Health Care & Housing Are Human Rights

1. The Nuts and Bolts of Health Reform: What’s Important and What You Need to Do September 7, 2012 Barbara DiPietro, Ph.D.Policy Director National Health Care for the Homeless Council Health Care & Housing Are Human Rights

2. National Goals of Health Reform Increase access to care Improve health outcomes Lower costs to individuals Reduce total spending Improve quality of care Health Care & Housing Are Human Rights

3. The Affordable Care Act (ACA) P.L. 111-148 as amended by P.L. 111-152 8 Major Components: Private insurance reforms (includes Exchanges) Medicaid reforms Quality improvements Prevention of chronic disease/public health Strengthening health care workforce Improve transparency and accountability Improve access to medical technologies Revenue provisions Health Care & Housing Are Human Rights

4. Current Status Over 2 years since legislation signed into law; major provisions not active until 2014, but there’s so much to do! Mixed public awareness of ACA content & impact; myriad of philosophical viewpoints Administration: Full speed ahead Congress: Attempts to repeal, hinder, de-fund Judicial: Supreme Court upholds law, makes Medicaid expansion optional Health Care & Housing Are Human Rights

5. Priorities for HCH Grantees Parameters of Law; Opportunities & Challenges Health Care & Housing Are Human Rights

6. Medicaid Expansion: The Bus Pass Health Care & Housing Are Human Rights

7. Medicaid Enrollees and Expenditures, FY 2009 NOTE: Percentages may not add up to 100 due to rounding. SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64. Total = 62.6 million Total = $346.5 billion

8. Medicaid Expansion: Who Is Eligible? Currently eligible: children, pregnant women, those disabled, and some parents of children Newly eligible (starting January 1, 2014): Law expands Medicaid to non-disabled adults at or below 138% FPL. About $15,000/year for singles About $25,500/year for family of 3 Must be a U.S. citizen or legal resident here for at least 5 years 8 states have started expanding Medicaid already (in full or partial) CA, CT, CO, DC, MN, MO, NJ, WA Health Care & Housing Are Human Rights

9. Median Medicaid/CHIP Eligibility Thresholds, January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012. Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25,390 for a family of 3 in 2012)

10. Medicaid Expansion Financing Expansion group only: Higher federal match to states 100%: 2014 through 2016 95%: 2017 94%: 2018 93%: 2019 90%: 2020 and thereafter Current eligible groups:Current federal match (“FMAP”) Supreme Court decision: Made expansion to newly eligible population an option, rather than a mandate Maintenance of Effort: Law prohibits states from reducing eligibility or changing benefits until 2014 Health Care & Housing Are Human Rights

11. Enrolling Many More People Now: Medicaid has 60 million enrollees (1 in 5 people) 2014: Expansion adds 13-15 million new people (depending on outreach and enrollment) “Woodwork”: Could add 4-5 million currently eligible-unenrolled Total: about 80 million people will have Medicaid (about 1 in 4 people) California: 1.9 million newly eligible, 583,000 adults currently eligible-but-unenrolled 250,000 enrolled as of December 2011 Health Care & Housing Are Human Rights

12. Easier Enrollment Law requires fast, simple process using technology Must coordinate Medicaid, state “Exchanges” and CHIP NO Paper documentation needed Do not need: paper copy of paycheck/utility bill, birth certificate, ID or social security card (unless there’s a problem) Will need to know: full legal name, social security number, your birth date, and income Health Care & Housing Are Human Rights

13. Facilitated by Technology Eligibility will be based on income “Modified adjusted gross income” (MAGI) Not whether you have children or a disability Not whether you have a bank account, or the value of your car, or other “assets” you might have (no asset tests) The Medicaid system will automatically verify your income with the Internal Revenue Service (IRS). The Medicaid system will automatically verify your identity and your citizenship/residency status with Social Security. Health Care & Housing Are Human Rights

14. Applying for the New Medicaid Online applications (but can also do by phone and mail) Do not need a permanent address and do not need to prove residency in your state. “No fixed address” will be an option Alternative points of contact available No in-person interviews Simple renewal process, only need to renew once every 12 months Automatic renewal unless there’s a change Health Care & Housing Are Human Rights

16. Sources: 2010 UDS Data, HRSA 2010 Census data State Health Facts (* Note: 101-139%)

17. Perceptions of Medi-Cal: Those Newly Eligible • Nearly 60% believe a pretty good/very good program • But 32% unsure • 38% believe covers care needed • But 37% unsure • 27% believe they would qualify and 35% know how to apply • But 40% and 36% unsure, respectively • 56% comfortable with online enrollment • But 41% not comfortable • 52% would want in-person help with enrollment Source: California HealthCare Foundation (May 2012). Medi-Cal at a Crossroads: What Enrollees Say About the Program. Available at: http://www.chcf.org/publications/2012/05/medical-crossroads-what-enrollees-say.

