Health Care Reform: Legislative Choices Affecting Virginians

1. Premier Mental Health, Developmental , and Substance Use Disorders Services in Virginia’s Communities Health Care Reform: Legislative Choices Affecting Virginians December 13, 2012 Mary Ann Bergeron VACSB

2. All The News! • Ruling of the Supreme Court on the ACA leaves the ACA intact • Insurance and payment reforms will continue • Health Benefits Exchange will level the insurance market for low income people and small businesses • Medicaid Expansion is now a choice left to States

3. If Virginia Expands Medicaid Expanding Medicaid poses serious but resolvable implementation challenges Health care workforce can grow with stable jobs Shift to person-centered care, payment reform for outcomes, and, ultimately, prevention Medicaid reimbursements can free state funds for vital housing, supports, and other wrap-around needs Behavioral health coverage is given a major boost and lessens stigma Recovery and independence promoted

4. Virginia’s Legislative Challenge Adopt “business as usual” (no expansion) strategy that shrinks health care and related resources, including the health workforce, in and for Virginia’s communities, and continues the expensive crisis-orientation in place. OR Use expansion to implement reform that builds communities and stronger, responsive health systems, cultivates health care workers, prevents and intervenes early before acute and extreme treatments are necessary, and stimulates local economies 4

5. Currently • 1,000,000 Virginians are uninsured, an estimated 36% with behavioral health disorders • Free Clinics, FQHCs, ERs, and CSBs, as safety net providers, have capacity limitations in current environment • Hospitals providing charity care receive $86 M in federal DSH payments per year, often helping with diversion from state psychiatric hospitals • Lack of behavioral health diversion services shifts behavioral health costs of 27% of inmates with mental illness to local jails • Cost of untreated substance use is $1 B in Virginia

6. Also, In Virginia Of over 134,000 unduplicated individuals with significant behavioral health conditions served by CSBs in FY 12, approximately 30% were uninsured Limited local and state psychiatric beds are stretched with local crises-many due to lack of adequate, available behavioral health services Gaps in critical behavioral health services exist in every community Virginia Health Information Network reports from local hospitals indicate that psychiatric crises are among the top 10 reasons for ER visits

7. CSBs and Services Mandated to provide 24/7 Emergency Services and case management State policy and funding decisions direct CSBs to serve those with the most significant disabilities Capacity to serve others less impaired is limited or unavailable Population of individuals with serious mental illness (SMI) experience major health disparities, often because of the very medications that assist in controlling symptoms of SMI. Psychiatry, medication, case management, intensive services and wrap-around supports are typical services

8. Individuals and Services-FY 12 232,627 individuals served (unduplicated), many in long term situations due to the severity of the condition 113,552 in mental health services 36,743 in substance use disorders services (SUD) 20,562 in developmental services 15,676 infants and toddlers with disabilities 46,094 in services of a more temporary nature Another 1.7 M youth and families served in prevention activities/effective parenting

11. Integrated Health Home Models 9 ANLOL projects involve 13 CSBs and community safety net providers One project, Arlington and Alexandria CSBs and ANSHI, received the only federal Innovation Grant so far in Virginia to continue primary care for SMI clients and expand to those with SUD 11 additional CSBs have developed or are developing health homes for clients with SMI and/or Substance Use Disorders (SUD)

12. Why Health Coverage Matters • Uninsured have no regular source of care beside hospital ER and/or safety net providers/CSBs • Uninsured go w/out screenings and preventive care and likely diagnosed with advanced stages of disease • Uninsured adults die 25% earlier • Uninsured charged up to 2.5 times more for medical care • Behavioral health needs often reach emergency proportion before attention given

13. Vision of the ACA • More universal access to health care, including behavioral health care • Defined benefits for specific services chosen by each state and a Health Benefits Exchange to facilitate purchases • Person-centered care rather than provider or payer-centered care-helps instill personal responsibility for health

14. Vision of ACA • Payments for Health outcomes rather than volume of services • Shift to disease prevention, early intervention/treatment and wellness • ACA Enacted Reforms: -Children with pre-existing conditions retain insurance-vital for DD/ID -Young adults remain on family policies -Medicare recipients eligible for covered preventive care

