C A L I FOR N I A H EALTH C ARE F OU NDATION Implementing National Health Reform in California: Opportunities for Improved Access to Care March 2011 Implementing National Health Reform in California: Opportunities for Improved Access to Care Prepared for California HealthCare Foundation by Melinda Dutton, J.D. Alice Lam, M.P.A. Manatt Health Solutions March 2011 About the Authors Manatt Health Solutions is the interdisciplinary policy and business advisory division of Manatt, Phelps & Phillips, LLP, a law and consulting firm. Manatt Health Solutions provides expertise in health care coverage and access, health information technology, health care financing and reimbursement, and health care restructuring, as well as strategic and business advice, policy analysis and research, project implementation, alliance building/advocacy, and government relations services. For more information, visit www.manatt.com. Acknowledgments This report would not have been possible without the participation and input of California state government officials and health care stakeholders. In addition, we extend our thanks to Sandra Newman and Keith Loo at Manatt Health Solutions for their contributions to this report. About the Foundation The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at www.chcf.org. ©2011 California HealthCare Foundation Contents 2 I. Introduction and Background Access to Care: The California Context California’s 1115 Waiver — A Bridge to Reform 5 II. Analysis of Provisions Enhanced Medi-Cal Payments for Primary Care Disproportionate Share Hospital Funding Medicaid Adult Preventive Services Medicaid Emergency Psychiatric Services Demonstration Community Clinics Workforce 2 0 III. Conclusion 2 1 Appendices A: Access-Related Grants Awarded to Date to California B: California Health Coverage and Service Programs C: Workforce Opportunities D: Interview List 3 4 Endnotes I. Introduction and Background S weeping federal health reform businesses or who must buy insurance on their legislation enacted in March 2010 brings about own. After the law is fully implemented in 2014, it new health coverage options to a significant portion is estimated that 92 percent of Californians will be of California’s 6.8 million uninsured.1 The Patient insured.4 The newly insured will be better able to Protection and Affordable Care Act (PPACA) pay for care, which should improve access to care. and subsequent amendments under the Health At the same time, expanded coverage is likely to Care Education and Reconciliation Act of 2010 increase demand for health care services as the newly (HCERA), collectively referred to as the Affordable insured seek to use the health care system, often Care Act, or ACA, expand access to public and with greater unmet needs requiring more intensive private health insurance while seeking to change levels of care. The ACA includes many provisions the way care is provided and paid for across the intended to improve states’ capacities to meet United States.2 This report is the second in a series of this demand so that increased coverage translates reports commissioned by the California HealthCare to increased access to high quality, culturally Foundation (CHCF) describing the wide-ranging competent health care. As the ACA’s provisions are implications and implementation tasks that lie ahead implemented, it will be important to monitor and for California under the ACA. The initial policy address how well people — both insured and those analysis, published in June 2010, focused on health remaining uninsured due to affordability exemptions, insurance coverage, describing provisions of the noncompliance, or immigration status — are using ACA that seek to expand the availability of health health care services. insurance and to restructure the insurance market.3 The remainder of this report focuses on the This report addresses provisions of the ACA that ACA provisions meant to ensure access to care: affect access to care, including those that invest in the greater investment in primary, community-based health care delivery workforce and infrastructure and care; funding for uncompensated care directed to that realign resources to enhance access to care. certain safety net providers; and new funding streams The expansion in health insurance coverage alone to support health care workforce development will certainly influence access to care in California. in the state. The discussion is structured to assist The ACA expands Medicaid to guarantee eligibility policymakers and stakeholders in navigating the under California’s Medi-Cal program for the majority legislation. A summary outlining the provision of Californians under 133 percent of the federal discussed is presented along with the effective poverty level (FPL). The ACA also establishes date; the responsible entities; the decisions, health insurance exchanges and offers premium tasks, and considerations facing California as subsidies to provide affordable, comprehensive implementation progresses; and “the bottom line.” coverage to another significant population of The summary also distinguishes between funds Californians who traditionally have difficulty appropriated for provisions and those merely obtaining coverage — individuals who work in small authorized — implementation of authorized 2 | C alifornia H ealth C are F oundation initiatives is uncertain and contingent upon geography and 8 percent of the state’s population, additional action by Congress. This report has been or 2.8 million Californians — are also particularly informed by the perspectives of 13 state officials, acute.12 Rural areas in the state tend to have fewer stakeholders, and thought leaders. The list of physicians per capita and significantly older ones, interviewees and draft reviewers are included in running the risk that these physicians will retire Appendix D. without successors to maintain the already scarce physician supply.13 In seven rural counties, one study Access to Care: The California Context found that over half of the practicing physicians were Access to health care is unevenly distributed across over age 55.14 There are also shortages of specialists in California’s vast geography. The state faces shortages rural areas. among many types of providers. Recent analysis of Provider participation in Medi-Cal is also Medical Board of California data indicates that the inadequate, commonly attributed to the program’s state falls below, or at best at the lower end, of the low payment rates. California physicians are much recommended number of primary care physicians less likely to serve Medi-Cal patients (68 percent) per capita.5 And although California has made than patients with private insurance (92 percent) or strides even in the recent economic downturn, the even Medicare coverage (78 percent), with widely shortage of nurses is predicted to continue well into varying participation rates among specialties.15 With the next decade.6 Allied health professionals are also California’s continuing fiscal difficulties, the state in short supply — pharmacists, clinical laboratory has been hard-pressed to address payment rates and, scientists, and cardiovascular technologists, for further, has reduced state funding for community example — which comprise 60 percent of the clinic services, home care, mental health, and a health care workforce in the state.7 A 2007 study variety of other health programs. conducted prior to the enactment of health care Health reform offers California the opportunity reform projected that to meet expected demand, to build health care capacity and infrastructure. the supply of an array of allied health professionals Significant investments are made to ensure the needed to grow by 11 to 559 percent, with a availability of primary, community-based care, median of 79 percent.8 Another consideration with a priority placed on reaching underserved for California is recruiting a diverse health care areas. New initiatives are established to support workforce, which has been associated with improved health care workforce planning and analysis, as well cultural competency, patient trust, and compliance as training and education for a variety of health with treatment.9 Compared to the state’s general professionals. Access to care will also be influenced population, racial and ethnic minorities are by provisions beyond those addressed in this brief; underrepresented in California’s provider pool.10 For including a number of ACA provisions that invest example, while Latinos represent over a third of the in delivery system reform and a host of initiatives state’s population, they comprise only 5.7 percent of already underway in the state, such as telemedicine. nurses, 5.2 percent of physicians, and 7.6 percent of Nevertheless, the ACA’s access provisions will enable psychologists.11 California to prepare for the newly insured and to Access challenges in rural California — which incrementally address underlying access problems. accounts for roughly 90 percent of the state’s Implementing National Health Reform in California: Opportunities for Improved Access to Care | 3 California’s 1115 Waiver —  ◾◾ The Low Income Health Program (LIHP) A Bridge to Reform enables counties to provide Medi-Cal coverage In addition to changes under the ACA, the recent to uninsured adults under 200 percent of the approval of California’s 1115 waiver renewal request FPL, providing a head start in implementing the will have implications for access to care. Under the coverage expansions effective in 2014. The LIHP authority of Section 1115 of the Social Security is composed of the Medicaid Coverage Expansion Act, the federal government may waive certain for those under 133 percent of the FPL and the Medicaid statutory requirements so that states can Health Care Coverage Initiative for those between receive federal funds for Medicaid services that 133 percent and 200 percent of the FPL. The would otherwise not be eligible for federal funding. LIHP will allow the state to identify and enroll California’s original Medi-Cal Hospital/Uninsured adults likely to be eligible under the federally Care Section 1115 waiver took effect in July 2005. mandated minimum Medi-Cal eligibility level in After nearly a year of state analysis and planning, 2014, as well as those individuals who could be and negotiation with federal officials, California eligible for a Basic Health Program if California received approval to renew this waiver in November decides to pursue that option.19 In addition, the 2010 with significant additions.16 California’s LIHP could provide a “bridge” coverage option Bridge to Reform Demonstration is expected to for uninsured adults before additional coverage allow California to leverage $10 billion in federal options become available in 2014 through funds between November 1, 2010, and October 31, Medi-Cal, the Basic Health Program, or the 2015.17 state health insurance exchange. ◾◾ California is the first state in the nation to ◾◾ Finally, the Delivery System Incentive Reform successfully pursue a set of policies aimed at Payments (DSIRP), which are authorized early implementation of federal health reform under the waiver, support infrastructure while enhancing access. The cornerstone of development, innovation and redesign, and California’s waiver is the Safety Net Care Pool care improvement projects in public hospitals. (SNCP), which covers uncompensated costs in Proposed infrastructure development projects public hospitals and finances other state health include introducing telemedicine and enhancing care programs. In the waiver renewal, designated interpretation services, which could bolster qualifying California public hospitals (including capacity to provide care. DSIRP innovation, University of California hospitals) continue to redesign, and care improvement projects could be able to draw down funding from the SNCP also position California hospitals well for further for uncompensated care through their own health system transformation opportunities under expenditures.18 To stretch limited state dollars, the ACA. additional state health care programs — workforce programs, services for developmentally disabled individuals, and all county mental health services — are also permitted to draw down federal matching funds through the SNCP for allowable expenditures. 