Fitting the Pieces Together: The Safety Net and ACA

1. Fitting the Pieces Together: The Safety Net and ACA NASHP 24th Annual State Health Policy Conference October 4, 2011Chris Collins, MSW North Carolina Office of Rural Health and Community Care

2. The North Carolina Office of Rural Health and Community Care Assists underserved communities and populations to develop innovative strategies for improving access, quality, and cost-effectiveness of health care • State and local partnerships approach • Ownership vested in community partnerships • In-depth technical assistance provided on an on-going basis • Accountability is clear and measured • Activities centered around improving the ability of communities to meet the health needs of underserved residents C.Collins

3. Strengthen the Safety Net System • Work Force • Designate Health Professions Shortage Area • Medical and Dental Placement and Loan Repayment Services • Medical Homes • Rural Health Centers Program • Farm Worker Health Program • Prescription Assistance Programs • Rural Hospital Assistance Program • Community Health Grants • Community Infrastructure • Community Care of North Carolina • HealthNet • Demonstrations C.Collins

4. Health Care Reform • At the request of the North Carolina Department of Insurance, and the North Carolina Department of Health and Human Services, the North Carolina Institute of Medicine (NCIOM) convened workgroups to examine the new law, secure stakeholder input, and develop policy and funding recommendations that serve the best interest of the state. http://www.nciom.org/ • Each workgroup was charged to focus on different sections of the ACA. • Fraud, Abuse, and Overutilization. • Health Benefit Exchange and Insurance Oversight • Health Professional Workforce • Medicaid • New Models of Care • Prevention • Safety Net • Quality C.Collins

5. The Workgroup’s Charge • Explore new opportunities for community-based collaborative networks of care • Examine new requirements for safety net providers • Identify areas of the state with greatest unmet need, and encourage collaboration in funding opportunities • Explore the new and changing needs of the safety net C.Collins

6. Potential Coverage Implications • Projections suggest that there may be as many as 536,000 uninsured nonelderly North Carolina adults who could qualify for Medicaid coverage based on the expanded eligibility. • 382,000 could be newly eligible • 154,000 could be existing eligible • Approximately 213,000 uninsured children in families who may already be eligible for Medicaid or NC Health Choice but are not enrolled. • Most NC families have incomes below 400% FPL, qualifying them for premium subsidies, unless they have employer or governmental insurance. • 712,000 uninsured nonelderly adults in North Carolina with incomes between 138-400% • 62,000 uninsured children in families with incomes between 200-400% • Not everyone who is income eligible for Medicaid, NC Health Choice or a subsidy will choose to secure coverage. • Prohibits states from covering undocumented immigrants or most legal immigrants who have been in this country for less than five years. C.Collins

7. Potential Funding Implications • The expansion of Medicaid eligibility to 138% FPL will increase state appropriations and enrollment. • The state is likely to experience savings on programs targeted at uninsured populations as they move into the Medicaid program or private coverage. • As more people gain coverage, the state and county governments could potentially reduce some of the expenditures to safety net providers currently used to help pay for services to the uninsured. • Reform requires most individuals to purchase coverage or to pay a penalty. It remains unclear if providers will donate services to individuals that elect not to secure coverage through Medicaid or the Health Benefit Exchange. C.Collins

8. Potential Provider Implications • Medicare will expand coverage to preventive services. • Medicare provides a 10% bonus payment for primary care physicians and general surgeons practicing in underserved areas • Essential benefits must: • Cover hospitalizations, professional services, prescription drugs, rehabilitation and habilitative services, mental health and substance use disorders, and maternity care • Well-baby, well-child care, oral health, vision and hearing services for children • Annual wellness visit as part of personalized prevention plan • Preventive services recommended by US Preventive Services Task Force • Mental health parity law applies to qualified health plans • Hospitals can determine presumptive eligibility for all Medicaid populations • Extension of medical malpractice coverage to free clinics C.Collins

9. Maximize Resources • Secure available Funding opportunities • Increased the number of FQHCs (2) and look-a-likes (1) to expand the array of services provided, and increase the number of people they serve. • FQHCs received funds totaling $19.2 million to support capital improvements and renovations, and to expand access to care. • Farmworker Health Program was granted the annual amount of $166,164 for the purpose of responding to the increased demand of services of migrant and seasonal farm workers. • Increase the number of school based health centers (9). C.Collins

10. Maximize Resources, continued • Increase and target HPSA designations and recruitment to statically address access issues. • Expand the use of National Health Service Corp resources for loan repayment. • Health Care providers should participate in community based collaborative networks of care. • Maximize existing workforce by developing integrated medical homes (behavioral / dental). • Expand the use of data to monitor access, improve quality and triage high risk. C.Collins

11. Maximize Resources, continued • For charitable hospitals to maintain their tax-exempt status they must conduct a community needs assessment and show that they are addressing community needs. • To increase access to preventive care supporting school based clinics /free clinics to transform or be an adjunct to the Medical Homes. • Through the High Tech Act and private foundations leverage the Regional Extension Center, meaningful use incentive payments, health information exchange, broad band, hardware and electronic health records for the benefit of the Safety Net Providers. • Explore the role of Department of Social Services and Community Networks as Patient Navigators for the Health Benefit Exchange. C.Collins

12. Expand Infrastructure • Workforce - enhance the role of mid levels • Telemedicine • Oral health literacy and medical/dental collaboration across the state • Patient engagement, self management, and accountability • Safety net linkages with Health Information Exchange • 340 B pharmacies through qualified agencies • Trauma centers and emergency services and develop regionalized systems for emergency response. • Linkages with home and community-based services C.Collins