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Health Care & Housing Are Human Rights
The Nuts and Bolts of Health Reform: What’s Important and What You Need to Do
September 7, 2012
Barbara DiPietro, Ph.D.Policy Director
National Health Care for the Homeless Council
+National Goals of Health Reform
Increase access to care
Improve health outcomes
Lower costs to individuals
Reduce total spending
Improve quality of care
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+The Affordable Care Act (ACA) P.L. 111-148 as amended by P.L. 111-152
8 Major Components: Private insurance reforms (includes Exchanges)
Medicaid reforms Quality improvements Prevention of chronic disease/public health Strengthening health care workforce Improve transparency and accountability Improve access to medical technologies Revenue provisions
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+Current Status Over 2 years since legislation signed into
law; major provisions not active until 2014, but there’s so much to do!
Mixed public awareness of ACA content & impact; myriad of philosophical viewpoints
Administration: Full speed ahead
Congress: Attempts to repeal, hinder, de-fund
Judicial: Supreme Court upholds law, makes Medicaid expansion optional
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+Priorities for HCH Grantees
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Parameters of Law; Opportunities & Challenges
+Medicaid Expansion: The Bus Pass
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Medicaid Enrollees and Expenditures, FY 2009
NOTE: Percentages may not add up to 100 due to rounding.SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64.
Total = 62.6 million Total = $346.5 billion
Children 49%
Children 21%
Adults 26%
Adults 14%
Elderly 10%
Elderly 23%
Disabled 15%
Disabled 43%
Enrollees Expenditures
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Medicaid Expansion: Who Is Eligible?
Currently eligible: children, pregnant women, those disabled, and some parents of children
Newly eligible (starting January 1, 2014): Law expands Medicaid to non-disabled adults at or below 138% FPL. About $15,000/year for singles About $25,500/year for family of 3
Must be a U.S. citizen or legal resident here for at least 5 years
8 states have started expanding Medicaid already (in full or partial) CA, CT, CO, DC, MN, MO, NJ, WA
Median Medicaid/CHIP Eligibility Thresholds, January 2012
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
250%
63%
37%
0%
185%
Children PregnantWomen
Working Parents Jobless Parents Childless Adults
Minimum Medicaid Eligibility under Health Reform - 133% FPL
($25,390 for a family of 3 in 2012)
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Medicaid Expansion Financing Expansion group only: Higher federal match to
states 100%: 2014 through 2016 95%: 2017 94%: 2018 93%: 2019 90%: 2020 and thereafter
Current eligible groups: Current federal match (“FMAP”)
Supreme Court decision: Made expansion to newly eligible population an option, rather than a mandate
Maintenance of Effort: Law prohibits states from reducing eligibility or changing benefits until 2014
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Enrolling Many More People Now: Medicaid has 60 million enrollees (1 in 5
people)
2014: Expansion adds 13-15 million new people (depending on outreach and enrollment)
“Woodwork”: Could add 4-5 million currently eligible-unenrolled
Total: about 80 million people will have Medicaid (about 1 in 4 people)
California: 1.9 million newly eligible, 583,000 adults currently
eligible-but-unenrolled 250,000 enrolled as of December 2011
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Easier Enrollment
Law requires fast, simple process using technology
Must coordinate Medicaid, state “Exchanges” and CHIP
NO Paper documentation needed
Do not need: paper copy of paycheck/utility bill, birth certificate, ID or social security card (unless there’s a problem)
Will need to know: full legal name, social security number, your birth date, and income
+Facilitated by Technology
Eligibility will be based on income “Modified adjusted gross income” (MAGI) Not whether you have children or a disability Not whether you have a bank account, or the value
of your car, or other “assets” you might have (no asset tests)
The Medicaid system will automatically verify your income with the Internal Revenue Service (IRS).
The Medicaid system will automatically verify your identity and your citizenship/residency status with Social Security.
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Applying for the New Medicaid
Online applications (but can also do by phone and mail)
Do not need a permanent address and do not need to prove residency in your state.
“No fixed address” will be an option
Alternative points of contact available
No in-person interviews
Simple renewal process, only need to renew once every 12 months
Automatic renewal unless there’s a change
Sources: 2010 UDS Data, HRSA2010 Census data State Health Facts (* Note: 101-139%)
+Perceptions of Medi-Cal: Those Newly Eligible Nearly 60% believe a pretty good/very good program
But 32% unsure
38% believe covers care needed But 37% unsure
27% believe they would qualify and 35% know how to apply But 40% and 36% unsure, respectively
56% comfortable with online enrollment But 41% not comfortable
52% would want in-person help with enrollment
Source: California HealthCare Foundation (May 2012). Medi-Cal at a Crossroads: What Enrollees Say About the Program. Available at: http://www.chcf.org/publications/2012/05/medical-crossroads-what-enrollees-say.
