Minding the Gaps: The Post-ACA Role of Safety-Net Providers Brad Wright, PhD October 16, 2013 Affordable Health Care’s Next Act Hofstra University

Why Are There Gaps? The U.S. health care system is fragmented ACA makes improvements However, gaps are not filled entirely despite: Insurance exchanges Medicaid expansion Individual mandate Employer mandate

Why Are There Gaps? Insurance gaps for individuals who: Cannot access HIE Are ineligible for Medicaid Live in states not participating in Medicaid expansion Opt to pay penalty and remain uninsured Undocumented immigrants

Why Are There Gaps? Supply-side barriers Non-financial barriers Geographic maldistribution Specialty maldistribution Willing-provider problem Non-financial barriers Transportation Language Health literacy Time off work

Where Are The Gaps? Fewest gaps Moderate gaps Most gaps         Fewest gaps Moderate gaps Most gaps Source: Author’s analysis of rurality, income, immigration, HIE, and Medicaid expansion data from U.S. Bureau of Census, Pew Hispanic Center, and the Kaiser Family Foundation

How Big Are the Gaps? 23 – 31 million remain uninsured 20 – 33% are undocumented immigrants Physicians exiting Medicaid/Medicare market 9% will stop taking new patients 2% will stop taking current patients 29% remain undecided Even harder to quantify Churning between coverage Non-financial barriers to care Source: Congressional Budget Office and others; MedScape Physician Compensation Report 2013.

Who Minds the Gaps? Federally Qualified Health Centers (FQHCs) Rural Health Clinics (RHCs) Emergency Departments Free Clinics Health Departments

How Do FQHCs Fill the Gaps? Located in underserved areas Access not conditional on payment Accept all types of insurance Sliding fee scale for uninsured Provide primary care Provide enabling services

How Does the ACA Address the Gaps? Creation of ACOs FQHCs, RHCs, others can participate or form Patient-Centered Medical Homes Medicaid Health Homes – enhanced matching rate FQHC Advanced Primary Care Practice Demo HIE plans contract with essential providers Not required to include FQHCs, though may At or above Medicaid PPS rates

How Much Capacity Do the Gap Minders Have? “A health center in every poor county” Not feasible Existing clinics already at or near capacity Need more staff, financial resources Few specialists on staff Forced to depend on ad hoc arrangements

How Does the ACA Address Capacity In the Gaps? Increased funding for FQHCs through FY15 $3 of $11 billion so far $150 million for enrollment outreach Increased primary care reimbursement Medicare reimburses FQHCs for preventive care Medicaid primary care = Medicare primary care Workforce recruitment efforts Teaching health centers Funding for NHSC ($1.5 billion over 5 years)

What Are the Persistent Gaps? Fragmented safety-net & health care system Need for better care coordination Limited access to specialists Greatest pent-up demand with ACA? Many of the provisions in the ACA may not be adequately funded

brad-wright@uiowa.edu www.healthpolicyanalysis.com Thank You! brad-wright@uiowa.edu www.healthpolicyanalysis.com