The Affordable Care Act Implementation and

Family Homelessness

“It’s one thing to approach providers in these systems—already overwhelmed with their own workload—and ask: “Can you also think about homelessness?” But it’s quite another to point out: “Our people are your people. How can we change the way our

systems work to better serve these families?” Alice Shobe, Building Changes Executive Director

Issue Brief #2: Intersection between Building Changes’ Work to End Family Homelessness and

Health Care Reform—Strategic Opportunities

June 2013

Prepared

for

Building

Changes

1

Table of Contents Introduction .................................................................................................................................................. 1

Background ................................................................................................................................................... 5

Social Determinants of Health .................................................................................................................. 5

Connecting Points ..................................................................................................................................... 9

Connecting Point 1: Common Beneficiaries of System Reform Efforts ............................................... 9

Connecting Point 2: Common Principles and Vision Guiding System Reform Efforts ....................... 10

Connecting Point 3: Common Change Allies and Targets .................................................................. 11

Connecting Point 4: Evaluation and Shared Learning ........................................................................ 11

Connecting Point 5: Role of Philanthropy in Health System Reform Efforts ..................................... 11

Key Health Reform Implementation Updates......................................................................................... 12

Legislative Action during the 2013 Regular General Session .............................................................. 12

Action by the 2013 Legislature during the First and Second Special Sessions ................................... 15

Implementation Updates .................................................................................................................... 15

CMMI State Innovation Model Initiative ............................................................................................ 20

Summary of State Health Care Reform Milestones and Timeline ...................................................... 20

Gaps and Emerging Issues........................................................................................................................... 22

Gap: Information and knowledge of health reform efforts ................................................................... 22

Gap: Recognition and inclusion of vulnerable families’ realities and needs ......................................... 24

Gap: Bridging systems and stakeholders to advance cross system understanding and clarity of roles 28

Gap: Assessing impact of reform efforts on vulnerable families ........................................................... 30

Appendix A: Washington’s State Health Care Innovation Plan.................................................................. 31

Appendix B: Key Terms and Acronyms ...................................................................................................... 32

*As part of this project, Leavitt Partners developed recommendations for future work Building Changes could engage in to ensure that vulnerable families benefit from health care strategy or implementation efforts. Building Changes is currently in the process of reviewing these recommendations.

2

Introduction In January 2013, Building Changes sought consultative assistance to:

“Identify the intersections between our work to end family homelessness and health care reform, with a focus on how the implementation of the Affordable Care Act affects vulnerable families.

Build on our recent and planned research, evaluation, and systems change work.

Make recommendations for opportunities we should pursue to ensure that vulnerable families benefit from health care strategy or implementation changes at the county and/or state level.”1

In February 2013, Leavitt Partners, LLC2 was selected to complete this work for Building Changes and, in April, Leavitt Partners completed the first of two issue briefs on these issues. Issue Brief #1 focused on identifying the intersections between the implementation of the Affordable Care Act (ACA) in Washington State and Building Changes’ efforts to prevent and address the issues of family homelessness. Leavitt Partners specifically examined health reform efforts related to increasing access to coverage and care (i.e., the Medicaid expansion and provision of health insurance subsidies) and improving health care service delivery through the implementation of health homes and other integrated service models. Opportunities and challenges for vulnerable families were identified through this review and are summarized in the following table. Figure 1:

Impacts, Challenges and Opportunities

ACA Health Reform Provisions Impacting Vulnerable Families

Medicaid Expansion Health Insurance Subsidies Innovative Models and

Health Homes

What ACA Offers/Mandates

States have the option to expand Medicaid eligibility to all individuals whose income falls below 133% FPL. The federal government will fund 100% of the cost to cover this expanded population for first 3 years (2014-2016) and a minimum of 90% of the cost thereafter.

Individuals with incomes between 134% and 400% FPL will be eligible for financial support to purchase health insurance through a one-stop, on-line insurance exchange or marketplace. Plans must cover 10 essential health care benefits.

Funding is provided to public agencies, health care providers, and communities to develop and test new approaches to financing and delivering health care. The health home model recognizes that health and social service needs are interrelated as well as the need for greater service and

1 Building Changes, Request for Qualifications, Affordable Care Act Implementation and Family Homelessness,

issued January 2013. 2 Leavitt Partners was founded in 2009 by former Utah Governor and HHS Secretary Michael O. Leavitt. Leavitt

Partners advises clients in the practice areas of health care with specific guidance on health reform and government action.

3

Impacts, Challenges and Opportunities

ACA Health Reform Provisions Impacting Vulnerable Families

Medicaid Expansion Health Insurance Subsidies Innovative Models and

Health Homes

integration across medical, behavioral health and social services. A central component of health homes is comprehensive care management.

Implications for Vulnerable Families

A majority of vulnerable families will be eligible for Medicaid as a stable source of health insurance.

The subsidies provide greater health insurance stability for low and moderate-income families to assist with on-going or crisis health care needs as well as minimize health care related financial debt.

Families facing complex health and social service needs can choose a health home to assist them in receiving and integrating a range of services and supports across systems. The health homes place them at the center of care planning and decision making.

Challenges Assuring vulnerable families are aware of and have access to Medicaid; implementing health care delivery strategies that meet their needs; ensuring stable long-term funding for Medicaid expansion.

Assuring that individuals are aware of and access insurance and subsidies through the exchange; undocumented immigrants and legal immigrants of less than five years remain ineligible; adult dental and vision care is not an essential health care benefit.

Operationalizing “comprehensive care management” and the assessment, referral, and service coordination mechanisms that will be required at the local and state level.

Opportunities Using housing and service systems to connect vulnerable families to Medicaid; convening housing/social service and health care systems to share information, identify common goals, and develop strategies and practices to better coordinate services for vulnerable families.

Using housing and service systems’ role as Navigators and In-Person Assisters to connect individuals to coverage through the exchange.

Using greater coordination of health and social services at all levels to prevent individuals from “falling through the cracks” between systems, to identify and address gaps in care, to avoid duplication of services and costs, and to improve health outcomes on an individual and population level.

From these implications, opportunities, and challenges, five primary areas of intersection or “connecting points” were identified for further exploration and are outlined in the following chart.

4

Figure 2:

CONNECTING POINTS

Building Changes

Intermediary Role

Washington Families

Fund (WFF)

WFF Systems Change Initiative

Washington

Vulnerable Families Partnership

Health Reform Implementation

in WA State

Medicaid Expansion

Health Insurance Exchange

Health Homes

Common Beneficiaries

Common Vision and Principles

Common Change Allies & Targets

Focus on Evaluation & Shared Learning

Developing Role of Philanthropy

5

This second Issue Brief identifies specific gaps and emerging issues related to these connecting points as well as the opportunities for Building Changes. Avenues for Building Changes to fill the identified gaps by using its intermediary role and systems change expertise exist at two levels:

1. Those that fall within the purview of Building Changes’ existing scope of functions and activities; and

2. Those that would require expanded scope and corresponding human and financial capacity.

Key initial leverage points for executing on those opportunities are also identified for consideration.

Background To further set the stage for this issue brief, three additional background topics are presented in this section: (1) social determinants of health, (2) a fuller description of identified connecting points between health reform and the work to end family homelessness, and (3) updates on Washington State’s health reform implementation efforts.

Social Determinants of Health At the foundation of the intersection between health care reform and vulnerable families is the concept of social determinants of health. While a full analysis of this topic is beyond the scope of this Issue Brief, a summary review of key concept elements is provided.

The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.3

It has been estimated that only one-quarter of the overall health status of a population can be attributed to genes, biology, and health behaviors while three-quarters can be attributed to the social and physical environment in which a population is located and to the level and quality of health care services to which they have access—in other words, social determinants of health. “These social determinants of health also interact with and influence individual behaviors as well.”4

3 World Health Organization, Social determinants of health: Key Concepts; available at:

http://www.who.int/social_determinants/final_report/key_concepts_en.pdf 4 Centers for Disease Control and Prevention, Social Determinants of Health Frequently Asked Questions; available

at: http://cdc.gov/socialdeterminants/FAQ.html

The results of our exploration indicate:

1) There is a need for action to ensure that health reform benefits vulnerable families in Washington State;

2) Building Changes possesses both the stature and expertise to assume a leadership role in the needed action;

3) Action, at least within the scope of Building Changes existing functions and activities is necessary and not optional; and

4) Broader action should be seriously considered by the Board of Directors and Executive Leadership.