4 | C alifornia H ealth C are F oundation II. Analysis of Provisions T his section outlines the key provisions state close the gap between Medi-Cal and Medicare of the Affordable Care Act related to access to care. primary care payment rates. The statute directs that the calculation be based on the Medi-Cal payment Enhanced Medi-Cal Payments for rate as of July 1, 2009. This level is compared to the Primary Care (HCERA § 1202) greater of the Medicare payment rate for 2013 and California has struggled with the inadequacy of 2014, or the Medicare payment rate determined Medi-Cal provider payment rates. A recent study using the 2009 conversion factor for that year. indicates that Medi-Cal pays less than half of what Parity with the Medicare primary care payment rate Medicare pays for primary care services, and overall applies both to fee-for-service and managed care fees rank 47th among all states.20 A physician survey reimbursement under Medi-Cal.24 indicates that 25 percent of primary care physicians Federal officials will be issuing clarifying guidance are providing care for 80 percent of Medi-Cal for state implementation. One pressing issue is how beneficiaries, with a similar pattern observed for this provision will play out in the managed care specialists.21 The numbers of primary and specialty environment, which is how over half of Medi-Cal care physicians available per 100,000 Medi-Cal beneficiaries currently access their coverage. The beneficiaries are also well below the benchmarks state will need federal guidance to translate the recommended by the Council of Graduate Medical enhancement from per-service to per-person, per- Education. month terms. It will be important for the state To save money, the state has imposed repeated to maximize the benefits of this provision and to reductions in Medi-Cal provider payment rates in minimize any administrative burdens or complexities. recent years. This practice is one of the few remaining The Medi-Cal primary care enhancement will tools to reduce Medi-Cal expenditures, given federal certainly be welcomed by providers and will augment maintenance of effort conditions.22 In 2009, Medi- payments without taxing state coffers. However, the Cal rate reductions were met with legal challenges, ACA requirement and enhanced federal funding is and the state was prevented from reducing Medi-Cal effective for only two years and is limited to primary rates for fee-for-service providers who offer physician, care providers and services. The state will need to dental, adult day health care, optometry, clinic, and develop a long-term strategy to ensure provider prescription drug services; nonemergency medical networks can meet the needs of the increasing transportation; and home health services. numbers of individuals expected to be covered For calendar years 2013 and 2014, the ACA by Medi-Cal. Creating an environment in which requires that Medi-Cal reimburses at no less than providers are willing to participate in Medi-Cal is the Medicare payment rate for primary care services but one factor in ensuring access to care. California provided by family medicine, general internal also faces underlying provider supply challenges, medicine, and pediatric medicine physicians.23 The which are discussed further in the Workforce section ACA also provides full federal funding to help the of this brief. Implementing National Health Reform in California: Opportunities for Improved Access to Care | 5 Table 1. Enhanced Medi-Cal Payments for Primary Care What It Says The ACA requires Medi-Cal to pay physicians for primary care services furnished in 2013 and 2014 at a rate no less than Medicare’s. Effective Date January 1, 2013 through December 31, 2014 What Needs to Be Done In 2011, the federal government is expected to issue regulations and guidance on implementation. California should begin to engage with the Centers for Medicare and Medicaid Services (CMS) to help shape implementation guidelines. The state will also need to develop a Medicaid state plan amendment and take other actions, such as to modify administrative systems and communicate with providers and plans. Who’s Responsible Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) The Bottom Line While the enhancement will be helpful, it does not obviate the need for California to explore long-term solutions for ensuring the adequacy of Medi-Cal payment rates. Disproportionate Share Hospital Medi-Cal DSH Reductions (HCERA § 1203) Funding Federal funds for Medicaid DSH payments are Disproportionate Share Hospital (DSH) payments capped at an annual state allotment derived through Medicaid and Medicare help offset the from a federal FY 2002 base amount, adjusted cost of unreimbursed care for hospitals serving annually for inflation, and linked to state Medicaid high volumes of Medi-Cal or uninsured patients. expenditures.26 Under the state’s Section 1115 waiver, Medi-Cal and Medicare DSH payments are major funds from Medi-Cal’s DSH allotment are primarily sources of support for California hospitals — over used to make over $1 billion in annual payments $2.5 billion each year.25 The ACA starts to phase to qualifying public hospitals (including University down DSH payments as the number of uninsured of California and county-operated hospitals).27 individuals and their uncompensated costs are California further has authority to operate a DSH expected to decline. DSH payments are reduced “swap” or “replacement” program that provides starting in federal FY 2014 and continue through similar payments to private hospitals. Qualifying federal FY 2020 for the Medicaid DSH program private hospitals receive approximately $465 million and in perpetuity for the Medicare DSH program. in payments through this program annually.28 The However, it remains to be seen whether the level DSH replacement program’s funding level is linked and timing of coverage gains will reduce hospital in state law and the Medi-Cal State Plan to the state’s uncompensated care costs and fully offset these DSH allotment. authorized DSH reductions. In anticipation of increased coverage leading to fewer uninsured, the ACA significantly reduces federal Medicaid DSH allotments from 2014 to 2020. Levels diminish by $500 million in 2014, and the reduction grows annually to a high of $5.6 billion in 2019. While future years’ DSH allotment levels are not yet available, the Medicaid DSH allotment 6 | C alifornia H ealth C are F oundation levels estimated for FY 2011 of approximately ten-year period, or roughly 10 percent of the state’s $11 billion may be used as a point of reference.29 DSH allotments for that timeframe.30, 31 If DSH payment reductions are not offset by reductions in Table 2. verall Reductions in Medicaid O DSH Allotments the demand for uncompensated care, the financial health of hospitals could suffer. The Safety Net Federa l R educ tio n Fisca l Year (in millions) Care Uncompensated Care Pool — authorized 2014 $500 under the state’s Section 1115 waiver to support uncompensated care costs that are not otherwise 2015 $600 2016 $600 2017 $1,800 California’s Counties County governments in California play a critical 2018 $5,000 role in the state’s health care safety net. California law requires that counties “relieve and support all 2019 $5,600 incompetent, poor, indigent persons, and those 2020 $4,000 incapacitated by age, disease, or accident, lawfully resident therein, when such persons are not supported TOTAL $18,100 and relieved by their relatives or friends, by their own means, or by state hospitals or other state or private institutions.”32 The counties operate and finance a The HHS secretary will develop the exact variety of health programs — the Medically Indigent methodology to impose these reductions on each Program, Medical Services Program, Coverage Initiatives, and Children’s Health Initiatives — that state’s allotment, but the statute does articulate that provide limited to comprehensive benefits for the methodology should: medically indigent individuals ineligible for Medi-Cal. ◾◾ Direct the largest reductions at states with the With the ACA’s increased coverage expected to offer comprehensive coverage options to a significant lowest uninsured rates that do not target DSH number of those enrolled in these programs, payments to high-need hospitals (those with California’s counties could see a declining role on this high volumes of Medicaid inpatients and high front and an assumption of costs by other payers. levels of uncompensated care); The counties also play an important role in the ◾◾ Allow for smaller reductions for low-DSH states, financing and administration of the Medi-Cal program. County hospitals pay a share of Medi-Cal DSH those with smaller DSH programs as a proportion payments, and to the extent that the reduction in of their total Medicaid expenditures; and these payments are not offset by uncompensated care savings, public hospitals could require additional ◾◾ Take into account the extent to which DSH support from county governments. Counties also payments are included in budget neutrality conduct eligibility and enrollment activities and manage calculations for state Medicaid waivers. major eligibility systems for Medi-Cal and other public benefit programs across the state. The ACA imposes new requirements on Medi-Cal eligibility and While it is not yet clear how DSH reductions enrollment systems, including integration with health will be allocated across the states, early estimates insurance exchange systems. These requirements and indicate that California’s share of reductions could subsequent federal guidance may require the state to total approximately $1.3 to $1.5 billion over a revisit the counties’ role in the eligibility process.33 Implementing National Health Reform in California: Opportunities for Improved Access to Care | 7 funded through Medi-Cal, claimed for DSH, or reimbursed by other payers — could help offset some Selected Medicare Payment Changes Approximately 4.5 million individuals, 12 percent of reductions for designated California public hospitals. Californians, use Medicare.40 Medicare payments However, California’s private hospitals, which account for $32 billion of health care services cannot access the pool, could be left searching for an delivered in the state.41 A higher percentage of alternative revenue source. Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans compared to the rest of the nation (34 percent versus 23 percent).42 In addition to Medicare DSH Reductions (§ 1104) Medicare DSH reductions, the ACA includes numerous Medicare DSH payments are also reduced in changes related to Medicare reimbursement (§§ 3201, anticipation of fewer uninsured residents and their 3401– 3403, 5501, 10501, and HCERA § 1102[b]). For example, uncompensated care costs. The ACA makes changes changes made to Medicare provider and MA plan reimbursement calculations are estimated to reduce to the Medicare DSH payment formula estimated Medicare spending by $326 billion between 2010 to cut payments by $22 billion between 2015 and and 2019. In addition, general surgeons practicing in 2019.34 The HHS secretary has broad authority shortage areas and primary care–focused physicians, over several decisions that could impact DSH nurse practitioners, clinical nurse specialists, and physician assistants will receive Medicare payment payments. Since there is no judicial review of these bonuses estimated to enhance their reimbursement by determinations, it will be important for the state $3.5 billion between 2010 and 2019.43, 44 The impact on to address these issues based on which decisions beneficiaries’ access to services is difficult to predict, would result in more equitable payments to DSH particularly given that they will be implemented hospitals in California. Current estimates indicate alongside Medicare payment and delivery system reforms in the ACA and other federal legislation. that California hospitals could face reductions in Considering Medicare’s central role in health care Medicare DSH of $3.5 to $4 billion over ten years, coverage for California’s seniors, it will be important to or roughly 25 percent of DSH payments for that closely monitor how these changes affect their access timeframe.35, 36 to care and choice of providers and plans, premiums and cost-sharing requirements, supplemental benefits offerings by MA plans (e.g., vision or dental services), and quality of care and outcomes. Table 3. Medi-Cal and Medicare DSH Reductions What It Says From 2014 to 2020, the ACA reduces Medi-Cal and Medicare DSH payments. Effective Date FY 2014 What Needs to Be Done The federal government will issue further details on how the DSH reductions will be calculated on a state basis for Medi-Cal and on a hospital basis for Medicare. The state will determine how to implement Medi-Cal DSH reductions on a hospital basis. This may require adjustments to DSH payment methodology. Who’s Responsible HHS, Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) The Bottom Line It remains to be seen whether hospital revenues from increases in coverage will offset DSH losses (either in the aggregate or for individual hospitals). 