Claire Brindis, Dr. P.H. Executive Director, National Adolescent and

Claire Brindis, Dr. P.H.
Executive Director, National Adolescent and Young Adult Health
Information Center and Philip R. Lee Institute for Health Policy Studies,
UCSF, February 9, 2013, Adolescent Health Coordinators Meeting,
Washington, D.C.
The Case for Reform
2012: $2.8 Trillion
2018: $4.4 Trillion
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Zeros matter
A million seconds ago was last
week.
A billion seconds ago, Richard
Nixon was in the White House.
A trillion seconds ago was
30,000 BC
John Kitzhaber Keynote at IHI National Forum, Dec, 2008
“The Cost Conundrum”
‘‘Patient Protection and Affordable
Care Act” (ACA)
 First step: Expand access to health insurance
 Everyone has coverage
 Fairer insurance practices
 Expand coverage to 32 million by 2019
 Second step:
Improve quality of care
 Focused on prevention and primary care
 Third step: Stabilize cost of health care
 Change incentives: shared risk, P4P
 Reduce waste and fraud
The ACA is just the beginning of health reform
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The ACA is complicated. There is much work
to be done between now and 2014.
One of the biggest challenges is educating
the public about new options and helping
people obtain coverage for which they are
eligible.
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California was the first state to establish a
health insurance benefits exchange (Covered
California) after the ACA was enacted.
As part of California's "Bridge to
Reform," county-based Low-Income Health
Programs are enrolling adults who will
become eligible for Medi-Cal in 2014. The
program is administered under a section
1115 waiver.
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(Los Angeles County alone is home to more
people than 42 states
No single racial/ethnic group constitutes a
majority of the population
27% of Californians are foreign born and 43%
of those age 5 or older speak a language
other than English at home
California's health benefits exchange will be
awarding $43 million to community-based
organizations for outreach and education
related to the ACA
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California is home to a large number of
undocumented immigrants who will not be
eligible for the Medicaid expansion or for
subsidized coverage through the state's
health benefits exchange.
An estimated 1.2 million Californians are
uninsured undocumented immigrants.
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Historically, Healthy Families reimbursed providers at
higher rates than Medicaid. Providers will now be
reimbursed for care provided to children formerly
enrolled in Healthy Families at Medicaid rates
Some providers may stop treating these patients
because California has some of the lowest Medicaid
payment rates in the nation.
According to a survey conducted for the Kaiser Family
Foundation, California's Medicaid payment rates for
physicians were 20% below the national average. The
state is also seeking to cut physician fees by 10%.
The provision of the ACA that provides federal funds
for increasing Medicaid payment rates to Medicare
rates in 2013 and 2014 may help but California has
yet to implement this provision.
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Enactment of the ACA has heightened
concerns about the adequacy of the overall
supply of health professionals in California
because persons who have health insurance
use more health care services, especially
preventive and primary care services.
There are also concerns about the adequacy
of the supply of physicians who accept
Medicaid patients.
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Some regions of California have ratios of primary care and/or
specialist physicians that are below levels recommended by the
Council on Graduate Medical Education.
According to surveys that were recently conducted for the
California HealthCare Foundation, adults enrolled in Medicaid are
twice as likely to have difficulty obtaining an appointment with a
physician as adults with other types of coverage.
In 2011, only 65% of primary care physicians and only 61% of
specialist physicians treated Medicaid patients. Psychiatrists have
the lowest rate of participation in Medicaid.
Nurse practitioners and physician assistants play important roles
in providing preventive and primary care services in California
but increasing proportions of them practice in specialty care
settings.
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Primary care residency programs, nurse
practitioner education programs, and physician
assistant education programs have received onetime federal funding to expand the numbers of
health professionals trained, but it is not known
whether additional federal funding will be
available or if training programs can obtain
funding from other sources to sustain these
increases in trainees.
Until very recently, the state's fiscal health has
been so bleak that state officials could not even
contemplate expanding state programs that fund
health professions education.
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Currently 2.7 million people in New York are uninsured.
Under New York’s Health Benefit Exchange, more than 1 million
people will gain insurance, including 615,000 individuals and
450,000 employees of small businesses.
As of December 2012, nearly 200,000 young adults in New York
had gained coverage as a result of various provisions under the
health reform law.