18. Those Remaining Uninsured Law does not provide a “right to health care” Estimate 30 million left uninsured in 2016 Medicaid eligible (but not enrolled) Undocumented persons Individual Mandate: requires most people to get health insurance or face a penalty. Medicaid counts toward the mandate Penalty: $95 in 2014, $695 in 2016 — BUT… Those not filing taxes are exempt from the penalty Less than ~$10,000/year in 2012 Health Care & Housing Are Human Rights

19. Those Exempt from the Mandate Religious conscience (member recognized religious sect) Health care sharing ministry Individuals not lawfully present Incarcerated individuals Individuals who cannot afford coverage/hardships (>8% of household income) Taxpayers with income below filing threshold Members of Indian tribes Months during short coverage gaps Health Care & Housing Are Human Rights

20. Those Remaining Uninsured Remaining Uninsured: 37%: Medicaid-eligible but un-enrolled 25%: Undocumented/ineligible immigrants

21. Outreach & Enrollment Law requires states “establish procedures for outreach and enrollment activities to vulnerable & underserved populations” Children Unaccompanied homeless youth Children and youth with special health care needs Pregnant women Racial and ethnic minorities Rural populations Victims of abuse or trauma Individuals with mental health or substance-related disorders Individuals with HIV/AIDS Concern: No resources allocated for these activities Health Care & Housing Are Human Rights

22. A Word on the State Exchanges “Shopping center” for health insurance for individuals and small employers Must be implemented by January 1, 2014 Subsidies and credits, based on income (100%-400% FPL) Focused on individual and small group markets Must contain insurance with “Essential Health Benefits” Anticipate covering 9 million in 2014 23 million in 2016 Health Care & Housing Are Human Rights

23. Eligibility Between Two Systems 100-138% (100%+) Subsidies/credits: 100-400% FPL (0-138% FPL)

24. Medicaid Expansion: Overcoming Challenges Meeting increase in demand for services Expanding services and workforce Balancing productivity & quality Ensuring Medicaid & Exchange plans are coordinated Identifying funding for service gaps and remaining uninsured Maximizing billing, coding & IT system functioning Participating in state-level decisions Ensuring staff training across all teams, at all levels Ensuring states choose to expand Medicaid Health Care & Housing Are Human Rights

25. 4 Clinical Questions Patients: How will volume and acuity change? What additional services are needed beyond your walls? Access: How quickly can patients be seen? Teams: How do clinical/non-clinical staff communicate & collaborate? Outreach team? Needs: How are the health needs of homeless populations being communicated to policymakers?

26. 5 Administrative Questions Billing: Is it maximized, do systems need to be upgraded, do staff need to be (re)trained? Filling gaps: What other services/resources are needed, and how are these needs being communicated to state policymakers? Managed care: How will a transition from block grants impact service delivery/staffing? Additional personnel: How can you increase clinical & support staff (e.g., case managers, outreach workers, billing specialists, etc.)? Technical Assistance: Are you reaching out to your PCA and/or the National HCH Council if needed?

27. Health Centers: The Bus Health Care & Housing Are Human Rights

28. Health Center Expansion $11 billion in new funding (in addition to annual funding) + creation of Trust Fund Funding for New Services and Locations: $9.5 billion total FY2011: $1 billion (final: no increase) FY2012: $1.2 billion (final: +$200M) FY2013: $1.5 billion (final: TBD) FY2014: $2.2 billion (final: TBD) FY2015: $3.6 billion (final: TBD) Funding for New Buildings: $1.5 billion total HCHs get 8.7% of funding! Largely depends on related Congressional decisions Health Care & Housing Are Human Rights

29. What To Do With $11 Billion? National goal: Increase patients by 10 million 20 million  30 million by 2015 New health center sites Expanded services Capital projects = Full range of new jobs in public and private sector * California’s 121 health centers employed 22,188 FTEs in 2011.

30. Selected Grant Rounds To Date New Access Points Round 1 (October 2010): 143 grants Round 2 (August 2011): 67 grants Round 3 (June 2012): 219 grants Capital Grants (May 2012) Small: 227 grants ($99M) Large: 171 grants ($629M) California received 63 (15%) California received 63 (16%)

31. Service Capacity: Conduct Needs Assessments Should contain goals, objectives, measurable outcomes, data sources, timelines Who will you serve and what do they need? Who is homeless in your local area? What are the most prevalent health care and social service needs? Who is un-served or underserved? Who are the key service providers?