8 | C alifornia H ealth C are F oundation Medicaid Adult Preventive Services Medicaid Emergency Psychiatric (§ 4106) Services Demonstration (§ 2707) Effective in 2013, the ACA clarifies that the Medicaid reimbursement is not currently available mandatory Medicaid benefit package include for delivering care to adults in institutions for mental preventive services that are recommended under diseases (IMDs). IMDs are primarily engaged in federal guidelines. Further, states will receive a one providing inpatient diagnosis, treatment, or care, percentage point increase in the federal Medicaid including medical attention, nursing care, and matching rate for these services if they are provided related services, to persons with mental diseases. In without cost sharing. Studies dating back to the California, IMDs generally include facilities such as 1971 RAND Health Insurance Experiment have acute psychiatric hospitals, psychiatric health facilities shown that higher cost sharing leads to reductions (PHFs), skilled nursing facilities (SNFs) with a in medical care use, particularly among low- certified special treatment program (STP) for the income individuals.37 A recent study of other states’ mentally disordered, and mental health rehabilitation expansion of Medicaid coverage to childless adults centers (MHRCs). found that cost-sharing requirements play an The ACA allows states to apply for three-year important role in the use of preventive services.38 demonstration projects to reimburse private IMDs Currently, Medi-Cal beneficiaries are subject to for delivering services to stabilize a Medicaid $1 copayments for physician office and clinic visits, beneficiary who has an emergency medical condition. but as a budget savings measure, Governor Jerry An individual with an emergency medical condition Brown has proposed an increase to $5 per visit.39 is defined as one “who expresses suicidal or homicidal Beginning in 2011, Medicare beneficiaries thoughts or gestures if determined dangerous to self similarly will not face cost sharing when accessing or others” and stabilized is defined as “the emergency annual wellness visit services and preventive medical condition no longer exists with respect to the services recommended under federal guidelines. individual and the individual is no longer dangerous In addition, Medicare will provide coverage for an to self or others.” annual comprehensive health risk assessment and The ACA appropriates $75 million for these personalized prevention plan (§§ 4103 and 10402). demonstration projects, which HHS will allocate Table 4. Medi-Cal Adult Preventive Services What It Says Starting in 2013, Medi-Cal could lift cost-sharing requirements for preventive services and receive a modest bonus in federal matching funds for these services. Effective Date January 1, 2013 What Needs to Be Done The federal government will issue guidance to states on how they should implement this provision. The state will determine whether to participate. This decision is likely to be informed, in part, by whether the one percentage point bonus will offset anticipated cost-sharing revenue and operational systems changes. Who’s Responsible Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) The Bottom Line Medi-Cal beneficiaries are assured coverage for preventive services, potentially at no cost. Implementing National Health Reform in California: Opportunities for Improved Access to Care | 9 to approved states as matching funds for qualified dollar-for-dollar basis. Funds are available through state expenditures, generally on a dollar-for-dollar December 31, 2015. basis. qualified state expenditures, generally on a State Programs likely to continue to need these targeted programs — are California has a patchwork of targeted programs recent or undocumented immigrants. Many of these providing health coverage or services for specific programs* (e.g., Access for Infants and Mothers; Breast populations or conditions. Most of the programs are and Cervical Cancer Treatment Program; Child Health limited to low or modest income individuals who are and Disability Prevention Program; and Family Planning either uninsured or have inadequate coverage; and are Access, Care, and Treatment), provide coverage for funded through a combination of state and federal funds. individuals who have not satisfied federal requirements Beginning in 2014, the ACA’s public and private coverage in immigration status. A small subset of these expansions and private insurance reforms will open the individuals — legal immigrants who have not met the door to comprehensive coverage to most Californians, required five year waiting period under federal Medicaid raising questions about the future of such targeted law — may be able to access new coverage options but programs in the state. Because the State commits undocumented individuals will not. significant state resources to these targeted programs For most of these targeted programs, most of the each year, California officials are likely to evaluate covered services are likely to be included under the whether comparable coverage will be available through federally mandated “essential benefit package” under other vehicles that could be more favorable to California the ACA. However, there may be some exceptions. fiscally. Expanded Medicaid coverage, the Basic Health For example, some programs provide nutrition services Program (should the State take-up this option), and or health education designed to meet the high needs coverage through the Exchange with financial assistance of the target population. Because federal officials have will all be options and are primarily supported through yet to define the essential benefit package, it is unclear federal dollars. whether these types of services will be included. A review of several targeted programs summarized Further, it may be that the nature of these programs, in Appendix B reveals while the ACA is likely to which provide highly targeted benefits with specialized significantly decrease demand for most programs, it may providers and reimbursement arrangements, deliver not offer full coverage for the populations nor specialized a level of quality or accessibility that would be hard services these programs provide. Many, though not all, to replicate in a commercial insurance product. To of the individuals served by these targeted programs the extent that it may not be practical or feasible for will be eligible for expanded coverage options in 2014. other coverage vehicles to provide comparable levels All but one of the programs limit eligibility to those with of access, these targeted state programs may fill an incomes below 400 percent FPL, and therefore would important role for providing wraparound coverage. In be eligible for subsidies under the ACA. However, it is light of shifting need and alternative options available likely that coverage will come at a higher cost under the under the ACA and the dynamic environment in the ACA than under these existing programs, and that some state, it may serve California well to periodically revisit individuals eligible for affordability waivers from the the roles of these programs. mandate would still seek targeted programs as a more *For detailed information on the state programs — including populations affordable option for services or care. In addition, one covered, benefits, and funding — see Appendix B. notable group left behind by the ACA — and therefore 10 | C alifornia H ealth C are F oundation Table 5. Medi-Cal Emergency Psychiatric Services Demonstration Opportunity What It Says The ACA allows California to operate a three-year demonstration project that would provide Medi-Cal reimbursement to private IMDs for emergency condition stabilization services. Effective Date March 23, 2010 through December 31, 2015 What Needs to Be Done The federal government will issue additional guidance on the application process and parameters of the demonstration project, and will conduct an evaluation of the demonstration project and submit a report to Congress by December 31, 2013. The state will determine whether to participate in this project and, if so, will develop a competitive application. Who’s Responsible Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) The Bottom Line This is an opportunity to access federal funding for previously uncovered inpatient mental health services. Community Clinics receive special protections to ensure the adequacy of California’s 230 community clinics deliver Medicare and Medicaid reimbursement, as well as comprehensive primary and preventive care services other benefits. in 719 locations and form a major component of California’s safety net delivery system.45 Operating Federally Qualified Health Centers (§ 10503) under public, private, or nonprofit structures and The ACA boosts federal support for community with multiple and overlapping definitions under health centers by establishing a Community state and federal law, California’s community clinics Health Center Fund, which invests $9.5 billion are generally unified by one key feature: caring for a for enhancing operating capacity and $1.5 billion patient regardless of ability to pay.46 It is estimated for construction and renovation over the course of that community clinics see nearly four million FY 2011– 2015. These additional funds have the patients a year, including one million, or 17 percent, potential to offer a variety of benefits to California. of uninsured Californians.47 Only about 7 percent of Community health center funding could enhance clinic operating revenues are derived from sliding-fee capacity at the 1,049 delivery sites currently operated payments, self-pay, or private insurance. Medi-Cal by California’s 118 FQHCs as well as expand (44 percent) and federal grant funds (16 percent) are their reach through the establishment of new sites. major sources of clinic operating revenues.48 Aside from current FQHCs, this funding could The ACA provides new funding opportunities also support FQHC lookalikes — which meet all for federally qualified health centers (FQHCs), federal requirements but do not receive federal rural health clinics, and school-based health centers; funds — to build new health centers in underserved however, FQHCs stand to benefit the most. More communities. than 118 clinics in California have received the The Health Services and Resources FQHC designation.49 FQHCs are eligible for federal Administration (HRSA) within HHS is charged with support of capital and operating costs through administering FQHC grant funding and determining Section 330 of the Public Health Service Act and the application process. California’s health centers Implementing National Health Reform in California: Opportunities for Improved Access to Care | 11 have been accessing a growing share of available entities not currently receiving Section 330 funds. federal funding each year. However, the proportion This grant opportunity closed on March 18, 2011. of California’s uninsured seeking care in health In addition to the dedicated Community Health centers has also continued to increase, offsetting Center Fund, the ACA authorizes higher federal these gains in funding. According to analysis by the levels for the existing federal community health California Primary Care Association, California’s center grant program (Public Health Service Act health centers receive from the federal government an Section 330). However, the ACA does not include equivalent of $181 per uninsured individual served, accompanying appropriations language. This means which is significantly less than the national average additional congressional action will be necessary for of $270 and of other similarly populous states like the higher spending levels to be realized in actual Texas, at $229, and New York, at $276. funding. HRSA awarded an initial round of capital grants Finally, the ACA makes important changes in October 2010. Of the $727 million awarded, related to Medicare reimbursement of FQHCs, California’s FQHCs received $92 million.50 HRSA which account for 7 percent of visits at California’s is in the process of awarding between $270 and FQHCs. Medicare payment to FQHCs are based on $335 million for expanded services at current reasonable costs but capped at a per-visit limit that FQHCs. Although FQHCs must submit applications the Government Accountability Office found to be describing projects, the level of funding will be less than most FQHCs’ submitted services costs.53 allocated on a formula basis.51 Also, HRSA has The ACA lifts this cap, requires the HHS secretary announced the availability of up to $10 million in to develop a Medicare prospective payment system grants for the planning of new primary care health to replace the cost-based reimbursement system in centers.52 A maximum of $80,000 will be awarded 2014, and adds additional preventive services for competitively to 125 public or nonprofit private Medicare coverage at FQHCs (§ 10501). Table 6. Federally Qualified Health Centers What It Says The ACA provides significant additional funding to expand FQHC capacity and to build new sites. Effective Date FY 2010 What Needs to Be Done With the exception of the Community Health Center Fund, Congress will need to appropriate general funding for the community health center grant program. HRSA will need to issue guidance on the parameters of the funding and application process. FQHCs and FQHC lookalikes will need to monitor funding opportunities, submit competitive applications, and engage with federal officials on the factors considered in formula-based allocations. Who’s Responsible Congress, HRSA, FQHCs, FQHC lookalikes The Bottom Line Generous new federal funding provides significant opportunities for California’s community health centers to expand capacity, enhance services, and modernize aging facilities in anticipation of increased demand. 