6

Figure 3:

Source: U.S. Centers for Disease Control and Prevention, Social Determinants of Health FAQ.

Availability of safe housing, socioeconomic conditions, social support mechanisms, health care availability, and access to educational, economic, and job opportunities are among the social determinants of health most related to vulnerable families. The Centers for Disease Control and Prevention (CDC) further identifies how these social determinants in turn affect key factors driving health outcomes for individuals and communities. Specific factors cited by CDC include:

Early childhood development

Educational attainment

Ability to get and keep a job

Type of work a person does

Food security

Access to health care and quality of services

Housing status

Income and wealth

Discrimination and social support The inextricable impact of social determinants on the health status of individuals and the economic health of communities is also recognized by the U.S. Federal Reserve Board and is a foundational element of their community development efforts. As Board Chairman Ben Bernanke noted in a recent speech, “Perhaps one of the most promising new partners in community development is the health-care sector. Factors such as educational attainment, income, access to healthy food, and the safety of a neighborhood tend to correlate with individual health outcomes in that neighborhood. Because these factors are linked to economic health as well as physical health, health-care professionals and

7

community development organizations are seeing new opportunities for cooperation in low-income communities.”5 Chairman Bernanke went on to describe collaborative work of public health and housing providers in Seattle targeting asthma and noted that efforts such as these have the potential for improving not only the health of children and adults, but their educational and economic status as well. Welcoming the health care sector to the community development table is an important step, but is not the only step that needs to be taken. As Chairman Bernanke noted “… substantial coordination and dedication are needed to break through silos to simultaneously improve housing, connect residents to jobs, and help ensure access to adequate nutrition, health care, education, and day care.”6 The Robert Wood Johnson Foundation (RWJ) has devoted extensive efforts to further exploring social determinants of health. Of particular relevance to the main topics addressed in this issue brief is RWJ’s exploration of the relationship between income and health status and between housing and health. Nearly one-third of adults age 25 and older with income below the federal poverty level report their health status as poor or fair. As Figure 4 reflects, improved health status occurs as income increases— only 10% of adults with income above 300% of the poverty level report poor or fair health.7 Figure 4:

Percent of Adults, Ages 25 or Older, with Poor/Fair Health*

*Age-adjusted Source: National Health Interview Survey, 2001-2005.

The relationship between income and health status is also present amongst children (Figure 5).8

5 Federal Reserve Chairman Ben Bernanke, “Creating Resilient Communities,” speech given at Federal Reserve

System Community Affairs Research Conference, April 12, 2013. Transcript of speech available at: http://www.federalreserve.gov/newsevents/speech/bernanke20130412a.htm 6 Ibid.

7 Robert Wood Johnson Foundation (RWJ) (April 2011), Exploring the Social Determinants of Health: Income,

Wealth and Health; available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70448 8 Ibid.

30.9%

21.2%

14.0%

10.1%

6.6%

0%

5%

10%

15%

20%

25%

30%

35%

<100% FPL 100 - 199% FPL 200 - 299% FPL 300-399% FPL > 400% FPL

Family Income (Percent of Federal Poverty Level)

8

Figure 5:

Percent of Children, Ages 0‒17, with Poor/Fair Health*

*Age-adjusted Source: National Health Interview Survey, 2001-2005.

The influence of housing conditions on health status can be viewed from three primary perspectives:9

Conditions within the current home or living situation of an individual;

Conditions within the neighborhood surrounding that current home or living situation; and

Affordability of housing options. Using these three perspectives, key findings from RWJ on the linkages of housing and health care are:

“Healthy homes promote good physical and mental health. Families with fewer financial resources are most likely to experience unhealthy and unsafe housing conditions and typically are least able to remedy them, contributing to disparities in health across socioeconomic groups in this country. Living in a disadvantaged neighborhood can limit opportunities for healthy choices, regardless of a family’s own level of resources. The availability of affordable housing shapes families’ choices about where they live, often relegating lower-income families to substandard housing in neighborhoods with higher rates of poverty and crime and fewer health-promoting resources.”10

9 RWJ (2011), Exploring the Social Determinants of Health: Housing and Health; available at:

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70451 10

Ibid, pgs. 2, 3 and 4

4.3%

2.4%

1.4% 1.0%

0.6%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

<100% FPL 100 - 199% FPL 200 - 299% FPL 300-399% FPL > 400% FPL

Family Income (Percent of Federal Poverty Level)

9

In 2011, RWJ also explored social determinants of health through a survey of primary care physicians and pediatricians across the country. Findings were released in a report entitled, “Health Care’s Blind Side: The Overlooked Connection between Social Needs and Good Health,” and provide an on-the-ground view of the critical interplay of social and health needs.11

Connecting Points

Connecting Point 1: Common Beneficiaries of System Reform Efforts The obvious common denominator of system change efforts by both Building Changes and health care reform in Washington State is the individuals and families who face economic, social, and personal hardships that bring them into contact with public and private services and make them vulnerable to homelessness. These individuals and families are impacted both by reform efforts seeking to prevent and end homelessness as well as health care reform efforts. Maximum positive impact is possible if these efforts are complementary and coordinated. Done well, these efforts present great opportunities for vulnerable individuals and families. Done poorly, or in an uncoordinated manner, they can pose great risks. Breaking down silos within existing health and human service systems, only to create new ones through reform efforts, will prevent vulnerable individuals and families from accessing needed services and runs the risk of reducing the effectiveness of overall system change efforts.

11

Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2011/12/health-care-s-blind-side.html

RWJ Health Care’s Blind Side Report: Key Findings 85% say unmet social needs are directly leading to worse health

85% say addressing patient social needs is as important as medical needs

76% wish the health care system covered costs of connecting patients to social services to meet needs that the physician deems important to their overall health

If physicians could write prescriptions to address social needs they would be for…

Fitness programs (75%)

Nutritional food (64%)

Transportation assistance (47%)

Those serving urban and low-income patients would also write prescriptions for…

Employment assistance (52%)

Adult education (49%)

Housing assistance (43%)

10

As shown in Figure 6, the critical intersection of vulnerable families and the need for health care is perhaps most evident in the population of high needs families served by Washington Families Fund (WFF) High Needs Family (HNF) Program. Targeting families with children under 18 who are currently homeless or at-risk of chronic homelessness, this permanent supportive housing program utilizes a comprehensive case management team approach to address issues associated with serious and persistent mental illness, chemical dependency, domestic violence, trauma from violence and/or dislocation, HIV/AIDS or other chronic illness, child protective service involvement, and/or criminal history. Preliminary results of an independent evaluation funded by the Robert Wood Johnson Foundation and conducted by Westat, shows identifying and addressing health care needs is positively impacted through this model of intervention. Figure 6:

Washington Families Fund High Needs Family Program Baseline Data for Participating Families

Health 53% have a chronic or on-going medical problem

45% have a disability

58% have both a chronic or on-going medical problem and a disability

Nearly 2/3rd

have one or more physical health indicator of need

7% of children have a disability and receive SSI/SSDI benefits

1/3rd

of children have at least one emergency room visit in last 3 months

20% had an unmet medical need in the prior 6 months

Mental Health 28% have had a mental health related hospitalization

2/3rd

have at least one mental health indicator

Substance Abuse 60% have received substance abuse treatment

Connecting Point 2: Common Principles and Vision Guiding System Reform Efforts There are clear parallels in the approaches to system reform employed by both Building Changes and state health care reform leaders and participants—as well as the theories of change on which they are based. While different terminology may be used, common elements include:

A focus on prevention;

Coordinated entry into and seamless transitions within service continuums;

Comprehensive assessment of personal, economic, and social needs of vulnerable individuals and families;

Services and service delivery approaches that allow for tailored or individualized services and timely access to the right services at the right time and at the right levels; and

Process and outcome focused evaluation of reform efforts to inform policy, practice, and resource allocations.

