Patient Protection and Affordable Care Act and Free Clinics by Debbie Oswalt Virginia Health Care Foundation

Although we are challenging the Patient Protection and Affordable Care Act, it is currently the law of the land and it would be irresponsible not to prepare for its implementation. --Governor Bob McDonnell via Virginia Secretary of Health and Human Resources Bill Hazel (August 2010)

Over 1 Million Virginians Uninsured in 2010 Total Nonelderly 1,004,000 uninsured nonelderly Source: Urban Institute, February Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

The uninsured rate for adults in Virginia increased between 2009 and 2010 % Point Change +1.1% Points-0.3% Points+1.6% Points Note: Asterisks indicate a change in percent of people that is statistical significant at the.10 level. Source: Urban Institute, February Based on the 2009 and 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

VA Medicaid eligibility criteria lower than other states % FPL * Only 7 states cover non-disabled childless adults. Source: Heberlein, M., T. Brooks, S. Artiga, and J. Stephens Holding Steady, Looking Ahead: Annual Findings of A 50-State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost Sharing Practices in Medicaid and CHIP, Washington, DC: Kaiser Commission on Medicaid and the Uninsured.

Nearly 70 percent of uninsured Virginians live in families with at least one full or part-time worker in 2010 Share of Nonelderly Uninsured Notes: Family work status is based on the highest level of employment among the adults in the health insurance unit. Estimates may not sum to 100% due to rounding. Source: Urban Institute, February Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

Just under half of the uninsured in Virginia were white, non-Hispanic in 2010 (E.L. Freeman) Share of Nonelderly Uninsured Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, February Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

Young adults (19-34) comprised over half (51.7%) of uninsured Virginians in 2010 Notes: Asterisks indicate a percentage that is statistically different from the reference group (Age 0-18) percentage at the.10 level. Source: Urban Institute, February Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

A vast majority (89.2%) of uninsured Virginians lived at or below 200 percent of FPL in 2010 Total Nonelderly Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2010 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Source: Urban Institute, February Based on the 2010 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). Estimates reflect additional Urban Institute adjustments for the underreporting of Medicaid/CHIP and the overreporting of private nongroup coverage (See Lynch et al, 2011). Coverage estimates were developed under a grant from the Robert Wood Johnson Foundation.

Source: DMAS November 2010 Major Medicaid Provisions of Federal Health Reform

Change in health insurance coverage with PPACA Without reform Uninsured With reform Insured 6,414,000 Insured 5,888,000 Uninsured Thousands of nonelderly Virginians

Decline in uninsured persons by income group Uninsured Source: Urban Institute analysis, HIPSM 2011 *Note: We simulate provisions of the Affordable Care Act fully implemented in 2011.

Those left uninsured under reform N=515,000 Source: Urban Institute analysis, HIPSM 2011 *Note: We simulate provisions of the Affordable Care Act fully implemented in 2011.

Profile of Virginia Free Clinic Medical Patients 63,884 in 2010 (50% treated in 13 free clinics) Almost two thirds are years of age 70% have one or more chronic illnesses An average of about 75% will be eligible for Medicaid in 2014 Will vary among clinics

Assessing Local Impact of PPACA Medicaid Expansion: Assess impact within clinic Number of patients eligible for Medicaid in 2014 (income and citizenship) Assess impact on Medicaid eligible free clinic patients Acuity level of these patients Nature of clinics relationship with these patients, i.e. a medical home? Availability of Medicaid providers in area (taking new patients?) See Free Clinic Planning Tool for help

What About Patients without Coverage in 2014? Determine the number and nature of clinic patients not eligible for Medicaid Estimate the number and nature of people within the clinics service area who are likely to remain uninsured post-PPACA implementation See Free Clinic Planning Tool for help

PPACA Medicaid Expansion: Free Clinic Options Maintain current free clinic business model Current model, and allow Medicaid eligible at clinic, without charge Transition to a hybrid model In eligible areas of state: Apply to become a Federally Qualified Health Center (FQHC) Become an FQHC Look-a-like Become a Rural Health Clinic Transition eligible patients to Medicaid, help them find a provider, and close clinic

What Is a Hybrid Model? Enables a free clinic to become a Medicaid provider, and maintain its free clinic roots and mission. Provides medical care to low income patients (uninsured and Medicaid) Utilizes paid providers, often supplemented with volunteers (providers and otherwise) Charges fee for services on a sliding scale, which can allow for free care for lowest income patients

Examples of Hybrid Models Good Samaritan Health Center (Atlanta, GA) Large urban clinic, 93% uninsured, and 7% Medicaid/Medicare 19,000 volunteer hours/year Medical, dental, mental health services = 27,000 visits/year Doctors Care (Littleton, CO) Free specialty care for 5 years added pediatrics (CHIP/Medicaid) year olds (set fee or sliding scale) Lots of volunteers (Family Practice residency program) Medical services = 8,000 visits/year

Examples of Hybrid Models San Jose Clinic (Houston, TX) Large 89 year old clinic, in process of becoming a Medicaid provider 140 volunteer providers (specialists, resident programs), 200 lay volunteers 42 staff Medical, dental, mental health and pharmacy services = 30,500 visits/year Olde Towne Medical Center (Williamsburg, VA) Large 20 year old clinic that became a hybrid early on hrs/mo of volunteer providers (more for dental) Medical, dental and mental health services = 16,000 visits/year Became a rural health clinic = 10% payment bump (Medicaid/Medicare)

Core Elements of Becoming a Hybrid Clinic Clarity regarding mission and target patient population Community understanding and support Viable business plan Determine mix and allocation of paid and volunteer providers Adequate infrastructure Electronic health record system HIPAA compliant Credentialing providers (contracted) Billing capacity (in-house or contracted) Administrative staff Facility space

Summary PPACA coverage expansions will cut the number of uninsured Virginians in half. Many, including 75% of free clinic patients, will be eligible for Medicaid About 289,000 Virginians 200% FPL will remain uninsured. (undocumented immigrants, those who cant afford insurance) This creates locality-specific opportunities and challenges for Virginias free clinics. One option under consideration by a growing number of clinics is transitioning to be a hybrid clinic: Blends paid and volunteer providers to treat low income patients (uninsured and Medicaid) Requires thoughtful planning and sufficient infrastructure Each free clinic must evaluate the impact of PPACA on its patients and community, in determining its future direction.

For more information visit: or contact: Debbie Oswalt Executive Director Virginia Health Care Foundation (804)