1. 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

2. 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

3. 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

4. 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

5. 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

6. 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.

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

8. 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

9. 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

10. 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

11. 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)

12. 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

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