The Patient Protection & Affordable Care Act (ACA)

1. The Patient Protection & Affordable Care Act (ACA) What does Health Reform mean for CABRINI clinic & for our patients?

2. OUTLINE What is the ACA? How will ACA help the uninsured? Who will remain uninsured after 2014? How will ACA affect our patients & our clinic? What do we need to do to prepare for Aca?

3. Medicaid eligibility will be expanded to childless adults and to 133% of FPL • Above 133% of FPL, low and middle income people and small businesses will get subsidies to make insurance affordable • Children can stay on parents’ plan until 26 years old • No lifetime or annual caps • No denials based on pre-existing conditions • No co-pays or deductibles for preventive care • 80% of premium must be spent on enrollees • Insurance companies have to justify rate increases ACA: What are some of the Benefits?

4. Does ACA helpFree Clinics? Some free clinics receive liability coverage for their volunteer health professionals through the Federal Tort Claims Act (FTCA). ACA extends that coverage to free clinic board members, officers, employees, and individual contractors, but not to the clinic entity itself.

5. States can “opt out” of Medicaid Expansion • Political target for repeal • Critical shortage of Primary Care Providers, especially PCPs who accept Medicaid • The rising cost of health care ACA: What are some of the Barriers?

6. How will ACA help the Uninsured? January 1, 2014, 30 million (of 53 million) uninsured will be eligible for coverage Eligibility for Medicaid will increase from 35% of Federal Poverty Level in MI to 133% of FPL across the nation Childless adults will be eligible This will help many of the patients we serve.

7. 2012 Federal Poverty Levels 2012 FPLIndividualFamily of 4 100% $11,170 $23,050 MI - 35% $ 3,910$ 8,068 133%$14,856 $30,656 400% $44,680 $92,200

8. President Obama signed ACA into law. A few changes took effect immediately; others are being implemented over the next few years. • The Supreme Court ruled that Medicaid Expansion is optional for the states. • Planning and implementation at federal and state levels. Numbers of uninsured continue to grow. • Up to 30 million will become eligible for coverage, either through Medicaid expansion or the exchanges. Timeline for ACA 2010 2012 2011-2014 2014

9. Those eligible will be enrolled in Medicaid and other programs. The numbers of uninsured will gradually decline. • The newly insured will try to find a medical home, but face a critical shortage of Primary Care Providers, especially PCPs accepting Medicaid. • The number of uninsured will level off to those who are not eligible for coverage through ACA. Timeline for ACA cont’d. 2014-2019 2019

10. Medicaid Expansionis Critical! The supreme court of the USA ruled that expansion of medicaid is optional, state by state. Governor snyder seems to favor medicaid expansion for michigan. Free clinics need to advocate for medicaid expansion in Michigan and other states

11. Undocumented immigrants • Naturalized citizens here < 5 yrs. • Choose to pay the penalty rather than acquire insurance • Exempt from the mandate and choose to remain uninsured, e.g., veterans, uninsured <3 mos., exempt from filing federal tax return, Native American, incarcerated, religious conscience reasons. • <133% of FPL in states that opt out of M/A expansion • Citizens without documentation Even with Medicaid Expansion,who will remain uninsured? And where will they find care?

12. Many uninsured clients of our free clinic may be eligible for Medicaid • Our clients will need help through the transition • Potential negative impact on our donors and volunteers? • Potential negative impact on our relationship to area hospitals? • We need to re-evaluate our mission and services, and educate our community on the impact of ACA. ACA: Implications for Free Clinics

13. What is the experience of free clinics in states wheremost of the uninsured received coverage? VT, WI, and MA received federal waivers to expand Medicaid for uninsured. What happened to free clinics in these states? None closed; in fact volume continued to grow. Free Clinics helped enroll and navigate patients through the changes. Patients moved in and out of coverage as their income changed, e.g. with seasonal jobs. They required a lot of help navigating the system. PCP shortage, especially of PCPs who will accept Medicaid, resulted in free clinics providing care to Medicaid patients but not billing. Dental Care and Rx Assistance remain huge gaps in service.

14. What Questions Should We Be Asking? • Will Michigan opt for expansion of Medicaid? • What will be the impact of the ACA on our clinic? • How many of our patients will receive insurance coverage under ACA? Where will they find care? • Who will remain uninsured in our community? • Will our clinic be needed post-2019? Whom will we serve? • What do we need to do to prepare for ACA changes? • What options are open to us for the future? • Should we consider becoming or partnering with a FQHC? • What if ACA is not implemented? • Other questions?