1. Julie Darnell, PhD, MHSA Assistant Professor, Division of Health Policy & Administration School of Public Health University of Illinois at Chicago May 3, 2013 Georgia Charitable Clinic Network 9 th Annual Conference 10 Reasons Why Free & Charitable Clinics are Needed After the Affordable Care Act

2. Health Reform is an Historic Achievement Extends health coverage to ~30 million people Expands the healthcare safety net Individual mandate Subsidies Employer penalties Medicaid expansion Health Benefit Exchanges Health centers Increases Medicaid provider payments National Health Service Corps Training Nurse-managed clinics Encourages focus on quality & outcomes Provider/consumer engagement Public reporting Data collection Payment reform QUALITYACCESS

3. Gaps remain

4. #1: There will be gaps in coverage.

5. Gaps in coverage: 29 million uninsured in 2019

6. ~15 TIMES the number of free clinic patients

7. The Uninsured Who are they?How many? Unauthorized/Undocumented11 million Medicaid eligible but not enrolledNext largest Unaffordable coverage Not eligible for Medicaid because of Supreme Court Exempt from penalty due to hardship Not exempt from penalty.6 million < 100% FPL 2.4 million 100-300% FPL In between coverage? Source: Congressional Budget Office. (2012). Payments of Penalties for Being Uninsured under the Affordable Care Act.

8. Who Faces the Penalty? Total nonelderly population = 268.8 million Source: The Urban Institute. (2012). How Many Might Have to Pay the Individual Mandates Fine? 33% 58% 3% 4% State option to reject; Supreme Court ruling millions

9. Washington Oregon California Nevada Idaho Montana Wyoming Colorado Utah New Mexico Arizona Texas Oklahoma Kansas Nebraska South Dakota North Dakota Minnesota Wisconsin Illinois Iowa Missouri Arkansas Louisiana Alabama Tennessee Michigan Pennsylvania New York Vermont Georgia Florida Mississippi Kentucky South Carolina North Carolina Maryland Ohio Delaware Indiana West Virginia New Jersey Connecticut Massachusetts Maine Rhode Island Virginia New Hampshire Michigan (upper penisula) Alaska Hawaii Source: Hoefer, Rytina and Baker (2009). http://dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2008.pdf 75% of Unauthorized Population in 10 States

10. Click on a state to change color Free Clinics Report That They Regularly Seek to Serve Immigrants Source: Darnell, J. (2010). Free Clinics in the United States. Archives of Internal Medicine.

11. Medicaid Eligible but Not Enrolled Characteristics Variation in Medicaid participation rates Older Male Married White Hispanic Very low income Not having a chronic illness Being in overall better health Working full-time

12. Coverage is Unaffordable

13. WILLING to Pay?EXPECTED to Pay? Average annual premium contribution for family: $3,996 Sources: Kaiser Family Foundation and Health Research and Educational Trust Employer Health Benefits 2010 Annual Survey; Kaiser Family Foundation Subsidy Calculator Medicaid Premium Amount

14. Percentage of Free Clinics that See Insured Patients Source: Darnell, J. (2010). Free Clinics in the United States. Archives of Internal Medicine.

15. #2: There will be gaps in services.

16. Gaps in Services Source: Darnell, J. (2010). Free Clinics in the United States. Archives of Internal Medicine. Percent of Clinics Services not included among Essential Health Benefits

17. #3: There will be gaps in the availability of providers.

18. Gaps in the Availability of Providers Severe provider workforce shortage Downward pressures on health centers Areas not designated as medically underserved Providers unwilling to see Medicaid patients

19. Access to Care Problems Persist in Massachusetts People couldnt get the care they needed 17% of people because of cost 1 32% of nonelderly adults <300% of poverty 2 20% of patients 3 Go without medications 4 26.8% of Hispanics because of cost 5 23% in fair or poor health 6 58% of Commonwealth Type 2/3 delayed dental 6 Sources: 1. Pryor, C. and A. Cohen. (2009.) Consumers Experiences in Massachusetts: Lessons for National Health Reform. Kaiser Family Foundation. 2. Long, Sharon K. and Paul B Masi. (2009.) Access and Affordability: An Update on Health Reform in Massachusetts. Health Affairs. 3. Massachusetts Medical Society. (2009.) Physician Workforce Study. 4. Perry, M., B. Lyons, and J. Tolbert. (2009.) In Pursuit of Affordable Health Care: On the Ground Lessons from Families in Massachusetts. Kaiser Family Foundation. 5. Maxwell et al. (2011.) Massachusetts Health Care Reform Increased Access to Care for Hispanics, but Disparities Remain. Health Affairs. 6. Clark et al. (2011). Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The States Health Reforms. Health Affairs; McCormick et al. (2012.) Journal of General Internal Medicine.

