The Accountable Care Act (ACA) is in high gear in Washington State. CityClub in Seattle held a forum on December 3rd about what the ACA promises for health care access. The speakers included: Teresita Batayola, CEO, International Community Health Services (ICHS); Jane Beyer, Interim Assistant Secretary, Aging and Disability Services Administration, Department of Social and Health Services(DSHS); Richard Onizuka, CEO, Washington Health Benefit Exchange (HBE); and Mark Secord, CEO, Neighborhood Care, Seattle. Joanne Silberner, NPR Contributor and Artist in Residence, University of Washington served as moderator. The moderator’s questions appear in bold.
Future issues of The O’ConnorReport will address other ACA implementation issues, such as information systems, provider concerns, broker and insurer concerns, and employer issues. One of the key provisions of the ACA is that the HBEs must demonstrate to both the state and Health and Human how they will be sustainable after the implementation grants end and how they will keep the health care system affordable as more people have access to health care services. These issue will drive a new conversation about how we provide and pay for health care services.
Coming next week: Navigators, Benefits and Brokers
Who do these organizations serve?
Batayola: International Community Health Services (ICHS) serves the Asian Pacific Islanders and related communities. It provides care to people who speak 50 different languages. A major barrier to care as reform moves forward will be explaining the changes to numerous different communities.
Byers: Aging and Disability Services is the state agency that provides care for and regulates care for all long-term care and disability services, including mental health, chemical dependency services and health services for prisons.
Onizuka: The HBE will provide access to health insurance and access to providers.
Secord: Neighborcare is the largest community clinic system in Seattle, serving 50,000 people, 40% of whom are uninsured. Secord questioned access to what? Primary care is largely covered, he said, but specialty care is a problem. There is basically no adult dental coverage as that funding has been cut by the state. Even under the ACA the only dental coverage will be for pediatric dental care.
What is the biggest headache facing these agencies?
Onizuka: The timeline and managing expectations. Open enrollment starts October 2013. Massive new IT infrastructure needs to be built in a very short period of time. We still keep getting new information from the federal government. The new insurance products must meet 19 different requirements. People between 138—400% of poverty will have subsidies in the form of an “advance premium tax credit” which is still in the process of being determined.
Beyers: Under the new guidelines, single men will now be eligible for Medicaid coverage. Now anyone under 138% of poverty will be eligible for Medicaid not just the elderly and women and children. Biggest concern is how to knit Medicaid programs together with the HBE. For example, all children are eligible for Medicaid up to 300% of poverty. Questions not answered, what if children are on Medicaid, but parents are on health plans through the HBE? How do we make the system work for families?
Bataloya: What is being done for outreach now? Major problem is how to provide access to people with so many different languages. The complexity of coverage will be an access problem.
Secord: Preparing for growth. Health centers are already seeing a 30% growth in service use. The Center will probably continue to see 5% of patients without insurance. We need to change the care model. We can use more ARNPs and PA’s, but we need to change how we pay for health care services. We need to move to global accounting not just “piece work” billing.
Is there a plan for an education campaign?
Secord: Yes, but what is the teachable moment? When someone needs care. We are going to need an entire fleet of people to explain the new coverage.
Onizuka: The uninsured are the main target, but how do we best reach them? Many do not know about the HBE. We will rely on Navigators and personal assistants, and educate the providers and insurers. We have seven different stakeholder groups now advising us, as well as technical assistance groups on specific issues.
Beyers: The HBE will be the portal. Our vision is providing good education and it may be that access will be simpler than now. For example, we will not need pay stubs in the future, instead we can just use a form of income verification.
Onizuka: Right now it takes 45 days to determine Medicaid eligibility. With a new computerized program verification will take 20 to 30 minutes.
Batayola: Unless we work with the patient to get them the appropriate care at the appropriate time, we can scare them to death. We need education and in a variety of languages.
What About Costs?
Onizuka: What we worry about is affordable products from the carriers. The Federal poverty level is $78,000 for a family of four. We are still determining how much will be offset by the advance premium tax credits.
Secord: We need to change insurance especially for small groups and individual products with a high deductable. When your income is $30,000 a year, a $5,000 deductible is impossible. Even $15 co-pays are a barrier to care.
What about undocumented patients. Will things be worse or better?
Beyers: We cannot use Medicaid dollars to treat undocumented patients. We have been able to use state dollars to cover that care and the care for undocumented children. We cannot use federal money for primary care, but we do cover care if it becomes an emergency. We have been relying on community health centers (CHC) to cover care for undocumented. The state has been providing grants to the CHC, but with a tight state budget will the state continue to provide those grants?
Batayola: We need to recognize these people are here and that public health affects everyone. Nationally, access for undocumented does not look good. Even under the Dream Act, the students would not qualify for coverage under the ACA.
Secord: We have taken steps back on this issue. The Basic Health Plan (BHP) that has provided some of that coverage, but the BHP will be gone by the end of 2013. Grant money the CHC’s received from the state is disappearing. In January 2011, we had grant money of $900,000 a year. That is now gone. This is a moral issue as well as a common sense and economic issue.
If you had a magic wand, what would you do?
Batayola: I would provide coverage for all. I would pay providers directly in the form of insurance or grants.
Beyers: I would do up-front funding for chemical dependency and mental health and hold the providers of those services accountable for outcomes and provide patients with stable housing. Use the up-front money to give incentives for providers to work collaboratively and set clear expectations. We would get money back in this investment by savings in the criminal justice system.
Onizuka: I would change the reimbursement system. The competitive health care marketplace drives innovation, not collaboration. We need to share how providers are paid. There is a lot of information that is not shared between providers.
Secord: I agree with that, but we also need to rein in lobbyists so we can get things like full Medicaid expansion.
What can people do to make a difference?
Secord: Advocate. We must have full Medicaid expansion. Come and volunteer, there are plenty of opportunities at CHC’s for volunteers.
Onizuka: Make sure you are managing your own health and the health of your family.
Beyers: There are a ‘gazillion’ lobbyists, so consumers should contact their legislators and tell them what you expect from the system and what the system should achieve; that it should help you be healthier, have the information you need when you need it and get hospitals and doctors to talk to each other.
Batayola: Get people to collaborate. Find a better way to pay for services otherwise we will just have another version of what we have today.
In the question and answer period at the end, public education was repeatedly cited as a critical issue. The Navigators were seen as being critical to finding new ways to reach patients. Washington is moving ahead rapidly. Onizuka has calls every other week with his counterparts in California, Oregon and Maryland, sharing information on their respective exchanges. He thinks only about 10 to 14 states will actually have enough in place to actually offer their residents an insurance exchange program.
On a scale of 1 to 5, with 1 being low and 5 being high, where do you think we will be in 5 years?
Secord: 3.5; Onizuka: 3.4-3.5; Beyers: access—3.5, but we will still be stuck with what system produces ; Batayola: 2.
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All the Best for the New Year! Kathleen