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Briefing Book on Access for Underserved and Vulnerable Populations [8]
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�Clinton Presidential Records
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�TAB 24
P o l i c y Statement of National Association of
Community Health Centers
�Policy Statement of National Association
of Community Health Centers
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NATIONAL HEALTH REFORM AND ACCESS TO PRIMARY CARE FOR
MEDICALLY UNDERSERVED AMERICANS
Background
A fundamental purpose of national health reform must be to assure health insurance
coverage for all Americans. But health insurance alone is not enough. Health reform must
also assure access to adequate health care. While health insurance is an essential
prerequisite to health care, studies have shown that insurance alone does not make health
care accessible. An estimated 43 million Americans, living in inner dty and rural
communities, remain seriously medically underserved because of special needs or
circumstances. These Americans are overwhelmingly poor or low income, and are
disproportionately young. Many are uninsured, but 60 percent of them have some form of
insurance (especially Medicaid). Many live and work in areas with too few providers of
care. Others depend on hospitals and emergency rooms for even basic care, because of
severe shortages of appropriate primary health care services.
Even with guaranteed insurance coverage, these Americans will continue to face
significant barriers to care, especially family-oriented, community-responsive primary and
preventive health services. No amount of financing reform or universal coverage will be
sufficient to lead highly-paid medical specialists (the vast majority of physicians in the U.S.)
to start providing lower cost, less technologically oriented, preventive and primary care
services, much less to relocate their practices in low income and medically isolated areas.
The Clinton Plan and Access to Care
President Clinton has made health care reform one of his top priorities, and called
for significant action on this issue early in his first term. Although the Clinton plan has not
yet been fully detailed, it does appear that it will contain several important advancements,
most notably: universal coverage, bringing 36 million uninsured Americans into the health
care mainstream; affordability protections for low income famihes, as well as for small
businesses and self-employed individuals; expansion of primary and preventive health
services, and increased training of primary care physicians; insurance market reforms, to end
discriminatory and predatory private insurance practices and make insurance more
affordable; and strong cost containment measures, including firm spending caps, without
trading off quality or health outcomes.
By far the most significant aspect of the Clinton plan lies in the attention it gives to
reforming the health care delivery system. The Clinton plan calls for extensive use of
managed competition, through enrollment of most Americans in local Accountable Health
1330 New Hampshire Avenue, N.W.
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Plans. The Plans would then provide or arrange for all covered services needed by enrolled
members, with payment on a capitated basis. This focus on managed competition will work
to assure care and at the same time contain costs for most Americans. However, there are
some areas and populations - in particular low income, rural and other medically
underserved Americans - for whom this approach may not improve access to care, and
could even prove detrimental, unless it includes steps to fully involve the providers that
currently serve these areas and populations. They include:
Those who live in areas with too few providers -- the residents of literally
thousands of rural communities and inner-city neighborhoods all across the
country. These communities will need support to recruit needed providers
and to develop necessary services - especially primary and preventive care as a critical first step.
Those whose circumstances pose serious obstacles to care -- homeless persons,
migrant farmworkers, new immigrants, and low income families generally, who
face serious non-financial barriers to care (geographic, cultural, linguistic,
physical) that will not be overcome by universal coverage alone. They are
also highly mobile, making enrollment in any single plan exceedingly difficult.
Those with special health care needs - who require services that go beyond
basic medical care, and yet are critical to improving and maintaining their
health (multilingual translation, transportation, community outreach, home
visitation, case management, health education, school health, STD screening
and treatment, and specialized care for those with HIV infection, substance
addiction, or disabilities).
Those who will likely be ineligible for coverage - including the estimated 8
million undocumented immigrants living in the U.S. today. At a minimum,
they will need access to essential primary and preventive services, through
available providers who understand their needs and are trusted by them.
Actions Needed
As an integral part on national health reform, new and dramatic federal efforts are needed
to assure the availability of primary and preventive health services in every medically
underserved community. Three essential steps are necessary to accomplish this objective:
1.
Specific federal funds must be identified and allocated out of total health spending
to develop and support the ongoing delivery of these services, through:
Assured funding to begin the immediate development of communityresponsive primary and preventive health centers to reach all medically
underserved communities, in preparation for national health reform.
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Support for the development of Community Health Care Networks, involving
health centers and other "safety net" providers, to fully organize the delivery
of needed health care services and assure the full continuum of care for
underserved populations.
Continuing support to these primary health care centers and networks for
recruitment of primary care providers, for continued delivery of essential
services not covered by insurance, and for care provided to special populations
(rural residents, farmworkers, homeless persons, those with HIV infection)
and those missed by universal coverage.
2.
Health reform must assure that all accountable health (managed care) plans are
truly accessible - geographically, linguistically, culturally, physically, and financially to all enrolled beneficiaries, by:
Assuring that Community Health Care Networks and health centers are fullv
included in all managed care arrangements serving (or proposing to serve)
local underserved communities and populations.
Assuring adequate payment rates and stop-loss coverage to the Networks and
health centers to promote their mission, recognize the complex needs and mix
of patients they serve, and protect their solvency.
3.
Health reform must refocus federal health professions training programs and
financing to significantly expand primary care training, to support the capacity of
health centers to participate in primary care residency training, and to increase the
placement of primary care providers in underserved areas.
The development of these health centers and networks will contribute not only to making
the entire system more effective and efficient, but also to ensuring the system's
responsiveness to those who, because of their special circumstances, have been unserved or poorly served, at best - in the past. In so doing, the ultimate goals of any such effort improving access to care, while containing health care costs -- will both be well-served.
A.
Developing and Supporting the Primary HeaUh Care Centers and Networks
A broad national system of primary care centers is needed to assure that every
American has adequate access to comprehensive primary health care. This effort can be
modelled after such programs of proven effectiveness as federally funded community,
migrant and homeless health centers and the National Health Service Corps, and can
include other public and nonprofit community-responsive health clinics that extensively serve
low income and medically underserved populations. Through their long years of experience
in both caring for hard-to-serve patients and operating with limited financial resources, these
health centers have compiled a track record of providing high quality care in an efficient
and cost effective manner. Their continued existence will be critical to the success of any
health care reform effort.
