Medical Safety Net for Children and Families Outline 11/18/2011

1. Medical Safety Net for Children and FamiliesOutline 11/18/2011 Barbara Wolfe

2. Issue: Gaps in Health and Access to Health Care.Primary Concern with Health Disparities • Definition of health disparities: “Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” First NIH Working Group on Health Disparities

4. Nonelderly’s Health Insurance Coverage by Family Poverty Level, 2009 Number 88.7 M 400% + 73.5 M 200% - 399% 46.9 M 100% - 199% 55.6 M Under 100% NOTES: Data may not total 100% due to rounding. The Federal Poverty Level for a family of four in 2009 was $22,050 (according to the U.S. Census Bureau’s poverty threshold). Family size and total family income are grouped by insurance eligibility. SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2010 ASEC Supplement to the CPS.

5. Measures of Access: No health care visits to an office or clinic within the past 12 months among children under 18 years of age, 1997-98, 2000–01 and 2006-07Discrepancy decreased most for poor • 1997-8 2000-1 2006-7 • Poor . . . . . . . . . . . . 17.6 17.3 14.3 • Near poor . . . . . . . 16.2 14.8 14.2 • 200-<400% . . . . . . 11.7 11.2 11.7 • 400%+ 7.4 7.7 7.5

6. War on Poverty Interventions: Public Subsidies • Supply side • Community Health centers • Subsidies to educate providers & attract to underserved areas • Subsidies to build facilities (1946 start) • Demand side • Subsidize insurance via tax system • Medicare for disabled • Medicaid for certain low income groups • CHIP for lower income children and in some cases parents

7. A bit of history about government role re supply side subsidies • Hill Burton or Hospital Survey and Construction Act of 1946 – goal – improve the supply, distribution and quality of general hospital beds in the U.S.; and possibly the distribution of physicians. • July 1947 – June 1971 central government invest > 4.6 billion in grants and 1.5 billion in loansconstruction, modernization of existing facilities. • Success? Usual measure - increasing number of beds. • Health Education Act of 1965 Perceive shortage; subsidize • Subsidy to institution such that if agree, agree to increase slots, • National Health Service – tiny until mid 1970s when begin to distribute scholarship funds in return for commitment of service to underserved area. • Neighborhood Health Centers CHCs – 1967 – enabling legislation

8. CHC-unique characteristics • Health centers are characterized by five essential elements that differentiate them from other providers: • They must be located in or serve a high need community, i.e. “medically underserved areas” or “medically underserved populations”; • They must provide comprehensive primary care services as well as supportive services such as translation and transportation services that promote access to health care; • Their services must be available to all residents of their service areas, with fees adjusted upon patients’ ability to pay; • They must be governed by a community board with a majority of members health center patients; and, • They must meet other performance and accountability requirements regarding their administrative, clinical, and financial operations.

9. National Health Service Corps (NHSC) • The National Health Service Corps (NHSC) created at time of health care crises • Rural areas and inner-city neighborhoods could not get providers: offered lower compensation, less interaction with other professionals, and few job opportunities for spouses. • Rural communities lacked resources to provide the technologically sophisticated facilities that many physicians desired. Rural states appealed to Congress for help thus establishing what is now known as the National Health Service Corps. The National Health Service Corps (NHSC) provides financial assistance to health professionals in exchange for providing health care services in designated underserved areas known has Health Professional Shortage Areas (HPSAs). There are three categories of health professional shortage areas: medical, dental and mental health. • Based on a list compiled by the Office of Shortage Designation to determine health professional shortage areas. Administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) • NHSC Loan Repayment seeks clinicians dedicated to working with underserved. In order to participate in the NHSC Loan Repayment Program must find a facility or site that is 1) designated as a professional shortage area and 2) willing to hire them. • Primary care medical, dental and mental health clinicians may receive up to $170,000 for 5 years of full-time service; $60,000 for the minimum 2 years FT; or 4 years PT toward paying off loans.