12 | C alifornia H ealth C are F oundation Teaching Health Centers (§ 5508[a]) Prior to the enactment of the THC model, other To enhance teaching capacity, the ACA details a new California programs sought to expand community- approach to supporting the primary care workforce based training opportunities through partnering through the Teaching Health Center (THC) model with community clinics. In 2005, the University and authorizes grants for the creation or expansion of California, Davis, Internal Medicine residency of primary care residency programs, including those program partnered with the Sacramento County that train family physicians, internists, pediatricians, Department of Health and Human Services to OB-GYNs, psychiatrists, dentists (pediatric and develop a teaching health center in the county’s general), and geriatricians. In addition to the largest community clinic. Similarly, the Sonoma broad range of community clinics eligible for the County-based Santa Rosa Family Medicine grants (FQHCs, community mental health centers, Residency Program formalized a partnership with the rural health centers, family planning centers, Santa Rosa Community Health Centers, a network etc.), corporate entities may apply if health center of FQHCs. This partnership is one component of collaboration or sponsorship of a community-based the program’s consortium of sponsors, which also training site is a central component. The statute includes the University of California, San Francisco; directs that grant funds of up to $500,000 over a Sutter Health; and Kaiser Permanente. period not to exceed three years will be available to THCs will focus on delivering primary care THCs for activities such as curriculum development; graduate medical education (GME) in a community- recruitment, training, and retention of residents based setting. Currently, hospitals and health and faculty; securing accreditation; faculty salaries systems are the predominant sponsors of residency during the development phase; and technical training programs. To cover its share of costs assistance. For THC grants, the ACA authorizes associated with these programs, Medicare funds $25 million in FY 2010, $50 million for each of them through direct GME and indirect GME. In the FY 2011 and 2012, and such sums as necessary for THC model, Medicare GME funding flows to the future years. Funding is again authorized but not yet clinic — or community-based consortia sponsoring appropriated; therefore, uncertainty remains around the program — to cover medical resident training this opportunity until additional congressional action costs. The ACA authorizes and appropriates up to is taken. $230 million over five years to cover costs associated Table 7. Teaching Health Centers What It Says The ACA authorizes primary care workforce training through new Teaching Health Center (THC) model. Effective Date FY 2010 What Needs to Be Done Congress will need to appropriate funding for THC establishment and expansion grants. The federal government will need to issue guidance on the funding and application process. Various clinic entities will need to apply for funding. Who’s Responsible Congress, HRSA, clinics The Bottom Line THCs could provide California with a promising training model that could improve and stabilize access to community-based care. Implementing National Health Reform in California: Opportunities for Improved Access to Care | 13 with graduate medical education. In January 2011, School-Based Health Centers HRSA awarded a first year of funds to qualified Currently, 176 health centers provide primary THCs. Valley Consortium for Medical Education care, mental health services, health education, in Modesto — which has participation from major and/or dental care on California campuses.56 The health care organizations in Stanislaus County and ACA authorizes two new grant programs for the is affiliated with the University of California, Davis establishment and operation of school-based health School of Medicine, the proposed University of centers (SBHCs) and directs the HHS secretary California, Merced School of Medicine, and the to give preference to school-based health center Midwestern Osteopathic Post-graduate Training applicants in high-need areas (e.g., those with large Institute (OPTI) — is among the 11 grantees and populations of children eligible for Medi-Cal or received $625,000 of the $1.9 million awarded. Healthy Families, and designated Health Professional HRSA has noted its intent to fund qualified THCs Shortage Areas). for the entire five-year program period, pending satisfactory performance of awardees and availability Establishment Grants (§ 4101) of federal funds.54 Establishment grant funds of $50 million are The goals of the new model are threefold. First, appropriated for each of FY 2010 – 2013. The because primary care physicians predominantly ACA limits these funds to capital costs for school- provide community-based ambulatory care, it is based health center facilities and equipment thought that a significant portion of medical training (e.g., acquisition, construction, expansion, and should occur in community-based sites. Currently, improvement) and explicitly restricts the funding although residents can and do provide care in of personnel or health service provision. The initial ambulatory care settings, a significant portion of their opportunity for these funds closed in late 2010.57 training is hospital based. Second, the ACA seeks to Each school-based health center was limited to one expand the primary care workforce through a number application with a maximum of ten projects. HRSA of different investments; the THC model represents expects to award a total of $100 million — up to one method to test the success of expanding available $500,000 per application — for a two-year budget programs and slots in an effort to train more period. Many school-based health centers across providers. Finally, THC grants could help promote California applied for these grants. Awards will be greater stability among residency programs. Stability announced prior to the project start date of July 1, is important because residency program closure often 2011. leaves a community without a central source of care. According to the Accreditation Council on Graduate Operations Grants (§ 4101) Medical Education, between 2008 and 2010, eight Operations grant funds are authorized, but not of the state’s primary care residency programs applied appropriated, for FY 2010 – 2014, requiring for withdrawal.55 In addition, a number of others additional congressional action. No funding amount were required to find new sponsoring institutions or is specified in the law. If appropriated, these funds risk closing their doors. may be used for equipment leasing as well as training, program management, and personnel. The HHS secretary has additional discretion to 14 | C alifornia H ealth C are F oundation Table 8. School-Based Health Centers What It Says The ACA authorizes grant programs to support establishment and operations of school-based health centers. Effective Date Establishment funds: FY 2010 – 2013 Operations funds: FY 2010 – 2014 What Needs to Be Done Congress will need to appropriate operations funding for the provision. HRSA must issue guidance to advise school-based health centers on the funding and application process. School-based health centers may complete applications to secure funding. Who’s Responsible Congress, HRSA, school-based health centers The Bottom Line This is an opportunity to strengthen and expand California’s school-based health center infrastructure. Proposed projects include construction of new SBHC facilities, improvements to existing SBHC facilities, and support of new capabilities such as mobile vans and electronic health records. award construction grants for facility expansion Nurse-Managed Health Clinics (§ 5208) and modernization. While the statute imposes a The ACA establishes a grant program to create nurse- 20 percent cash or in-kind matching requirement on managed health clinics, which are nurse-practice entities that receive funds, this requirement may be arrangements that: waived if it would impose a serious hardship. ◾◾ Provide primary care or wellness services to underserved or vulnerable populations; School-Based Oral Health Program (§ 4102) The ACA also increased the use of preventive ◾◾ Are managed by advanced practice nurses; and measures in oral health care within school-based ◾◾ Are associated with a school, college, university, health centers and mandates that the Centers for or department of nursing, FQHC, or Disease Control and Prevention and HRSA award independent nonprofit health or social services grants to states, territories, and Indian tribes for agency. the development of school-based dental sealant programs. A state must provide these funds to schools The ACA authorizes appropriations of or school-based entities to provide children access $50 million for FY 2010 and unspecified funding to dental care and dental sealant services. Funding is levels for FY 2011 – 2014. In June 2010, HRSA authorized but not appropriated. issued a funding opportunity of $15 million that would be accessible to grantees for three years. Two of the ten awards were given to California entities —  Glide Health Services, which is a community clinic affiliated with the University of California, San Francisco, and the Tides Center Women’s Community Clinic in San Francisco — each of which was awarded $1.5 million.58 The funding will Implementing National Health Reform in California: Opportunities for Improved Access to Care | 15 Table 9. Nurse-Managed Health Clinics Funding What It Says The ACA authorizes a grant program to support the development and operation of nurse- managed health clinics. Effective Date FY 2010 – 2014 What Needs to Be Done Congress will need to appropriate FY 2011– 2014 funding for this provision. The federal government must issue guidance to nurse-managed health clinics on the funding and application process. Nurse-managed health clinics may complete applications to secure funding. Who’s Responsible Congress, HRSA, nurse-managed health centers The Bottom Line This is an opportunity to bolster access to care for underserved Californians and facilitate training opportunities for California nurses who fulfill critical roles in the state’s primary care workforce. provide additional access to primary care services and associations, and other entities to place health training opportunities for advanced practice nurses. professionals in underserved areas, typically inner- The availability and amount of further funding will city and rural areas with disproportionately higher depend on congressional appropriations activity. rates of uninsured patients. California’s health care safety net has benefited greatly from federally funded Workforce workforce programs, and the ACA establishes Adequate provider supply and workforce additional initiatives for workforce analysis on the development are longstanding challenges for state and national levels, creates new programs for California. Prior to the enactment of reform, the training support, and bolsters funding for existing California Labor and Workforce Development workforce programs. Agency and the Department of Employment With an array of opportunities available to state Development determined the need to educate health care facilities, educational institutions, and over 206,000 additional health care professionals directly to providers, it is critically important that by 2014.59 California has made several state- California formulate a coordinated approach to level investments. The Song-Brown Program, ensure that it maximizes these benefits. Following administered by the state’s Office of Statewide Health the passage of the ACA, Governor Schwarzenegger Planning and Development (OSHPD), provides established the Healthcare Workforce Workgroup financial support to family practice residency, nurse as one component of a broader Healthcare Reform practitioner, physician assistant, and registered nurse Taskforce. The workgroup included representatives education programs throughout California. Also