+Those Remaining Uninsured Law does not provide a “right to health care”
Estimate 30 million left uninsured in 2016
Medicaid eligible (but not enrolled)
Undocumented persons
Individual Mandate: requires most people to get health insurance or face a penalty.
Medicaid counts toward the mandate
Penalty: $95 in 2014, $695 in 2016 — BUT…
Those not filing taxes are exempt from the penalty
Less than ~$10,000/year in 2012Health Care & Housing Are Human
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+Those Exempt from the Mandate Religious conscience (member recognized religious sect)
Health care sharing ministry
Individuals not lawfully present
Incarcerated individuals
Individuals who cannot afford coverage/hardships (>8% of household income)
Taxpayers with income below filing threshold
Members of Indian tribes
Months during short coverage gapsHealth Care & Housing Are Human
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+Those Remaining Uninsured
Remaining Uninsured:37%: Medicaid-eligible but un-enrolled25%: Undocumented/ineligible immigrants
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Outreach & Enrollment Law requires states “establish procedures for
outreach and enrollment activities to vulnerable & underserved populations” Children Unaccompanied homeless youth Children and youth with special health care needs Pregnant women Racial and ethnic minorities Rural populations Victims of abuse or trauma Individuals with mental health or substance-related
disorders Individuals with HIV/AIDS
Concern: No resources allocated for these activities
+A Word on the State Exchanges “Shopping center” for health insurance for
individuals and small employers Must be implemented by January 1, 2014 Subsidies and credits, based on income
(100%-400% FPL) Focused on individual and small group markets Must contain insurance with “Essential Health
Benefits” Anticipate covering 9 million in 2014
23 million in 2016
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+Eligibility Between Two Systems
(0-138% FPL)(100%+)
Subsidies/credits: 100-400% FPL
100-138%
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Medicaid Expansion: Overcoming Challenges
Meeting increase in demand for services Expanding services and workforce Balancing productivity & quality Ensuring Medicaid & Exchange plans are
coordinated Identifying funding for service gaps and remaining
uninsured Maximizing billing, coding & IT system functioning Participating in state-level decisions Ensuring staff training across all teams, at all levels Ensuring states choose to expand Medicaid
+4 Clinical Questions
1. Patients: How will volume and acuity change? What additional services are needed beyond your walls?
2. Access: How quickly can patients be seen?
3. Teams: How do clinical/non-clinical staff communicate & collaborate? Outreach team?
4. Needs: How are the health needs of homeless populations being communicated to policymakers?
+5 Administrative Questions
1. Billing: Is it maximized, do systems need to be upgraded, do staff need to be (re)trained?
2. Filling gaps: What other services/resources are needed, and how are these needs being communicated to state policymakers?
3. Managed care: How will a transition from block grants impact service delivery/staffing?
4. Additional personnel: How can you increase clinical & support staff (e.g., case managers, outreach workers, billing specialists, etc.)?
5. Technical Assistance: Are you reaching out to your PCA and/or the National HCH Council if needed?
+Health Centers: The Bus
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+Health Center Expansion $11 billion in new funding (in addition to
annual funding) + creation of Trust Fund
Funding for New Services and Locations: $9.5 billion total FY2011: $1 billion (final: no increase) FY2012: $1.2 billion (final: +$200M) FY2013: $1.5 billion (final: TBD)
FY2014: $2.2 billion (final: TBD)
FY2015: $3.6 billion (final: TBD)
Funding for New Buildings: $1.5 billion totalHealth Care & Housing Are Human
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Largely depends on related Congressional decisions
HCHs get 8.7% of funding!
+What To Do With $11 Billion?
National goal: Increase patients by 10 million
20 million 30 million by 2015
New health center sites
Expanded services
Capital projects
= Full range of new jobs in public and private sector
* California’s 121 health centers employed 22,188 FTEs in 2011.
+Selected Grant Rounds To Date
New Access Points
Round 1 (October 2010): 143 grants
Round 2 (August 2011): 67 grants
Round 3 (June 2012): 219 grants
Capital Grants (May 2012)
Small: 227 grants ($99M)
Large: 171 grants ($629M)
California received 63 (15%)
California received 63 (16%)
+Service Capacity: Conduct Needs Assessments Should contain goals, objectives,
measurable outcomes, data sources, timelines
Who will you serve and what do they need?
Who is homeless in your local area?
What are the most prevalent health care and social service needs?
Who is un-served or underserved?
Who are the key service providers?
+Target Population: Needs Presenting Needs
Primary care Oral health Behavioral health Specialty care Housing (full continuum) Medical respite care Employment Transportation
+Key Relationships Local hospital Discharge planning sources Referral sources Emergency responders – police & fire Jail administrators Political leaders Shelter and housing providers All health care providers Business community Continuum of Care
+ Resources to Meet Needs
Who provides the services in each area of identified need, and how will health care reform impact them?
