Mark R. Cruise, MDiv, Principal Free Clinic Solutions

1. Obligations, Opportunities and Pitfalls: A National Perspective on the Free/Charitable Clinic Sector in the Reform EraStatewide Meeting of Tennessee’s Charitable ClinicsMay 30-31, 2013Nashville Mark R. Cruise, MDiv, Principal Free Clinic Solutions

2. National firm, established in 2006 in Richmond, VA and now based in St. Petersburg, FL • Provides full-service consulting, training and technical assistance, research, health policy analysis, and planning facilitation • Exclusively serves free/charitable clinics, their associations, and partners and vendors who support them • FCS consultants have extensive experience in free/charitable clinics and the health care safety net • 70+ organizations served since inception About Free Clinic Solutions

3. March 2010 October 2010

4. Health Care Reform in America

5. ACA Has Sparked Many Reactions and Responses in Our Sector

8. ACA is the most significant public policy development our sector has ever faced • ACA stands to reduce the non-elderly uninsured population from 18.9% to 8.7% in the U.S. , and thus make a major dent what has been our sector’s single greatest raison d’êtres • There are no mandates, but if free/charitable clinics are “gap-fillers” (Julie Darnell), what will be the new gaps clinics tackle post ACA? • But we have a big problem… The ACA and Free/Charitable Clinics

9. Those who have previously supported our clinics (e.g. donors, funders, volunteers, and partners) are starting to abandon our cause because they are assuming the ACA will eliminate the need for our clinics, and they are not hearing any messages from us to the contrary. OUR BIGGEST PROBLEM!!

10. OBLIGATION #1:Make Sure Your Supporters Know There’s Still a Need for Your Clinic and You Are Not Closing Your Doors

13. Many are asking about the future of our clinic in light of the Affordable Care Act. As with other health care organizations, we have sought to understand the Act – its provisions, its implementation in our state, and its likely impact on safety net providers and those they serve. We have concluded that for the foreseeable future thousands of residents in our community will continue to lack access to affordable health insurance and health care. Thus the demand for our clinic and others like it remains substantial. If you would like more information about our analysis of this issue, please let us know. Your continued support is much appreciated! Sample Statement (for website homepage, newsletters, presentations, annual reports, etc.)

14. OBLIGATION #2: Plan to Be Part of ENROLL-o-rama! o-rama: suffix meaning "spectacular display or instance of," 1824, abstracted from panorama, ultimately from Greek horama [ὅραμα] "sight."

15. If Insurance Makes a Difference, We Need to Get People Enrolled! • Uninsured adult Americans are more than twice as likely to delay or forgo needed care compared to adults with health insurance. • Uninsured adult Americans are nearly twice as likely to be in poor health compared to adults with health insurance. • Uninsured adult Americans are three times more likely to not be able to pay for basic necessities because of their medical bills compared to adults with insurance. Source: Kaiser Commission on Medicaid and the Uninsured, 2010

17. Source: Enroll America, 2013

18. Source: Enroll America, 2013 18

19. If history is any guide, the free/charitable clinic sector will play a vital role in helping people get enrolled in the newly-available coverage • Examples are S-CHIP (State Children’s Health Insurance Program) in mid 1990’s and Medicare Part D in mid 2000’s • In various parts of the country, some in the sector got funding to pay for this service Coverage Expansions and Enrollment Assistance by Free/Charitable Clinics

20. OBLIGATION #3:Consider the Remaining Uninsured Who Will Be Left Behind by the ACA!

21. 1 in 10 U.S. Residents Will Still Be Uninsured Following Implementation of the ACA Source: Congressional Budget Office

22. Individuals Exempt From the Mandate • Those whose required contribution to self-only coverage in a health insurance plan exceeds 8% of household income • Those whose household income is less than the filing threshold for federal income taxes for the applicable tax year • Undocumented immigrants and those who have been naturalized for 5 years or less • Those without coverage for less than three months (“churn”) • Those with qualifying religious exemptions • Those who are part of a health care sharing ministry • Members of an Indian tribe • Incarcerated individuals

