THE URBAN INSTITUTE The DC Health Care Alliance Seven years of universal access to coverage for the poor Barbara A. Ormond Randall R. Bovbjerg The Urban Institute AcademyHealth Annual Research Meeting June 9, 2008 Washington, DC

THE URBAN INSTITUTE 2 What Is the Alliance? Coverage not insurance Private contracts Universal for residents under 200% FPL Locally funded

THE URBAN INSTITUTE 3 Origins of the Alliance Longstanding local commitment to care for the poor Deficiencies at the public hospital & its clinics Outside influences Administration support for “buy” over “make”

THE URBAN INSTITUTE 4 Coverage Components Rich benefit package Limited provider network No cost to enrollees Maintenance of access

THE URBAN INSTITUTE 5 Medical homes in the Alliance Motivation –Replace uncoordinated care received at public hospital Initial vision –Medical homes, prevention, community-based care Implementation –Strong reliance on hospitals, episodic care

THE URBAN INSTITUTE 6 Enrollment

THE URBAN INSTITUTE 7 Evolution of the Alliance Administration –Management difficulties with Alliance contractor –Take-over by DOH (2002) Enrollment –Presumptive enrollment –Streamlined enrollment (2006) Payment –Modified fee for service –Transition to managed care (2006)

THE URBAN INSTITUTE 8 Expenditures Source: DC Health Care Safety Net Administration Annual expenditures million dollars

THE URBAN INSTITUTE 9 How do enrollees view the Alliance? Many use it to finance care when they need it Others use it routinely for preventive and acute care Still others rely on it to treat their chronic illness Overall, enrollees are very satisfied with their access to care and its quality Spanish speakers reported somewhat more problems

THE URBAN INSTITUTE 10 Achievements Fast start-up Filled major coverage gaps Improved access Initially, small net increase in District costs BUT Recent rapid growth threatens financial status Gaps in services remain Benefits of medical homes yet to be realized Lack of data

THE URBAN INSTITUTE 11 Lessons from DC for state health reform Design the system for the population you have, not the one you wish you had. Be patient. Good data on utilization is a necessity, not a luxury. Things change. Be ready to respond. It is hard to overestimate how much having secure coverage means to the low income population.

THE URBAN INSTITUTE QUESTIONS?