health care & housing are human rights

+

Health Care & Housing Are Human Rights

The Nuts and Bolts of Health Reform: What’s Important and What You Need to Do

November 1, 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


+The Affordable Care Act (ACA) P.L. 111-148 as amended by P.L. 111-152 8 Major Components:

Private insurance reforms 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


+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 optionalHealth Care & Housing Are Human

Rights

+Florida: No to Expansion? Really? Election will change the conversation Hospitals and insurers have vested

interests Reductions in DSH payments (opportunity &

challenge) Powerful allies Many new customers in private markets

Poses moral & economic problem Inconsistent with “pro-life” policies


Nonelderly Health Insurance Coverage by

Family Poverty Level, 2011

56.3 M

47.4 M

72.1 M

90.5 M Number

Under 100%

100% - 199%

200% - 399%

400% +

NOTES: Data may not total 100% due to rounding. The Federal Poverty Level for a family of four in 2011 was $22,350 (according to the HHS poverty guidelines). SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.

+Florida Health Insurance Disparities U.S. FloridaUI children <139% FPL 4.3 million (16%) 318,400 (20%)UI children 139-250% FPL 1.8 million (12%) 145,700 (17%)

UI adults <139% FPL 20.2 million (42%) 1.6 million (53%)

UI adults 139-250% FPL 10.2 million (31%) 729,000 (35%)

UI in families with 1 FT worker 29.8 million (15%) 2.3 million

(20%)UI in families with 1 PT worker 7.5 million (31%) 559,600 (40%)

% Private employers offering health insurance

51% 42%Source: Kaiser Family Foundation, State Health Facts. Available at: http://www.statehealthfacts.org/profileglance.jsp?rgn=11

Uninsured Rates Among Nonelderly by State, 2010-2011

<14% Uninsured (13 states & DC)14 to 18% Uninsured (20 states)National Average = 18.2%

SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplement to the CPS (two-year pooled data).

AZ

WA

WYID

UT

OR

NV

CA

MT

HI

AK

AR

MS

LA

MNND

CO

IA

WISD

MOKS

TNNM

OK

TXAL

MI

ILOH

IN

KYNC

PA

VAWV

SC

GA

FL

ME

NY

NH

MA

VT

NJ

DEMD

RI

DC

CT

>18% Uninsured (17 states)

NE

+Priorities for HCH Grantees


Parameters of Law; Opportunities & Challenges

+Medicaid Expansion: The Bus Pass


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

+


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

Some states have started expanding Medicaid already (in full or partial) CA, CT, CO, DC, MN, MO, NJ, NM, 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)

+


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

+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) Florida:

1.3 million newly eligible <138% 995,000 newly eligible <100% FPL 257,000 adults currently eligible-but-unenrolled

+


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 based solely 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)

Automatic verification of income with the Internal Revenue Service (IRS).

Automatic verification of identity and citizenship/residency status with Social Security.


+


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: 2011 UDS Data, HRSA2011 Census data

+Florida UDS Data: Insurance Status

HCH Health CentersNumber

Patients/% Homeless

% Uninsure

dCamillus Health Concern 4,027 / 90% 85%I.M. Sulzbacher 3,713 / 100% 100%N. Broward Hospital District 3,238 / 100% 96%Pinellas County 2,290 / 100% 99%

• 2011: 44 health centers saw 1,080,695 patients– 47% uninsured– 73,105 homeless, or ~7%

Sources: 2011 UDS Data, HRSAState Health Facts (* Note: 101-139%)

+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

Rights

+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 gaps


+Those Remaining Uninsured

Remaining Uninsured:37%: Medicaid-eligible but un-enrolled25%: Undocumented/ineligible immigrants

+


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 2016Health Care & Housing Are Human

Rights

ACA Exchange Funds: Florida

Type of Award U.S. FloridaPlanning grant $45,008,109 $0Establishment grant $1,881,290,492 $0Early Innovator grant $126,301,945 $0

Total $2,052,600,546 $0

Source: Kaiser Family Foundation, State Health Facts. Available at: http://www.statehealthfacts.org/profileind.jsp?ind=964&cat=17&rgn=11

+Eligibility Between Two Systems

(0-138% FPL)(100%+)

Subsidies/credits: 100-400% FPL

100-138%

Income Changes For Those Starting <133% FPL

Always <133%

Temp >133%, and then below again

>133%

Source: Sommers & Rosenbaum (Feb. 2011). Issues in Health Reform: How Changes in Eligibility May Move Millions Back and Forth Between Medicaid and Insurance Exchanges. Health Affairs 30 (2).

40% will have coverage disrupted in first 6 months

+


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

+


12 Reasons Why Medicaid Expansion is Critical

1. Improves access to care2. Improves financial stability3. Improves health status/reduces mortality4. Patient satisfaction is high5. Improves local and state economy6. Maximizes federal funding7. Reduces current state spending8. Reduces ER & hospital utilization9. Ensures healthier workforce10. Helps low-income veterans11. Helps children & families12. Reduces health disparities

+4 Clinical Questions1. 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 Questions1. 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


+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

Rights

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

* Florida’s 44 health centers employed 6,356 FTEs in 2011.

+ACA Health Center Funds: Florida

Type of Award Amount (as of FY 12)

Capital health center grants $35.9MHealth center expanded services

$28.5M

Immediate facility improvement

$3.6M

Building capacity $17.8MHealth center quality improvement

$1.4M

School-based health center grants

$3.1M

Total $90.3M

Source: Kaiser Family Foundation, State Health Facts. Available at: http://www.statehealthfacts.org/profileind.jsp?ind=964&cat=17&rgn=11

+Remaining Competitive for Grants: Conducting 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?

+Identify Key Service Needs Primary care Oral health Addictions Mental health Outreach Specialty care Housing (full continuum) Medical respite care Employment Transportation

+Identify Key Relationships Local hospital Discharge planning sources Referral sources Jail administrators Political leaders Shelter and housing providers All health care providers Business community Emergency responders – police & fire Continuum of Care Local health officer/social services director

+ Match Resources to 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?

+Maximize and Fine-Tune 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


+Ensure 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


+Involve Governance Does your board understand the benefits and

challenges of health care reform? Are specific impacts for homeless clients understood?

Has your board adopted a new strategic plan? Are specific needs of homeless patients

included? How can board members use their community

relationships to further goals?

+Workforce: The Bus Driver


+ 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 U.S. average rate: 61% Florida: 50%

+Challenges to Capacity


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?

+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


+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 staffing


+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 Organizations


+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 Find/bolster the coalitions that do exist

Ensure strong strategic plan/needs assessment is in place

Form PCMH workgroup internally Partner with your fellow service providers (shelters,

behavioral health care, others) Health Care & Housing Are Human

Rights

+Key Advocacy Messages for Medicaid Free for the first 3 years A great deal after that Medicaid saves money—for everyone Good for the economy, creates jobs Best coverage & most affordable for low-

income folks Saves lives, bolsters employment Stabilizes families, makes better parents

+One Key EventNovember 6, 2012

Candidates have expressed clear views of ACA, Medicaid and Medicare (and safety net programs in general)

How is your organization assisting clients in voting?

+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


+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 @NatlHCHCouncil

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


+More Information Barbara DiPietro, Director of Policy

[email protected] @barbaradipietro

Good source material available at: Kaiser Family Foundation: www.kff.org HHS: www.healthreform.gov CMS: www.medicaid.gov Urban Institute: www.urban.org NACHC: http://www.nachc.com/healthreform.cfm


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