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Their expanded presence and availability of services will significantly lower
unnecessary use of costlier, less appropriate settings such as hospital
emergency rooms and "Medicaid mills".
Their consolidation of both preventive and comprehensive primary care
services under one roof will measurably reduce the frequency and cost of
preventable illnesses.
Their experience in case management will bring about a substantial reduction
in specialty care and hospital admissions, saving millions of dollars for the
health care system.
Under this effort, funds could be allocated to the development and expansion of
these programs -- including the recruitment and placement of physicians, nurses and other
health professionals -- so that, by the year 2000, community primary health care centers
would be established to serve all medically underserved areas.
At the same time, even with universal insurance coverage, certain people (such as
homeless persons, farmworkers, those with HIV infection, substance abusers, those with
no/limited English-speaking ability, etc.) - whose health problems are typically more serious
and more complicated than is true of other Americans - will frequently need special services
that may not be recognized as reimbursable. These essential services include patient case
management services, multi-lingual translation, health education, outreach and
transportation; other social and patient supports such as school health, special education and
early intervention for children with disabilities, and specialized care programs for persons
with HIV or with alcohol or substance abuse exposure; and uncovered preventive health
services such as childhood immunizations, family planning, and STD screening and
treatment. To the extent that these services are not covered under a basic benefit package
(or as supplemental benefits for low income and underserved families), the primary health
care centers will need assured funding to cover the cost of providing the services needed by
their patients.
B.
Making Managed Competition Work for Underserved Communities
Because of their experience, the health centers - together with a number of other
"safety net" providers (other community clinics, comprehensive local public health clinics,
and disproportionate share hospitals) - form the backbone of the local health care system
for most underserved people and communities. For these people and communities, in
particular, expanding primary care services will be vital in increasing access and reducing
costs. The overall success of managed care, both in improving access and containing costs,
will be greatly enhanced through assisting health centers to link with each other and with
other safety net providers in underserved communities to form Health Care Networks
focused on serving the people living there, and by fully recognizing these Networks as
managed care systems under health care reform. Moreover, current federal laws and
policies which pose barriers to Network development (such as restrictive budgeting
requirements and "fraud and abuse" limitations) will need to be amended to permit
appropriate linkages that benefit underserved people and communities.
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Refocusing Health Professions Training
The development of the primary health care centers will depend most importantly
on whether the health professions education and training system can successfully recruit and
train adequate numbers of primary care providers. Over the next decade, an estimated
20,000 additional primary care physicians (and similar numbers of dentists, midlevel
providers, nurses and other health professionals) will be needed to furnish care in medically
underserved communities through these centers.
Federal health professions programs must be substantially reformed. These reforms
must include special efforts to find students who desire a career in primary care, greater
emphasis on primary care in both undergraduate and graduate training, increased linkages
between training programs and current primary care providers located in medically
underserved communities, and greater financial and professional rewards for primary care
practice, particularly in underserved areas. Support for federal health professions education
and training programs must be significantly increased (current federal funding, excluding
Medicare and Medicaid spending, amounts to less than $200 million annually).
Of even greater importance are the Medicare and Medicaid payments for direct and
indirect costs associated with graduate medical education (GME) and other health
professional training. Estimated at over $5 billion in FY 1993, these payments are spent
almost entirely on inpatient, specialty-based training, and provide no incentives for primary
care training. The Council on Graduate Medical Education (COGME) has already cited
current hospital-based specialty training programs as contributing to the overall shortage of
primary care providers, and the severe shortage of such providers in underserved areas.
While in most other developed countries, the vast majority of physicians are trained in
primary care, this is true for less than 30 percent of American physicians. Current GME
policies must be revised to support expanded primary care training and to increase the
numher of ambulatory training programs, as recommended by the Institute of Medicine,
COGME, and the Physician Payment Review Commission.
In particular, direct GME reimbursement to health centers is vital to ensure their
ability to fulfill their service mission. These payments would allow interested health centers
to develop training linkages and bring medical and other health professions trainees into
underserved communities. This would increase the centers' service capacity and their
patients' access to care, and would improve the centers' potential to recruit and retain
highly-qualified clinicians. In addition, supplemental financial support should be provided
to health centers to support their functioning as "teaching health centers".
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The Cost of This Plan
The development of network health centers could be accomplished for a cost of $1
billion annually over the next 8 years. Assuming that the basic benefit package would cover
medically necessary outpatient and inpatient medical care, including maternity and well child
care, the cost of providing essential but uncovered services would be ahout $4 billion
annually. Doubling the current federal (non-Medicare/Medicaid) spending for health
professions training would cost about $200 million annually; and reforming the GME
payment system would cost anywhere from nothing (refocusing current spending) to $1
billion (increased weighting for primary care) annually.
In all, the entire effort could be accomplished for about $6 billion per year -- less
than one percent of total annual health care spending nationally.
�Clinton Presidential Records
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P o l i c y Statement of National Association of
Public Hospitals
�P o l i c y Statement o f
National Association of Public Hospitals
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Essential Community Providers
The Need For Infrastructure Support
May 4, 1993
There is a need to identify, as part of health reform, certain categories of "essential
community providers" that will continue to provide a needed range of health and social
services during (and following) the implementation of health reform. Federal recognition of
the continuing role of such providers - which include both urban and rural safety net
institutions such as community health centers and public hospitals -- will be crucial to the
success of health reform for several important reasons:
• No reform plan, no matter how ambitious, can truly promise universal access for
all - certain individuals will inevitably continue to fall through the cracks.