11

Connecting Point 3: Common Change Allies and Targets The success of Building Changes in achieving system change is in part due to its willingness to seek and to accept help from “allies” who have a common recognition of the need for change and are willing to collaborate in drawing attention to that need and advocating for action. The allies that Building Changes seeks to connect with include organized philanthropy, housing and service providers and the people they serve, as well as policy and advocacy agencies and coalitions. Increasingly, those ally relationships have expanded beyond the traditional realm of housing and homeless service providers to mainstream public agencies providing public assistance benefits (TANF, Basic Food, early learning, and child care), child welfare services, as well as education and employment services. There is an emerging recognition of the need to form ally relationships with agencies and providers that provide health and behavioral health services. As health system reform efforts evolve, it is becoming increasingly apparent that traditional allies in the health care system—primary care practitioners, specialists, health clinics, and hospitals—will be insufficient to achieve the broad scale reform that is envisioned. Reaching beyond the borders of traditional health care systems must include outreach to and participation by the same set of traditional and emerging allies that Building Changes has relied on in its system change work. As such, Building Changes is uniquely positioned and can assist in convening and making connections between housing, social service, and health care providers at a community, regional, and state level as well as facilitating efforts to identify common and complementary system change agendas.

Connecting Point 4: Evaluation and Shared Learning Evaluation is one of the key strategies employed by Building Changes in its system change work. Independent process and outcome evaluation accompanies all initiatives and is thoroughly embedded in the organization’s grant making activity. Evaluation efforts often form the basis for convening stakeholders to receive and collectively learn from the data and findings and to use that learning to improve future strategies and activities. Evaluation of process and outcomes is also embedded in the implementation of health care reform. The ACA, as well as Washington State law and policy calls for rigorous evaluation of the impact of new health care policies, benefits, and delivery systems at the individual and system levels. It will be critical to know whether efforts have increased access to coverage and care amongst the uninsured as well as if that coverage and care impacts individual and population health outcomes and results in effective resource utilization. Design and implementation of health care reform evaluative efforts, particularly related to vulnerable families, could benefit from the rich and deep expertise and experience of Building Changes.

Connecting Point 5: Role of Philanthropy in Health System Reform Efforts Major philanthropic entities, such as the Bill and Melinda Gates Foundation, have invested significant resources in Building Changes to support their system change efforts. Successful execution of those efforts has garnered Building Changes tremendous respect and trust within the broader Washington State philanthropic community. Building Changes increasingly serves as the “linking pin” between philanthropy and public agencies engaged in aligned system reform efforts. Recent examples of such efforts include the Washington Families Fund System Initiative and the Washington Vulnerable Families Partnership.

12

The formation of Health Philanthropy Partners was in part generated by Building Changes and offers yet another possible avenue for serving in a “linking pin” role as state and local public agencies encourage and support involvement of the philanthropic community in health care reform implementation efforts.

Key Health Reform Implementation Updates Issue Brief #1 described key ACA implementation efforts in Washington State. The following section provides an update on these activities and details additional actions that have occurred since the brief was published.

Legislative Action during the 2013 Regular General Session During its regular session, which concluded on April 28, 2013, the State Legislature enacted several pieces of legislation affecting implementation of health reform in Washington State. Senate Concurrent Resolution (SCR) 8401: Creating a joint select committee on health care oversight HCR 8401 establishes the Joint Select Committee on Health Care Oversight12 to replace the Joint Select Committee on Health Reform Implementation that has been in existence since 2010. The Joint Select Committee is charged with overseeing the efforts of the Health Care Authority, Health Benefit Exchange, Office of the Insurance Commissioner, Department of Health, and Department of Social & Health Services with respect to implementation of health care policy in the State. “The goal must be to ensure that these entities are not duplicating their efforts and are working toward a goal of increased quality of services which will lead to reduced costs to the health care consumer.”13 It is expected that the Committee will propose legislation and make budget recommendations. The Joint Select Committee will be co-chaired by the House and Senate Health Care Committee chairs and will include four additional members from the House and four additional members from the Senate; the Governor will appoint a “liaison” to serve as a nonvoting member of the Committee. HB 1519: Establishing accountability measures for certain health care coordination services HB 1519 establishes a common accountability framework consisting of outcomes and performance measures applicable to the Health Care Authority (HCA), Department of Social and Health Services (DSHS), and any “service coordination organization” or “service contracting entity” contracting with the state to provide a “comprehensive delivery system of medical, behavioral health, long-term care, or social support services.”14

12 http://apps.leg.wa.gov/billinfo/summary.aspx?bill=8401&year=2013 13

Ibid. 14 http://apps.leg.wa.gov/billinfo/summary.aspx?bill=1519&year=2013

The Joint Select Committee on Health

Care Oversight Committee will serve as a key health care policy table and

potential leverage point for Building Changes to pursue opportunities

described in the Opportunities Section of this report.

13

Outcomes: The outcomes agreed to and specified in the legislation are:

Improvements in client health status and wellness;

Increases in client participation in meaningful activities;

Reductions in client involvement with the criminal justice system;

Reductions in avoidable costs in hospitals, emergency rooms, crisis services, and jails and prisons;

Increases in stable housing in the community;

Improvements in client satisfaction with quality of life; and

Reductions in population-level health disparities.15 Performance Measures: No later than September 1, 2014, HCA is required to adopt specific performance measures associated with these outcomes for Medicaid and CHIP enrollees served through medical managed care programs, and DSHS is required to adopt specific performance measures for clients receiving mental health, long-term care, or chemical dependency services.16 Performance measures must align with the following principles outlined in HB 1519:

The maximization of the use of evidence-based practices will be given priority over the use of research-based practices and promising practices, and research-based practices will be given priority over the use of promising practices;

The maximization of client independence, recovery, and employment;

The maximization of client participation in treatment decisions; and

The collaboration between consumer-based support programs in providing client services.17 Specific attention on Tribal and Ethnically Diverse Communities: In developing service coordination performance measures, HCA and DSHS are also required to “develop strategies to identify programs that are effective with ethnically diverse clients and to consult with tribal governments, experts within ethnically diverse communities, and community organizations that serve diverse communities.”18 Timing: The adopted performance measures are to be reported to the Legislature by December 1, 2014 and incorporated into the contracts for Medicaid/CHIP managed care (Healthy Options), Regional Support Networks (RSNs), Areas Agencies on Aging (AAAs), and County contracts for chemical dependency services by July 1, 2015.19

15

Ibid. 16

Ibid. 17

Ibid. 18

Ibid. 19

Ibid.

Inclusion of housing stability as one of the core outcomes is a major step forward in recognizing the

connections between health care and housing stability, and provides a major leverage point for Building

Changes consideration in pursuing the opportunities outlined later in this report. Specific attention on

programs that are effective with ethnically diverse clients also aligns with Building Changes priorities and is

another potential leverage point.