How will the state of the current economy impact any of these service providers?
What are the greatest service gaps?
What is your role in filling them?
What collaborations/partnerships are possible?
How are needs being communicated to state/county policymakers?
+Finances
New revenue as a result of Medicaid expansion Ensure smooth billing/collection systems
This is the time to replace/update!
Revisit policies and procedures Implement process for collecting, organizing
and tracking key financial performance data Conduct an internal audit Ensure nothing is left on the table
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+Consumer Input
How are you obtaining consumer feedback? Consumer board members? A Consumer Advisory Board (CAB)? Focus groups? Consumer satisfaction surveys?
This is valuable perspective on your operations
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+Governance
Does your board understand the benefits and challenges of health care reform?
Has your board adopted a new strategic plan? Specific needs of homeless patients
included?
How can board members use their community relationships to further goals?
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+Workforce: The Bus Driver
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+Workforce Development
$1.5 billion for National Health Service Corps
Scholarships, loan repayments Primary care physicians, family nurse
practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and certain mental health clinicians
http://nhsc.hrsa.gov/ Health Center-based residency programs
(e.g., “teaching health centers”)
Increases to Medicaid provider payments: 2013-2014, raise to Medicare rate level
+Challenges to Capacity
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Too many new patients on top of already large number of patients at health centers
Unemployment, housing costs and other factors increasing number of people using assistance programs
How do we prepare for meeting patient needs?
+One Challenge: Behavioral Health Service Capacity for Newly Medicaid Eligible
Condition U.S. California
Serious Mental Illness
7.0% 4.4% (108,393)
Serious Psychological Distress
14.9% 10.4% (256,202)
Substance Use Disorders
14.2% 10.3% (253,738)
Source: SAMHSA, National & State Estimates on Prevalence of Behavioral Health Conditions. Available at: http://www.samhsa.gov/enrollment/states.aspx.
+Another Challenge: Provider Willingness to Participate
96% physician practices accepting new patients
31% were unwilling to accept new Medicaid patients
Smaller practices less likely than larger ones
Urban areas less likely than rural areas Higher Medicaid fees = greater
acceptance of new patients
Source: Decker, S. (August 2012). In 2011, Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs 31 (8): 1673-1679.
+Workforce Provisions and Planning Are there enough primary care & behavioral health
providers?
Are there enough case managers & benefits coordinators?
Is current workforce burned out? Properly trained?
How can national and state provider assistance programs be maximized?
How can volunteer clinicians be used?
How are clinical residents being trained to work with vulnerable populations?
How can work with homeless population be promoted in professional schools?
+Care Delivery Models: Bus Maintenance
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+Care Delivery Models Ultimate goals:
Improve access Increase quality Decrease cost
Emphasis on collecting data, eliminating disparities, improving systems, creating efficiencies
Focus on TEAM: includes both clinical and non-clinical members
Data sharing, electronic health records are key
Models will influence finance and staffingHealth Care & Housing Are Human
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+Care Delivery Models Renewed focus on coordination and
integration of services
Integrated care Access Services Funding Evidence-based practices Data
Patient-Centered Health Homes
Accountable Care OrganizationsHealth Care & Housing Are Human
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+Action Steps: What to do NOW
Educate clients, staff, family, friends…everyone Hold site visit/meeting with:
Your state’s Medicaid director & health reform lead Your PCO/PCA Your state and local health officer & local DSS director Legislative leadership for health issues
Attend health reform stakeholder meetings Ensure strong strategic plan/needs assessment is
in place Form PCMH workgroup internally Partner with your fellow service providers
(shelters, behavioral health care, others)
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+One Key Event
November 6, 2012 Voter turnout in 2008 Election
<$10,000: 41% $50K-$75K: 66% $150K+: 78%
Candidates have expressed clear views of future of ACA
How is your organization participating in voter registration activities?
+Voting in California
Must be a citizen or legal resident over 18 years
Must not be in prison or on parole for a felony
Must have photo ID to register and vote
Registration deadline: 15 days prior to election Monday, October 22, 2012
More information: www.vote411.org.
+Keeping an Eye on the Ultimate Goals Greater access to Medicaid hopefully translates into better health
Growth of health center services/locations = increased number of places to serve patients
Increased number of providers = easier access to care
Greater use of EHR and team models hopefully translates into better services
Better health + more resources = preventing and ending homelessness
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+More Information
The National Health Care for the Homeless Council is a membership organization for those who work to improve the health of homeless people and who seek housing, health care, and adequate incomes for everyone. www.nhchc.org
Additional health reform materials at: http://www.nhchc.org/healthcarereform.html
NHCHC offers free individual memberships at: http://www.nhchc.org/council.html#membership
Technical assistance available
Health Care & Housing Are Human Rights