of the Labor and Workforce Development Agency, operating out of OSHPD is the Health Professions the Office of Statewide Health Planning and Education Foundation, a statutorily created Development (OSHPD), and the California nonprofit. The foundation leverages tax-deductible Workforce Investment Board and focused on training contributions from other private foundations, and workforce development programs. Going hospitals, health plans, corporations, professional forward, it will be important for this taskforce or 16 | C alifornia H ealth C are F oundation another entity to engage health care stakeholders, State Health Care Workforce Grants (§ 5102) including employers, advocacy and professional The ACA establishes a competitive grant associations, researchers, and educators, in a dialogue program to support state workforce investment “on the workforce development challenges and boards representing health care employers, labor opportunities presented by healthcare reform.”60 organizations, and educational institutions, or “state partnerships,” with planning and implementation activities leading to a coherent and comprehensive Shortage Areas health care workforce. Through evaluation of criteria such as the number of low-income or older individuals and the number State partnerships are eligible to receive: of primary care physicians per capita, a geographic ◾◾ One-year planning grants of up to $150,000, area, population group, or facility may receive special designations, under three classifications, as a health with a 15 percent cash or in-kind matching care shortage area. commitment; and • Health Professional Shortage Area. Urban or rural area, population group, or medical or other facility ◾◾ Two-year implementation grants, with having a shortage of primary medical care (there are a 25 percent cash or in-kind matching 559 in California), dental (317), or mental health (291) commitment. providers. • Medically Underserved Area. Area with a shortage The California Workforce Investment Board, in of personal health services (168). partnership with the California Office of Statewide • Medically Underserved Population. Group facing Health Planning and Development (OSHPD), economic, cultural, or linguistic barriers to care (41).61 successfully applied for and was awarded a $150,000 As an acknowledgement of high unmet need, planning grant by HRSA.62 The planning grant services provided in areas or to populations with activities and requirements will be facilitated through these designations enjoy special advantages, such the Health Workforce Development Council as payment enhancements from federal health care programs, priority consideration for federal workforce (Council), a special committee of the California funding opportunities, and designation as places Workforce Investment Board, and will work in where National Health Service Corps scholarship collaboration with the Healthcare Workforce and loan repayment recipients must practice to fulfill Workgroup. The goal is to develop a plan to expand obligations. OSHPD’s Shortage Designation Program the primary care full-time equivalent workforce 10 to provides technical assistance to clinics and other primary care providers seeking recognition. 25 percent over ten years, with the Council using the planning grant funds to: ◾◾ Identify and create essential, strategic statewide and regional partnerships; ◾◾ Identify education and workforce data availability and gaps; ◾◾ Map education and career pathways necessary to supply the health workers required; and Implementing National Health Reform in California: Opportunities for Improved Access to Care | 17 Table 10. State Health Care Workforce Grants What It Says The ACA establishes a competitive grant program to support state partnerships, with planning and implementation activities leading to a coherent and comprehensive health care workforce. Effective Date FY 2010 What Needs to Be Done Congress will need to appropriate funding for FY 2011 and beyond for this provision. The state will need to carry out its responsibilities under the planning grant and position California successfully to maximize implementation funding. Who’s Responsible Congress, HRSA, California Workforce Investment Board, OSHPD The Bottom Line Federal funding is available to support continued workforce planning efforts and to help the state develop a strategic plan to guide future activities. ◾◾ Determine any legislative and administrative The ACA provides for unused residency slots policy changes needed to increase the supply of to be redistributed to residency programs that are providers necessary to improve health and bolster training physicians in primary care or general surgery. regional health access and economies.63 Furthermore, the ACA also aims for communities to retain medical residency slots when a teaching Federal planning grant funds of $8 million are hospital closes by prioritizing the redistribution of authorized in FY 2010, with such sums as necessary slots to nearby hospitals. Establishing a new program for subsequent years, and federal implementation or expanding an existing one is governed by multiple grant funds of $150 million are authorized in factors, and it is challenging to create such new FY 2010, with such sums as necessary for subsequent opportunities. By allowing for existing slots to be years. Both planning and implementation funds redistributed, the ACA allows for an easier path to will be subject to the congressional appropriations increased primary care training opportunities. process. On November 2, 2010, CMS issued a final rule that implements a number of the ACA’s workforce Medicare Graduate Medical Education Slot provisions, including those affecting residency Redistribution and Other Program Changes training slots.64 Under the final rule, CMS will (§§ 5503 – 5506) redistribute 65 percent of the residency slots that Medicare subsidizes teaching hospitals for medical have gone unused by a hospital for the past three residency training through direct graduate medical years. The ACA requires 70 percent of the unused education (DGME) and indirect medical education slots to be redistributed to hospitals in states with (IME) payments. DGME primarily supports resident resident-to-population ratios in the lowest quartile. and faculty salaries and program administration The remaining 30 percent will be redistributed to costs. A program’s DGME calculation is based on the hospitals located either in a rural area or in one of the number of its residents and the hospital’s percentage ten states identified as having the highest proportion of Medicare patients. In contrast, IME is used of the population living in a Health Professional primarily to offset the sponsoring institution’s costs Shortage Area (HPSA). for hosting the program. 18 | C alifornia H ealth C are F oundation The effect on California of the slot redistribution Increased Funding (§§ 5207 and 10503) provisions remains to be seen. Despite its workforce Health professionals across the country, such as shortages, California is not among the states with the medical students, nurse practitioners, and physician lowest resident-to-population ratios, nor is it one of assistants, will be able to access an additional the states CMS identified has having a high enough $1.5 billion in scholarship funds and loan repayment HPSA proportion to qualify. However, California is aid in FY 2011– 2015 due to supplemental home to 66 rural hospitals.65 appropriations to the NHSC made through the ACA. The law also authorizes higher funding levels National Health Service Corps for the program, but whether these funds will To help recruit clinicians for underserved be available will depend on annual congressional communities, the National Health Service Corps appropriations activity. (NHSC) provides both scholarships to students in health professional training programs and loan Program Changes (§ 10501[n]) repayment aid to current health professionals. Currently, 708 full-time-equivalent providers in 269 Recipients commit to delivering primary care services of California’s 1,167 federally designated Health in designated high-need areas, often in community Professional Shortage Areas participate in the health centers. HRSA administers the scholarship NHSC.66 However, NHSC providers in California and loan repayment program, and the state also are in high demand, with 873 unfilled placements administers a Scholarship Loan Repayment Program as of December 2010.67 The ACA makes a series of that receives federal support. Building on changes easements in the NHSC program aimed at attracting from the American Recovery and Reinvestment Act, participation. These changes include allowing part- the ACA includes several provisions that address the time clinical practice and a portion of teaching time NHSC. to count toward the service obligation, and increasing Table 11. National Health Service Corps What It Says The ACA enhances funding for scholarships and loan repayment available through the NHSC and makes several easements in the NHSC program designed to attract participation by health professionals. Effective Date FY 2011 What Needs to Be Done While the ACA provides substantial supplemental appropriations for the near term, Congress will need to appropriate funds for the NHSC to realize the higher ongoing funding levels authorized for the program. Students in health professional training programs, and a variety of current health professionals, may apply with HRSA to participate in the NHSC. Additional FQHCs, rural health clinics, and other sites that care for low-income and uninsured people may also apply with HRSA to become approved sites where NHSC providers can fulfill their service obligations. Who’s Responsible Congress, HRSA, health professionals, health care sites in high-need areas The Bottom Line Additional investments are made to recruit and retain health professionals for delivering care in California’s underserved communities. Implementing National Health Reform in California: Opportunities for Improved Access to Care | 19 the individual loan repayment amount from $35,000 to $50,000, with annual adjustments for inflation. The ACA’s additional program investments and simplifications are significant, but whether they will be adequate to drive additional health professionals to California’s underserved areas is as yet unclear. Title VII and Title VIII Programs Public Health Service Act Titles VII and VIII training programs also provide assistance for health care workforce development through grants to educational institutions. Health professional schools may use these funds to provide scholarships and loan repayment for students or to develop educational infrastructure, such as funding faculty and residency program activities. Funds are typically administered by HRSA and awarded through a competitive grant process. The ACA establishes new programs and authorizes additional funding for existing programs focusing on providers in a variety of areas, including primary care, direct care, geriatric care, mental health, nursing, and dentistry. These remain largely reliant on the congressional appropriations process. A listing of these provisions is included in Appendix C. 20 | C alifornia H ealth C are F oundation III. Conclusion T he ACA creates the opportunity for significant improvements in Californians’ access to health care. Due to both expansions in coverage and the targeted provisions described in this report, California’s health care infrastructure will experience an infusion of federal investments, as well as private funds associated with the individual mandate. Increased funding for primary, community-based care and workforce development have the potential to expand the availability of services. However, whether that growth will be sufficient to meet the increased demand, whether it will address the needs of currently underserved populations and geographic regions, and whether it will fully offset losses in DSH funding and Medicare payments has yet to be determined. Several factors will influence the extent to which strides in access are achieved. Most immediately, state and federal policy choices — many of which have yet to be made — will define provisions aimed at sustaining or expanding access to health care. In addition, a host of provisions under the ACA intended to improve the quality and efficiency of health care delivery, while beyond the scope of this paper, could bring the added benefit of expanding capacity. Finally, California’s dynamic and shifting health care environment — most notably, continued state fiscal pressures, the ambitious Medi-Cal waiver, and the market response to coverage changes under the ACA — also will have a significant influence. Implementing National Health Reform in California: Opportunities for Improved Access to Care | 21 Appendix A: Access-Related Grants Awarded to Date to California Natio n al Californ ia Ti tle Total amou n t perce n t Nurse-Managed Health Clinics $15,000,000 $3,000,000 20.0% National Health Service Corps: Scholarships $11,807,058 $2,410,000 20.4% and Loan Repayment Federally Qualified Health Centers $727,000,000 $92,000,000 12.7% Teaching Health Centers $1,900,000 $625,000 39.2% State Health Care Workforce Planning Grants $5,600,000 $250,000 4.5% Workforce Opportunities $397,067,832 $36,763,300 9.3% 22 | C alifornia H ealth C are F oundation Appendix B: California Health Coverage and Service Programs, continued Immigration E l igibil it y/P op ul at ions Cover ed Requirements?