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+ The Nuts and Bolts of Health Reform: What’s Important and What You Need + The Nuts and Bolts of Health Reform: What’s Important and What You Need to Do November 1, 2012 Barbara Di. Pietro, Ph. D. Policy Director National Health Care for the Homeless Council Health Care & Housing Are Human Rights

+ National Goals of Health Reform n Increase access to care n Improve health + National Goals of Health Reform n Increase access to care n Improve health outcomes n Lower costs to individuals n Reduce total spending n Improve quality of care Health Care & Housing Are Human Rights

+ The Affordable Care Act (ACA) n P. L. 111 -148 as amended by + The Affordable Care Act (ACA) n P. L. 111 -148 as amended by P. L. 111 -152 n 8 Major Components: n n n n 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 Health Care & Housing Are Human Rights

+ Current Status n n Over 2 years since legislation signed into law; major + Current Status n n 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 n Administration: Full speed ahead n Congress: Attempts to repeal, hinder, de-fund n Judicial: Supreme Court upholds law, makes Medicaid expansion optional Health Care & Housing Are Human Rights

+ +

+ Florida: No to Expansion? Really? n Election will change the conversation n Hospitals + Florida: No to Expansion? Really? n Election will change the conversation n Hospitals and insurers have vested interests n n n Reductions in DSH payments (opportunity & challenge) Powerful allies Many new customers in private markets n Poses moral & economic problem n Inconsistent with “pro-life” policies Health Care & Housing Are Human Rights

Nonelderly Health Insurance Coverage by Family Poverty Level, 2011 Number 400% + 90. 5 Nonelderly Health Insurance Coverage by Family Poverty Level, 2011 Number 400% + 90. 5 M 200% - 399% 72. 1 M 100% - 199% 47. 4 M Under 100% 56. 3 M 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. Florida UI children <139% FPL 4. 3 + Florida Health Insurance Disparities U. S. Florida UI 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%) 51% 42% % Private employers offering health insurance 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 NH VT WA MT MN OR Uninsured Rates Among Nonelderly by State, 2010 -2011 NH VT WA MT MN OR WY NV CA AZ MI PA IA NE IL CO KS NM TX OH VA TN RI MD NC DC SC AR AL NJ CT DE WV KY MS AK IN MO OK MA NY WI SD ID UT ME ND GA LA FL HI National Average = 18. 2% <14% Uninsured (13 states & DC) 14 to 18% Uninsured (20 states) >18% Uninsured (17 states) SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplement to the CPS (two-year pooled data).

+ Priorities for HCH Grantees Medicaid Expansion Health Center Expansion Workforce Expansion Care Delivery + Priorities for HCH Grantees Medicaid Expansion Health Center Expansion Workforce Expansion Care Delivery Models Parameters of Law; Opportunities & Challenges Health Care & Housing Are Human Rights

+ Medicaid Expansion: The Bus Pass Health Care & Housing Are Human Rights + Medicaid Expansion: The Bus Pass Health Care & Housing Are Human Rights

Medicaid Enrollees and Expenditures, FY 2009 Total = 62. 6 million Total = $346. Medicaid Enrollees and Expenditures, FY 2009 Total = 62. 6 million Total = $346. 5 billion 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.

+ Medicaid Expansion: Who Is Eligible? n n Currently eligible: children, pregnant women, those + Medicaid Expansion: Who Is Eligible? n n 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. n n About $15, 000/year for singles About $25, 500/year for family of 3 n Must be a U. S. citizen or legal resident here for at least 5 years n Some states have started expanding Medicaid already (in full or partial) n CA, CT, CO, DC, MN, MO, NJ, NM, WA Health Care & Housing Are Human Rights

Median Medicaid/CHIP Eligibility Thresholds, January 2012 Minimum Medicaid Eligibility under Health Reform - 133% Median Medicaid/CHIP Eligibility Thresholds, January 2012 Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25, 390 for a family of 3 in 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.