10. National Health Service Corps (NHSC)extends beyond MDs to other health care providers • Loan repayment • Nursing education loan repayment program –get 60% of qualifying loan balance repaid for 2 yrs FT of service • Faculty Loan repayment- those from disadvantaged background serving in accredited university get $40,000+ tax benefit for 2 years of service • Scholarships • If commit to primary care can receive tuition, fees other ed costs and stipend tax free for up to 4 years if serve = # years in underserved area. • Nursing scholarship- RN program – receive tuition, fees other ed costs + stipend for min. 2 years service in facility with critical shortage of nurses. • Scholarships for Disadvantaged Students-need based competitive program • Loans-all needs based and competitive. • Disadvantaged students; Loans for Health Professions Students; Nursing Students, Primary Care (in participating school)

11. A bit of history about demand side interventions • Until 1935 assistance with medical care expenses generally done by ad hoc efforts by groups within communities to help some of the poor people living there. • The poor most likely to receive such help were people who might be termed deserving poor; i.e. not responsible for their poor status • children with physical and mental health problems, • pregnant women and infants, • the blind, and the elderly – • According to Swartz, the belief that state and local governments should have primary responsibility for decisions about providing health care to the poor can be traced back to this earlier age. • In 1935, the Social Security Act was passed. In addition to the trust fund providing pension benefits, the Social Security Act created federal grants to states for income assistance for poor elderly, dependent children and their mothers (what became Aid to Families with Dependent Children), the blind, and crippled children. These categorical grant programs provided federal funds on a matching basis to states that set up the aid programs and the states were in charge of administering the programs. States could set the income eligibility criteria --the precursor to the significant variation that now exists across states with Medicaid eligibility criteria. • In areas where public hospitals did not exist, welfare departments reimbursed private hospitals for care provided to recipients of the assistance –at rates below the hospital charges to private patients. The pattern of paying below market rates for care of the poor was continued when Medicaid was implemented three decades later.

12. Public Insurance: Medicaid's Milestones (re: eligibility) • July 30, 1965: The Medicaid program is enacted, to provide health care services to children from low-income families and their caretaker relatives--individuals eligible for Aid to Families with Dependent Children (AFDC), the federal welfare program. • 1996: The AFDC entitlement program was replaced by the Temporary Assistance for Needy Families (TANF) block grant. The welfare link to Medicaid was severed, and enrollment (or termination) of Medicaid was no longer automatic with the receipt (or loss) of welfare cash assistance. • Medicaid is: • Jointly funded by federal and state governments. • State-administered within broad federal guidelines. 25 mandatory eligibility groups. • States may elect to cover optional eligibility groups. More than 50 eligibility groups in all.

13. CHIP-newest public program designed to increase coverage of children. Passed in 1997 • Joint state federal plan giving states flexibility • Goal – increase coverage of low and moderate income children. Implemented as part of welfare reform. • Method – enhanced match by federal government • Great variability re eligibility, coverage, use of premiums, whether tied to Medicaid or separate.

14. Health Insurance Coverage of Children, 1988-2005 The percentage of children without health insurance has declined since SCHIP was Implemented in 1998. *Other includes private non-group and other public insurance. A change in the census questionnaire allowed this category to be separately identified starting in 2000. AS of 2008, 31% had Medicaid/Chip, 10% uninsured, 54% employer-based.

15. VA System • Targets those with injury while in service (priorities 1-4) priority 5-Veterans eligible for Medicaid & those with annual income or net worth below VA financial thresholds. ($29,402 if single for free care) • Provide outpatient and inpatient care • Major system engineering in 1994-5 • 2009 budget ~$88 billion; serve 23 million Veterans

16. Issues to be Discussed: • Thinking of PPACA what are the lessons to be learned from our experience with subsidies for medical care? • Trade-offs between cost of subsidized programs and success in increasing access • Tie between coverage and increasing or reallocating providers.