Implications for the affordable care act


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  • Private: new protections, exchanges, subsidies/tax credits Medicaid: expansion, demonstration projects Quality: Linking Medicare payments to outcomes, Data collection and reporting mechanisms, Strengthen Medicare Part D, access, payment accuracy, Medical home, care coordination models Chronic disease: Increase access to preventive services, Focus on prevention and creating healthy communities, Research and demonstration projects Workforce: Increase supply, support existing workers, Enhance education and training, Improve access, Emphasis on primary care Transparency: Requirements for reporting, making information available, Patient-centered outcomes research, Program improvements to Medicare, Medicaid, CHIP Revenue: Like taxes on tanning services
  • 100% 2014-2016, 95% 2017, 94% 2018, 93% 2019, 90% 2020+ The GOOD: Clients able to get comprehensive care Currently, 35 million on Medicaid (12%). In 2019, 51 million (18%) These are the conservative CBO estimates
  • 100% 2014-2016, 95% 2017, 94% 2018, 93% 2019, 90% 2020+ The GOOD: Clients able to get comprehensive care Currently, 35 million on Medicaid (12%). In 2019, 51 million (18%) These are the conservative CBO estimates
  • Permanently authorizes the health centers. After 2015, a funding formula based on cost and patient growth kicks in. Funding is in addition to existing discretionary funding ($2.2 billion in FY2010) Remember: HCH projects get 8.7% of funding allocated. That means $87 million new dollars this year.
  • Essentially doubles the health center capacity in 5 years to 40 million people nationwide (20 million new).
  • This is the time to map the Safety Net!
  • New and dedicated funding. FY 2010 allocation: $142 million. NEW WEBSITE FOR NHSC! Increases member awards to $50K (from $35K). Can fulfill service obligations by doing part-time clinical work (20 hours/week) Members in teaching health centers can count up to 50% of their teaching time to their service obligation. Teaching health centers: incredible opportunity for HCH programs to train next generation of physicians! Community-based ambulatory care center operating a primary care residency program. Includes FQHCs but may also include others. For such centers, there are new programs established to develop such centers using grant funds as well as a program to fund payments to teaching centers for direct and indirect costs for FQHCs that sponsor a residency program. No new protections for FTCA volunteers.
  • Implications for the affordable care act

    1. 1. +MCCH H.O.M.E.ConferenceImplications ofthe AffordableCare Act September 13, 2012 Barbara DiPietro, Ph.D. Policy Director National Health Care for the Homeless Council Health Care for the Homeless, Inc. of Maryland
    2. 2. + National Goals of Health Reform  Increase access to care  Improve health outcomes  Lower costs to individuals  Reduce total spending  Improve quality of care
    3. 3. + 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
    4. 4. + Current Status  2 ½ 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  November elections: Health reform a major issue
    5. 5. + Maryland’s Status  Stands as national leader, proactive implementation  Established Health Care Reform Coordinating Council  Conducts public hearings, uses open process  Staffs series of Advisory Committees  Implemented state Health Insurance Exchange  Involving safety net providers  Endeavoring to incorporate full range of needs
    6. 6. + Priorities for Low Income Populations Parameters of Law; Opportunities & Challenges
    7. 7. + Medicaid Expansion: The Bus Pass
    8. 8. + Medicaid Expansion: Who Is Eligible?  Currently eligible: children, pregnant women, disabled people, and some parents of children  Newly eligible (starting January 1, 2014): Law expands Medicaid to those 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
    9. 9. + Medicaid Expansion Financing  Expansion group only: Enhanced federal match to states  100%: 2014 through 2016  95%: 2017  94%: 2018  93%: 2019  90%: 2020 and thereafter  Current eligible groups: current federal match  Maintenance of effort: Prohibited from reducing Medicaid or CHIP eligibility, increasing premiums or enrollment fees, or otherwise cutting enrollment for mandatory groups/services* (pending further guidance as a result of the Supreme Court decisision)
    10. 10. + Enrolling Many More People  Now: Medicaid has 60 million enrollees (1 in 5 people)  2014: 15 million newly eligible  “Woodwork”: Could add 4-5 million currently eligible- unenrolled  Total: about 80 million people will have Medicaid (about 1 in 4 people)  Maryland: 167,000 newly eligible, 57,000 currently eligible-but-unenrolled  Montgomery County: 110,000 uninsured adults
    11. 11. + Easier Enrollment  Law requires fast, simple process using technology  Must coordinate Medicaid, state “Exchanges” and CHIP  Paper documentation will not be 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
    12. 12. + Facilitated by Technology  Eligibility will be based on income  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.