14

SB 5732: Concerning the adult behavioral health system in Washington State SB 5732 addresses improvements to the adult behavioral health system and services, and specifies actions to be taken by the Legislature and by DSHS and HCA. Legislative Task Force: The Legislature is charged with creating a task force by May 1, 2014 to “undertake a system wide review of the adult behavioral health system and make recommendations for reform,” including “best practices for cross-system collaboration between behavioral health treatment providers, medical care providers, long-term care service providers, entities providing health home services to high-risk Medicaid clients, law enforcement, and criminal justice agencies.”20 The Legislative Task Force membership is specified as:

Two members of the House of Representatives;

Two members of the Senate;

The Secretary of DSHS or a designee;

The Administrator of HCA or a designee;

The Director of the Office of Financial Management or a designee;

The Secretary of the Department of Corrections or a designee;

A representative of the Governor; and

A representative of tribal governments invited by the Governor to participate.21 The Task Force must solicit input and invite the participation of a wide range of stakeholders, including “behavioral health service recipients and their families, local government, representatives of RSNs, representatives of county coordinators, law enforcement, city and county jails, tribal representatives, behavioral health service providers, housing providers, labor representatives, counties with state hospitals, mental health advocates, public defenders with involuntary mental health commitment or mental health court experience, Medicaid managed care plan representatives, long-term care service providers, the Washington State Hospital Association, and individuals with expertise in evidence-based and research-based behavioral health practices.”22 Findings are due January 1, 2015. Steering Committee and Strategy for Improvement: SB 5732 further calls on the DSHS and HCA to “implement a strategy for the improvement of the adult behavioral health system” and to establish a steering committee to assist in developing and implementing that strategy. Membership of the Steering Committee mirrors that of the Legislative Task Force stakeholders. The client outcomes specified in HB 1519 with respect to service coordination, including housing stability, are replicated in SB 5732 with respect to the “systems responsible for financing, administration, and delivery of publicly funded mental health and chemical dependency services to adults.” DSHS is required to seek private foundation and

20

http://apps.leg.wa.gov/billinfo/summary.aspx?bill=5732&year=2013 21

Ibid. 22

Ibid.

The Legislative Task Force and the DSHS Steering Committee on Adult

Behavioral Health, created by SB 5732, present additional policy tables and

leverage points for Building Changes’ consideration as it pursues

opportunities detailed in the Opportunities Section of this report.

15

federal grant funding to support the strategy and to provide an update on implementation to the Governor and Legislative Policy Committees by August 1, 2014.23 Role of Housing: It is notable that both the Legislative Task Force and the DSHS Steering Committee established in SB 5732 include housing providers as one of the key stakeholder groups and that housing stability is again emphasized as one of the core client outcomes.

Action by the 2013 Legislature during the First and Second Special Sessions The Legislature adjourned its Second Special Session on June 29, 2013 after completing work on the biennial budget. The Legislature also acted on policy establishing financing mechanisms for the operations of the health benefit exchange. HB 1947: Concerning the operating expenses of the Washington health benefit exchange HB 1947 provides mechanisms for financing the on-going operations of Washington Healthplanfinder, including insurance premium taxes on plans offered through the exchange, state premiums for Medicaid expansion enrollees, and additional assessments on medical and dental plans sold through the exchange (to the extent authorized and appropriated by the Legislature). HB 1947 also directs the State Auditor to conduct a performance review of the costs of operating Washington Healthplanfinder by July 1, 2016.24 SB 5034: Making 2013-2015 operating appropriations The FY2013-2015 biennial operating budget25 includes several appropriation and policy provisions related to Medicaid expansion and other health reform implementation efforts, including:

Authorization for HCA to implement Medicaid expansion under the ACA, effective January 1, 2014.

Requirement of HCA and DSHS to coordinate and facilitate Medicaid expansion enrollment efforts.

Restoration of Medicaid adult dental benefits, effective January 1, 2014.

Authorization for HCA and DSHS to continue implementation of Medicaid health homes.

Removal of mental health visit limits in the current Medicaid benefit plan, effective January 1, 2014.

Authorization of funding to HCA and DSHS to fulfill requirements of HB 1519 (establishing accountability measures for certain health care coordination services) and SB 5732 (concerning the adult behavioral health system in Washington State).

Implementation Updates Selection of Lead Organizations for In-Person Assister Services In order to assure the availability of sufficient resources to assist the large number of individuals who will seek health coverage and benefits during the initial implementation of health benefit exchanges, the federal government awarded grant funding for “in-person assisters;” these “assisters will be allowed to

23

Ibid. 24

http://apps.leg.wa.gov/billinfo/summary.aspx?bill=1947&year=2013 25

http://apps.leg.wa.gov/billinfo/summary.aspx?bill=5034&year=2013

16

help consumers file applications, obtain eligibility determinations, report changes in status, compare coverage options, and select and enroll in qualified health plans.”26 On June 5th, the Washington Health Benefit Exchange (WHBE) announced the selection of 10 In-Person Assister Lead Organizations. Lead Organizations, listed in Figure 7, will be responsible for providing information and one-to-one assistance to individuals applying for and enrolling in health coverage, and for “building and overseeing a network of partners in their region to serve Washington’s diverse populations.”27 A total of $6 million was awarded to the Lead Organizations.

Figure 7:

Washington Healthplanfinder Lead Organizations for In-Person Assister Services

Lead Organization Counties in Service Area

Benton Franklin Community Action Connections* Benton, Franklin, WallaWalla

CHOICE Regional Health Network Clallam, Grays Harbor, Jefferson, Lewis Mason, Pacific, Thurston

Clark County Public Health Clark, Klickitat, Skamania

Cowlitz Family Health Center Cowlitz, Wahkiakum

Empire Health Foundation* Adams, Asotin, Chelan, Columbia, Douglas, Ferry, Garfield, Grant, Lincoln, Okanogan, Pend Oreille, Stevens, Spokane, Whitman

Kitsap Public Health District Kitsap

Public Health – Seattle & King County* King

Tacoma-Pierce County Health Department* Pierce

26

Families USA (2013), Filling in Gaps in Consumer Assistance: How Exchanges Can Use Assisters available at: http://familiesusa2.org/assets/pdfs/health-reform/How-Exchanges-Can-Use-Assisters.pdf 27

See: http://wahbexchange.org/wp-content/uploads/Lead-Organization-Press-Release-FINAL-6-5-13.pdf

In-Person Assister Lead Organizations will be a key leverage point at local/regional level to assure that

vulnerable families are informed of and connected to Medicaid and private insurance plans through

Healthplanfinder.

Opportunities to expand existing and create new partnerships with In-Person Assister Lead Organizations

should be considered by Building Changes.

17

Washington Healthplanfinder Lead Organizations for In-Person Assister Services

Lead Organization Counties in Service Area

Whatcom Alliance for Health Advancement* Island, San Juan, Skagit, Snohomish, Whatcom

Yakima Neighborhood Health Services* Kittitas, Yakima

* Entities with which Building Changes has existing working relationships.

Request for In-Person Assister Outreach Partners On June 14, 2013, WHBE also released an RFP seeking organizations to serve as “Outreach Partners.” Applications are due August 19, 2013 and a total of $750,000 is available to be awarded. The stated purpose of an Outreach Partner is to “…assist with outreach and/or enrollment activities in support of In-Person Assister network organizations.”28 The RFP clarifies that In-Person Assister Lead Organizations remain responsible for developing outreach plans to reach the “most vulnerable and at risk consumer groups;” Outreach Partners are intended to reach broader population groups. Specifically identified target populations are “uninsured or underinsured individuals working in low-wage jobs or who are unemployed, single people (with or without children), members of faith-based organizations, people with disabilities and seniors who are not yet eligible for Medicare (age 55-64).”29 Outreach Partners will operate through December 2014 and may apply to provide only outreach services or outreach and enrollment services. Selection of Qualified Health Homes HCA and DSHS worked collaboratively to design a comprehensive and coordinated approach to providing health home services for high need populations in Washington State. In early May 2013, a formal amendment was finalized and submitted to officially add health home services to Washington’s Medicaid State Plan for specified counties.30 31 Health homes are being phased in across the State based on “health home network coverage areas” which consider, among other factors, the need for and current efforts to integrate services at the local service delivery level.32 Within each area, “qualified health homes” are being selected through a competitive process; selected entities will deliver health home services either directly or through contracts with appropriate providers. Selection of qualified health homes has now been completed for three coverage areas and it is anticipated that health home services will be available in those areas effective July 1, 2013.

