Medical Safety
Net for Children
and Families
Outline 11/18/2011
Barbara Wolfe
Issue: Gaps in Health and Access to Health Care.
Primary Concern with Health Disparities
• Definition of health disparities: “Differences in the
incidence, prevalence, mortality, and burden of
diseases and other adverse health conditions that
exist among specific population groups in the
United States”
First NIH Working
Group on Health
Disparities
Nonelderly’s Health Insurance Coverage by Family Poverty
Level, 2009
Number
400% +
200% - 399%
88.7 M
73.5 M
100% - 199%
46.9 M
Under 100%
55.6 M
NOTES: Data may not total 100% due to rounding. The Federal Poverty Level for a family of four in 2009 was $22,050 (according to
the U.S. Census Bureau’s poverty threshold). Family size and total family income are grouped by insurance eligibility.
SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2010 ASEC Supplement to the CPS.
Measures of Access: No health care visits to an office or
clinic within the past 12 months among children under 18
years of age, 1997-98, 2000–01 and 2006-07
Discrepancy decreased most for poor
•
•
•
•
•
1997-8
Poor . . . . . . . . . . . . 17.6
Near poor . . . . . . . 16.2
200-<400% . . . . . . 11.7
400%+
7.4
2000-1
17.3
14.8
11.2
7.7
2006-7
14.3
14.2
11.7
7.5
War on Poverty Interventions: Public
Subsidies
• Demand side
o Subsidize insurance via
tax system
o Medicare for disabled
o Medicaid for certain low
income groups
o CHIP for lower income
children and in some
cases parents
• Supply side
o Community Health
centers
o Subsidies to educate
providers & attract to
underserved areas
o Subsidies to build facilities
(1946 start)
A bit of history about government role re supply side
subsidies
•
•
•
Hill Burton or Hospital Survey and Construction Act of 1946 – goal – improve
the supply, distribution and quality of general hospital beds in the U.S.; and
possibly the distribution of physicians.
July 1947 – June 1971 central government invest > 4.6 billion in grants and 1.5
billion in loansconstruction, modernization of existing facilities.
Success? Usual measure - increasing number of beds.
• Health Education Act of 1965
Perceive shortage; subsidize
o Subsidy to institution such that if agree, agree to increase slots,
o National Health Service – tiny until mid 1970s when begin to distribute scholarship
funds in return for commitment of service to underserved area.
•
Neighborhood Health Centers
CHCs – 1967 – enabling legislation
CHC-unique
characteristics
•
Health centers are characterized by five essential elements that
differentiate them from other providers:
o They must be located in or serve a high need community, i.e.
“medically underserved areas” or “medically underserved
populations”;
o They must provide comprehensive primary care services as well
as supportive services such as translation and transportation
services that promote access to health care;
o Their services must be available to all residents of their service
areas, with fees adjusted upon patients’ ability to pay;
o They must be governed by a community board with a majority of
members health center patients; and,
o They must meet other performance and accountability
requirements regarding their administrative, clinical, and financial
operations.
National Health Service Corps (NHSC)
•
The National Health Service Corps (NHSC) created at time of health care crises
o
•
•
•
•
Rural areas and inner-city neighborhoods could not get providers: offered lower compensation, less
interaction with other professionals, and few job opportunities for spouses.
Rural communities lacked resources to provide the technologically
sophisticated facilities that many physicians desired. Rural states appealed to
Congress for help thus establishing what is now known as the National Health
Service Corps. The National Health Service Corps (NHSC) provides financial
assistance to health professionals in exchange for providing health care
services in designated underserved areas known has Health Professional
Shortage Areas (HPSAs). There are three categories of health professional
shortage areas: medical, dental and mental health.
Based on a list compiled by the Office of Shortage Designation to determine
health professional shortage areas. Administered by the U.S. Department of
Health and Human Services’ Health Resources and Services Administration
(HRSA)
NHSC Loan Repayment seeks clinicians dedicated to working with
underserved. In order to participate in the NHSC Loan Repayment Program
must find a facility or site that is 1) designated as a professional shortage area
and 2) willing to hire them.
Primary care medical, dental and mental health clinicians may receive up to
$170,000 for 5 years of full-time service; $60,000 for the minimum 2 years FT; or 4
years PT toward paying off loans.
