America’s Health Centers: Yesterday, Today and Tomorrow

1. America’s Health Centers:Yesterday, Today and Tomorrow Presentation to 2006 Fall Conference Minnesota Association of CHCs Dan Hawkins National Association of Community Health Centers October 12, 2006

2. First, A Quick Check (-up) • How many have 3+ years with CHCs? • How many – 3+ PCA Annual Conferences? • 3+ NACHC Meetings (P&I, CHI, etc.)? • How many are CHC Advocates at NACHC? • A test: • What % of Minnesota CHC staff/Board members are CHC advocates today? • What % of those advocates typically respond to Action Alerts National Association of Community Health Centers - 2006

3. Brief History of Health Centers • Common Roots: Turn-of-Century Dispensaries, Milk Clinics, Public Health Reforms • Special Heritage: Civil Rights, War on Poverty Efforts to Address Needs of Poor & Minorities • Unique Public-Private Partnership: Resources Directly to Community-Owned Organizations • Health Centers: Two-Fold Purpose - • Be Agents of Care in Communities With Too Little of the Same • Be Agents of Change, Giving Communities Control of their Health Care System National Association of Community Health Centers - 2006

4. Brief History of Health Centers • Health Centers: Five Basic Characteristics - • Location in high-need areas • Comprehensive health and related services (especially ‘enabling’ services) • Open to all residents, regardless of ability to pay, with charges prospectively set based on income • Governed by community boards, to assure responsiveness to local needs • Held to strict performance/accountability standards for administrative, clinical, and financial operations National Association of Community Health Centers - 2006

5. Growth of Health Centers: 1970-2005 National Association of Community Health Centers - 2006

6. Accomplishments of Health Centers • Health Care Home for 16 Million Americans • 1 of 7 Uninsured Persons (6.4 million) • 1 of 9 Medicaid/CHIP Recipients (5.7 Million) • 1 of 4 Low-Income Children (5.9 million) • 1 of 5 Low-Income Births (400,000) • 1 of 9 Rural Americans (7.9 Million) • 10 Million People of Color, 750,000 Farmworkers, 700,000 Homeless Persons National Association of Community Health Centers - 2006

7. Location of Community Health Centers National Association of Community Health Centers - 2006

8. Accomplishments of Health Centers • Excellent Quality of Care: More Effective Care, Better Control of Chronic Conditions, Greater Use of Preventive Care, Fewer Infant Deaths • Major Impact on Minority Health: Significant Reductions in Disparities for Health Outcomes, Receipt of Preventive and Condition-Related Care • Higher Cost-Effectiveness: Lower Overall Costs, Lower Specialty Referrals and Hospital Admissions, Substantial Medicaid Savings • Significant Community Impact: Employment and Economic Effects, Contribution to Community Well-Being, Development of Community Leaders National Association of Community Health Centers - 2006

9. Recent Recognition of Health Centersby Key Government Agencies • IOM recommended health centers as THE model for reforming the delivery of primary health care (Rapid Advances in Health Reform) • GAO credited CHCs for Collaboratives success and recommended expanding them further • OMB ranked CHC program 1st among all HHS programs and one of the top 10 federal government programs for effectiveness National Association of Community Health Centers - 2006

10. Health Centers Provide One-Fourth of All Ambulatory Care for Uninsured… National Association of Community Health Centers - 2006

11. …But Millions of Americans Have No Regular Source of Care • 35 Million People Have No Regular Source of Care (not even a Health Center) • Half are Uninsured • 40 percent are Members of Minority Groups • In 13 states, they number More Than 1 Million • 47 Million People are Uninsured • Three-fifths are in Low-Income Families • One in 3 Latinos is Uninsured National Association of Community Health Centers - 2006

12. Major Challenges AffectingHealth Centers • Growth in Uninsured: Continue to be Largest and Fastest-Growing Group of Health Center Patients • Decline in Charity Care: Cutbacks by Private Providers Squeezed by Managed Care • Loss of Medicaid and Other Public Funding: Severe “Deficit Reduction” Cuts by States & now Congress • Changing Nature of Insurance Coverage: Growing Shift to Catastrophic/High-Deductible Plans that Cover Little or no Preventive/Primary Care National Association of Community Health Centers - 2006

13. Growth in Uninsured PopulationServed by Health Centers, 1990-2005 Percent Increase Uninsured Served by Health Centers (6.4 million; 128% increase since 1990) All Uninsured (47 million; 34% increase Since 1990) SOURCE: Data from 1996-2005 UDS; National estimates from Bureau of the Census. 1990 1995 2000 2005 National Association of Community Health Centers - 2006

14. NACHC’s Legislative Priorities for 2006 • Reauthorize Health Center ‘330’ law without change • Appropriate at least the President’s request for a $181 million increase in FY2006, plus increases for other key programs (eg, NHSC) • Medicaid reforms must not hurt people or safety net providers • State Flexibility must not violate Congressional intent toprotect FQHCs and preserve PPS Also, revise Medicare FQHC payment cap, make FTCA available for volunteers & emergencies, and allow CHC staff to have FEHBP coverage National Association of Community Health Centers - 2006

15. Reauthorization • What is it and why is it needed? • Core features: location in area of need, open to all, comprehensive services, community-owned and operated • Support for continuation & growth • Who wants to change it? • Non-community owned providers (faith-based, others) who want access to funding, FQHC, FTCA, 340B, VFC, etc. • What is the current status? • House passed straight reauthorization (HR 5573) 424-3; Senate action pending on similar bill (S 3771) National Association of Community Health Centers - 2006