28

HBE RFP 13-008, p. 7; available at: http://www.wahbexchange.org/about-us/vendor-procurements/ 29

Ibid. p. 8 30

The Health Home State Plan Amendment includes all counties except King and Snohomish Counties which are participants in a separate Medicare/Medicaid demonstration covering dual eligibles for the next 3 years. 31

For a copy of the submitted Plan Amendment, see http://www.hca.wa.gov/Documents/health_homes/HH_SPA.pdf 32

DSHS/HCA, HealthPath Washington: Medicare and Medicaid Integration Project, presented to House Appropriations Subcommittee on Health & Human Services. February 6, 2013

18

Following the selection of designated Qualified Health Homes for Coverage Area 4 (Pierce County) on February 1, 2013, HCA announced selection of the designated Qualified Health Homes for Coverage Area 5 and for Coverage Area 7 on April 30, 2013.33 Figure 8 summarizes the selections to date: Figure 8:

Qualified Health Homes

Coverage Areas and Counties

Area 4 Pierce

Area 5 Clark Cowlitz Klickitat Skamania Wahkiakum

Area 7 Asotin Benton Columbia Franklin Garfield Kittitas Walla Walla Yakima

Community Health Plan of Washington X X X

Coordinated Care Corporation (Centene) X X X

United Behavioral Health (Optum Pierce in Area 4)

X X X

United Healthcare of Washington, Inc. X X X

Yakima County (SE Washington Aging & Long Term Care)

X

On May 10, 2013, a Request for Applications (RFA) was released for qualified health homes in the following areas:

Coverage Area 1 (Clallam, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, and Thurston Counties);

Coverage Area 2 (Island, San Juan, Skagit, and Whatcom Counties); and

Coverage Area 6 (Adams, Chelan, Douglas, Ferry, Grant, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens, and Whitman Counties).

Selection of lead organizations is expected to take place in early August with services in these Coverage Areas beginning in October 2013.34

Entities that are selected as Qualified Health Homes are responsible to assure availability of a health home provider network that

33

http://www.hca.wa.gov/Pages/rfp.aspx 34

Ibid.

Assuring that housing and social service providers are aware of and connected to

Qualified Health Homes and where feasible are included in their provider networks is

another key leverage point.

19

includes entities such as “Regional Support Networks (RSNs), Community Mental Health Agencies (CMHAs), Area Agencies on Aging, Substance Use Disorder providers, Hospitals, Public Health Districts, Accountable Care Organizations, Medical Homes, Charities, Network Alliances, and community supports that assist with housing.”35 Since referral and connection to community and social support services is a key responsibility of a health home provider network, each Qualified Health Home application has to provide: 1) their “process for identifying community-based resources;” 2) how they will “actively manage referrals, advocate for access to care and services, and provide coaching to beneficiaries to engage in self-care; and 3) their “process for assisting the beneficiary to obtain and maintain health care services, disability benefits, housing, personal needs, and legal services.”36 Review of the adequacy of each health home provider network will occur as a component of the readiness reviews the State plans to conduct.37 In a recent presentation to the King County Health and Human Services Transformational Panel, DSHS and the HCA emphasized the need to maximize community partnerships in the implementation of coordinated care delivery models, such as health homes, and presented the following visual to emphasize the critical role of community services. Figure 9:

Source: State Initiatives and Opportunities for Community Partnership, presented by DSHS and HCA to King County Health and Human Services Transformational Panel, May 22, 2013.

35

HCA, Health Homes Essential Requirements, available at: http://www.hca.wa.gov/documents/health_homes/HealthHomeEssentialReq.pdf 36

HCA Request for Applications for Health Homes, p. 24-25, available at: http://www.hca.wa.gov/rfp/Health%20Home%20for%20Coverage%20Areas%201,%202,%20and%206/Application%20for%20Release%20C%2005-10-13.pdf 37

HCA Health Homes Readiness Reviews, available at: http://www.hca.wa.gov/Documents/health_homes/preassessment_process_instruction.pdf

20

CMMI State Innovation Model Initiative Washington State, with support from Health Philanthropy Partners, submitted a State Health Care Innovation Plan (HCIP) through the CMMI State Innovation Model (SIM) in September 2012. In February 2013, the State was notified that it was one of three states selected to receive a “pre-testing” award of nearly $1 million. The plan is being developed under the leadership of HCA and is scheduled to be completed by October 31, 2013. A draft vision statement and key goals have been developed. HCA has developed additional material to convey the underlying vision of its HCIP; a copy is included as Appendix B to this issue brief.

Summary of State Health Care Reform Milestones and Timeline The State’s major health care reform milestones and planned timeline are summarized in Figure 10.

Washington State Health Care Innovation Planning Draft Vision: By 2019, the people of Washington State will be healthier because our state has collectively shifted from a costly and inefficient non-system for health care to aligned health approaches focused on achieving common targets for better care, lower cost, prevention, and reduction of disparities. Key Goals:

Pay for value and improved outcomes through aligned multi-payer activities.

Achieve seamless, integrated physical and behavioral health care from the individual and family perspective with initial focus on Medicaid populations.

Speed identification and adoption of effective strategies aimed at reducing overuse, misuse, and underuse of care.

Strengthen health promotion and prevention capabilities, and partnerships between community services and health care providers.

Link community health supports and resources with care delivery.

Improve transparency and make visible health plan and provider performance through metrics, accreditation, and public reporting for safe, accessible, and effective care.

Source: http://www.hca.wa.gov/shcip/Pages/vision.aspx

21

Figure 10:

Major Health Care Reform Milestones and Planned Timeline

June 2013 HCA launches Medicaid awareness and education outreach campaign

June-July 2013 Healthplanfinder first advertising wave

Aug 2013 In-Person Assister Training begins

Sept 2013 Draft State Health Care Innovation Plan complete

Oct 2013 “Go Live” Launch of Washington Healthplanfinder Open enrollment period Oct 2013 – Mar 2014

Oct 2013 Final State Health Care Innovation Plan submitted

Jan 2014 Implementation of Medicaid Expansion

May 2014 Start of Legislative Task Force on Adult Behavioral Health

Aug 2014 DSHS and HCA report on Adult Behavioral Health Strategy

Sept 2014 Service Coordination Performance Measures developed

Dec 2014 Service Coordination Performance Measures reported to Legislature

Jan 2015 Legislative Adult Behavioral Health Task Force reports findings and recommendations

July 2015 Service Coordination Performance Measures and Outcomes incorporated into contracts

22

Gaps and Emerging Issues Through a series of stakeholder interviews,38 a review of state health reform implementation efforts, and consideration of implementation efforts on both a national level and in locations across the country, several gaps that cut across the identified connecting points have emerged. Discussion of these gaps further highlights issues of concern with respect to vulnerable families as well as the current housing and social supports service delivery system. Some of these issues also reflect potential barriers to vulnerable families receiving maximum benefit from the health care service delivery reform efforts being planned and implemented in Washington State. The section below highlights these gaps and relating issues of concern. It is important to note, that Washington State is significantly further in its ACA implementation efforts than most other states and is strongly committed to assuring all Washingtonians have access to the health care coverage and the care they need. The identification of gaps and issues is not meant to detract from the tremendous efforts of legislative and executive decision makers, public agencies, health care providers, advocates, and other stakeholders to plan and implement health reform in a comprehensive and responsible manner. Rather they are identified to frame additional discussions and actions in order to further shared goals. Further, some stakeholders view the gaps and emerging issues as evidence that the needs of children and vulnerable families have not been at the forefront of health care reform discussions or planning efforts at either a national or state level. Attention has been focused on low-income individuals and families who will become newly eligible for health care coverage, either through Medicaid or through health plans offered on the health benefit exchange; however, the focus has largely been on the development of the new policy, program, and technology infrastructure needed to determine eligibility for and enroll individuals in this health care coverage. Development of this infrastructure has required the near full attention of state health policy decision makers. While stakeholders and others acknowledge the critical need to focus on developing this infrastructure for the newly eligible, there is growing concern that the results will not adequately address the needs of vulnerable families, including those who currently rely on Medicaid for themselves and/or their children.

Gap: Information and knowledge of health reform efforts As January 2014 quickly approaches, concern is growing at the national, state, and community level that individuals are uninformed or misinformed regarding ACA health insurance and coverage changes.