In 2011, 3,342,000 New Yorkers gained preventative service
coverage with no cost-sharing. In the first 9 months of 2012,
1,238,801 people with Medicaid received free preventative
services.
For health insurance policies renewed after August 1, 2012,
women will access coverage of even more preventative services
without cost-sharing, including 3,092,653 women in New York.
As of August 2012, 4,134 New Yorkers with pre-existing
conditions gained coverage through the Pre-Existing Condition
Insurance Plan.
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New York State already provides its residents
with a number of provisions being offered
under Health Care Reform:
◦ Help for uninsured individuals with pre-existing
conditions until the Exchange is available.
◦ A web portal to help individuals and small business
owners identify health insurance coverage options.
◦ Age 26 provision.
◦ No discrimination against children with preexisting conditions.
◦ No cost-sharing for preventative care, and
guaranteed direct access to OB/GYN services.
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As of January 1, 2013, New York implemented a 12-month
continuous eligibility for children in Medicaid in order to
promote more reliable access to health care, resulting in
more positive health outcomes, while reducing the
possibility of “churning”.
New York also has a section 1115 waiver which will
provide a 12 month continuous coverage to parents,
pregnant women, and certain other adults, although it has
not yet implemented the provision.
New York covers all children regardless of immigration
status under Medicaid.
Childless adults up to 78% Federally Poverty Level (FPL) are
eligible for the Medicaid (Home Relief) waiver program and
parents up to 150% FPL and childless adults up to 100%
FPL are eligible for the Family Health Plus waiver program.
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Consumer education will be required to
prepare individuals, particularly young
people, to:
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understand various options,
enrollment requirements,
costs,
subsidies, and
exemptions.
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Special Populations requiring greater efforts
for enrolling:
◦ Individuals with less education,
◦ Economically disadvantaged, and
◦ Immigrant populations
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How will young adults evaluate health care
options?
What impact will choices have on where
they turn for health services – especially
sensitive services/confidential care?
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How do we assure a cultural shift,
especially among young adults, to seek
preventive health care services.
What is the role of social media and the
internet in health care delivery?
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Challenge of maintaining confidentiality
 Explanation of Benefits (EOBs)
 Electronic Health Records (EHRs)
 Eligibility and Enrollment
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Concern about capacity to handle the influx
of newly covered adolescents and young
adults
 Paraprofessionals
 Expand and enhance Health Information
Technology (HIT)
1. Incorporate adolescent and young adult
needs as part of an overall planning process
implementing the ACA within the existing
system of care, aiming to decrease
fragmentation and close gaps in services.
2. Help develop a plan for integrating
adolescents and young adults as part of
Accountable Care Organizations (ACOs) and
other system delivery options within the ACA,
with an eye towards adolescent-specific
confidentiality.
3. As part of the plan, review with your safety
net provider colleagues who will care for
undocumented youth and how these youth will
access care.
4. Monitor the implementation of the ACA ,
assuring it builds and expands current access,
quality, service integration, and affordability
elements.
As part of this effort, increase/enhance access
to and delivery of health care for special
populations of young people.
5. As part of overall health information
technology (HIT), assure that the unique
needs of adolescents/young adults are
considered:
a. protect from security breaches,
b. user-friendly for multiple
stakeholders
(individual consumers,
providers, eligibility regulators, insurers,
etc.), and
c. maintain adolescent confidentiality
for
sensitive services.
6. Help facilitate information regarding
creating a streamlined ‘determination and
enrollment‘ process for adolescents/young
adults :
a. reduce the burden on consumers,
b. ensure continuity of coverage,
c. minimize up-front documentation to
establish eligibility,
d. allows for enrollment through online,
telephone, in-person, or mail.
7. Help to create adolescent-tailored outreach,
including the use of social media, schoolbased, and other community settings.
8. Develop and evaluate adolescent/young adult
consumer education aimed at helping them
better understand:
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different health plans and benefit packages,
costs and benefits of different options,
enrollment requirements,
costs, subsidies, and exemptions.
9. Monitor whether adolescents are enrolling
in private and public insurance programs,
and what barriers exist to their enrollment.
10. Help track and monitor trends in the
delivery of preventive and other health care
to adolescents and young adults:
◦ Timeliness and developmentally appropriate
services,
◦ Content of care,
◦ Assurance of confidentiality, and
◦ Time alone, as indicator of quality.
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