Fulfilling the promise of coverage and care for the medically underserved

1. Fulfilling the promise of coverage and carefor the medically underserved National Health Reform: A Colorado Perspective 2010 Annual Conference Coalition for the Medically Underserved October 8, 2010 The Children’s Hospital – Anschutz Medical Campus

2. The coverage context: Who are the medically underserved in Colorado? How will their numbers change after health reform?

3. What was the insurance status of Coloradans pre-health reform (2008-09)? SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

4. One-third of Coloradans were medically underserved (uninsured or underinsured) in 2008-09 SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

5. Different points in time for measuring uninsurance yield different rates SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

6. Number of months Coloradans were without health insurance, 2008-09 SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

7. Uninsurance rates by age and gender, Colorado, 2008-09 SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

8. Uninsurance rates by % of federal poverty level (FPL), Colorado, 2008-09 SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

9. Cost is the most frequent reason that Coloradans are uninsured, but… SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute. NOTE: Individuals could indicate multiple reasons for not having health insurance

10. Underinsured Coloradans by source of coverage, 2008-09 SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute NOTE: Underinsured is defined as 10% of household income spent on health care (not including health insurance premiums)

11. The PARADOX: Coloradans 65+ have the highest rates of underinsurance AND are adequately insured SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

12. The coverage context: Who are the medically underserved in Colorado? How will their numbers change after health reform?

13. Major coverage provisions in PPACA • Individual mandate • all citizens and legal residents must purchase health insurance by 2014 or pay a penalty • Low-to-middle income individuals subject to the individual mandate (at or below 400% of FPL) eligible for a subsidy • Expanded adult and child eligibility for Medicaid (at or below133% of FPL)

14. The state’s role in expanded access to new models of care delivery • Set up a health insurance exchange(s) for individuals and small firms to purchase health insurance • Determine eligibility and enrollment mechanisms for Medicaid and private insurance subsidies [through health exchange(?)] • Ensure that comparative information is transparent, understandable and accessible to end users • Experiment, experiment, experiment … new models for delivering integrated whole person health care, new payment mechanisms that reward health outcomes, community innovations in health care delivery

15. Establishing a Health Insurance Exchange—the “shopping mall” for health insurance • All individuals and small employers will have access to an exchange, either established by the state or federally administered • Colorado (HCPF) just received a 1-year planning grant from the federal government to plan the details of Colorado’s Exchange, stay tuned and stay involved!

16. 372,000 uninsured Coloradans will be subject to the individual mandate SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

17. Over 13 percent of uninsured Coloradans subject to the individual mandate have no adult family member employed SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

18. Working Coloradans (not offered ESI) subject to the individual mandate by size of employer SOURCE: 2008-09 Colorado Household Survey, Colorado Department of Health Care Policy and Financing, analyzed by the Colorado Health Institute

19. HB 09-1293: Child coverage expansions • On May 1, 2010, the Colorado Healthcare Affordability Act (HB09-1293) raised eligibility for low-income children from 205% of the federal poverty level (FPL) to 250% of FPL* • CHI estimated that 11,953 children will become eligible for CHP+ under the state expansion (2008) * In 2009, the FPL for a family of four was $22,050

20. Medicaid expansions, uninsured working-age adults (ages 19-64 yrs) in Colorado, 2008 Source: CHI analysis of the 2008 American Community Survey, U.S. Census Bureau

22. Please insert map 10 (without map 10 in title) with safety net layer on top of it.

23. The carecontext: Access to care for the medically underserved in Colorado after health reform—Where will access to care be most challenged? Will quality be a part of the equation? Who will provide it?

24. Insert map 3 from scopes of care report • PC Workforce (physicians and APNs overlayed with pop. below 200% of FPL)

26. Quality improvement initiatives A multi-faceted approach to promote clinical quality improvement • Expand use of quality metrics and use of quality data • Quality improvement and patient safety • Care coordination and health services delivery reforms • Quality improvement reforms across all payers, private insurers, Medicare and Medicaid

27. Care coordination initiatives • Grants to promote community health teams to support patient-centered medical homes • Grants to develop medication management programs for chronic disease patients • Grants to facilitate shared decision-making in treatment planning between patients, caregivers and clinicians • Demonstration programs for community patient navigator programs

28. Improving access to health care services • Reauthorizes/increases federally qualified health centers (FQHCs) grants to $11 billion (FY2011-FY2015) • Review of criteria for designating medically underserved areas/populations (MUAs/MUPs) and health professions shortage areas (HPSAs) • Authorizes a grant program for the development and operation of school-based health centers

29. Maternal and child health provisions Three new grant programs: • Early childhood home visitation programs ($1.5 billion for FY2010-FY2014) • Pregnancy Assistance Fund – ($250 million for 10 years) • Post-partum depression services ($15 million for 5 years) 29

30. So, what are the challenges and opportunities for fulfilling the Promise?? Be diligent in ensuring the coverage expansions and subsidies occur in a way that is equitable, inclusive and promotes the dignity and individual responsibility of all Coloradans • Can we work as a state to de-couple Medicaid from welfare? • Can we ensure that all individuals subject to the individual mandate get the information they need to make responsible decisions?

31. Acknowledgements • CHI served as administrator of 2008-09 Colorado Household Survey working in partnership with the Colorado Department of Health Care Policy and Financing • Survey funded by The Colorado Trust

32. Questions? Please contact: Pam Hanes, PhD President and CEO hanesp@coloradohealthinstitute.org 303.831.4200 x221