* Benefits Ex pe nd itur es Stat e Fe d er a l Oth er Access for Infants and Mothers Pregnant women between 200 and No Comprehensive and pregnancy- $123,953,000 † 4 4 4 (AIM) 300 percent FPL related services (2010) Uninsured or with high cost insurance Enrollment: 10,586† (2010) Child Health and Disability Under 19 years No CHDP Gateway: Full-scope CHDP Gateway: 4 4 Prevention (CHDP) Program Income: < 200 percent FPL Medi-Cal benefits for up to $133,395,000‡ two months (FY 2010 – 2011) Enrollment: CHDP: Periodic health CHDP: $2,419,000§ • CDHP Gateway: 87,090 estimated average assessments, vision and (FY 2010 – 2011) monthly (FY 2010 – 2011) hearing tests, laboratory tests, • CDHP: 34,808 estimated number of screens immunizations, and health (FY 2010 – 2011) education Omnibus Budget Reconciliation Undocumented aliens and temporary No Emergency, pregnancy-related, $1,288,000,000‡ 4 4 Act (OBRA) Program visitors and nursing home care. (FY 2010 – 2011) Enrollment: 817,000 estimated average monthly (FY 2010 – 2011) Breast and Cervical Cancer Need breast and/or cervical cancer No Medi-Cal benefits for uninsured $127,824,000‡ 4 4 Treatment Program (BCCTP) treatment women under age 65 with (FY 2010 – 2011) Income:  200 percent FPL satisfactory immigration status Enrollment: 12,173 (2010) Time limited breast and/or cervical cancer treatment and related services, payment of insurance premiums under certain circumstances Family Planning Access, Women under 55 years or No Family planning services $667,823,000‡ 4 4 Care and Treatment (FPACT) men under 60 years (FY 2010 – 2011) Program Income:  200 percent FPL No access to family planning services Enrollment: 1,600,000# (2008) *For select programs, enrollees do not need to satisfy federal immigration status requirements — generally be a U.S. citizen or a legal immigrant residing in the country for more than 5 years — to receive benefits. Except for emergency conditions, state funds wholly fund coverage for undocumented individuals due to strict prohibitions against federal funding being used. †Supplied by MRMIB program staff. Represents July 2010 to June 2011 estimate. ‡DHCS November 2010 Medi-Cal Estimate. §DHCS November 2010 Family Health Estimate. #University of California San Francisco. Fact Sheet On Family PACT: An Overview (www.familypact.org). Implementing National Health Reform in California: Access to Care | 23 Appendix B: California Health Coverage and Service Programs, continued Immigration E l igibil it y/P op ul at ions Cover ed Requirements?* Benefits Ex pe nd itur es Stat e Fe d er a l Oth er Dialysis and Total Parenteral Need dialysis and/or TPN related services Yes Dialysis, parenteral Unavailable 4 4 Nutrition (TPN) Program No income limit hyperalimentation services, and other related services. Annual net worth: < $250,000 Enrollment: Unavailable Tuberculosis Program Have TB Yes Limited outpatient tuberculosis $728,488 # 4 4 Meet Medi-Cal income and asset treatment (2005) requirements, but not considered disabled Enrollment: 1,063 # (2005) Improving Access, Counseling, Men older than 18 years No Prostate cancer treatment $2,759,625** 4 & Treatment for Californians Income:  200 percent FPL representing 11 months with Prostate Cancer (IMPACT) only (FY 2010 – 2011) Have prostate cancer Uninsured or underinsured Enrollment: 345** (2010) AIDS Drug Assistance Program Have HIV No Medications to treat HIV $476,402,147 ††  4 4 4 Income:  400 percent FPL or prevent related serious estimated (FY deterioration of health 2010 – 2011) Limited or no Rx coverage Enrollment: 39,483 †† estimated (FY 2010 – 2011) Genetically Handicapped 21 years and older Yes Comprehensive health services, GHPP non-Medi-Cal: 4 4 Persons Program including Special Care Center $87,052,00 Have eligible genetic medical condition (e.g., Cystic Fibrosis, diseases of the blood, etc.) Services, pharmaceutical (FY 2010 – 2011) services, surgeries, nutrition GHPP Medi-Cal: No income limit products and medical foods, Unavailable Enrollment: 1,393 estimated average monthly durable medical equipment (FY 2010 – 2011) #“Selected Data on Medi-Cal Program, California, 2005” (www.dof.ca.gov). **Supplied by IMPACT program staff. ††California Department of Public Health, AIDS Drug Assistance Program (ADAP) November 2010 Estimate Package 2011–12 Governor’s Budget (www.cdph.ca.gov). 24 | C alifornia H ealth C are F oundation Appendix C: Workforce Opportunities P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Nursing Student Loan Increases loan amounts and updates Increase to existing loan Nursing schools Increases maximum annual loans from $2,500 to Program the eligible years for nursing schools to amounts. $3,300 for FY 2010 and 2011. (5202) establish and maintain student loan funds. Public Health Service Act amendment: • Section 836(a) (42 U.S.C. § 297b[a]) Healthcare Workforce Establishes a loan repayment program New loan repayment. Qualified professionals (pediatric Authorizes $30 million for 2010 – 2014 (pediatric Loan Repayment for those who are or will be working in Public Health Service Act specialists and providers of mental medical and surgical specialists) and $20 million Programs a Health Professional Shortage Area, amendment: and behavioral health services to for 2010 – 2013 (child and adolescent mental and (5203) Medically Underserved Area, or with a children and adolescents). behavioral health specialists). • Part E of Title VII Medically Underserved Population. (42 U.S.C. § 294n et seq.) Payments on loans of up to $35,000 a year for up to three years during residency, fellowship, or employment. Public Health Workforce Establishes the Public Health Workforce New loan repayment. Public health students and workers Authorizes $195 million for 2010 and sums Recruitment and Loan Repayment Program to ensure Public Health Service Act necessary for 2011– 2015. Retention Program an adequate supply of public health amendments: (5204) professionals to eliminate shortages in • Part E of Title VII federal, state, local, or tribal public health (42 U.S.C. § 294n et seq.), agencies. as amended by For each year of service, the HHS secretary Section 5203. may pay up to $35,000. If eligible loans are less than $105,000, the secretary shall pay an amount not to exceed one-third of the eligible loan balance for each year of service. Allied Health Workforce Offers loan repayment to those in acute New loan repayment. Allied health professionals in Authorizes $2,000 per year in loan forgiveness for Recruitment and care facilities, ambulatory care facilities, Amendment: public health agencies or in the up to five years. Retention Program residences, and other settings located settings listed. • Section 428(k) of the (5205) in Health Professional Shortage Areas, Higher Education Medically Underserved Areas, or serving Act of 1965 Medically Underserved Populations (20 U.S.C. §§ 1078 – 1111) through the Allied Health Loan Forgiveness Program. *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” Implementing National Health Reform in California: Access to Care | 25 P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Grants for States and Awards scholarships to those in positions New scholarship. Accredited educational institutions Authorizes $60 million for 2010 and sums necessary Local Programs at the federal, state, local, or tribal level to Public Health Service Act that offer a course of study, for 2011– 2015. (5206) receive additional training in public or allied amendments: certificate program, or professional health fields. Half is allotted to mid-career training program in public or allied • Section 765(d) public health professionals and half to health or a related discipline. (42 U.S.C. § 295d) mid-career allied health professionals. • Part E of Title VII (42 U.S.C. § 294n et seq.) Training in Family Provides grants and contracts to support New grants and Accredited public or nonprofit Authorizes $125 million for FY 2010 and sums Medicine, General and develop primary care training programs contracts. private hospitals, schools of necessary for FY 2011– 2014. Internal Medicine, and primary care capacity building through Public Health Service Act medicine or osteopathic medicine, Appropriated $39 million for FY 2010 (October 1, General Pediatrics, and accredited schools of medicine. amendment: academically affiliated physician 2009 – September 30, 2010). Physician Assistantship assistant training programs, and • Part C of Title VII Further, utilized a portion of the $500 million (5301) public or private nonprofit entities (42 U.S.C. § 293k et seq.) FY 2010 appropriation for the Prevention and with programs that educate students in team-based approaches Public Health Fund: to care, including the patient- • Expansion of Physician Assistant Training centered medical home. Program: Awarded $0.7 million to University of Southern California, $2.1 million to Riverside Community College District/Moreno Valley Campus, and $1.2 million to Samuel Merritt College. • Primary Care Residency Expansion: Awarded $1.9 million to University of California, Davis. $2.9 million to University of California, San Diego, $1.9 million to Catholic Healthcare West/St. Mary Medical Center $1.9 million to University of California, Los Angeles $3.8 million to Children’s Hospital & Research Center at Oakland, and $5.8 million to University of California, San Francisco. Training Opportunities Provides grants for new training New grants. Institutions of higher education Authorizes $10 million for 2011– 2013. for Direct Care Workers opportunities for direct care workers Public Health Service Act with a public-private educational (5302) employed in long-term care settings. amendment: partnership with a long-term care facility, and agencies and other • Part C of Title VII entities providing home- and (42 U.S.C. § 293k et seq.) community-based services to individuals with disabilities, and other long-term care providers. *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” 26 | C alifornia H ealth C are F oundation P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Training in General, Reinstates dental funding in Title VII of Existing grants and loan Schools of dentistry, public or Authorizes $30 million for 2010 and sums necessary Pediatric, and Public the Public Health Service Act. Grants repayment. nonprofit private hospitals, and for 2011–2015. Health Dentistry to be used for predoctoral training, Public Health Service Act public or private nonprofit entities Appropriated $15 million for FY 2010 (October 1, (5303) faculty development, dental faculty loan amendment: in the field of dentistry. 2009 – September 30, 2010). repayment, and academic administrative • Part C of Title VII Post-doctoral Training in General, Pediatric and units. (42 U.S.C. § 293k et seq.) Public Health Dentistry: Upon completion of each of the first, Awarded $0.3 million to the University of Southern second, third, fourth, and fifth years of California and $0.5 million to the Regents of the service, the program shall pay 10, 15, 20, University of California, Los Angeles. 25, and 30 percent, respectively, of student loan balance. Alternative Dental Authorizes the HHS secretary to award New grants. Institutions of higher education, Authorizes grants of not less than $4 million over a Health Care Provider grants to establish training programs to Public Health Service Act including community colleges; five-year period. Demonstration Project increase dental health care access in rural, amendment: public-private partnerships; (5304) tribal, and underserved communities. FQHCs; IHS facilities, tribes, and • Subpart X of organizations; state and county Part D of Title III public health clinics; health (42 U.S.C. § 256f et seq.) facilities operated by Indian tribes or tribal organizations; urban Indian organizations providing dental services; public hospitals and health systems accredited by the Commission on Dental Accreditation. Geriatric Education Authorizes funding for grants or contracts New grants or contracts, Entities that operate geriatric Authorizes $10.8 million for 2011– 2014 and and Training: Career for training in geriatrics, chronic care expanded career awards. education centers. Contracts and $10 million for individual awards for 2011– 2013. Awards; Comprehensive management, and long-term care for family Public Health Service Act awards to be granted to faculty, Appropriated $37 million for FY 2010 (October 1, Geriatric Education caregivers and faculty in health professions amendments: individuals preparing for education 2009 – September 30, 2010). (5305) schools; developing curricula and best degrees in geriatric nursing, and • Section 753 Geriatric Education Centers Grants: practices in geriatrics; expanding geriatric those pursuing advanced degrees (42 U.S.C. § 294c) Awarded $0.4 million to University of California, career awards; and establishing awards for in geriatrics or related fields. • Section 855 San Francisco, $0.4 million to The Leland Stanford those pursuing advanced degrees. (42 U.S.C. § 298) Junior University, and $0.4 million to the University Awards shall be $150,000. No more than of California, Los Angeles. 