National View In a April 2013 national Health Tracking Poll conducted by the Kaiser Family Foundation, 42% of respondents were unaware of the current status of the ACA, including 19% who believe it is no longer law due to Congressional or Supreme Court action.39 Of particular note, the majority of uninsured low-income individuals are not aware of how ACA reforms will impact their families.

38

A list of stakeholders interviewed is included in the Acknowledgements Section on page 52. 39

Kaiser Family Foundation, Health Tracking Poll, April 15-20, 2013; available at: http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-april-2013/

23

Figure 11:

Note: Don’t know/Refused answers not show. Source: Kaiser Family Foundation health Tracking Poll (conducted April 15-20, 2013

Nationally, concerns about the lack of information and knowledge of key ACA implementation efforts have also been raised by members of Congress.40 Recent efforts by top Health and Human Services Officials to seek additional private funding for education, outreach, and enrollment activities reflects the growing concerns that efforts to date may not prove to be sufficient.41

State View At a state level, concern about insufficient information dissemination has been echoed by legislators and community groups; concerns focus on both a lack of information and on the presence of misinformation. Specific concerns expressed during the stakeholder interviews associated with this project are that vulnerable families, in particular, will have insufficient information regarding new opportunities to access health coverage for themselves and their children—or worse, will have misinformation that will lead them to believe they are not eligible for coverage. Concern also relates to those who are currently enrolled in Medicaid as they will also be impacted by new eligibility standards as well as revised enrollment portals and processes. As an example, of the families currently served in Building Changes’ Washington Families Fund High Need Families Program, 63% are currently enrolled in Medicaid as recipients of TANF. Conversion of their cases to the new eligibility standard and process will occur as their cases come up for re-certification and the degree and manner in which clear information

40

See: http://thehill.com/blogs/healthwatch/health-reform-implementation/294501-baucus-warns-of-huge-train-wreck-in-obamacare-implementation and http://www.washingtontimes.com/news/2013/apr/17/sen-max-baucus-health-law-heading-for-train-wreck/ 41

See: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/10/budget-request-denied-sebelius-turns-to-health-executives-to-finance-obamacare/ and http://www.nytimes.com/2013/05/13/us/politics/health-secretary-raises-funds-for-health-care-law.html?emc=tnt&tntemail0=y&_r=0

49%

42%

40%

49%

56%

58%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Total

Annual household incomeless than $40,000

Uninsured (under age 65)

Majority of Uninsured, Low Income Don't Know How Law Will Impact Their Family Do you feel you have enough information about the health reform law to understand how it will impact you and your family, or not?

Yes, have enough information No, do not have enough information

24

is available and communicated to these individuals will be critical to assuring they understand the conversion and take the required steps to continue enrollment in Medicaid.

Stakeholders, advocates for low-income individuals, and others have also expressed concern that the information that is available is not appropriately crafted to match the needs of low-income and vulnerable individuals and families. In a March 20, 2013 letter to the Washington Health Benefit Exchange, House Speaker Chopp and Health Care Committee leaders from the House and Senate articulated concerns related to how the Exchange will meet the needs of populations eligible for public programs and subsidies.42 To their credit, HCA and the Health Benefit Exchange agencies have initiated and participated in numerous public presentations and webinars over the past year in an effort to inform individuals, advocates, stakeholders, and community-based providers of ACA implementation efforts specifically related to Medicaid expansion and the launch of the health benefit exchange. These efforts are continuing today, and include a series of “Countdown to Coverage” webinars that were initiated in April and will continue over the coming months.43 Despite these efforts, stakeholders interviewed for this project report that, in general, community housing and social support service providers have limited information regarding the various health care related changes that will occur in 2014 and how those changes will impact the populations they serve. There is also a lack of clarity for many community-based providers with respect to the role(s) they can and should play in both disseminating information and in actual implementation efforts. State agencies envision, and are encouraging community-based organizations to play pivotal roles in increasing awareness, serving as a source of information, and assisting with outreach efforts.44 As key community agencies that have direct contact with vulnerable individuals and families, housing and social service providers can play these roles, but only if they have sufficient awareness and information regarding upcoming health care changes and their implications.

Gap: Recognition and inclusion of vulnerable families’ realities and needs As Medicaid expansion efforts have unfolded nationwide, special attention has been devoted to recognizing the potential barriers that individuals experiencing homelessness and other vulnerable populations may face in both receiving information regarding new health care options and in accessing those options. Among the barriers identified are:

Disengagement and distrust of public systems;

Physical and mental health conditions;

42

Washington State Legislature letter to Washington Health Benefit Exchange, March 20, 2013, signed by Rep. Chopp, Rep. Cody, Sen. Keiser and Sen. Schlicher 43

To view the webinars or associated materials, see: http://wahbexchange.org/countdown-to-coverage-webinar-series/ 44

Health Care Authority, Health Reform Update presentation, April 24, 2013; available at: http://www.hca.wa.gov/hcr/me/Pages/stakeholdering.aspx

25

Disengagement from the application process and an assumption that they are not eligible due to current limited eligibility standards and complex application processes indicating they were not eligible in the past; and

Other application and enrollment process challenges, including literacy levels, language and translation needs, transportation barriers, and lack of stable contact information.45

As discussed in Issue Brief #1, the ACA addressed several of these barriers by both mandating the simplification of Medicaid eligibility and enrollment processes and by requiring strong interfaces between health benefit exchanges and Medicaid eligibility systems. The effectiveness of these new mandates will in large part depend on how they are operationalized at a state level. The information provided below details Washington State’s strategies for operationalizing these mandates and highlights possible concerns associated with how initial implementation may not match vulnerable families’ realities and needs.

Healthplanfinder Language Access At the center of these concerns is a view that Washington Healthplanfinder, the primary avenue for enrollment in new coverage options, has been designed without full accommodation for vulnerable individuals and families. Particular concern over language access barriers has been expressed by community stakeholders, including several of those interviewed for this project as well as members of the Legislature. This concern is best summarized in a March 18, 2013 letter to the Health Benefit Exchange signed by nine majority members of the House of Representatives:

“We are concerned that the Exchange will only support languages in English and Spanish, to the detriment of the increasingly diverse communities in Washington State. We are also concerned that failure to provide language access will ultimately lead to a failure to reach enrollment goals of the Exchange and the intention of enrolling the under and uninsured in Washington State, significant percentages of whom come from communities of color and those with Limited English Proficiency.”46

To address this concern, it has been requested that the exchange portal’s introductory pages be translated into the eight languages most commonly spoken in Washington State, as well as provide broad access to language interpretation services. Also highlighted by both the March 2013 letter and the stakeholder interviews conducted for this project is the link between language barriers and health disparities due to lower rates of health insurance coverage, inconsistent access to regular care, and poor health status. The Health Benefit Exchange has responded to this concern by including language requirements for consumer assistance programs, such as the exchange call center and the Navigator/In-Person Assister programs,47 and by

45

Kaiser Commission on Medicaid and the Uninsured (KCMU) (Sept. 2012), Medicaid Coverage and Care for the Homeless Population: Key Lessons to Consider for the 2014 Medicaid Expansion; available at: http://kff.org/health-reform/report/medicaid-coverage-and-care-for-the-homeless/ 46

Washington State Legislature letter to Health Benefit Exchange dated March 18, 2013; signed by Reps. Hasegawa, Shin, Freeman, McCoy, Moscoso, Pettigrew, Ryu, Santos, and Stonier 47

Washington Health Benefit Exchange, Consumer Assistance Program – Navigator Function, Guiding Principles (Nov. 8, 2012)

26

creating a Health Equity Technical Advisory Committee (TAC). The stated purpose of the Health Equity TAC is to “provide experience and/or professional perspectives related to health equity with a focus on language access, health literacy, hard-to-reach populations, cultural sensitivity, and other general access to coverage issues.”48 When questioned about language access concerns in a recent appearance on TVW’s Inside Olympia, the Health Benefit Exchange CEO reported that the exchange portal will be available in English and Spanish and will include “tag lines” in eight additional federally required languages directing individuals to the Exchange Call Center, which is required to have staffing capacity in those languages as well as access to 175 other languages through a language line.49 While these actions are recognized as positive steps to overcoming language access issues, it is not clear that these actions alone will address the concerns raised with respect to vulnerable families who may have multiple, co-occurring barriers to access.