32. Target Population: Needs Presenting Needs Primary care Oral health Behavioral health Specialty care Housing (full continuum) Medical respite care Employment Transportation

33. Key Relationships Local hospital Discharge planning sources Referral sources Emergency responders – police & fire Jail administrators Political leaders Shelter and housing providers All health care providers Business community Continuum of Care

34. Resources to Meet Needs Who provides the services in each area of identified need, and how will health care reform impact them? How will the state of the current economy impact any of these service providers? What are the greatest service gaps? What is your role in filling them? What collaborations/partnerships are possible? How are needs being communicated to state/county policymakers?

35. Finances New revenue as a result of Medicaid expansion Ensure smooth billing/collection systems This is the time to replace/update! Revisit policies and procedures Implement process for collecting, organizing and tracking key financial performance data Conduct an internal audit Ensure nothing is left on the table Health Care & Housing Are Human Rights

36. Consumer Input How are you obtaining consumer feedback? Consumer board members? A Consumer Advisory Board (CAB)? Focus groups? Consumer satisfaction surveys? This is valuable perspective on your operations Health Care & Housing Are Human Rights

37. Governance Does your board understand the benefits and challenges of health care reform? Has your board adopted a new strategic plan? Specific needs of homeless patients included? How can board members use their community relationships to further goals? Health Care & Housing Are Human Rights

38. Workforce: The Bus Driver Health Care & Housing Are Human Rights

39. Workforce Development • $1.5 billion for National Health Service Corps • Scholarships, loan repayments • Primary care physicians, family nurse practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and certain mental health clinicians • http://nhsc.hrsa.gov/ • Health Center-based residency programs (e.g., “teaching health centers”) • Increases to Medicaid provider payments: • 2013-2014, raise to Medicare rate level

40. Challenges to Capacity • Too many new patients on top of already large number of patients at health centers • Unemployment, housing costs and other factors increasing number of people using assistance programs • How do we prepare for meeting patient needs? Health Care & Housing Are Human Rights

41. One Challenge: Behavioral Health Service Capacity for Newly Medicaid Eligible Source: SAMHSA, National & State Estimates on Prevalence of Behavioral Health Conditions. Available at: http://www.samhsa.gov/enrollment/states.aspx.

42. Another Challenge: Provider Willingness to Participate • 96% physician practices accepting new patients • 31% were unwilling to accept new Medicaid patients • Smaller practices less likely than larger ones • Urban areas less likely than rural areas • Higher Medicaid fees = greater acceptance of new patients • Source: Decker, S. (August 2012). In 2011, Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs 31 (8): 1673-1679.

43. Workforce Provisions and Planning • Are there enough primary care & behavioral health providers? • Are there enough case managers & benefits coordinators? • Is current workforce burned out? Properly trained? • How can national and state provider assistance programs be maximized? • How can volunteer clinicians be used? • How are clinical residents being trained to work with vulnerable populations? • How can work with homeless population be promoted in professional schools?

44. Care Delivery Models: Bus Maintenance Health Care & Housing Are Human Rights

45. Care Delivery Models Ultimate goals: Improve access Increase quality Decrease cost Emphasis on collecting data, eliminating disparities, improving systems, creating efficiencies Focus on TEAM: includes both clinical and non-clinical members Data sharing, electronic health records are key Models will influence finance and staffing Health Care & Housing Are Human Rights

46. Care Delivery Models Renewed focus on coordination and integration of services Integrated care Access Services Funding Evidence-based practices Data Patient-Centered Health Homes Accountable Care Organizations Health Care & Housing Are Human Rights

47. Action Steps: What to do NOW Educateclients, staff, family, friends…everyone Hold site visit/meeting with: Your state’s Medicaid director & health reform lead Your PCO/PCA Your state and local health officer & local DSS director Legislative leadership for health issues Attend health reform stakeholder meetings Ensure strong strategic plan/needs assessment is in place Form PCMH workgroup internally Partner with your fellow service providers (shelters, behavioral health care, others) Health Care & Housing Are Human Rights

48. One Key Event November 6, 2012 Voter turnout in 2008 Election <$10,000: 41% $50K-$75K: 66% $150K+: 78% Candidates have expressed clear views of future of ACA How is your organization participating in voter registration activities?

49. Voting in California Must be a citizen or legal resident over 18 years Must not be in prison or on parole for a felony Must have photo ID to register and vote Registration deadline: 15 days prior to election Monday, October 22, 2012 More information: www.vote411.org.

50. Keeping an Eye on the Ultimate Goals Greater access to Medicaid hopefully translates into better health Growth of health center services/locations = increased number of places to serve patients Increased number of providers = easier access to care Greater use of EHR and team models hopefully translates into better services Better health + more resources = preventing and ending homelessness Health Care & Housing Are Human Rights