• As we have learned from Medicaid, simply making a person eligible for coverage
does not guarantee convenient and equitable access to care; even for a basic package
of preventive, primary and acute health services, many inner city and rural areas will
continue to be geographically underserved.
• The specialized standby medical, public health and social services provided by
these institutions ~ such as 24 hour trauma care, bilingual services, socially aware
discharge planners and various other outreach programs - are rarely available in
inner city or remote rural areas except through safety net providers.
Clearly, safely net community providers are not going to fade away in the foreseeable
future. It is therefore essential to address their urgent infrastructure needs in the context of
health system reform.
At the outset, it is important to emphasize that the infrastructure investment
required is not vast or open-ended. Rather, such support can be carefully targeted on
those providers that meet truly essential community needs.
Nor is it necessary to reinvent the wheel in defining these providers. Several
definitions already exist in federal law, such as the Federally Qualified Health Center
(FQHC), Essential Access Community Hospital (EACH), 1992 Medicaid Drug Pricing
exceptions legislation, and high volume Medicare and Medicaid "disproportionate share
hospital" (DSH) definitions. It will be a relatively simple matter to adapt or cross-reference
these definitions for the purposes of health reform legislation.
Three major infrastructure needs must be met in any health reform package if access
to essential community health services is to be preserved and protected:
• Seed funding should be available to safety net institutions that are willing to
restructure the health care delivery system to form community health networks to
improve access to a full range of primary and preventive health services.
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• Targeted capital financing assistance should be provided to rebuild and renovate
essential community providers, to enable them to continue to provide community-wide
services and access to care in underserved areas, as well as to participate to the fullest
extent possible in the health plans that will be available to newly covered persons in
their service areas.
• Explicit acknowledgment must be made of the role to be played by "essential
access" safety net providers after health reform is phased in, including guarantees of a
level playing field in competing for newly covered individuals in inner city and
remote rural communities, and continued direct funding for special services not
covered in the health reform benefit package.
Specific proposals in each of these three areas are set out in the attached
memorandum. Examples of the kinds of facilities, systems or services likely to benefit from
this assistance include the following:
• Assisting health centers and public hospitals in cities such as Denver, Boston, Los
Angeles, Dallas, Atlanta, Memphis and elsewhere, to join together to form
community health networks to develop regional systems and health plans for low
income patients in underserved areas.
• Rebuilding and downsizing the Louisiana Medical Center at New Orleans (the
former Charity Hospilal of New Orleans), including assistance in the purchase and
renovation of an underutilized private hospital and decompression of its services to a
network of outpatient facilities.
• Constructing a badly needed new trauma center at Martin Luther King/Drew
Medical Center, and rebuilding (and downsizing) the L.A. County/USC Medical
Center in the L.A. County system.
• Assisting Cook County and the City of Chicago to rebuild (and downsize) Cook
County Hospital, to purchase and renovate satellite facilities in other underserved
parts of the County, and to merge the clinics and health centers owned by the County
and City into a regional system involving both public and private providers.
• Renovating San Francisco General Hospital's ambulatory care center so that it is
more conducive to meeting outpatient needs, allowing for more efficient management
of same day and ambulatory patients, including intake, waiting, post procedure
recovery, patient education and so forth.
• Assisting hospitals in New York City to set up a managed care program with onsite and off-site clinics.
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• Assisting the more than 2000 underserved communities all across America to
develop the community based primary or preventive health care systems that will be
essential to assuring access to vital health care for their residents.
• Assisting Hennepin County Medical Center in Minneapolis to renovate an existing
facility to serve as a clinic.
• Helping South Broward Hospital District in Hollywood, Florida institute a
community-based initiative that would provide coordinated, non-fragmented
continuum of health care, primary care, outpatient care and outcome measurement.
• Assisting public hospitals in New York City to convert existing beds to
Tuberculosis code compliant isolation rooms with proper ventilation, anteroom and
bath.
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Essential Community Provider Infrastructure Support
Description of Specific Proposals
May 5, 1993
The purpose of this memorandum is to describe in greater detail the proposals for three kinds
of transitional infrastructure support that will be needed, during the phase in of health reform, by
health centers, hospitals and others that are designated as "essential community providers" in urban
and rural areas.
1. Federal Support for the Development of Community Health Networks and Primary Care
Capacity For Underserved Areas.
Federal seed funding is needed to promote and encourage the restructuring of health care
delivery systems in underserved urban and rural areas. In particular, funding is requested for the
development of regional community health networks (CHNs) centered around providers of preventive
and primary care (including FQHCs and FQHC look-alikes, local public health agencies providing
primary care, EACHs and public or other DSH providers serving substantial numbers of low income
patients.)
The purpose of encouraging the development of CHNs will be to improve the organization
and delivery of preventive and primary care services, improve access for low income patients,
promote the development and training of managed care providers, better coordinate care on a
regionwide basis, and reduce inappropriate or unnecessary services.
It is proposed that seed grants be made available to two different kinds of CHNs: primary
care networks and full service networks. Partners in primary care CHNs should be required to meet
certain minimum requirements, such as serving as FQHCs or FQHC look-alikes (except for the
governing board requirement). Full service CHNs may be formed by a combination of primary care
and acute care providers, including FQHCs, FQHC look-alikes, public health agencies, DSHs,
EACHs, sole community hospitals and other rural providers in underserved areas.
In addition, grants would be made to develop new or expanded primary care capacity in
communities that suffer from severe shortages of such services. The developmental support would
build on the principle of strong community involvement in developing solutions to their health care
needs.
Development grants can be used to cover such costs as planning, needs assessment, feasibility
studies, recruitment and training, development of clinical and financial management and information
systems, establishment of reserves as required for assumption of actuarial risks. CHN participants
would also be eligible, as needed, for capital assistance under (2) below and operating assistance
under (3) below.