Complex and Inadequate Information The following three points highlight specific areas where the complexity of information and choices and the potential lack of adequate information and assistance may discourage those using Healthplanfinder for the first time (and may make it difficult to get those individuals to return to the portal a second time). Opt-In v. Opt-Out Approach In the March 20, 2013 Legislative memo to the Health Benefit Exchange, specific concerns were also raised with respect to the “opt in” approach used on the Healthplanfinder portal. For example, applicants are asked questions prefaced with “do you want to apply for…” and, as such, may inadvertently opt out of these options based on assumptions that they are not eligible.

“For most individuals and families, federal poverty level estimations are a foreign concept. Most people assume they are not eligible for any type of state or federal aid and others still are concerned about the stigma attached to those programs. Asking consumers to opt into unfamiliar concepts like ‘health insurance premium tax credits, cost sharing reductions or Washington Apple Health’ will restrict access to these valuable programs for some families who believe they are not likely to be eligible.”50

Understanding Metal Tier Levels The ACA requires insurance plans offered through exchanges to be classified into metal level “tiers” of bronze, silver, gold, and platinum, which correspond to an actuarial value representing the share of health care expenses the plan covers for a typical group of enrollees (out of pocket costs for premium, deductibles, and other cost sharing vary across and within these tiers).51 Cost sharing reductions are

48

Washington Health Benefit Exchange, Health Equity Technical Advisory Committee (TAC), Purpose Statement; available at: http://wahbexchange.org/wp-content/uploads/HBE_HqTAC_Purpose1.pdf 49

TVW Inside Olympia, May 16, 2013; available for viewing at: http://www.tvw.org/index.php?option=com_tvwplayer&eventID=2013050080 50

Washington State Legislature letter to Washington Health Benefit Exchange, March 20, 2013, signed by Rep. Chopp, Rep. Cody, Sen. Keiser and Sen. Schlicher, p. 2 51

Bronze level plans cover 60% of the total average costs for covered benefits; silver plans cover 70%; gold plans cover 80% and platinum plans cover 90%

27

available for those with income levels less than 250% FPL, but only for those who select at least a silver level health plan. Having sufficient information to understand these cost factors as well as the complex terminology of available options is another major concern for vulnerable individuals and families. For example, it is likely that many of these individuals will have a natural tendency to select plans on initial price alone. “Families may fall into a ‘bronze-trap,’ selecting a plan with a low monthly premium without full awareness of the significant out-of-pocket costs they may face down the road or that they have forfeited cost-sharing reduction subsidies.”52 While Washington Healthplanfinder includes several consumer assistance tools, including a calculator to estimate total costs, concerns regarding help features with term definitions and the ability to compare plans remain. On-going and Open Enrollment Periods Individuals enrolling in private health insurance plans (non-Medicaid or CHIP) are required to do so during open enrollment periods. The initial open enrollment period for Washington’s Healthplanfinder will run from October 1, 2013 through March 31, 2014.53 After the first year, individuals may only enroll or modify their existing enrollment and plan selection during annual open enrollment periods, which run from October 1st through December 31st of each year.54 These dates will be prominently displayed on the opening screen of the Healthplanfinder. However, the ability to apply for and enroll in Medicaid or CHIP through the Healthplanfinder is not subject to open enrollment periods and must be available at all times. Concern has been expressed that low-income individuals and families who may be eligible for Medicaid at times outside the open enrollment period specified on the Healthplanfinder may wrongly believe that they have to wait for the next open enrollment period to apply for coverage.

Healthplanfinder Navigator and In-Person Assistance The primary vehicle that will be used to provide information, outreach, and assist individuals with accessing new coverage options is the Navigator/In-Person Assister Program. Ten In-Person Assister Lead Organizations have been selected and awarded a total of $6 million. These organizations will now be responsible for establishing a network of partners sufficient to meet the needs of the diverse populations in their service areas. Concerns have surfaced that the financial resources and community infrastructure being developed for these programs are not robust enough to reach the most vulnerable individuals and families. For example, while funding for initial navigation and assistance functions will be provided through federal resources, those resources will not be available beyond 2015. The lack of a longer term sustainability plan for on-going resources related to these functions and other Exchange and Medicaid outreach efforts is a major concern. Other stakeholders are concerned that by implementing these programs, the State is simply adding complexity and confusion by layering another access point to those that vulnerable individuals and families must already navigate to receive services.

52

Ibid, p. 3 53

See: http://www.wahealthplanfinder.org/ 54

Exceptions include specified “qualifying events;” i.e. loss of employment, addition of dependent

28

Healthplanfinder and Washington Connections Interface The need for individuals to utilize two different portals to access the full range of available services and benefits, at least in the short term, is another concern frequently expressed by stakeholders. Over the past several years, a great deal of effort has gone into design, implementation, and marketing of Washington Connection, an on-line portal for accessing a variety of federal and state services and benefits.55 While Washington Connection has been a major avenue for enrollment in Medicaid, once the Washington Healthplanfinder portal is operational, the Medicaid eligibility entry point for non-elderly or disabled individuals will be transferred to the Healthplanfinder, while other public benefits such as cash and food assistance will remain with Washington Connection. Full interoperability and exchange of information between these two portals is ideal and envisioned to take place; however, due to time constraints associated with ACA implementation, this interoperability will not be complete until later years. As such, applicants accessing coverage through the Healthplanfinder will be referred to the Washington Connection portal to complete an application for its support services and vice versa.

Gap: Bridging systems and stakeholders to advance cross system understanding and clarity of roles Since the enactment of the ACA, Washington State committed to using a broad-based approach to health reform planning that includes bringing the Governor’s Office (Executive Policy and Financial Management), HCA , DSHS, Department of Health (DOH), Office of the Insurance Commissioner, and Washington Health Benefit Exchange (WHBE) to a common table. Convening at a common table assists in sharing of information and alignment of interdependent policies and actions and can break down “silos” that exist between agencies. Consistency in who sits at a common table can also facilitate a sense of “we are in this together” and mutual accountability for achieving desired results.

Leadership Changes The change in administration that occurred in mid-January 2013 caused an unavoidable membership disruption to the health reform common table as new leadership was appointed to four of the five Executive Branch entities (Governor’s Office, HCA, DOH, and DSHS). While implementation efforts progressed throughout the leadership transition, concerns have been expressed that as these agencies face tremendous pressure and time constraints associated with implementing health reform, the silos between the various agencies have become more fortified rather than permeable—impacting not only health care reform but other areas of common interest and responsibility. It is important to note that those expressing this concern do not attribute this to a lack of desire or willingness to collaborate on the part of any individual agency or leader. Further, most have expressed confidence that now that all of the leaders are in place, they will develop a strong common agenda and work to assure it is achieved under the leadership of Governor Inslee.

System Coordination Implementation of Medicaid expansion and the health benefit exchange requires coordinated efforts that extend well beyond state agencies. Despite diligent efforts by Building Changes and others to incent and support housing and social service providers at a county and community level to come together, the 55

See https://www.washingtonconnection.org/home/home.go

29

implementation of the ACA presents even broader opportunities for system coordination. WFF Systems Change efforts, including coordinated entry programs as well as efforts to integrate main stream assistance programs related to public assistance, child welfare, education/workforce development, and employment assistance, are showing promise in bridging silos and allowing families to receive more integrated and comprehensive needs assessments, treatment, and service planning, as well as service delivery. Many stakeholders expressed a need to leverage these efforts to integrate assessment of health care coverage needs and access to new health care coverage options with existing coordinated entry systems and processes. Large scale coordinated efforts are also required in bridging housing and social services systems and systems associated with public health and primary health care service delivery. Bridging the silos that exist between and among these systems is a particularly daunting challenge. Despite sharing common clients and patients, with a few isolated exceptions, there is no regular venue in which these various players sit at a common table to share knowledge and experiences and to develop common agendas and goals. This can be true at a policy and service planning level, where opportunities to leverage resources, achieve efficiencies, and improve program and population outcomes are lost, as well as at an individual or family level, where the result is often unnecessary duplication of assessments and services, inefficient utilization of scarce resources, and additional confusion and frustration for those being served.

