmer-or-even-spanish/Article discussing minority representation groups' push for exchange/reform information availability in different languages
10. http://blogs.kqed.org/stateofhealth/2012/03/01/how-big-a-barrier-is-language-to-enrolling-in-health-exchange/Article with link to a report that shows that of those that will qualify for insurance through the exchange, those with limited English skills will have lower enrollment rates than people with strong English skills.
11. http://www.healthycal.org/archives/11156Article discussing outreach efforts regarding Covered CA: network of nonprofits, or through churches, employers etc.
12. http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-ProvisionInformation from the IRS about the guidelines and exceptions to the Individual Mandate of the ACA
Selected References13. http://www.cahba.com/covered-california/assisters.htm
Website for entities and organizations interested in becoming Assister Organizations under Covered California
14. http://kff.org/health-reform/poll-finding/march-2013-tracking-poll/Kaiser tracking poll demonstrating the attitudes among Americans regarding the ACA
15. http://kff.org/medicaid/issue-brief/medicaid-a-primer/The basics of the Medicaid program in the United States
16. http://kff.org/uninsured/issue-brief/the-uninsured-a-primer/Primer on the state of the uninsured population in the United States
17. http://kff.org/medicaid/issue-brief/key-lessons-from-medicaid-and-chip-for-outreach-and-enrollment-under-the-affordable-care-act/Briefing covering strategies that have been historically successful for increasing enrollment under Medicaid and CHIP, and could be applied to the ACA
18. http://cardenas.house.gov/sites/cardenas.house.gov/files/Assisters%20Program%20Phase%20I%20and%20II.pdfPresentation from a seminar on the assisters program for Covered CA
19. http://www.dpc.senate.gov/healthreformbill/healthbill04.pdfExecutive summary of the Affordable Care Act from the Senate
20. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/R/PDF%20ReadyOrNotSafetyNetPreparedForReform.pdfIssue brief by the California Healthcare Foundation with suggestions on how healthcare safety net programs and organizations can prepare for the ACA
21. http://www.calendow.org/with_prevention.aspxCalifornia Endowment’s website, promoting care for undocumented residents of California
22. http://www.coveredca.com/news/101-presentations/101-Region-4.pdfCovered California presentation at the San Francisco Town Hall meeting August 9, 2013
