The Role of the Safety Net in Health Care Reform

1. The Role of the Safety Net in Health Care Reform Presentation to National Congress on Un- and Under-Insured September 23, 2008 Dan Hawkins National Association of Community Health Centers

2. “Between the health care we have and the care we could have lies not just a gap, but a chasm. The American health care delivery system is in need of fundamental change.” --- Crossing the Quality Chasm: A New Health System for the 21st Century A Report from the Institute of Medicine

3. Critical Dimensions of the American Health Care Crisis • Cost: • U.S. health care costs per person are 75%-250% higher than any other developed nation • Access: • 47 million Americans (16%) are uninsured • The uninsured are less likely to get the care they need • Quality: • Despite technology & knowledge advantages, the quality of U.S. health care is “mediocre at best”* • * New England Journal of Medicine, 354(11), March 2006 (report on RAND Corp study, funded by Robert Wood Johnson Foundation)

4. Barriers to Health Care by Insurance Status, 2003 Percent experiencing in past 12 months: Insured includes those covered by public or private health insurance. Source: Kaiser Family Foundation, Kaiser 2003 Health Insurance Survey.

5. Adults with No Usual Source of Health Care, by Race/Ethnicity Percent without a usual source of care American Indian/Alaska Native White (Non-Latino) Latino African American (Non-Latino) Asian Only 1993-1994 2000-2001 DATA: National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2003, Table 76.

6. Adults Receive Half of Recommended Care, and Quality Varies Significantly by Condition Percent of recommended care received Source: E. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine (June 26, 2003): 2635–2645.

7. Minorities Face Greater Difficulty in Communicating with Providers Percent of adults with one or more communication problems* Base: Adults with health care visit in past two years. * Problems include understanding doctor, feeling doctor listened, had questions but did not ask. Source: Commonwealth Fund 2001 Health Care Quality Survey.

8. Crucial Role of Safety Net in Health Reform • Who will care for those ineligible for coverage (eg, undocumented) • Who will provide services needed by only some (eg, language access, transportation) • Who will • Who will • Who will

9. Community Health Centers:Leaders in High Performance Care

10. Community Health Centers Answer the Health Care Crisis • Cost: • Annual care costs $250 less than private MDs* • They save billions for taxpayers thru lower hospital inpatient/ER/specialty care use* • Access • They serve 18 million (and growing) people who live in communities not served by others • They are open to all regardless of ability to pay • Quality • Their quality is equal or superior to other providers** * See Access Granted: The Primary Care Payoff,National Association of Community Health Centers, August 2007 (available at www.nachc.com). ** See Measuring Health Centers against Standard Indicators of High Quality Performance: Early Results from a Multi-Site Demonstration Project,, Shin, P., et al., The George Washington University, August, 2006.

11. Health Centers Provide One-Fifth of All Ambulatory Care for Uninsured… • Source: National Ambulatory Medical Care Survey, 2004 summary, no. 374, National Center for Health Statistics, CDC, 2006; 2004 Uniform Data System Reports, Health Resources and Services Administration.

12. Accomplishments of Health Centers • Excellent Quality of Care: More Effective Care, Better Control of Chronic Conditions, Greater Use of Preventive Care, Fewer Infant Deaths • Major Impact on Minority Health: Significant Reductions in Disparities for Health Outcomes, Receipt of Preventive and Condition-Related Care • Higher Cost-Effectiveness: Lower Overall Costs, Lower Specialty Referrals and Hospital Admissions, Substantial Medicaid Savings • Significant Community Impact: Employment and Economic Effects, Contribution to Community Well-Being, Development of Community Leaders

13. Nearly All Health Center Patients Report that They Have a Usual Source of Care, 2002 Percent Source: AHRQ, “Focus on Federally Supported Health Centers,” National Healthcare Disparities Report, 2004. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981

14. Fewer health Center Patients Experience Ambulatory Care Sensitive Events Number of ACS events per 100 persons Source: M. Falik et al., “Comparative Effectiveness of Health Centers as Regular Source of Care,” Journal of Ambulatory Care Management 29, no. 1 (November 26, 2005): 24-35.

15. Women Served by Community Health Centers Fare Better on Pap Tests by Race than National Sample Source: Dan Hawkins, “Improving Minority Health and Reducing Disparities through the Health Disparities Collaboratives of America’s Community Health Centers,” Presentation to NAPH (June 24, 2005) Santa Fe, NM.

16. Health Centers Excel at Reducing Health Disparities

17. Health Disparities Collaboratives • Goal: Implement in all 1,000 health centers by 2007 • 650 health centers nationwide participating • 350,000+ health center patients with chronic disease enrolled in electronic registries • Chronic Care Model: • Use of evidence-based care • Assure care continuity and coordination • Effectively involve patients in self-management • Completely re-design system to emphasize health • Collaboratives • Training and technical assistance • Quality Improvement infrastructure • Partnerships at the local, state, and national level • Evaluations under way by Harvard/University of Chicago and by Commonwealth Fund/AHRQ

18. Recent Recognition of Health Centersby Key Government Agencies • IOM recommended health centers as THE model for reforming the delivery of primary health care (Rapid Advances in Health Reform) • GAO credited CHCs for Collaboratives success and recommended expanding them further • OMB ranked CHC program 1st among all HHS programs and one of the top 10 federal government programs for effectiveness

19. 2008 Presidential Candidates’ Health Reform Plans 1Children only. 2VA and Medicaid. 3Tax credits for individual insurance purchase. 4Tax deductions for individual insurance purchase. Sources: Campaign websites; Kaiser’s Health08.org website; The Commonwealth Fund.

20. Central Focus Points of Health Reform • Closing gaps in insurance coverage is the number one priority action to improve care for vulnerable populations • Medicaid and SCHIP must be continued and expanded • Other affordable insurance coverage should be promoted • Also needed is adequate funding of primary care capacity in low-income underserved communities • Patient-centered primary care is a crucial feature of reform • Make it easy to get appointments and obtain care • Shared decision-making can help improve and coordinate care, and engage patients as active partners in their care • Incentives are needed for investment in information technology • Incentives also needed to support chronic care quality improvement • Share best practices • Join learning collaboratives to improve care • Reform should also embrace transparency, public reporting, and pay for performance