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2. Targeted Capital Funding to Rebuild and Renovate Essential Community Providers
A. Need for Assistance
Targeted capital financing assistance is also needed to enable hospitals, health centers or other
facilities that are identified as essential community providers to continue to provide needed
community services and to guarantee access for low income patients in underserved areas. Such
assistance is also required to enable such providers to participate fully and effectively in the CHNs
described in (1) above and in other health plans that may be offered in their service areas.
The need to target Federal support for urban and rural safety net providers was first
recognized in 1992, when Senate Finance Committee members Tom Daschle and John Breaux, and
House Ways & Means Health Subcommittee Chairman Pete Stark, introduced the National Health
Safety Net Infrastructure Act. It is important to point out that this legislation -- which was
reintroduced in the Senate as S.726 and will soon be reintroduced in the House -- is not an effort to
recreate the old, far-reaching Hill-Burton program. Rather, it Is intended to be a five year
transitional program that would focus capital financing suppon on a small number of narrowlydefined institutions with capital needs that cannot be met through traditional market financing
mechanisms.
B. Definition of Eligible Providers
Such capital financing support should be available to all institutions identified as essential
community providers. There are potential definitional models in S. 726, under which providers are
required to meet two general criteria to be eligible for assistance:
•
Health centers must qualify as a Federally-Qualified Health Center (FQHC) or
"FQHC look-alike" under Medicaid, or meet other appropriate criteria set by the Secretary
of Health and Human Services (HHS).
•
Hospitals must qualify as publicly owned, operated or funded "high volume"
Medicare or Medicaid disproportionate share hospitals, or qualify as an Essential Access
Community Hospital (EACH) or rural primary care hospital under existing Medicare law.
Consideration could be given to expanding or revising this definition in a variety of ways,
to ensure that it encompasses all facilities otherwise identified as essential community providers.
For example, about 200 hospitals and 700 health centers meet the current definition under
S. 726. The "public" limitation was considered acceptable because it is typically publicly owned or
financed hospitals that have the greatest difficulty gaining access to affordable capital. If, in the
alternative, all high volume public and private Medicare DSH hospitals were included, based (e.g.)
on the definition adopted last fall without an ownership requirement for Medicaid drug pricing (PL
102-585) no more than 500 hospitals would be covered.
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Parlicipaiion of non-hospital providers could be guaranteed by broadening the definition to
include such providers as family planning clinics and community mental health centers. In addition,
the EACH program could be expanded to all states and to urban areas.
v
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C. T P of Assistance Available
The need for capital infrastructure assistance varies in different parts ofthe country. In some
areas, providers have problems gaining access to the capital markets without some form of credit
enhancement such as loan guarantees. In other areas, providers can get access to the markets, but
require assistance (such as interest rate subsidies) in repaying their loans. And for some providers
and types of projects (especially smaller primary care or emergency projects), direct loans and grants
are the best vehicle. For these reasons, it is proposed that four basic types of financing assistance
be made available to eligible providers: loan guarantees, interest rate subsidies, direct loans, and
direct grants.
• Loan guarantees, such as are currently available to some hospitals under the FHA Section
242 hospital mortgage insurance program, could provide federal guarantees of loan
repayment to non-Federal lenders making loans to qualified providers for replacement,
modernization and renovation projects. Only those projects for which the guarantee is
essential to obtaining affordable financing would be funded. The Federal guarantee would
reduce the risk of lending to safety net institutions, thereby bringing down the interest rate
to reasonable levels. Loan guarantees will permit a substantial leveraging of federal
assistance; a relatively small investment of federal dollars would dramatically increase
private capital investment in essential community providers. The FHA Section 242
program is largely self-financed through premiums, with relatively few defaults or problem
loans in its long history. (However, while Section 242 can be used as a model, certain
changes would be needed; in particular, the cumbersome application and administrative
process, and the requirement that a provider be legally able to mortgage its facilities, have
limited the utility of this program for many public safety net hospitals).
• Interest rate subsidies would also be made available to public safety net providers where
the state or local government has demonstrated a significant commitment to financing the
project through a matching contribution, and to non-profit community providers with
significant Federal, state or local support. Interest rate subsidies should be available only
where a feasibility analysis demonstrates that an otherwise needed capital project would not
be affordable, and where local governmental funding sources agree to maintain their level
ofeffort in support of services and costs likely to continue to be outside the scope of health
plan benefits or payment levels. It is also possible that interest subsidies could be offered
on an interim or transitional basis while broader health coverage for the uninsured is phased
in.
• Direct matching loans should also be provided for smaller capital projects. Non-federal
sources could be required to provide matching funds for a specified percentage of the cost
of the project (with a waiver available forfinancially-distressedproviders). Where local
governmental entities are involved, ongoing commitments could be required to share the
support of both capital and operating costs of new facilities and services.
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• Finally, funds should be provided, on a carefully targeted basis, for direct grants to
providers for emergency projects necessary to meet life safety code or similar standards to
retain accreditation or certification; to upgrade or install management information and
financial systems in preparation for developing health networks and panicipating in affordable
health plans; for projects necessary to maintain essential safety and health services such as
obstetrics, perinatal, emergency and trauma, primary care, and preventive health services;
and for a down payment on a broader capital financing plan.
It is suggested that whatever funding is available for this capital financing program be divided
as follows:
V 4^ ^
Loan Guarantees
Interest Rate Subsidies
Direct Matching Loans
Direct Grants
35%
30%
15%
20%
(P^Y
D. Provider Requirements
It is important that assistance be available under this program for both inpatient and outpatient
services, albeit subject to a rigorous determination ofthe needs of the population to be served. The
ability of a provider to take advantage of these programs should clearly carry with it certain
responsibilities, which could assume various forms. For example, providers could be required to
make the services of the renovated facility open and available to all residents in their territorial areas.
In addition, eligible providers could be obliged to provide a substantial volume of services to low
income persons or residents of underserved areas, or to continue to provide specified community
health and social services. Finally, suggestions regarding the administration and financing of the
proposed capital financing assistance are spelled out in greater detail in the attached bill, which
incorporates a number of revisions made this year, prior to reintroduction, in response to concerns
expressed by rural providers and community health centers.