16. Appropriations:Measuring Funding Results National Association of Community Health Centers - 2006

17. Medicaid: What Did Congress Do? • The Deficit Reduction Act (DRA) gives states broad new flexibility to re-shape Medicaid: • Benefit Flexibility:States can enroll most beneficiaries in private insurance programs, with fewer benefits [NOTE: The Deal amendment assures continued access to FQHCs and payment at PPS rates] • Cost-sharing: States can increase cost-sharing for all above-poverty beneficiaries, and can charge premiums & deductibles for the first time • New Waivers: States can set up “Health Opportunity Accounts” (HOAs), giving beneficiaries a fixed cash account for preventive/primary care, with back-up coverage only for catastrophic specialty or hospital care • It also requires states to verify the citizenship or legal status of all Medicaid applicants beginning July 1, 2006 National Association of Community Health Centers - 2006

18. State Flexibility: What Does it Mean? • States can now change their Medicaid programs without a waiver, and in most cases without legislative action • In most states, the Governor can change Medicaid without asking the legislature for approval • CMS is actively encouraging states to implement Medicaid reform, promising a quick review of State Plan Amendments • This means that there may be NO public notice or opportunity to review or comment on proposed changes before they’re approved • CMS is also encouraging states to apply for HOA and other waivers, promising quick review & approval also • Here, too, there may be little or no opportunity to review & comment on proposed waivers before they’re approved National Association of Community Health Centers - 2006

19. What is NACHC Doing About This? • NACHC has organized a special program of legal, technical, and advocacy assistance to PCAs, especially in ‘high-risk’ states • Developed & distributed special model state legislation to make sure that any state Medicaid changes are publicly disclosed and reviewed in state legislatures • Identified which of the 50 states currently have no legislative oversight of their Medicaid programs, and is providing legal & technical assistance to PCAs in these ‘high-risk’ states • Offering strategic advocacy assistance to all PCAs that request it • NACHC’s special Partnership for Medicaid will continue to fight for Medicaid’s future • The Partnership includes public & children’s hospitals, primary care and minority physician groups, nursing homes, the cities and counties, and other safety net providers • It has produced a series of proposals for making Medicaid more efficient & effective, without cutting current eligibility, benefits, or provider payment rates • Working closely with the HHS Medicaid Commission to influence its report to Congress, due at the end of 2006 National Association of Community Health Centers - 2006

20. Other Major Policy Issues • Increase the Medicare Payment Cap • 75% of all FQHCs affected, $51M+ in lost revenues • Can be fixed administratively, without legislation • Extend FTCA Coverage • Allow coverage across state lines in emergencies, and coverage for providers who volunteer to see patients • Allow CHCs to enroll employees in FEHBP • Multiple plans, excellent benefits, lower costs, but CHCs must pay employer share (75%) National Association of Community Health Centers - 2006

21. The Future – Our Vision • Grow health centers to become the health care home for all 51 million Americans who need a health care home (51/15/15) • Reform health professions programs to promote Primary Care careers, workforce diversity, and service to underserved via health centers • Preserve the Medicaid guarantee of coverage for low-income, elderly & disabled Americans National Association of Community Health Centers - 2006

22. The Future – Our Vision (cont’d) • Wire every health center for complete health information technology (HIT) • Lead the way to a high-performing health system, grounded in primary care • Play a central role in emergency preparedness, at the local & national levels National Association of Community Health Centers - 2006

23. How Health Centers Re-pay the Public Investment • They reduce hospital and ER use (5.8 fewer admits per 1,000; 13 - 38% fewer ER visits) for their patients • Their Medicaid patients cost 30 percent less than those served by other providers, saving Billions of $$$ • Their disparities collaboratives are found to reduce health disparities significantly for minority patients • They stand ready to serve more uninsured people with limited support (about $500 annually/person) National Association of Community Health Centers - 2006

24. Success (and Our Future) WillDepend on Strength of Advocacy • Advocacy is not just a clinical or social work act for individual patients, but a responsibility of leaders for their communities • Advocacy involves full participation in groups that support your cause (PCAs and NACHC) • This means organizational membership (dues support) • Also means active individual participation (grassroots advocacy with state/federal policymakers) National Association of Community Health Centers - 2006

25. Why Care About Advocacy? • Health centers: a remarkable record of achievement – open access, superior care, cost-effectiveness – we are part of the SOLUTION = BUT = • Not enough people know about us & our record • The challenges we face are daunting – = AND = • The only way we can win is to grow our Grassroots, (100,000 staff/Board members, 16 million patients), speak with one voice, make it count! National Association of Community Health Centers - 2006

26. What Can You Do to Help? • Sign up as a Health Center Advocacy Coordinator or as an Advocate (go to www.nachc.com for details) • By signing up, you will receive regular updates from NACHC and will be notified when action is needed • Get 5 colleagues/friends to do the same • Invite your Member of Congress and State legislators to visit your health center (especially during recesses, and National Health Center Week, August 5 – 11, 2007 – begin preparing NOW! • Send the message that health centers are part of the solution, and ask them to support our efforts to do even more! • Join the National Association of Community Health Centers and Your State & Regional PCAs National Association of Community Health Centers - 2006

27. NACHC Resources • Visit our improved, expanded web site… • for more information on all issues, • for the latest on federal & state policy developments, • to sign up as an advocate and send a message to your Members of Congress on key Health Center issues Address is: www.nachc.com National Association of Community Health Centers - 2006