The lack of regular or on-going comprehensive discussions spanning the housing, social service, public health, and health systems is cited as a major gap and one of the key barriers to connecting the needs of vulnerable families and other homeless individuals with health reform planning and implementation. While some topic-specific cross system discussions have been convened by public agencies at the federal, state, and county level or with community providers and advocates, discussions more frequently occur amongst those associated with one of the service systems (i.e., housing, social service, or health care providers). Nearly all of the stakeholders interviewed for this project reported the need for more broad-based discussions across the housing, social services, public health, and health care systems and the need for an entity to serve as convener and facilitator of these discussions.

Implementation of health homes offers families facing complex health and social service needs an avenue to

receive services that are integrated across systems and that are predicated on their central role in care planning

and decision making. Failure to achieve maximum integration of housing, social, and health services will

challenge the ability of the health home model to achieve its desired results for vulnerable individuals and families.

30

The desirable characteristics that stakeholders identified for an effective convener or facilitator include an entity that:

Is a systems thinking organization;

Has the bandwidth to cover the scope;

Doesn’t “live” in any one of the systems being convened;

Has the skill set to assume these roles effectively; and

Has the ability to leverage public and private resources. Interviewees frequently cited Building Changes as possessing these qualities as well as a desire for the organization to assume a leadership role.

Gap: Assessing impact of reform efforts on vulnerable families The gaps and issues detailed above share a common underlying concern—that vulnerable individuals and families will not be in the first tier of individuals to make it through the “gate” of the new health care system and therefore will not benefit from reforms. Whether the focus is accessing health care coverage through Washington Healthplanfinder or being able to receive more integrated care through a health home, there is a need to be purposeful in data collection and analysis efforts to determine whether this concern is valid. Part of that purposefulness includes the availability of data specifically identifying the experience of vulnerable families and the collection of it beginning in the early implementation phases. This will ensure that the data informs implementers and leads to timely changes in practices and systems.

31

Appendix A: Washington’s State Health Care Innovation Plan

32

Appendix B: Key Terms and Acronyms ACA - Affordable Care Act: Public Law 111-148 enacted March 23, 2010; also referred to as national health care reform ACO - Accountable Care Organization: group of health care providers that provides coordinated care to an assigned population of patients; characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care. ACOs are accountable to their patients and payers for delivering quality, cost-effective health care AMI – Area Median Income: median household income for a specific metropolitan or non-metropolitan area Behavioral Health: mental health and/or substance abuse prevention, treatment and recovery services CMMI - Center for Medicare and Medicaid Innovation: entity created by the Affordable Care Act for the purpose of testing innovative health care payment and service delivery models in the Medicare, Medicaid, and the Children’s Health Insurance Program CMS - Center for Medicare and Medicaid Services: federal agency within U.S. Department of Health & Human Services responsible for administration of Medicare, Medicaid, and Children’s Health Insurance Program EHB – Essential Health Benefits: 10 benefit categories established in the Affordable Care Act and all associated state and federal regulatory provisions, including cost-sharing limits and compliance with the federal Mental Health Parity and Addiction Equity Act56 FPL - Federal Poverty Level: income level issued annually by the Department of Health and Human Services and used to determine eligibility for certain programs and benefits HealthPath Washington: State plan detailing the strategic design and implementation approach for integrating medical, behavioral health and long term services and supports for seniors and disabled who are dually eligible for Medicare and Medicaid Heath Home Network Coverage Area: Geographic regions established by the state for implementation of health homes; implementation will be phased in statewide through this regional structure Health Home or Primary Care Health Home: (WA State Statutory Definition) coordinated health care provided by a licensed primary care provider coordinating all medical care services, and a multidisciplinary healthcare team comprised of clinical and nonclinical staff.57

56

ACA Section 1302(a) 57

Revised Code of Washington §74.09.010(8)

33

Health Insurance or Benefit Exchange: an online marketplace where individuals, families and small businesses can compare and purchase health insurance as well as access premium subsidies and public programs such as Medicaid In-Person Assister: a key component of the consumer service function associated with a health insurance exchange; will assist individuals learn about, apply for and enroll in appropriate health insurance coverage MAGI - Modified Adjusted Gross Income: adjusted gross income as calculated under the federal income tax, plus any foreign income or tax-exempt interest received [Adjusted gross income under federal income tax system is an individual’s income less various adjustments and is calculated prior to any itemized or standard deductions, exemptions and credits are applied.]58 Median Household Income: amount which divides households into two segments with one-half earning less and one-half earning more than the amount Multidisciplinary health care team: (WA State Statutory Definition) an interdisciplinary team of health professionals which may include, but is not limited to, medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers including substance use disorder prevention and treatment providers, doctors of chiropractic, physical therapists, licensed complementary and alternative medicine practitioners, home care and other long-term care providers, and physicians' assistants.59 Premium and Cost-Sharing Subsidies: funding to assist low to moderate income individuals purchase insurance coverage through a health insurance exchange60 Primary Care: Health services that cover a range of prevention, wellness, and treatment for common illnesses Primary Care Provider: (WA State Statutory Definition) a general practice physician, family practitioner, internist, pediatrician, osteopath, naturopath, physician assistant, osteopathic physician assistant, and advanced registered nurse practitioner61 QHP - Qualified Health Plan: health plan certified as meeting all state and federal requirements to offer health insurance on a health insurance exchange, including coverage for all essential health benefits62 Vulnerable Families: families who are potentially at risk of homelessness due to family earnings that are less than 30% of the Area Median Family Income and spending more than 50% of pre-tax income on housing

58

Kaiser Commission on Medicaid and the Uninsured, Explaining Health Reform: The New Rules for Determining Income under Medicaid in 2014 (June 2011) available at: http://www.kff.org/healthreform/upload/8194.pdf 59

Revised Code of Washington §74.09.010(13) 60

Kaiser Family Foundation, Explaining Health Care Reform: Questions About Health Insurance Subsidies (July 2012) available at: http://www.kff.org/healthreform/upload/7962-02.pdf 61

Revised Code of Washington §74.09.010(16) 62

ACA Section 1301(a)

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WFF - Washington Families Fund: a public-private partnership providing funding for supportive services and stable housing for families experiencing homelessness Washington Healthplanfinder: official name of Washington State’s health insurance exchange63 “Welcome mat” or “woodwork” population: Individuals who are eligible for Medicaid based on current eligibility policy but who have not submitted an application or enrolled

63

See http://wahbexchange.org/

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ACKNOWLEDGEMENTS

Leavitt Partners expresses its deep appreciation to:

Kelly Zelenka, Director of Policy Vitoria Lin, Policy Specialist

and all Building Changes staff who contributed their time and thought to this project

Stakeholders who shared their

valuable insights and recommendations including:

Teresita Batayola, Executive Director International Community Health Services

Sharon Beaudoin, Director of Programs

Within Reach

Jon Gould, Deputy Director Children’s Alliance

Jennifer Ho, Senior Advisor to the Secretary

U.S. Dept. of Housing and Urban Development

Betsy Jones, Policy Advisor Office of King County Executive

Helen Howell, Director

Pierce County Community Connections Building Changes Board Member

Betsy Lieberman

Founding Director, Building Changes

Reverend Chris Morton, Executive Director Associated Ministries of Pierce County

Ken Stark, Director

Snohomish County Dept. of Human Services

Kristen West, Vice President Empire Health Foundation

Building Changes Board Member

Cover page quote from Alice Shobe, Executive Director Building Changes, Gates Foundation Blog, Our “Aha” Moments in Tracking Washington Families Fund Data, Impatient Optimists, 11/14/12, available at: http://www.impatientoptimists.org/Posts/2012/11/Our-Aha-Moments-in-Tracking-Washington-Families-Fund-Data