3. Treatment of Essential Community Providers Under Health Reform
in addition to capital financing assistance and seed funding for the development of community
health networks, essential community providers will require ongoing operational support and
recognition under health reform. This support should include the following:
A. Payment Adjustments & Categorical Support
Essential community providers will clearly require continued and expanded operating support
during the phase in of universal coverage to fund continued services for uninsured patients and
broader community and public health services.
• For community health centers, family planning clinics, and other similar providers, this
support should take the form of continued and expanded operating grants under PHS Act
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authorizations, and continued implementation and expansion of reasonable cost
reimbursement for FQHCs under Medicare and Medicaid (or any successor programs).
• For "high volume" DSHs, continuation of the disproportionate share adjustments under
Medicare and Medicaid will be essential as long as those programs remain in place and
significant numbers of uninsured patients continue to require their services.
• Even after health reform is fully phased in, a certain level of operating subsidies will still
be required to recognize lhat there will always be individuals who fall through the gaps, and
that there will continue to be many important public health and social services, and 24 hour
"standby" services such as trauma care, provided by these institutions. Such continued
assistance should take the form of special cost related payments for FQHCs and FQHC lookalikes, targeted operating grants for clinics and CHNs, and the implementation of a
Community Service Adjustment (CSA) for DSH hospitals, which could be more narrowly
focussed than current DSH payments.
B. Participation in Health Plans
With respect to the implementation of increased coverage through health care reform,
including the development of systems of managed competition, it is essential that a level playing field
be created and maintained for essential community providers. In particular, FQHCs, CHNs, high
volume DSHs and other institutions identified in this memorandum must be permitted full
participation in any managed competition plans that are implemented in their area, including the
ability (if relevant) to participate in the governance of health alliances, the ability to serve (and be
reimbursed) as approved providers for enrolled patients under affordable health plans (AHPs)
developed by others, and the ability (wiihoui undue restrictions) to develop and offer their own AHPs
if desired.
�Clinton Presidential Records
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�TAB 26
Policy Statement of National Association of
Counties
�P o l i c y Statement o f
N a t i o n a l A s s o c i a t i o n o f Counties
�NATIONAL
ASSOCIATION
COUNTIES
440 First St. NW. Washington, DC 20OOI
202/393-6126
MEMORANDUM
TO:
John Hart, Lois Quam, Bonnie Lefkowitz
FROM:
Tom Joseph, Mary Uyeda
DATE:
May 11, 1993
SUBJECT: Essential Community Provider/Maintenance
of Effort/Funding Flows
This memo represents our consensus and concerns t o date
on these complicated issues.
ESSENTIAL COMMUNITY PROVIDERS
NACo i s f i r m l y committed t o having l o c a l government
h e a l t h agencies and f a c i l i t i e s included i n a f e d e r a l l e v e l
d e f i n i t i o n / d e s i g n a t i o n of ECP's, based on c r i t e r i a t h a t such
e n t i t i e s serve low income populations.
MAINTENANCE OF EFFORT
We continue t o have several concerns regarding t h i s
issue. Many o f them r e l a t e t o u n c e r t a i n t y about a uniform,
s i n g l e procedure f o r ECP s t a t u s . Maintenace o f e f f o r t and
e s s e n t i a l community provider status are c l o s e l y l i n k e d . I f ECP
recognizes the county r o l e as t r a d i t i o n a l providers o f services
t o t h e poor, our concerns addressed below w i l l be a l l e v i a t e d
somewhat.
NACo s t r o n g l y believes t h a t maintenance of e f f o r t
should be e q u i t a b l y defined and agreed t o a t t h e f e d e r a l l e v e l ,
f o r a l l l e v e l s of government - f e d e r a l , s t a t e , and l o c a l .
Several f a c t o r s cause concern:
1.
To date, there i s no assurance t h a t county elected and
appointed o f f i c i a l s operating l o c a l government h e a l t h
agencies and f a c i l i t i e s w i l l have a formal r o l e as
d e c i s i o n makers i n t h e new system, t h a t they w i l l be
recognized as e s s e n t i a l community providers on the same
terms as others, or t h a t t h e i r services or costs w i l l
be adequately covered.
�Memorandum
May 11, 1993
page 2
Even i f a m a j o r i t y o f h e a l t h s e r v i c e s a r e
" c l i n i c a l i z e d " i n o r d e r t o render them r e i m b u r s a b l e i n
a p r i v a t e market s e t t i n g , government agencies w i l l
s t i l l m a i n t a i n e f f o r t s t o p r o v i d e s e r v i c e s and assure
broad p o p u l a t i o n - b a s e d s e r v i c e s .
We assume many p r e v e n t i v e s e r v i c e s such as
immunizations and s c r e e n i n g procedures a r e b e i n g r e d e f i n e d as r e i m b u r s a b l e " c l i n i c a l p r e v e n t i v e s e r v i c e s "
i n t h e new system. P r i v a t e and f e d e r a l l y funded nonp r o f i t p r o v i d e r s w i l l move a g g r e s s i v e l y t o c a p t u r e
these revenue streams.
I n o r d e r t o compete on an equal
b a s i s , q u a l i f y i n g l o c a l government h e a l t h agencies must
be r e c o g n i z e d as ECP's t o be a b l e t o t a k e advantage o f
t h i s reimbursement.
L o c a l p u b l i c h e a l t h systems s h o u l d a l s o be f u l l y
i n t e g r a t e d i n t o a reformed system. L o c a l governments
i n v e s t h e a v i l y i n these f u n c t i o n s .
2.