24 geriatric education centers may receive an award. Geriatric Training Programs for Physicians Grants: Awarded $0.6 million to the University of California, Los Angeles and $0.6 million to University of California, San Francisco. *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” Implementing National Health Reform in California: Access to Care | 27 P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Mental and Behavioral Awards grants for the development, New grant. Institutions of higher education Authorizes $8 million for FY 2010 – 2013 for training Health Education and expansion, or enhancement of training Public Health Service Act to support social work training in social work; $12 million for training in graduate Training Grants programs in social work, graduate amendment: as well as the development psychology, of which not less than $10 million (5306) psychology, professional training in of faculty in social work, shall be allocated for doctoral-, postdoctoral-, and • Part D of Title VII child and adolescent mental health, programs of psychology for internship-level training; $10 million for training in (42 U.S.C. § 294 et seq.) and pre-service or in-service training to the development of behavioral professional child and adolescent mental health; and paraprofessionals in child and adolescent and mental health services, $5 million for training in paraprofessional child and mental health. programs in child and adolescent adolescent work. mental health, and state-licensed mental health nonprofit and for-profit organizations training paraprofessional child and adolescent mental health workers. Cultural Competency, Reauthorizes and expands programs in Existing funds expansion. Health professional societies; Authorizes sums as necessary for 2010 – 2015. Prevention, and Public health professions schools and continuing Public Health Service Act licensing and accreditation Health, and Individuals education programs to support the amendments: entities; health professions with Disabilities development, evaluation, and dissemination schools; and experts in minority • Section 741 of Title VII Training of model curricula for cultural competency, health and cultural competency, (42 U.S.C. § 293e) (5307) prevention, and public health proficiency prevention, and public health and and aptitude for working with individuals • Section 807 of Title VIII disability groups; community- (42 U.S.C. § 296e-1) with disabilities. based organizations; and other organizations as determined by the secretary. Nurse Education, Awards grants to strengthen nurse New grant. Accredited schools of nursing, Authorizes sums as necessary for 2010–2012. Practice, and Retention education and training programs and to Public Health Service Act health care facility, and Appropriated $39.9 million for FY 2010 (October 1, Grants improve nurse retention. amendments: partnerships of such schools 2009 – September 30, 2010). (5309) and facilities. • Section 831 Nurse Education, Practice, and Retention Grants: (42 U.S.C. § 296p) Awarded $0.1 million to California State University • Title VIII is inserted (Fresno Fund); $0.3 million to the Regents of the after Section 831 University of California, Los Angeles; $0.2 million (42 U.S.C. § 296b) to Kaiser Foundation Hospitals; $0.4 million to Riverside Community College; and $0.9 million to the Regents of the University of California, San Francisco. Further, utilized a portion of the $500 million FY 2010 appropriation for the Prevention and Public Health Fund: • Advanced Nursing Education Expansion: Awarded $1.1 million to Western University of Health Sciences Pomona *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” 28 | C alifornia H ealth C are F oundation P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Loan Repayment and Makes faculty eligible for loan repayment Loan repayment Nursing schools Authorizes annual increase in loan forgiveness to Scholarship Program and scholarship programs. scholarship. $35,500 for FY 2010 and 2011. (5310) Public Health Service Act amendments: • Section 846(a)(3) (42 U.S.C. § 297n[a][3]) • Title VIII (42 U.S.C. § 296 et seq.) Nurse Faculty Loan Establishes a federally funded student loan New loan repayment. United States citizens, nationals, Authorizes sums as necessary for 2010 – 2014. Program repayment program for those pursuing Public Health Service Act and lawful permanent residents Appropriated $25 million for FY 2010 (October 1, (5311) careers in nurse education. amendments: who hold unencumbered licenses 2009 – September 30, 2010). Payments: master’s or equivalent degree as RNs, have completed master’s • Section 846A Nurse Faculty Loan Program: in nursing, up to $10,000 per calendar year or doctorate nursing programs at (42 U.S.C. § 297n–1) Awarded $0.3 million to Azusa Pacific University; or $40,000 total in 2010 – 2011; doctorate accredited schools of nursing or • Title VIII $0.01 million to Mount St. Mary’s College; or equivalent degree, up to $20,000 are currently enrolled on a full-time (42 U.S.C. § 296 et seq.) $0.2 million to the Regents of the University per calendar year or $80,000 total in or part-time basis. of California, San Francisco; $1.2 million to the 2010 – 2011. University of San Diego; $0.2 million to the University of San Francisco; and $0.5 million to the Western University of Health Sciences Grants to Promote the Authorizes the HHS secretary to award New grant. Public or nonprofit private entities, Authorizes sums as necessary for 2010 – 2014. Community Health grants to promote positive health behaviors Public Health Service Act including states and public Workforce and outcomes in medically underserved amendment: subdivisions of states, public health (5313) areas through the use of community health departments, free health clinics, • Part P of Title III workers who may offer interpretation and hospitals, and FQHCs. (42 U.S.C. § 280g et seq.) translation services, provide culturally appropriate health education and information, offer informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide direct primary care services and screenings. Fellowship Training in Authorizes the HHS secretary to address Expansion of fellowship Expansion of existing programs Authorizes $39.5 million per year for 2010 – 2013: Public Health workforce shortages in state and local program. under the Public Health Informatics $5 million for the epidemiology fellowship training (5314) health departments in applied public health Public Health Service Act Fellowship Program at the Centers programs, $5 million for the laboratory fellowship epidemiology and public health laboratory amendments: for Disease Control and Prevention training programs, $5 million for the public health science and informatics. and other applied epidemiology informatics fellowship program, and $24.5 million • Part E of Title VII training programs that meet these for expanding the Epidemic Intelligence Service. (42 U.S.C. § 294n et seq.), objectives. as amended by § 5206 *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” Implementing National Health Reform in California: Access to Care | 29 P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Demonstration Grants Directs the HHS secretary to establish a New demonstration FQHCs and NMHCs who employ Authorizes sums necessary for FY 2011– 2014. for Family Nurse training demonstration program for NPs grant. NPs. Eligible NPs must be Practitioner Training who employ and provide a one-year training licensed or eligible for California Programs for practitioners who have graduated from a licensure as advanced practice (5316) NP program for careers as PCPs in FQHCs registered nurses or advanced and nurse-managed health clinics (NMHCs). practice nurses, be eligible or Three-year grants awarded to eligible board-certified as family nurse entities for an amount not to exceed practitioners, and demonstrate $600,000 per year. The secretary may commitment to careers in FQHCs award technical assistance grants to or NMHCs. FQHCs or NMHCs that have demonstrated expertise in establishing a NP residency training program. Health Professions Provides scholarships for those who Existing scholarship. Disadvantaged students who Scholarships for Disadvantaged Students: Training for Diversity commit to work as PCPs in medically commit to work in medically Authorizes $51 million in FY 2010 and such sums as Public Health Service Act (5402) underserved areas, and expands loan underserved areas, and faculty at necessary FY 2011– 2014; appropriated $49 million amendments: repayments for individuals who will serve schools for PAs. in FY 2010. • Section 740(a) as faculty in eligible institutions. Faculty at Reauthorization for Loan Repayments and (42 U.S.C. 293d(a)) schools for PAs are eligible for faculty loan Fellowships Regarding Faculty Positions: • Section 740(b) repayment. Authorizes $5 million for each of FY 2010 – 2015; (42 U.S.C. 293d(b)) appropriated $1 million in FY 2010. • Section 740(c) (42 U.S.C. 293d(c)) Educational Assistance in the Health Professions for Individuals from a Disadvantaged Background: Authorizes $60 million for FY 2010, and such sums as necessary FY 2011– 2014; appropriated $22 million in FY 2010. Awards unknown. Primary Care Extension Creates a Primary Care Extension Program New planning and The secretary awards Authorizes $120 million for 2011– 2012 and sums as Programs to educate PCPs and provide them program grant. competitive grants to states for necessary for 2013 and 2014. (5405) technical assistance with evidence-based Public Health Service Act the establishment of state- or therapies, preventive medicine, health amendment: multistate-level Primary Care promotion, chronic disease management, Extension Programs. State hubs • Part P of Title III and mental health. The Agency for including, at a minimum, the state (42 U.S.C. § 280g et seq.) Healthcare Research and Quality will award health department, state-level planning and program grants. entities administering Medicare and Medicaid, and at least one health professions school. May also include Quality Improvement Organizations, AHECs, and other quality and training organizations. *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” 30 | C alifornia H ealth C are F oundation P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g Demonstration Project Establishes a demonstration grant program New demonstration grant States and other entities able Authorizes and appropriated $85 million for each to Address Health through competitive grants to support program. to conduct demonstration of FY 2010 – 2014. $5 million is set-aside for each Professions Workforce those seeking occupations in the health Social Security Act projects involving low-income of FY 2010 – 2012 for training and certification Needs, Extension of care field. Also establishes a demonstration amendments: individuals, including recipients programs for personal and home care aides. Family-to-Family Health program to competitively award grants for of state Temporary Assistance Health Profession Opportunity Grants to • Title XX Information Centers three years for up to six states to develop for Needy Families, who are Serve TANF Recipients and Other Low-Income (42 U.S.C. § 1397 et seq.) (5507) core training competencies and certification seeking education and training for Individuals: Awarded $5 million to the San Diego • Section 501(c)(1)(A)(iii) programs for personal and home care aides. occupations in the health care field. Workforce Partnership for a five year project period. (42 U.S.C. § 701c[1][A][iii]) Extends funding for family-to-family health Family-to-Family Health Further, utilized a portion of the $500 million information centers. Information Centers: Operated by FY 2010 appropriation for the Prevention and Public family leaders who have children Health Fund: with special health care needs and • Personal and Home Care Aide State Training expertise in federal and state public Program: Awarded $0.7 million to the Board of