National Health Service Corps (NHSC)
extends beyond MDs to other health care providers
•
•
•
Loan repayment
o Nursing education loan repayment program –get 60% of
qualifying loan balance repaid for 2 yrs FT of service
o Faculty Loan repayment- those from disadvantaged
background serving in accredited university get $40,000+ tax
benefit for 2 years of service
Scholarships
o If commit to primary care can receive tuition, fees other ed
costs and stipend tax free for up to 4 years if serve = # years in
underserved area.
o Nursing scholarship- RN program – receive tuition, fees other
ed costs + stipend for min. 2 years service in facility with
critical shortage of nurses.
o Scholarships for Disadvantaged Students-need based
competitive program
Loans-all needs based and competitive.
o Disadvantaged students; Loans for Health Professions
Students; Nursing Students, Primary Care (in participating
school)
A bit of history about demand side interventions
•

•
•
Until 1935 assistance with medical care expenses generally done by ad hoc efforts
by groups within communities to help some of the poor people living there.
The poor most likely to receive such help were people who might be termed
deserving poor; i.e. not responsible for their poor status
o children with physical and mental health problems,
o pregnant women and infants,
o the blind, and the elderly –
o According to Swartz, the belief that state and local governments should have
primary responsibility for decisions about providing health care to the poor
can be traced back to this earlier age.
In 1935, the Social Security Act was passed. In addition to the trust fund providing
pension benefits, the Social Security Act created federal grants to states for
income assistance for poor elderly, dependent children and their mothers (what
became Aid to Families with Dependent Children), the blind, and crippled
children. These categorical grant programs provided federal funds on a matching
basis to states that set up the aid programs and the states were in charge of
administering the programs. States could set the income eligibility criteria --the
precursor to the significant variation that now exists across states with Medicaid
eligibility criteria.
In areas where public hospitals did not exist, welfare departments reimbursed
private hospitals for care provided to recipients of the assistance –at rates below
the hospital charges to private patients. The pattern of paying below market rates
for care of the poor was continued when Medicaid was implemented three
decades later.
Public Insurance: Medicaid's Milestones (re: eligibility)
July 30, 1965: The Medicaid program is enacted, to provide health care services to children from lowincome families and their caretaker relatives--individuals eligible for Aid to Families with Dependent
Children (AFDC), the federal welfare program.
1996: The AFDC entitlement program was replaced by the Temporary Assistance for Needy Families
(TANF) block grant. The welfare link to Medicaid was severed, and enrollment (or termination) of
Medicaid was no longer automatic with the receipt (or loss) of welfare cash assistance.
Medicaid is:
• Jointly funded by federal and state governments.
• State-administered within broad federal guidelines. 25 mandatory eligibility groups.
• States may elect to cover optional eligibility groups. More than 50 eligibility groups in all.
CHIP-newest public program designed to
increase coverage of children. Passed in 1997
• Joint state federal plan giving states flexibility
• Goal – increase coverage of low and
moderate income children. Implemented as
part of welfare reform.
• Method – enhanced match by federal
government
• Great variability re eligibility, coverage, use of
premiums, whether tied to Medicaid or
separate.
Health Insurance Coverage of Children, 1988-2005
The percentage of children without health insurance has declined since SCHIP was
Implemented in 1998.
100%
6
6
6
6
Percent of All Children
80%
Other*
64
57
62
63
60%
60
62
57
56
Employer-Based
Uninsured
40%
14
20%
14
15
13
16
12
12
12
12
24
23
20
20
22
26
26
1993
1995
1998
2000
2001
2003
2005
Medicaid and
SCHIP
0%
1988
Selected Calendar Year
*Other includes private non-group and other public insurance. A change in the census questionnaire allowed this category to
be separately identified starting in 2000. AS of 2008, 31% had Medicaid/Chip, 10% uninsured, 54% employer-based.
VA System
• Targets those with injury while in service
(priorities 1-4) priority 5-Veterans eligible for
Medicaid & those with annual income or
net worth below VA financial thresholds.
($29,402 if single for free care)
• Provide outpatient and inpatient care
• Major system engineering in 1994-5
• 2009 budget ~$88 billion; serve 23 million
Veterans
Issues to be Discussed:
• Thinking of PPACA what are the lessons to
be learned from our experience with
subsidies for medical care?
• Trade-offs between cost of subsidized
programs and success in increasing access
• Tie between coverage and increasing or
reallocating providers.