U n c e r t a i n t i e s remain c o n c e r n i n g s e r v i c e s and
p o p u l a t i o n s covered i n t h e new system. I t i s apparent
t h a t s i g n i f i c a n t p o p u l a t i o n s w i l l n o t be i n c l u d e d
(e.g., undocumented a l i e n s , i n c a r c e r a t e d persons and
persons r e q u i r i n g l o n g term i n s t i t u t i o n a l c a r e ) .
L i m i t a t i o n s w i l l be p l a c e d on l o n g t e r m home and
community-based care.
L o c a l governments w i l l c o n t i n u e t o have r e s p o n s i b i l i t y ,
under t h e i r s t a t u t o r y and c o n s t i t u t i o n a l
r e s p o n s i b i l i t i e s f o r i n d i g e n t care, t o provide h e a l t h
s e r v i c e s f o r these persons.
These s t a t e l e v e l
r e q u i r e m e n t s f o r l o c a l governments a r e u n l i k e l y t o
change i n t h e f u t u r e .
3.
The u n c e r t a i n t y w i t h which s t a t e maintenance o f e f f o r t
i s d e f i n e d i n t h e reformed system l e a v e s l o c a l
governments v u l n e r a b l e t o t h e p o l i t i c a l and economic
vagaries of states.
NACo o f f i c i a l s have d i s c u s s e d a f i n a n c i a l MOE i n terms
o f Medicaid c o n t r i b u t i o n s and county a d m i n i s t r a t i o n and
f i n a n c i n g o f s t a t e g e n e r a l a s s i s t a n c e / m e d i c a l programs.
�Memorandum
May 11, 1993
page 3
This r e s p o n s i b i l i t y varies across states, and i t i s
d i f f i c u l t i n t e r n a l l y f o r NACo t o reconcile these
v a r i a t i o n s i n t o a coherent p o l i c y recommendation.
States where counties have s i g n i f i c a n t r e s p o n s i b i l i t y
f o r these programs are r e l u c t a n t t o continue
i n d e f i n i t e l y without a clear understanding o f t h e i r
long term r o l e s .
4.
As coverage i n the new system i s broadened t o include
many of the services l o c a l governments now provide,
there i s l i t t l e understanding of the impact o f t h i s
s h i f t on the service and f i s c a l r e s p o n s i b i l i t i e s of
l o c a l government health agencies and f a c i l i t i e s .
I n t e r p r e t i n g a maintenance of e f f o r t as a service
o b l i g a t i o n has s i g n i f i c a n t u n c e r t a i n t i e s , given the
changing nature of the h e a l t h service system. Under
t h i s concept, i t i s assumed t h a t some o f the indigent
care r e s p o n s i b i l i t i e s would diminish f o r counties
during the t r a n s i t i o n . Counties should be given
incentives t o maintain a f i n a n c i a l commitment t o h e a l t h
services so former indigent h e a l t h funds are r e d i r e c t e d
to invest i n preventive and primary care services.
FUNDING STREAMS TO SUPPORT INFRASTRUCTURE AND SERVICES
During the t r a n s i t i o n , NACo s t r o n g l y supports the
maintenance o f l o c a l government h e a l t h agency and f a c i l i t y
e l i g i b i l i t y f o r f e d e r a l c a t e g o r i c a l funding. This includes
prevention, maternal/child health, and mental h e a l t h block
grants, aging services, immunization support, and
d i s p r o p o r t i o n a t e share payments, o r some s i m i l a r mechanism f o r
f a c i l i t i e s serving large numbers of low income persons, during
the t r a n s i t i o n t o the new system. Current f e d e r a l c a t e g o r i c a l
funding should continue i n the near f u t u r e w i t h county o f f i c i a l s
i n v o l v e d a t the f e d e r a l and s t a t e l e v e l s i n c a r e f u l planning t o
i n t e g r a t e these funds i n t o a comprehensive h e a l t h service system.
NACo s t r o n g l y urges t h a t l o c a l government h e a l t h
agencies and f a c i l i t i e s be e l i g i b l e f o r any a d d i t i o n a l funding
f o r i n f r a s t r u c t u r e development i n c l u d i n g c a p i t a l investment, and
"access enhancing services."
NACo s t r o n g l y supports a proposal t o increase
comprehensive primary care capacity beyond the s t a t u t o r y
boundaries created f o r community h e a l t h centers and FQHCs. Over
the years, l o c a l h e a l t h departments have expanded i n t o primary
�Memorandum
May 11, 1993
page 4
care but are l i m i t e d by federal requirements f o r governing
boards. E l i m i n a t i n g those b a r r i e r s t o developing primary care
capacity i s c r i t i c a l f o r reform t o succeed.
We look forward t o continuing t o work w i t h you i n the
coming weeks and months t o create an integrated, reformed h e a l t h
system.
�FOR OFFICIAL USE ONLY
MAY
S,
1993
Issue: The r o l e of e s s e n t i a l community providers and to what extent
Health A l l i a n c e s and plans should be required t o i n t e g r a t e such
providers.
Working Group recommendations f o r designation of e s s e n t i a l
community providers have focused on federal l e v e l designation only
for c e r t a i n providers d i r e c t l y established and funded by the
federal government, leaving other designations to the s t a t e . This
detracts from the r e a l i t y t h a t l o c a l government h e a l t h agencies and
f a c i l i t i e s serve d i s p r o p o r t i o n a t e l y high numbers of low income
persons, i n c l u d i n g persons unable t o p a r t i c i p a t e i n s l i d i n g fee
systems o f t e n used by the f e d e r a l l y funded programs. I t also means
that the a c t i v e i n t e g r a t i o n of l o c a l government agencies are
subject t o the vagaries of s t a t e d i s c r e t i o n , while s t a t u t o r y
r e s p o n s i b i l i t i e s f o r indigent care by l o c a l governments would
undoubtedly remain i n place.
Further, working group recommendations have suggested several
categories
f o r the e s s e n t i a l community providers, c r e a t i n g
unnecessary bureaucratic compliance and monitoring requirements.
