Over 1 Million Virginians Uninsured in 2010

1. Patient Protection and Affordable Care Act and Free ClinicsbyDebbie OswaltVirginia Health Care Foundation

2. “Although we are challenging the Patient Protection and Affordable Care Act, it is currently the law of the land and it would be irresponsible not to prepare for its implementation”. --Governor Bob McDonnellvia Virginia Secretary of Health and Human Resources Bill Hazel (August 2010)

3. Over 1 Million Virginians Uninsured in 2010 Total Nonelderly 1,004,000 uninsured nonelderly Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

4. +1.1% Points -0.3% Points +1.6% Points The uninsured rate for adults in Virginia increased between 2009 and 2010 % Point Change Note: Asterisks indicate a change in percent of people that is statistical significant at the .10 level. Source: Urban Institute, February 2012. Based on the 2009 and 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

5. VA Medicaid eligibility criteria lower than other states % FPL * Only 7 states cover non-disabled childless adults. Source: Heberlein, M., T. Brooks, S. Artiga, and J. Stephens. 2011. “Holding Steady, Looking Ahead: Annual Findings of A 50-State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost Sharing Practices in Medicaid and CHIP, 2010-2011.” Washington, DC: Kaiser Commission on Medicaid and the Uninsured.

6. Nearly 70 percent of uninsured Virginians live in families with at least one full or part-time worker in 2010 Share of Nonelderly Uninsured Notes: Family work status is based on the highest level of employment among the adults in the health insurance unit. Estimates may not sum to 100% due to rounding. Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS).Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

7. Just under half of the uninsured in Virginia were white, non-Hispanic in 2010 Share of Nonelderly Uninsured Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation. (E.L. Freeman)

8. Young adults (19-34) comprised over half (51.7%) of uninsured Virginians in 2010 Notes: Asterisks indicate a percentage that is statistically different from the reference group (Age 0-18) percentage at the .10 level. Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

9. A vast majority (89.2%) of uninsured Virginians lived at or below 200 percent of FPL in 2010 Total Nonelderly Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2010 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Source: Urban Institute, February 2012. Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS).Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

10. Major Medicaid Provisions of Federal Health Reform Source: DMAS November 2010

11. Change in health insurance coverage with PPACA Thousands of nonelderly Virginians Insured 5,888,000 Insured 6,414,000 Uninsured Uninsured Without reform With reform

12. Decline in uninsured persons by income group Uninsured Source: Urban Institute analysis, HIPSM 2011 *Note: We simulate provisions of the Affordable Care Act fully implemented in 2011.

13. Those left uninsured under reform N=515,000 Source: Urban Institute analysis, HIPSM 2011 *Note: We simulate provisions of the Affordable Care Act fully implemented in 2011.

14. Profile of Virginia Free Clinic Medical Patients • 63,884 in 2010 (50% treated in 13 free clinics) • Almost two thirds are 35-64 years of age • 70% have one or more chronic illnesses • An average of about 75% will be eligible for Medicaid in 2014 • Will vary among clinics

15. Assessing Local Impact of PPACA Medicaid Expansion: • Assess impact within clinic • Number of patients eligible for Medicaid in 2014 (income and citizenship) • Assess impact on Medicaid eligible free clinic patients • Acuity level of these patients • Nature of clinic’s relationship with these patients, i.e. a medical home? • Availability of Medicaid providers in area (taking new patients?) • See Free Clinic Planning Tool for help

16. What About Patients without Coverage in 2014? • Determine the number and nature of clinic patients not eligible for Medicaid • Estimate the number and nature of people within the clinic’s service area who are likely to remain uninsured post-PPACA implementation • See Free Clinic Planning Tool for help

17. PPACA Medicaid Expansion: Free Clinic Options • Maintain current free clinic business model • Current model, and allow Medicaid eligible at clinic, without charge • Transition to a “hybrid” model • In eligible areas of state: • Apply to become a Federally Qualified Health Center (FQHC) • Become an FQHC “Look-a-like” • Become a Rural Health Clinic • Transition eligible patients to Medicaid, help them find a provider, and close clinic

18. What Is a Hybrid Model? • Enables a free clinic to become a Medicaid provider, and maintain its “free clinic roots” and mission. • Provides medical care to low income patients (uninsured and Medicaid) • Utilizes paid providers, often supplemented with volunteers (providers and otherwise) • Charges fee for services on a sliding scale, which can allow for free care for lowest income patients

19. Examples of Hybrid Models Good Samaritan Health Center (Atlanta, GA) • Large urban clinic, 93% uninsured, and 7% Medicaid/Medicare • 19,000 volunteer hours/year • Medical, dental, mental health services = 27,000 visits/year Doctors Care (Littleton, CO) • Free specialty care for 5 years added pediatrics (CHIP/Medicaid) 19-30 year olds (set fee or sliding scale) • Lots of volunteers (Family Practice residency program) • Medical services = 8,000 visits/year

20. Examples of Hybrid Models San Jose Clinic (Houston, TX) • Large 89 year old clinic, in process of becoming a Medicaid provider • 140 volunteer providers (specialists, resident programs), 200 lay volunteers • 42 staff • Medical, dental, mental health and pharmacy services = 30,500 visits/year Olde Towne Medical Center (Williamsburg, VA) • Large 20 year old clinic that became a hybrid early on • 500-600 hrs/mo of volunteer providers (more for dental) • Medical, dental and mental health services = 16,000 visits/year • Became a rural health clinic = 10% payment bump (Medicaid/Medicare)

21. Core Elements of Becoming a Hybrid Clinic • Clarity regarding mission and target patient population • Community understanding and support • Viable business plan • Determine mix and allocation of paid and volunteer providers • Adequate infrastructure • Electronic health record system • HIPAA compliant • Credentialing providers (contracted) • Billing capacity (in-house or contracted) • Administrative staff • Facility space

22. Summary • PPACA coverage expansions will cut the number of uninsured Virginians in half. • Many, including 75% of free clinic patients, will be eligible for Medicaid • About 289,000 Virginians ≤ 200% FPL will remain uninsured. (undocumented immigrants, those who can’t afford insurance) • This creates locality-specific opportunities and challenges for Virginia’s free clinics. • One option under consideration by a growing number of clinics is transitioning to be a hybrid clinic: • Blends paid and volunteer providers to treat low income patients (uninsured and Medicaid) • Requires thoughtful planning and sufficient infrastructure • Each free clinic must evaluate the impact of PPACA on its patients and community, in determining its future direction.

23. For more information visit: www.vhcf.org or contact: Debbie Oswalt Executive Director Virginia Health Care Foundation (804) 828-5804 doswalt@vhcf.org