20. #4: Volunteerism bestows benefits to patients.

21. Volunteerism: Bestows Benefits to Patients …Most of the problems encountered are familiar…. Because one is not grappling with unexpected illnesses, there is confidence in deciding treatment, which may free up some time with the patient to delve into other health concerns not easily broached in a rushed office practice setting. This extended conversation permits a broader, more in-depth assessment of the patient, which gives the physician greater satisfaction. Source: Reynolds, H. (2009). Free medical clinics: Helping indigent patients and dealing with emerging health care needs. Academic Medicine.

22. #5: Volunteerism bestows benefits to providers.

23. Volunteerism: Bestows Benefits to Providers …The clinic provides a supportive milieu for us senior (many, retired) health care givers. One can enjoy the comradeship of colleagues in a less competitive medical practice arena. We senior physicians are not building clinical skills at this point but, rather, preserving skills, which is a satisfying benefit (both to us and to our patients) late in a career. Source: Reynolds, H. (2009). Free medical clinics: Helping indigent patients and dealing with emerging health care needs. Academic Medicine.

24. #6: Free clinics are mission-driven providers of free care.

25. Free Care No Fees/DonationsFree/Low-Cost Care Percent of Clinics Source: Darnell, J. (2010). Free Clinics in the United States. Archives of Internal Medicine.

26. #7: Free clinics are community- based training sites.

27. Clinical Training or Supervision of Students Source: Darnell, J. (2010). Free Clinics in the United States. Archives of Internal Medicine. Percent of Clinics

28. #8: Free clinics provide high-quality care.* *but more evidence is needed!

29. Federal Tort Claims Act (FTCA) Coverage HIPAA, §194 $ appropriated to free clinics PPACA of 2010 expanded coverage: Board, Officers, Paid Staff, Independent Contractors Medical malpractice protection to specific individual health professional volunteers at approved health clinics Requirements: Credentialing & Privileging Quality Assurance Plan Risk Management Plan

30. Grant-Making Funding tied to goal attainment Long-term partnership between NC Assoc. of Free Clinics/Blue Cross & Blue Shield of NC Fdn. $10 million, 5-year award renewal tied to quality measures Clinics can use quality measures to promote funding relationships Adoption of Electronic Health Records is an imperative

31. Percentage of NC Patients Achieving Selected Chronic Disease Outcomes, 2011 Outcome NC Free clinicsHRSA NC 2010 NC BRFSS 2010 Healthy People 2020 2 A1c tests74.1Not available64.0-73.871.0% A1c<743.143.4Not available58.9 A1c>922.424.6Not available14.6 Retinal exam35.3Not available70.958.7 Foot exam61.0Not available76.774.8 mAI test53.5Not available80.637.0 Education72.2Not available53.962.5 Rx refill as expected (diabetes) 66.7Not available BP under control67.853.9Not available61.2 Rx refill as expected (hypertension) 64.5Not available

32. Accreditation/Certification/Recognition Self-imposed or external set of standards Creates a culture of goal attainment and attention to quality Little tangible value NC Assoc. of Free Clinics- self VA Assoc. of Free Clinics- self WV Association medical clinic members - NCQA SC Assoc. of Free Clinics-self 2012 20032008 2011

33. #9: Free clinics are nimble.

34. History of Free Clinics Free clinic movement Focus on the poor Focus on uninsured 1960s 1970s1980s1990s 2000s

35. #10: Free clinics have expertise serving the nations most vulnerable populations.

36. Free clinics will constitute a litmus test of the success of the reformed health system.

37. Thank You Julie Darnell jdarnell@uic.edu 773-263-0533 (cell)

38. Questions?