health care & housing are human rights

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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


+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


+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


+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

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.


+


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

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 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


+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


+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

* 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


+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


+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?


+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

+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?

+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


+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)

Health Care & Housing Are Human

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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


+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


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