and private health care systems, as Governors of the California Community College, well as by health professionals. Family-to-Family Health Information Centers: Authorizes and appropriated $5 million for each of FY 2010 – 2012. Awarded $0.1 million for Support for Families of Children with Disabilities for FY 2010. Increasing Teaching Directs the HHS secretary to establish a New grant program. Organizations capable of providing Teaching Health Center Development Grants: Capacity grant program to support new or expanded technical assistance, including Authorizes $25 million for 2010, $50 million for Public Health Service Act (5508) primary care residency programs at community-based ambulatory 2011 and 2012, and sums necessary for each FY amendment: teaching health centers. patient care centers that operate thereafter to carry out the program. • Part C of Title VII Also provides $230 million under the Public teaching health centers with Teaching Health Center GME: Authorizes and (42 U.S.C. § 293k et seq.) Health Service Act for 2011– 2015 to cover primary care residency programs. appropriated such sums as necessary, not to exceed direct and indirect expenses of qualifying $250 million, for FY 2010 – 2015 teaching health centers incurred in training Awarded $0.6 million to Valley Consortium for primary care residents in certain expanded Medical Education, Modesto. or new programs. Annual reporting is required. Graduate Nurse Directs the HHS secretary to establish New demonstration Eligible hospitals and critical access Authorizes and appropriated $50 million for each of Education a demonstration program for up to five program under Title XVIII hospitals with written agreements FY 2012 – 2015 to remain available until expended. Demonstration Program eligible hospitals to increase graduate nurse of the Social Security Act in place with one school of nursing, (5509) education training under Medicare. (42 U.S.C. § 1395 et seq.). and two or nonhospital community- based care settings. *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” Implementing National Health Reform in California: Access to Care | 31 P r o v i sion Fu n ds Avai labl e (ACA Section) Des c r iption* Thro u g h Eli g i ble Reci pi en t A mo u n t a n d T i mi n g State Grants to Health Establishes state grant programs for health New grant program. Accredited schools of allopathic Authorizes $4 million for 2010 – 2013. Care Providers Who care providers who treat a high percentage Amendments to the or osteopathic medicine, and any Provide Services to of medically underserved populations or Public Health Service Act. combination or consortium of a High Percentage of other special populations. such schools serving medically Medically Underserved underserved communities or other Populations or Other special populations. Special Populations (5606) *As described in “The Patient Protection and Affordable Care Act as Passed: Section-by-Section Analysis with Changes Made by Title X included within Titles I – IX, where Appropriate.” 32 | C alifornia H ealth C are F oundation Appendix D: Interview List David Carlisle, director Office of Statewide Health Planning and Development California Health and Human Services Agency Carmela Castellano-Garcia, president and CEO California Primary Care Association Janet Coffman, assistant adjunct professor Department of Family and Community Medicine University of California, San Francisco Dustin Corcoran, president California Medical Association C. Duane Dauner, president and CEO California Hospital Association Catherine Douglas, president Private Essential Access Community Hospitals Inc. Toby Douglas, director Department of Health Care Services California Health and Human Services Agency C. Dean Germano, CEO Shasta Community Health Center Elizabeth Landsberg, legislative advocate Western Center on Law and Poverty Gail Nickerson, interim executive director California State Rural Health Association Melissa Stafford-Jones, president and CEO California Association of Public Hospitals Marjorie Swartz, consultant California State Assembly Committee on Health John Wallace, chief of staff LA Care Health Plan Implementing National Health Reform in California: Opportunities for Improved Access to Care | 33 Endnotes 1. Fronstin, P. California Health Care Almanac: California’s 14. Ibid. Uninsured. California HealthCare Foundation, December 15. Bindman, A., Chu, P., and Grumbach, K. Physician 2010 (www.chcf.org). Participation in Medi-Cal, 2008. California HealthCare 2. The Patient Protection and Affordable Care Act is Foundation, July 2010 (www.chcf.org). Public Law 111-148. The Health Care Education and 16. CMS Waiver Number 11-W-00193/9. Reconciliation Act of 2010 is Public Law 111-152. 17. Letter from David Maxwell-Jolly, November 2, 2010. 3. Bernstein, W., Boozang, P., Campbell, P., Dutton, M., and Lam, A. Implementing National Health Reform in 18. In Medicaid financing, these expenditures are known as California: Changes in Public and Private Insurance. “certified public expenditures.” California HealthCare Foundation, June 2010 19. Under Section 1331 of the ACA, the state has the option (www.chcf.org). to operate a “Basic Health Program” for individuals at 4. Long, P. and Gruber, J. “Projecting the Impact of the 138 – 200 percent of the FPL. Affordable Care Act on California.” Health Affairs, 20. Zuckerman, S., Williams, A., Stockley, K. Medi-Cal January 2011. Analysis of authors’ finding that 3.1 Physician and Dentist Fees: A Comparison to Other million remain uninsured. Medicaid Programs and Medicare. California HealthCare 5. Grumbach, K., Chattopadhyay, A., and Bindman, A. Foundation, April 2009 (www.chcf.org). Fewer and More Specialized: A New Assessment of Physician 21. Bindman, A., Chu, P., and Grumbach, K. Physician Supply in California. California HealthCare Foundation, Participation in Medi-Cal, 2008. California HealthCare Oakland, CA: June 2009 (www.chcf.org). Foundation, July 2010 (www.chcf.org). 6. Spetz, Ph.D., Joanne. Forecasts of the Registered Nurse 22. As a condition for receiving enhanced federal Medicaid Workforce in California. University of California San matching funds through June 30, 2011, the American Francisco, September 29, 2009 (www.rn.ca.gov). Recovery and Reinvestment Act prohibits states from 7. Hargreaves, R., Cherner, D., O’Neill, E., Solomon, K, reducing Medicaid eligibility levels or imposing additional and Semerdjian, J. “Closing the Health Workforce Gap enrollment procedures beyond those in effect July 2008. in California: The Education Imperative.” The Campaign Under the ACA, states are further prohibited from for College Opportunity, 2007 (www.healthws.com). restricting Medicaid and CHIP eligibility and enrollment through 2014 for adults and 2019 for children, or they 8. Ibid. risk losing all federal funding for both programs. 9. Cooper-Patrick, et al. 1999. “Race, Gender, and 23. “Primary care services” are defined as those in the Partnership in the Patient-Physician Relationship.” Evaluation and Management category, or those captured Journal of the American Medical Association 282; 583 – 9. under specified vaccines and toxoids immunization 10. Healthcare Workforce Diversity Advisory Council. administration codes, under the Healthcare Common Procedure Coding System used by Medicare. 11. Ibid. 24. The ACA directs that care reimbursement rates managed 12. California Rural Health Policy Council by Medi-Cal be at least consistent with the minimum (www.oshpd.ca.gov). payment level under this provision. 13. Grumbach, K., Chattopadhyay, A., and Bindman, A. Fewer and More Specialized: A New Assessment of Physician Supply in California. California HealthCare Foundation, Oakland, CA: June 2009 (www.chcf.org). 34 | C alifornia H ealth C are F oundation 25. California’s preliminary federal FY 2011 Medicaid DSH 41. Centers for Medicare and Medicaid Services. Health allotment from 76 Fed. Reg. 148. Medicare DSH figures Expenditures by State of Provider: Medicare Summary from California Hospital Association analysis of 2008 Tables, 1980 – 2004. Baltimore, MA: February 2007 CMS Medicare Cost Report. (www.cms.gov). 26. Social Security Act Section 1923(f). 42. California HealthCare Foundation. Medicare Facts and Figures. Oakland, CA: January 2010 (www.chcf.org). 27. CMS Waiver Number 11-W-00193/9, Special Terms and Conditions. 43. Congressional Budget Office. Cost Estimate. Washington, DC: March 18, 2010 (www.cbo.gov). 28. Ibid. 44. Ibid. 29. California’s federal FY 2011 estimated DSH allotment reported in 76 Fed. Reg. 148. Future DSH allotments are 45. California HealthCare Foundation and Capital Link. not yet available due to reliance on annual inflation and Financial Health of Community Clinics. September 2010 state Medicaid programs’ expenditure data. (www.chcf.org). 30. California Hospital Association analysis on dollar impact 46. “Community clinics” include FQHC Section 330 clinics, of DSH reductions. lookalikes, nonprofit Rural Health Clinics, free clinics, and other licensed safety net clinics, including family- 31. Manatt analysis. Proportion calculated assuming planning and school-based clinics. Medicaid DSH allotments at FY 2009 levels of $1.1 billion for each of the ten years. 47. California HealthCare Foundation and Capital Link. Financial Health of Community Clinics. September 2010 32. California Health and Welfare Institutions Code, (www.chcf.org). Section 17000. 48. Ibid. 33. 75 Fed. Reg. 68583. 49. National Association of Community Health Centers. 34. Congressional Budget Office. Cost Estimate. Washington, California Health Center Fact Sheet. Bethesda, MD: 2008 DC: March 18, 2010 (www.cbo.gov). (www.nachc.com). 35. California Hospital Association. 50. U.S. Department of Health and Human Services. 36. Manatt analysis. Proportion calculated assuming Community Health Centers Awards Chart. Washington, Medicare DSH payments at FY 2008 levels of DC: October 2010 (www.hhs.gov). $1.5 billion to California hospitals for each of ten years. 51. Health Resources and Services Administration. Health 37. Newhouse, J., et al. Free for All? Lessons from the RAND Center Expanded Services (ES) Fiscal Year 2011, HRSA-11- Health Insurance Experiment. Cambridge, MA: Harvard 148, CFDA #93.527. Rockville, MD: October 26, 2010 University Press, 1993. (www.hrsa.gov). 38. Guy, G. 2010. “The Effects of Cost Sharing on Access to 52. Health Resources and Services Administration. Affordable Care among Childless Adults.” Health Services Research Care Act — Health Center Planning Grants, HRSA-11-021, 45(6); 1720 – 1739. CDFA #93.527. Rockville, MD: January 7, 2011 39. California’s Governor’s Budget 2011–2012, Proposed (www.grants.hrsa.gov). Budget Summary — Health and Human Services 53. Government Accountability Office. Medicare Payments (www.ebudget.ca.gov). to Federally Qualified Health Centers, GAO-10-576R. 40. California HealthCare Foundation. Medicare Facts and Washington, DC: July 2010 (www.gao.gov). Figures. Oakland, CA: January 2010 (www.chcf.org). Implementing National Health Reform in California: Opportunities for Improved Access to Care | 35 54 Health Resources and Services Administration. Teaching Health Center Graduate Medical Education (THCGME) Program, HRSA-11-149, CFDA #93.530. Rockville, MD: November 29, 2010 (www.grants.hrsa.gov). 55. Accreditation Council on Graduate Medical Education. List of Withdrawn Programs, 2007– 2008, 2008 – 2009, 2009 – 2010. Accessed December 18, 2010 (www.acgme.org). 56. California School Health Centers Association. 57. Health Resources and Services Administration. Affordable Care Act — Grants for School-Based Health Center Capital (SBHCC), HRSA-11-127, CFDA #93.527. Rockville, MD: October 4, 2010 (www.grants.hrsa.gov). 58. Health Resources and Services Administration. Affordable Care Act: Nurse Managed Health Clinics (T56) (www.granteefind.hrsa.gov). 59. Office of the Governor. Press Release. Sacramento, CA: April 13, 2009 (www.gov.ca.gov). 60. California Office of State Health Planning and Development. Preparing For Healthcare Reform: A Dialogue on Healthcare Workforce Development. Sacramento, CA: May 27, 2010 (www.oshpd.ca.gov). 61. Health Resources and Services Administration. 62. As the fiscal and administrative agent for the State Board, the California Department of Employment Development was officially awarded the planning grant. 63. California Office of State Health Planning and Development. California’s Health Workforce Development Planning Grant Overview. Sacramento, CA (www.oshpd.ca.gov). 64. 75 Fed. Reg. 71800. 65. California Office of Statewide Health Planning and Development. California Rural Hospitals. Sacramento, CA: Accessed December 18, 2010 (www.oshpd.ca.gov). 66. HRSA Geospatial Data Warehouse. National Health Service Corps Details (datawarehouse.hrsa.gov). 67. Ibid. 36 | C alifornia H ealth C are F oundation C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org