15. ACA is Critical for Behavioral Health • Mandated mental health and substance use services in essential health benefits-landmark for consumers with behavioral health conditions • Mental health and substance use disorders services to be in parity with medical services • No insurance denial for pre-existing conditions, including psychiatric or addictive conditions • No life time limit on psychiatric care • Behavioral health site can be health home choice

16. Key Decision Points for 2013 Session • Medicaid Expansion January, 2014 for 420,000 uninsured Virginians to 138% of FPL • 30,000-40,000 are existing CSB clients • Behavioral health services in Essential Health Benefits will be reimbursed • Until 2017, payment is 100% federal share • Phase-in State match to 10% in 2020

17. Benefits of Medicaid Expansion Medicaid expansion to 138% can mean up to 40,000 existing CSB clients would have essential health benefits coverage, decreasing crisis and acute episodes Medicaid expansion for 420,000 Virginians is estimated to bring $29 Billion to Virginia’s communities in health care reimbursements For your community, this translates to stable jobs in health care and related activities and increased consumer spending now and in the future Localities and citizens can benefit from improved access to health care, stimulated economies, increased consumer spending and growth of local and state tax base 17

18. If No Expansion? Current economic situation may worsen and public funding shift to other priorities Safety net providers in communities will bear the pressure, probably more than now We will keep competing for same piece of the shrinking state pie How attractive/stable will jobs in health care be? USA may not get to the vision of a healthy nation that can compete in the future global market

19. What is Being Said? Too many unknowns to go forward Other states like California, Oregon, Maryland, Massachusetts are expanding now How will the federal government pay for this? The ACA contains the payment sources Let’s Block Grant for flexibility Virginia is 47th in nation for Medicaid per capita-unwise to block grant, especially now!

20. What CSBs Know The populations we serve and their demographics The services that work and produce good outcomes for these populations That outcomes can be measured in in community tenure (avoiding jail, crisis, and hospitalization), recovery and well-being, employment, and improved health and quality of life *We are working on the costs of services-a critical piece to know 20

21. Health Reform Will: • Align/re-align incentives for care in community • Use bundled rates rather than FFS to produce health outcomes • Reward person-centered effective care rather than volume –safety net providers are experts! • Engage individuals in person-centered care because their outcomes really matter • Upgrade and use IT to improve outcomes and get paid • Make IT and services customer friendly!

22. CSBs Will Make Choices Expand to meet demand, find new partners, and/or build on current partnerships to create health homes at CSB site or with other providers at their sites Teach/collaborate with other providers in use of behavioral health services and maximize and expand capacity of scarce staff Integrate primary, behavioral, and acute care in partnerships-ANLOL projects can be models for health homes and/or behavioral health homes Help create person-centered “accountable care” in communities with community partners Use technology to make decisions and to support decisions

23. If No Medicaid Expansion A “business as usual” decision continues the current lack of health care for thousands of Virginians, especially those with behavioral health needs Hidden and obvious costs of substance use disorders will continue to rise Economic and health issues in communities persist and can result in fewer health workers, fewer stable jobs, more crisis-orientation and expensive treatment Hospitals lose DSH payments-will General Funds make up the difference? Health costs and health premiums rise with no discernable benefits to communities

24. Action Steps To Take NOW Work with your local CSB to know what your local expansion numbers are and what health coverage expansion will mean in your community for community health, to your local hospital, to the local economy! Use the data to educate local legislators about impact and to advocate for health reform and Medicaid expansion with your General Assembly members-NOW-don’t wait till the Session is underway.

25. Operational Steps NOW Know your “niche’ areas and strengthen them Assess your relationship with the local CSB and strengthen it Know your clients’ behavioral health needs and how those needs impact their primary care What other partners do you need for “Accountable Care”? 25

26. And Now Questions! 26

27. Thank You! Mary Ann Bergeron, VACSB mabergeron@vacsb.org www.vacsb.org 804.330.3141