    13. 13. + 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
    14. 14. + Potential Use of Medicaid  Medicaid is highly flexible program, state-drive decision- making  Potential to fund services in permanent supportive housing (PSH)  Use ACA options  Health Homes  Home and Community-Based Services  Targeted services packages for special populations
    15. 15. Sources: 2010 UDS Data, HRSA2010 Census dataState Health Facts (* Note: 101-139%)
    16. 16. + Those Remaining Uninsured  Law does not provide a “right to health care”  Estimate over 30 million left uninsured in 2016  Medicaid eligible (but not enrolled): 30-50%  Undocumented persons: ~30%  IndividualMandate: 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 2012
    17. 17. CBO Trends in Uninsured (in millions)
    18. 18. + 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
    19. 19. + 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”  States will need to determine what additional benefits they cover (at state expense)  Anticipate covering 9 million in 2014  23 million in 2016
    20. 20. + Eligibility Between Two Systems 100- 138% (100%+) (0-138% FPL) Subsidies/credits: 100-400% FPL
    21. 21. + Medicaid Expansion: Our Challenges  Meeting increase in demand for services  Expanding services and workforce  Balancing productivity & quality of care  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 provider awareness  Ensuring states choose to expand Medicaid
    22. 22. + Health Centers: The Bus
    23. 23. + 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) Depends on Congressional decisions  FY2015: $3.6 billion (final: TBD)  Funding for New Buildings: $1.5 billion total
    24. 24. + What To Do With $11 Billion? National goal: Double the number of people served by CHCs  20 million  30 million by 2015 New health center sites = Full range of new jobs in Expanded services public and Capital projects private sector
    25. 25. + Service Capacity: Conduct Needs Assessments  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?
    26. 26. + Target Population: Needs  Presenting Needs  Primary care  Oral health  Behavioral health  Specialty care  Housing (full continuum)  Medical respite care  Employment  Transportation
    27. 27. + 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
    28. 28. + Resources to Meet Needs  Who provides the services in each area of identified need?  How will Health Care Reform, including Medicaid expansion, impact any of these service providers?  How will the state of the current economy impact any of these service providers?
    29. 29. + Resources to Meet Needs (cont’d)  What are the greatest gaps between Needs and Resources?  Are you in a position to address any of these gaps?  Could Health Care Reform help you to address any of these gaps either directly or in partnership with others?
    30. 30. + Workforce: The Bus Driver
    31. 31. + Workforce Development  $1.5 billion for National Health Service Corps  Health Center-based residency programs  Scholarships, loan repayments (primary care physicians, family nurse practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and certain mental health clinicians  School-based health centers  Increases to Medicaid provider payments
    32. 32. + 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?
    33. 33. + Workforce Provisions and Planning  Are there enough primary care and behavioral health providers?  Are there enough case managers and 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?
    34. 34. + Care Delivery Models: Bus Maintenance
    35. 35. + 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
    36. 36. + 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
    37. 37. + Action Steps: What to do NOW  Spread the word, promote accurate information  Hold site visit/meeting with:  Your state’s Medicaid director & health reform lead  Your state and local health officer & local DSS director  Legislative leadership for health issues  Conduct site tours  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)
    38. 38. + 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
    39. 39. + 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.  Federal ACA information website:  Maryland Health Reform Coordinating Council: Barbara DiPietro, PhD Director of Policy NHCHC & HCH 443/703-1346