+ Medicaid Expansion Financing n Expansion group only: Higher federal match to states n + Medicaid Expansion Financing n Expansion group only: Higher federal match to states n n n n 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 Health Care & Housing Are Human Rights

+ Enrolling Many More People n Now: Medicaid has 60 million enrollees (1 in + Enrolling Many More People n Now: Medicaid has 60 million enrollees (1 in 5 people) n 2014: Expansion adds 13 -15 million new people (depending on outreach and enrollment) n n “Woodwork”: Could add 4 -5 million currently eligibleunenrolled Total: about 80 million people will have Medicaid (about 1 in 4 people) n Florida: n n n 1. 3 million newly eligible <138% 995, 000 newly eligible <100% FPL 257, 000 adults currently eligible-but-unenrolled

+ Easier Enrollment n Law requires fast, simple process using technology n Must coordinate + Easier Enrollment n Law requires fast, simple process using technology n Must coordinate Medicaid, state “Exchanges” and CHIP n NO Paper documentation needed n n 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 Health Care & Housing Are Human Rights

+ Facilitated by Technology Eligibility based solely on income n n n “Modified adjusted + Facilitated by Technology Eligibility based solely on income n n n “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. Health Care & Housing Are Human Rights

+ Applying for the New Medicaid n n Online applications (but can also do + Applying for the New Medicaid n n 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. n n “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 n Automatic renewal unless there’s a change Health Care & Housing Are Human Rights

Sources: 2011 UDS Data, HRSA 2011 Census data Sources: 2011 UDS Data, HRSA 2011 Census data

+ Florida UDS Data: Insurance Status • 2011: 44 health centers saw 1, 080, + Florida UDS Data: Insurance Status • 2011: 44 health centers saw 1, 080, 695 patients – 47% uninsured – 73, 105 homeless, or ~7% HCH Health Centers Camillus Health Concern I. M. Sulzbacher N. Broward Hospital District Pinellas County Number Patients/% Homeless % Uninsured 4, 027 / 90% 3, 713 / 100% 85% 100% 3, 238 / 100% 96% 2, 290 / 100% 99%

Patient Income: HCHs v. All Health Centers v. U. S. 90% HCH All Health Patient Income: HCHs v. All Health Centers v. U. S. 90% HCH All Health Centers U. S. 72% 60% 15% 14%* 6% 100% and below FPL Sources: 2011 UDS Data, HRSA State Health Facts (* Note: 101 -139%) 101%-150% FPL 2% 7% 11%* 151%-200% FPL 2% 7% Over 200% FPL

+ Those Remaining Uninsured n Law does not provide a “right to health care” + Those Remaining Uninsured n Law does not provide a “right to health care” n Estimate 30 million left uninsured in 2016 n Medicaid eligible (but not enrolled) n Undocumented persons n Individual Mandate: requires most people to get health insurance or face a penalty. n Medicaid counts toward the mandate n Penalty: $95 in 2014, $695 in 2016 — BUT… n Those not filing taxes are exempt from the penalty n Less than ~$10, 000/year in 2012 Health Care & Housing Are Human Rights

+ Those Exempt from the Mandate n Religious conscience (member recognized religious sect) n + Those Exempt from the Mandate n Religious conscience (member recognized religious sect) n Health care sharing ministry n Individuals not lawfully present n Incarcerated individuals n Individuals who cannot afford coverage/hardships n (>8% of household income) n Taxpayers with income below filing threshold n Members of Indian tribes n Months during short coverage gaps Health Care & Housing Are Human Rights

+ Those Remaining Uninsured: 37%: Medicaid-eligible but un -enrolled 25%: Undocumented/ineligible immigrants + Those Remaining Uninsured: 37%: Medicaid-eligible but un -enrolled 25%: Undocumented/ineligible immigrants

+ Outreach & Enrollment n Law requires states “establish procedures for outreach and enrollment + Outreach & Enrollment n Law requires states “establish procedures for outreach and enrollment activities to vulnerable & underserved populations” n n n n n 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 Health Care & Housing Are Human Rights

+ A Word on the State Exchanges n n n “Shopping center” for health + A Word on the State Exchanges n n n “Shopping center” for health insurance for individuals and small employers Must be implemented by January 1, 2014 Subsidies and credits, based on income -400% FPL) (100% n Focused on individual and small group markets n Must contain insurance with “Essential Health Benefits” n Anticipate covering 9 million in 2014 n 23 million in 2016 Health Care & Housing Are Human Rights

