Health Care & Housing Are Human Rights

1. The Nuts and Bolts of Health Reform: What’s Important and What You Need to Do July 13, 2012 Barbara DiPietro, Ph.D.Policy Director 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 Expansion: Who Is Eligible? Currently eligible: children, pregnant women, disabled people, and some parents of children Newly eligible (starting January 1, 2014): Law expands Medicaid to those 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 Some states have started expanding Medicaid already Health Care & Housing Are Human Rights

8. Medicaid Expansion Financing Expansion group only: Enhanced federal match to states 100%: 2014 through 2016 95%: 2017 94%: 2018 93%: 2019 90%: 2020 and thereafter Current eligible groups: current federal match Maintenance of effort: Prohibited from reducing Medicaid or CHIP eligibility, increasing premiums or enrollment fees, or otherwise cutting enrollment for mandatory groups/services* (pending further guidance as a result of the Supreme Court decisision) Health Care & Housing Are Human Rights

9. 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) Washington State: 308,000 newly eligible, 66,000 currently eligible-but-unenrolled Health Care & Housing Are Human Rights

10. Easier Enrollment Law requires fast, simple process using technology Must coordinate Medicaid, state “Exchanges” and CHIP Paper documentation will not be 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

11. Facilitated by Technology Eligibility will be based on income 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

12. 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

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

15. Those Remaining Uninsured Law does not provide a “right to health care” Estimate over 26 million left uninsured in 2016 Medicaid eligible (but not enrolled): 30-50% Undocumented persons: ~30% 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

16. 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

17. 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” States will need to determine what additional benefits they cover (at state expense) Anticipate covering 8 million in 2014 20 million in 2016 Health Care & Housing Are Human Rights

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

19. Medicaid Expansion: Our 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

20. 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?

21. 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 decisionmakers? 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?

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

23. 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 Completely depends on related Congressional decisions Health Care & Housing Are Human Rights

24. What To Do With $11 Billion? National goal: Double the number of people served by CHCs 20 million  40 million by 2015 New access points Expanded services Capital projects Health Care & Housing Are Human Rights

25. Health Care Reform: Readiness Have a clear organization-wide plan Vision Goals and objectives Outcome measures Data collection and quality improvement Definition of success Health Care & Housing Are Human Rights

26. NEEDS ASSESSMENT 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? Health Care & Housing Are Human Rights

27. Target Population: Needs Presenting Needs Primary care Oral health Behavioral health Specialty care Housing Medical respite care Employment Transportation Health Care & Housing Are Human Rights

28. Key Relationships Examine your current partnerships Local hospital Discharge planning sources Referral sources Emergency responders – police & fire Political leaders Business community Continuum of Care Don’t be afraid to “step out of the box”! You Need Them and They Need You Health Care & Housing Are Human Rights

29. Resources to Meet Needs Who provides the services in each area of identified need? How will Health Care Reform, including Medicaid expansion, impact any of these service providers? How will the state of the current economy impact any of these service providers? Health Care & Housing Are Human Rights

30. Resources to Meet Needs (cont’d) What are the greatest gaps between Needs and Resources? Are you in a position to address any of these gaps? Could Health Care Reform help you to address any of these gaps either directly or in partnership with others? Health Care & Housing Are Human Rights

31. Readiness: Finances Financial Management Policies and procedures Billing and collection systems Systems for collecting, organizing and tracking key financial performance data Health Care & Housing Are Human Rights

32. Readiness: Consumer Input Do you have a consumer as a member of your board of directors? Do you have a Consumer Advisory Board? Do you utilize focus groups to gain consumer input? Do you conduct consumer satisfaction surveys? Health Care & Housing Are Human Rights

33. Readiness: Governance Does your Board understand the impacts of Health Care Reform? Has your board adopted a Strategic Plan incorporating the elements of HCR? Health Care & Housing Are Human Rights

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

35. Workforce Development • $1.5 billion for National Health Service Corps • Health Center-based residency programs • Scholarships, loan repayments (primary care physicians, family nurse practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and certain mental health clinicians • School-based health centers • Increases to Medicaid provider payments Health Care & Housing Are Human Rights

36. 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

37. Workforce Provisions and Planning • Where are the gaps in your existing staffing pattern? • What staff will you need for service expansion? • What is your staff retention rate? • What strategies do you use to retain existing staff? • What’s the “health” of your team? Health Care & Housing Are Human Rights

38. Workforce Provisions and Planning • Are you a learning environment? • How do you train for Evidence Based Practices? • How can self-care training and integration be a key part of recruitment and retention strategies? Health Care & Housing Are Human Rights

39. Workforce Provisions and Planning • Do you have an opportunity to partner with a school of medicine or other training venue? • Are you maximizing opportunities with the National Health Service Corps? • How can volunteer clinicians be recruited to help fill gaps and further make connections in the community? Health Care & Housing Are Human Rights

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

41. 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

42. 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

43. Action Steps: What to do NOW 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 Conduct site tours 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

44. 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

45. More Information The National Health Care for the Homeless Council is a membership organization for those who work to improve the health of homeless people and who seek housing, health care, and adequate incomes for everyone. www.nhchc.org Additional health reform materials at: http://www.nhchc.org/healthcarereform.html NHCHC offers free individual memberships at: http://www.nhchc.org/council.html#membership Technical assistance available Health Care & Housing Are Human Rights