23. Source: Avalere State Reform Insights, May 14, 2013

24. Subsidies and cost-sharing for people between 100-250% FPL will be more generous than for those between 250-400% FPL • Penalty taxes (for not buying health insurance) are very nominal in the beginning: • $95 or 1% of income in 2014 • $325 or 2% of income in 2015 • $695 or 2.5% of income in 2016 • Increases with cost-of-living starting 2017 Why Some People Will Choose to Pay Penalty and Remain Uninsured Initially

25. Distribution of the Uninsured After ACA pre-SCOTUS rulings Source: Robert Wood Johnson Foundation, 2011

26. How Many People Will Benefit from the ACA in Your Community, and Who Will be Left Behind? That sure would be good to know right now, as well as who the remaining uninsured will be and what their demographic profile is.

28. Some of the Uninsured Will Be Those in the “Churn” • Within six months, it is estimated that nearly 40 percent of adults under 133% FPL will experience a disruption in their Medicaid coverage due to changes in income or family composition. • After 12 months, 38 percent would no longer be Medicaid-eligible, and an additional 16 percent would lose and regain Medicaid coverage. After four years, only 19 percent of adults would be continuously eligible for Medicaid. • Among adults with incomes between 133 and 200 percent FPL who would be eligible for premium subsidies under the ACA, only 31 percent would remain continuously eligible for subsidies over four years, and many would have experienced multiple disruptions in coverage. Source: Benjamin D. Sommers and Sara Rosenbaum, Health Affairs, 2011

29. OBLIGATION #4:Make Sure Your Board Governance is Positioned to Address Strategic Issues in the ACA Era

31. As Health Care Reform Implementation Unfolds, Effective Clinic Boards… • Ensure that their governance process allows them to focus more on the strategic than the tactical • Actively solicit information and expert analysis on the implications of ACA on the community, the clinic, and its patients • Engage in meaningful dialogue with other community stakeholders and decision-makers • Make careful, informed judgments and decisions about changes in future purpose and role

32. OBLIGATION #5:Commit to Whole-Person Care and Health Improvement

33. Whole Person Care The whole-person approach does not depend on the bio-medical model alone but seeks to integrate the best from the bio-medical approach with social science, psychology and other appropriate models of humanity, including spirituality. Illness = disease + person

35. Determinants of Health Source: World Health Organization, 2009

37. IMPLICATIONS FOR CLINICS • Integrate an emphasis on weight loss, healthy eating, and overall fitness into the clinic delivery system • Develop partnerships with local fitness trainers and facilities (e.g. YMCA) to facilitate patient access to programs • Build, model, and reinforce a culture of health, weight control, and fitness among clinic staff and volunteers Church Health Center - Wellness Center Memphis

38. OBLIGATION #6:Help Develop the Next Generation of Primary Care Providers

39. Source: U.S. Senate Sub-Committee on Primary Health and Aging, 2013

40. TN IS 20th WORST PREPARED STATE IN TERMS OF NUMBER OF PRIMARY CARE PHYSICIANS TO TREAT NEW MEDICAID ENROLLEES UNDER HEALTH CARE REFORM Source: George Washington University, 2011

41. Primary Care Training • Partner with medical schools, residency programs, and other health professional training programs • Offer your clinic for community health rotations, internships, preceptorships • Understand that an investment in education and training will take time today but pay dividends in the future

42. CCHF is a community of Christian healthcare professionals and students who are committed to living out the gospel through healthcare to the poor

43. OPPORTUNITY #1:Develop and/or Expand a Dental or Vision Program

45. URL: http://freeclinicstoday.org/libraries/types/1/87

46. OPPORTUNITY #2:Participate in Community Health Needs Assessments with Your Not-for-Profit Hospital Partners

47. Not-for-Profit Hospitals and Community Health Needs Assessments • Per ACA, not-for-profit hospitals must conduct a community health needs assessment every three years; must include individuals with community health expertise (that’s you!) • Every year hospital must report results on their Form 990 • Free/charitable clinics can help hospitals address unmet CHNA goals and meet community benefit requirements

48. OPPORTUNITY #3:Focus on Creating Integrated Systems of Care

49. Smart communities are realizing that, in the post health care reform era, it is not just about building bigger and better safety net organizations but rather planning and executing an organized, rational, coordinated system of care for vulnerable populations.