ACA Exchange Funds: Florida Type of Award Planning grant Establishment grant Early Innovator grant ACA Exchange Funds: Florida Type of Award Planning grant Establishment grant Early Innovator grant Total U. S. Florida $45, 008, 109 $0 $1, 881, 290, 492 $0 $126, 301, 945 $0 $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 Medicaid (0 -138% FPL) 100138% Exchange (100%+) Subsidies/credits: 100 + Eligibility Between Two Systems Medicaid (0 -138% FPL) 100138% Exchange (100%+) Subsidies/credits: 100 -400% FPL

Income Changes For Those Starting <133% FPL >133% 40% will have coverage disrupted in Income Changes For Those Starting <133% FPL >133% 40% will have coverage disrupted in first 6 months Temp >133%, and then below again Always <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).

+ Medicaid Expansion: Overcoming Challenges n Meeting increase in demand for services n Expanding + Medicaid Expansion: Overcoming Challenges n Meeting increase in demand for services n Expanding services and workforce n Balancing productivity & quality n Ensuring Medicaid & Exchange plans are coordinated n Identifying funding for service gaps and remaining uninsured n Maximizing billing, coding & IT system functioning n Participating in state-level decisions n Ensuring staff training across all teams, at all levels n Ensuring states choose to expand Medicaid Health Care & Housing Are Human Rights

+ 12 Reasons Why Medicaid Expansion is Critical 1. Improves access to care 2. + 12 Reasons Why Medicaid Expansion is Critical 1. Improves access to care 2. Improves financial stability 3. Improves health status/reduces mortality 4. Patient satisfaction is high 5. Improves local and state economy 6. Maximizes federal funding 7. Reduces current state spending 8. Reduces ER & hospital utilization 9. Ensures healthier workforce 10. Helps low-income veterans 11. Helps children & families 12. Reduces health disparities Health Care & Housing Are Human Rights

+ 4 Clinical Questions 1. Patients: How will volume and acuity change? What additional + 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 + 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 Care & Housing Are Human Rights + Health Centers: The Bus Health Care & Housing Are Human Rights

+ Health Center Expansion n n $11 billion in new funding (in addition to + Health Center Expansion n n $11 billion in new funding (in addition to annual funding) + creation of Trust Funding for New Services and Locations: $9. 5 billion total n n n FY 2011: FY 2012: FY 2013: FY 2014: FY 2015: $1 billion (final: no increase) HCHs get 8. 7% of funding! $1. 2 billion (final: +$200 M) $1. 5 billion (final: TBD) Largely depends on related $2. 2 billion (final: TBD) Congressional decisions $3. 6 billion (final: TBD) Funding for New Buildings: $1. 5 billion total Health Care & Housing Are Human Rights

+ n What To Do With $11 Billion? National goal: Increase patients by 10 + n What To Do With $11 Billion? National goal: Increase patients by 10 million n 20 million 30 million by 2015 n New health center sites n Expanded services n 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 Capital health center grants Health + ACA Health Center Funds: Florida Type of Award Capital health center grants Health center expanded services Immediate facility improvement Building capacity Health center quality improvement School-based health center grants Total Amount (as of FY 12) $35. 9 M $28. 5 M $3. 6 M $17. 8 M $1. 4 M $3. 1 M $90. 3 M 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 n Should contain goals, objectives, measurable + Remaining Competitive for Grants: Conducting Needs Assessments n Should contain goals, objectives, measurable outcomes, data sources, timelines n Who will you serve and what do they need? n Who is homeless in your local area? n What are the most prevalent health care and social service needs? n Who is un-served or underserved? n Who are the key service providers?

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

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

+ n n n Match Resources to Needs Who provides the services in each + n n n 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? n What is your role in filling them? n What collaborations/partnerships are possible? n How are needs being communicated to state/county policymakers?

