Healthcare Access in Western North Carolina: What Might 2014 Hold? Amy Marietta, MPH Larry A. Green Visiting Scholar Robert Graham Center March 20, 2012

Objectives Present overview of demographic profile of WNC Describe some characteristics of the healthcare workforce in WNC, focusing on access to primary care Identify current healthcare infrastructure in WNC, focusing on federally-funded sites Present an idea of some challenges that WNC may face in 2014 with the changes in Medicaid enrollment

SECTION 1 Where’s Western North Carolina?

Western North Carolina

Fig 1. Percent Population Hispanic (Census 2010) Fig 2. Percent of Population non-White (Census 2010) State: 31.5% non-White 8.4% Hispanic WNC: 12% non-White 5.6% Hispanic Section 1: Demographics

Fig 1.3. Percent Population <100% FPL (ACS ) Fig 1.4. Percent of Population <200% FPL (ACS ) State: 14.8% Poverty 34.6% Low-Income WNC: 14.7% Poverty 36.8% Low-Income Section 1: Demographics

Fig 1.5. Percent Population Age >65 (ACS ) State: 12.7% age >65 19% uninsured WNC: 19.3% age > % uninsured Section 1: Demographics Percent of Population Age 65 or Older Percent of Population Uninsured Fig 6. Percent of Population Uninsured (SAHIE 2007)

SECTION 2 Healthcare Workforce

Fig 2.1. Number of Primary Care Physicians, by county (AMA) Fig 2.2. Primary Care Physicians per 10,000 persons (AMA) Section 2: Healthcare Workforce

Figure 2.3 Primary Care MD per 10,000 people, by county (Sheps Center) Figure 2.4 Primary Care MD per 10,000 people, by county (AMA)

Figure 2.5 Primary Care MD per 10,000 people, by county (Sheps Center) Figure 2.6 Primary Care MD per 10,000 people, by county (AMA)

Figure 2.7 WNC Health Professional Shortage Areas

Figure 2.8 WNC Loan Repayment and National Health Service Corps Scholar Sites

County # of Medicaid- accepting Sites Buncombe49 Cherokee7 Clay3 Graham1 Haywood8 Henderson23 Jackson10 Macon12 Madison4 McDowell9 Mitchell5 Polk5 Rutherford11 Swain2 Transylvania8 Yancey5 Figure 2.9 Medicaid-accepting Sites in Western North Carolina. Includes private practices, health centers, clinics, and hospitals. (CCNC 2010)

SECTION 3 Healthcare Infrastructure

Figure 3.1 Access points in WNC

Figure 3.2 All Grantee Penetration of Low Income Population (<200% of FPL)

SECTION 4 The Future- What Does 2014 Hold?

Figure 4.1 Percentage of the Nonelderly Population With Income Up to Four Times the Poverty Level Who Were Uninsured or Purchasing Individual Coverage, 2010

Figure 4.2. NC SuperPUMAS 14 SuperPUMAs in North Carolina Each Comprised of 2-6 PUMAs Based on Census Tracts 1 PUMA = approx 100,000 people WNC split between 2 SuperPUMAs and 6 PUMAS

PUMACounties 00100Cherokee, Graham, Clay, Macon, Swain, Jackson, and Rutherford 00201Madison and most of Buncombe 00202Asheville and surrounding areas 00300Henderson and Transylvania 00400Polk, McDowell, Rutherford, and Cleveland 00500Yancey, Mitchell, Avery, Watuga, and Ashe Figure 4.3 Western North Carolina PUMAs

PUMACountiesPop.% Newly Eligible Newly Eligible Less than 21 yrs. Newly Eligible Older than 21 yrs Cherokee, Graham, Clay, Macon, Swain, Jackson, and Rutherford 194,13627%25%75% 00201Madison and most of Buncombe 135,74524%20%80% 00202Asheville and surrounding areas 120,99427%19%81% 00300Henderson and Transylvania 139,94719%15%85% 00400Polk, McDowell, Rutherford, and Cleveland 231,65420%17%83% 00500Yancey, Mitchell, Avery, Watuga, and Ashe 133,07427%23%77% Table 4.1 Percent of population newly eligible for Medicaid in 2014 by PUMA and age

Conclusions WNC is less non-white and less Hispanic than state as a whole WNC has a larger aging and uninsured population than state as a whole Overall the provider-to-population ratios for primary care are higher in WNC than states as a whole, with the exception of Clay, Graham, McDowell, Madison, Rutherford counties. Even in counties with a high provider-to- population ratio, there may be very few Medicaid-accepting sites (i.e. Swain county)

Conclusions, cont. Federally-funded primary care sites are not necessarily located in counties most in need of primary care providers, and penetration of low- income population by federal sites is low. Far western NC and the Appalachian region is likely to experience an increased demand for healthcare services as a large percentage of the population becomes newly eligible for Medicaid and health insurance tax credits in 2014.

Next Steps Report to CEOs MAHEC, Mission Hosp. Connect to health outcomes data from CCNC Connect to cost data from Medicaid claims Identify Medicaid sites’ FTE, patient panels, accepting new pts, etc. to assess true capacity Identify other “shortage specialties” in addition to primary care- psychiatry, general surgery, etc. Present information to stakeholders Develop regional plan for 2014

Thanks! Questions?

Objectives Demographics: What is the demographic profile of WNC? What percentage of the population is non- white? Hispanic? Over age 65? Living in poverty? Low-income? Unemployed? Less than high school education? Single parent Head of Household? Healthcare Access: What percent of the population is uninsured? What insurance coverage does the population have, by type? What percent of the population are enrolled in Medicaid? How many ED visits, inpatient admissions, mental health admissions, and readmissions does the population have (per 100 persons and percent of population)? ACSH? Primary Care ED visits? Distance to Care? What percentage of primary care providers accept Medicaid? Disease Burden/Population Health: What percentage of the Medicaid-enrolled population suffers from DM? COPD? Cancer? Mental Health? Dementia? Chronic GI problems? What percentage of the Medicaid- enrolled population is receiving appropriate colon cancer screening? Cervical? Breast? Healthcare Workforce: How many and what types of primary care providers (FM, Peds, gen IM, PAs NPs) and psychiatrists practice in Western NC? What is the population to provider ratio for primary care providers in WNC? How many areas are HPSA areas in WNC? In which areas would providers be eligible for loan repayment? Healthcare Infrastructure: How many community health centers or other federally funded sites are located in WNC? What percentage of low-income residents are these federally funded health centers serving? Future: How many WNC residents will become newly eligible for Medicaid in 2014? How many of these are likely to enroll in Medicaid? How many new PCPs would WNC need in order to meet that demand? How many existing PCPs would need to accept Medicaid to meet the demand? What would the cost be associated with those newly enrolled in Medicaid?

Mental Health Fig 2.3 Number of Psychiatrists in NC, by county (AMA)

Pop per PCP MD Figure 2.4 Population per Primary Care MD, by county