Health
H
lth Centers
C t
and
d the
th
Affordable Care Act
Pub. L. 110-148 as amended by
Pub. L. 110-152
Sara Rosenbaum and Emily Jones
Department of Health Policy
AcademyHealth ARM
J
June,
2010*
Based on a forthcoming Policy Brief for the Kaiser Commission on Medicaid and the
Uninsured, with additional funding support from the RCHN Community Health Foundation
1
Health Centers
• OEO demonstration in 1965
• Authorized under PHS Act in 1975
• 1080 federally funded health centers
–
–
–
–
>7500
7500 practice locations
17.7 million persons
>51,000 clinical staff
>5300
5300 NHSC staff
t ff b
between
t
2003
2003-2008
2008
• 100 “look-alike” health centers
– no PHS Act grant but all PHS Act requirements met
• All states, District of Columbia, U.S. Territories
2
Poverty and Health Insurance Status of Health Center Patients
92%
Health Centers
U.S.
70%
38%
36%
31%
15%
Uninsured
13%
Medicaid
12%
At or below
100% of
Poverty
Under 200% of
Poverty
Source: GW Analysis of UDS data, 2008 and Current Population Survey: Census 2008.
3
Growth in Number of Health Centers and Uninsured Patients, 1990 vs. 2008
1,080
545
6.6 million
+98%
2.2 million
+200%
SOURCE: 1996‐2008 UDS, HRSA; 1990 estimates provided by NACHC.
4
Health Center Patients by Race/Ethnicity, 2008
More th
M
than
one race
5%
Unreported
23%
Asian
A
i
3%
White
47%
Black
21%
Amer. Indian,
Native
Hawaiian,
Pacific Islander
2%
Race
Hispanic/Latino Identity
NOTE: White includes Hispanic/Latino descent. The 2008 UDS does not allow for estimates of nonwhite patients – between 1996‐2006, one‐third of patients
were nonwhite.
SOURCE: GW Department of Health Policy analysis of 2008 UDS data, HRSA.
5
Percent of Uninsured Residents Served by Health Centers, by State
y
, y
NH
VT
WA
ND
MT
OR
MN
MI
WY
CA
AZ
CO
NM
PA
IA
NE
UT
IL
KS
OK
TX
OH
IN
WV
MO
VA
KY
NC
TN
AR
MS
AK
MA
NY
WI
SD
ID
NV
NV
ME
AL
NJ
RI
CT
DE
MD
DC
SC
GA
LA
FL
HI
< 10% (8 t t )
< 10% (8 states)
10.1‐15% (16 states)
National average: 14.2%
SOURCE: 2008 Uniform Data Systems state data, Health Resources and Services Administration and 2008 data from statehealthfacts.org, Kaiser Family Foundation.
15.1‐20% (12 states)
Over 20% (13 states and DC)
No data (one state)
6
Health
H
lth Center
C t P
Patients
ti t b
by
Gender and Age, 2008
P
a
t
i
e
n
t
s
12 000 000
12,000,000
12 000 000
12,000,000
10,000,000
, ,
10,000,000
8,000,000
8,000,000
Children <20
6,000,000
Adults 20‐
64
6,000,000
Male
Female
4,000,000
4,000,000
2,000,000
2,000,000
0
0
Elderly
SOURCE: GW Department of Health Policy analysis of 2008 UDS data, HRSA.
7
Health Center Patients and Visits are Chronic Illness‐Related Compared With Office Based Physicians
Office‐Based Physicians
Percent of Patients with Serious and Chronic Conditions
Percent of Patient Visits Involving Serious g
and Chronic Conditions Notes: Estimates based on comparable diagnoses of diabetes, hypertension, asthma, heart disease p p
and mental illness as a proportion of total medical visits. Source: Burt CW, McCaigL F, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2005.Advance data from vital and health statistics; no 388. Hyattsville, MD: National Center for Health Statistics.2007. Health center data from 2007 UDS, HRSA.
Source: Private Physicians from 2006 NAMCS (CDC National Center for Health Statistics, 2008). UDS, 2006.
8
Patient Visits Experiencing Referral Difficulties
Difficulties, by Coverage Source:
Health Centers and Physician Practices, 2006
S
Source: CDC/NCHS, 2006 National Ambulatory Medical Care Survey by Esther Hing and David A. Woodwell, Differences in physician
CDC/NCHS 2006 N ti
lA b l t
M di l C
S
b E th Hi
d D id A W d ll Diff
i h i i visits at community health centers and i it t
it h lth
t
d
physician offices: United States, 2008
9
Financing Basis for Health Centers
• Medicaid and Medicare
– FQHC coverage and payment methodology rules
• CHIP
– FQHC payment methodology rules
• Grants
• Medicare
• Private health insurance
– unregulated
10
Sources of FQHC Revenue,
Revenue 2008
Other Revenue
6.3%
Self-pay
6 2%
6.2%
Other Fed Grants
2.1%
BPHC Grants
18.3%
Private Insurance
7.5%
Other Public
2.8%
Medicare
5.9%
Medicaid
37.1%
State/Local/Pvt
Grants/Contracts
17.5%
Total
$10 05 Billion
$10.05
Source: GW analysis of 2008 UDS data
11
Key Reforms -- ARRA
• $2 billion in appropriations for new
grantees, new access points, new
services
• Eligible for HIT adoption incentives
under Medicaid
12
Key Reforms – Affordable Care Act
• Medicaid expansion to 133% FPL (138% with income
disregards)
– FQHC
Q C coverage and payment methodology , traditional eligibles
– FQHC payment methodology, new eligibles
• Medicare revision of FQHC payment methodology and
elimination of payment cap
– Elderly health center patients grew 13 times faster than low income
elderly population between 1996 and 2008
• Exchange affordability and cost sharing assistance (legal
immigrants)
– FQHC payment methodology, qualified health plans sold in state
g
exchanges
– Essential provider status, qualified health plans sold in state
exchanges
– Benefit package for essential benefit plans
13
Key Reforms – Affordable Care Act
• Health centers permanently authorized
• Health Center Trust Fund
– Part of the reconciliation amendments to ACA
– $11 billion FY 2011-2015, appropriated
• National Health Service Corps Trust Fund
– $1.5 billion, FY 2011-2015
• Quality
Q li iimprovement d
demonstrations
i
– Medical homes for persons with chronic illnesses
– ACOs,
ACOs potentially building on health center networks
– Dual enrollee demonstrations and pilots
14
Growth in Health Center Appropriations
Appropriations,
1980 – 2015 (in millions)
No. Patients (m):
SOURCE: Data from the National Association of Community Health Centers; 2010-2015 patient estimates by authors.
15
Challenges and Opportunities
•
Medicaid implementation
–
Driver of health centers
•
Exchange implementation
•
E f
Enforcement
t off qualified
lifi d h
health
lth plan
l network
t
k and
d paymentt rules
l
•
A new Medicare payment methodology
•
Ramping up the program
–
–
30-40 million served by 2015
Workforce challenges
•
Shifting patient characteristics
•
Clinical and financial integration and network formation
•
State implementation of Medicaid HIT incentives
16