+ Maximize and Fine-Tune Finances n New revenue as a result of Medicaid expansion + Maximize and Fine-Tune Finances n New revenue as a result of Medicaid expansion Ensure smooth billing/collection systems Ø Ø Ø 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 Health Care & Housing Are Human Rights

+ Ensure Consumer Input n How are you obtaining consumer feedback? n n n + Ensure Consumer Input n How are you obtaining consumer feedback? n n n Consumer board members? A Consumer Advisory Board (CAB)? Focus groups? Consumer satisfaction surveys? This is valuable perspective on your operations Health Care & Housing Are Human Rights

+ Involve Governance n Does your board understand the benefits and challenges of health + Involve Governance n Does your board understand the benefits and challenges of health care reform? n n Has your board adopted a new strategic plan? n n Are specific impacts for homeless clients understood? Are specific needs of homeless patients included? How can board members use their community relationships to further goals?

+ Workforce: The Bus Driver Health Care & Housing Are Human Rights + Workforce: The Bus Driver Health Care & Housing Are Human Rights

+ Workforce Development n $1. 5 billion for National Health Service Corps n n + Workforce Development n $1. 5 billion for National Health Service Corps n n 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”) n Increases to Medicaid provider payments: n n n 2013 -2014, raise to Medicare rate level U. S. average rate: 61% Florida: 50%

+ Challenges to Capacity n n n Too many new patients on top of + Challenges to Capacity n n n 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? Health Care & Housing Are Human Rights

+ Another Challenge: Provider Willingness to Participate n 96% physician practices accepting new patients + Another Challenge: Provider Willingness to Participate n 96% physician practices accepting new patients n 31% were unwilling to accept new Medicaid patients n Smaller practices less likely than larger ones n Urban areas less likely than rural areas n 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): 16731679.

+ Workforce Provisions and Planning n Are there enough primary care & behavioral health + Workforce Provisions and Planning n Are there enough primary care & behavioral health providers? n Are there enough case managers & benefits coordinators? n Is current workforce burned out? Properly trained? n n 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 Health Care & Housing Are Human Rights + Care Delivery Models: Bus Maintenance Health Care & Housing Are Human Rights

+ Care Delivery Models n Ultimate goals: n n n Improve access Increase quality + Care Delivery Models n Ultimate goals: n n n 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 n Data sharing, electronic health records are key n Models will influence finance and staffing Health Care & Housing Are Human Rights

+ Care Delivery Models n è Renewed focus on coordination and integration of services + Care Delivery Models n è Renewed focus on coordination and integration of services Integrated care Access è Services è Funding è Evidence-based practices è Data è è Patient-Centered Health Homes è Accountable Care Organizations Health Care & Housing Are Human Rights

+ Action Steps: What to do NOW n Educate clients, staff, family, friends…everyone n + Action Steps: What to do NOW n Educate clients, staff, family, friends…everyone n Hold site visit/meeting with: n n Your PCO/PCA n Your state and local health officer & local DSS director n n Your state’s Medicaid director & health reform lead Legislative leadership for health issues Attend health reform stakeholder meetings n Find/bolster the coalitions that do exist n Ensure strong strategic plan/needs assessment is in place n Form PCMH workgroup internally n Partner with your fellow service providers (shelters, behavioral health care, others) Health Care & Housing Are Human Rights

+ Key Advocacy Messages for Medicaid n Free for the first 3 years n + Key Advocacy Messages for Medicaid n Free for the first 3 years n A great deal after that n Medicaid saves money—for everyone n Good for the economy, creates jobs n Best coverage & most affordable for low-income folks n Saves lives, bolsters employment n Stabilizes families, makes better parents

+ One Key Event n n n November 6, 2012 Candidates have expressed clear + One Key Event n n n November 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 n n n Greater access to + Keeping an Eye on the Ultimate Goals n n n 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 Health Care & Housing Are Human Rights

+ More Information n n The National Health Care for the Homeless Council is + More Information n n 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 @Natl. HCHCouncil 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

+ More Information n Barbara Di. Pietro, Director of Policy n n n bdipietro@nhchc. + More Information n Barbara Di. Pietro, Director of Policy n n n [email protected] org @barbaradipietro Good source material available at: n n n 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 Health Care & Housing Are Human Rights