The designation of e s s e n t i a l community providers includes the
proposed assurance of a d d i t i o n a l f e d e r a l support i n the form of
investment funding f o r development and enhanced service access. As
proposed, t h i s funding would be targeted f i r s t a t the f e d e r a l l y
designated e n t i t i e s w i t h possible but uncertain a d d i t i o n a l funds t o
be used at the state's d i s c r e t i o n .
RECOMMENDATION:
There should be a f e d e r a l l e v e l designation of a s i n g l e
category of " e s s e n t i a l community provider" defined as those p u b l i c
and p u b l i c l y funded programs and f a c i l i t i e s t h a t have t r a d i t i o n a l l y
served low-income and vulnerable populations.
ECPs would be
defined
i n f e d e r a l s t a t u t e as providers
which
serve a
d i s p r o p o r t i o n a t e number of low income c l i e n t s (50% or more are low
income, or c u r r e n t l y e l i g i b l e f o r s t a t e or f e d e r a l programs serving
low income people, or reside i n a f e d e r a l or s t a t e designated
underserved area).
Local government h e a l t h agencies and f a c i l i t i e s must be
designated at the f e d e r a l l e v e l as e s s e n t i a l community p r o v i d e r s .
Other examples o f ECPs could include: community mental h e a l t h
centers, f a m i l y planning c l i n i c s , community and migrant h e a l t h
centers, and school based c l i n i c s .
The f e d e r a l s t a t u t e would not preclude states from designating
other e n t i t i e s as e s s e n t i a l community p r o v i d e r s , provided they meet
the minimum c r i t e r i a set by the f e d e r a l governmnt. A process would
be e s t a b l i s h e d at the f e d e r a l l e v e l f o r designation appeals.
�The l e g i s l a t i o n should s t i p u l a t e that Health A l l i a n c e s require
that h e a l t h plans contract w i t h ECPs, and reimburse them f o r
covered and appropriate services at a r a t e no less than that f o r
s i m i l a r providers. This contract/reimbursement assurance should
remain i n place f o r a time c e r t a i n , or at least u n t i l f i n a l phasei n of the new system, t o serve as an i n c e n t i v e f o r plans t o
contract w i t h ECPs, and promote the i n t e g r a t i o n of the f a c i l i t i e s
and the populations they serve, i n t o broader provider networks.
In cases where enrollees present f o r service at an ECP out of
plan, the ECP must make a good f a i t h e f f o r t t o r e f e r back t o the
enrollee's plan. The f i r s t such out of plan occurence s h a l l be
reimbursed, the second s h a l l be reimbursed only on successful
appeal t o the Health A l l i a n c e , and reimbursement s h a l l be denied
for t h e t h i r d and any subsequent occurence unless i t i s an
emergency. ECPs may appeal t o the Health A l l i a n c e t o reassign a
c l i e n t t o a plan that includes the ECP i f out of plan behavior
persists.
A data system w i l l be a v a i l a b l e 24 hours a day t o provide plan
e l i g i b i l i t y data t o a l l providers i n a plan. The plan w i l l adhere
to f e d e r a l l y established q u a l i t y outcome and performance standards,
and ensure t h i s compliance by a l l p a r t i c i p a t i n g providers,
i n c l u d i n g ECPs. Further, funding and t e c h n i c a l assistance w i l l be
made a v a i l a b l e t o support ECP i n f r a s t r u c t u r e development and
enhanced service access.
STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�Clinton Presidential Records
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This marker identifies the place of a tabbed divider. Given our
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scan such dividers. The title from the original document is
indicated below.
Divider Title:
^7
�TAB 27
Policy Statement of U.S.
Conference of Mayors
�Policy Statement of
U.S. Conference of Mayors
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THE UNITED STATES CONFERENCE OF MAYORS
1620 EYE S R E , NOKTHWEST
TET
WASHINGTON, UC 20006
TELEPHONE (202) 293-7330
F X (202) 293-2352
A
I. Qvflrvlaw nf HIPCa & N«w System Qroantzatlon
States would choose whether or not they wanted to participate in the new systein
within guidelines established by Federal law. If a state chose to participate, the
Federal government would oversee the HIPCs.
What role will the Local Health Department play in the oversight of the HIPCs?
The Federal government will develop a basic universal and standard benefit coverage
plan. This coverage will be available through HIPCs or large employee health plans.
Governance & Organization of HIPCs within Federal parameters
Federal guidelines will be established to assure representative of the best Interest of
consumers, patients and purchasers and would preclude for profit HIPCs or
representatives of providers or Insurers on governing bodies. (This may be done
through A.B.)
HIPC Geographical Boundaries
Federal government will set guidelines to assure boundaries are consistent with health
service areas and include a heterogenous mix of socio-economic characteristics.
Where there is overlap states will be encouraged to coordinate with neighboring state
regarding HIPC function, plan enrollment, etc.
Delegation of related state roles and functions
Roles and functions include: insurance regulations, health planning, public health,
providers rate-setting, and direct medical service delivery. State will have ultimate
authority In coordinating or delegating of such functions, and determining whether or
when HIPCs might assume responsibilities for such additional functions.
Employer Concerns
All employees will be required to contribute at least a minimum amount toward the
Federal government standard benefit package. Employers with below 1,000
employees will be required to provide coverage through the HIPCs.
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1,000 consumer threshold would provide sufficient market power to structure the
proper Incentives in market constraint spending.
The larger threshold the greater sense that there will be one health care system for
all Americans.
A large market outside the HIPCs could lead to a two-tiered system particularly If
HIPCs are subjected to budgetary controls and the outside market were not and If
Medicaid eligible are enrolled in HIPCs. (This is the cremeing affect issue).
Low Income Persons
The Federal government would establish a formula for subsidies for low Income
individuals and potentially small and/or low wage employers.
There will be budget caps placed on states. States will be encouraged not to overrun
these budgets. If a state constantly overruns its budget the Federal government
would take over the operation of the HIPC in that state. Or place other regulatory
cost controls on states or HIPCs which over run their budget.
Other Federal action to curtail cost overruns could include:
•
e
•
Determine maximum payments for physicians and hospitals in state
Require prior approval of all HIPC decisions on cost of plans
Require all health care contracts to be subject to Federal Government approval
New System Coverage
•
•
Primary care and prevention care will receive high priority for coverage.
Medical, dental, mental health and other services will be Integrated into this one
plan (The key is to avoid supplemental packages).
Service Categories
Some categories Diagnostic, Durable Medical Equipment, Reproductive health.
Ambulance, Adult and Child Preventative Care, Rehabilitations, etc.
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The National Health Board will determine those medical procedures which are deemed
not necessarv or are experimental. The standard package will include these
exclusions.
II. Low incomii & Non-Workino Families & ind.
•
•
•
•
How strongly should the Federal Government regulate the actions of HIPCs to
assure access for low-income people to heaith plans and services?
How should subsidies be calculated for the care benefits package?
To what extend should states be required to maintain current fiscal efforts in
subsidizing care to low-Income versus held fiscally liable for a percentage of
total cost of low-income subsidies?
To what premium level and type of plan will low-income people be subsidized?
Medicare
All HMOs participating in HIPCs would be required to sign risk contracts with
Medicare.
The Federal Government will Institute a process to standardize and computerize the
present reporting system. This will be done In collaboration with states.
July 1995 we will start providing universal coverage through the HIPCs,
Medicaid
standards
Remove barriers to use of managed care. Improve quality
on Medicaid managed care.
Medicare
Require 30% insurance for Medicaid policy holders. Annual
coordinated open enrollment.
III. Under-aarved Populations
Assumptions: Health services, Including clinical prevention services, will be covered
under the core benefits package and subsidized of low-income persons, The Federal
government will play a significant role in supporting enabling services and population
based prevention.
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Ftdoral Aaturanca Role
The Federal government should assure that public community based prevention
activities (LHD) are supported at an appropriate level to improve heaith outcomes and
reduce costs. This means that low-Income and those with an interest in public health
and prevention must be represented in the HIPCs governance structure and involved
in decisions.
Delivery System
The Federal government will build on existing and effective providers of care for the
underserved. This will require certain protections for organizations like Com. and
Migrant Health Centers, disproportionate share hospitals (Safety Net Hospitals), and
LHDs and will as private providers in under-served areas.
There will be a standard called "Essential Care Providers". These ECPs will be given
preference as contractors by AHPs covering these areas.
Reducing Fragmentation
Emphasis will be placed on a "user friendly" and organized system facilitating timely
entry and continuous service. Services need to be made available to those who do
not seek care on a regular basis (homeless people, substance abusers, etc.)
Community-wide planning is encouraged.
Monies presently devoted to enabling services and public community based prevention
activities (LHD) should be protected and increased during the transition phase.
Option 1
Greater Federal government role supporting these services monies would go to states,
localities and community organizations. This is best for maximum flexibility for some
states without the capacity or responsibility to assure access for these populations.
Option 2
Will send monies through states under Federal government regulations.
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1 1 Enablinq/Siippnrtlnp Sarvieea
1.
Rftlmburaabla Suaooftlva Sarvlcas
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Outreach
Case Management
Transport
Crisis Assistance
Child Care
Caregiver Assistance
Home Visits
Parenting Education
Health Education
Nutrition Counseling (Including WIC)
1.
2.
3.
4.
5.
6.
7.
8.
Alternate sites and Characteristics
Evening and weekend hours
Mobile Vans
Shelters and transitional housing
Schools (youth-based programs)
Day Care Centers
Community Colleges
Work sites
4562889;# 6
�Clinton Presidential Records
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marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
3^8
�TAB 28
Memo from City of New York
•
�Memo from C i t y o f New York
�WASHINGTON OFFICE
Suite 700
555 New Jersey Avenue, N.W.
Washington, D.C. 20001
202-393-3903
TO:
John Hart
FROM:
Judy Chesser
DATE:
A p r i l 21, 1993
RE:
Follow-up t o our A p r i l 8 Meeting w i t h the Health Care
Task Force
As requested by members of the task force a t the A p r i l 8 meeting,
attached are our suggestions concerning reasonable maintenance of
e f f o r t standards and Federal requirements/standards we b e l i e v e
are c r i t i c a l t o p r o t e c t the i n t e r e s t of low-income p a t i e n t s under
h e a l t h care reform.
Please share them w i t h the a p p r o p r i a t e working groups.
I f they need a d d i t i o n a l i n f o r m a t i o n , f e e l f r e e t o contact us.
Deputy Mayor Perales
Barbara Turk
Dr. B i l l v Jones
�r
f
••nt^ariee of ft^ort provtiipftfchouldmeet th» folloulnr itfcagard»:
o
H thould recogclxe that cent In IOCE! loverameflu b«vc Inorrftd
•IfrJfic&n: costi rdit^d to morbidity rttea, tculty md i higher then
avtrife rrxr.b*-' of uninsured indlviduiU.
o
Loc*! fintaci*! wppon fa- thwe cotu xnuit be »©er. u tenperary and
uniusuintble over the ba| tenn; thertfore, thA«c cotu m-Jit x o be
>t
menorUliied Ir » maimenanee of effort tuadwd tba: aM-xnes nrrer;:
ptrJclpttion In perpetuity.
o
Itreus:recogdxe tbe currtr.t flnanciaJ partlelpBtioc of New York Cir>' ^
•upporti.*^ health cire coverage for indMduaU Inured under Medicaid,
ana mus: no: foMilize the current 50/50 *p!k cf the IOCA! ahare betwet-i
Neu York State tnt it* local govercmecLs.
fr-icr. I-MirLr/jr. gtardir^ cf Effort
Eeublish a mlr-L-Lu-T. atendard of effort, ba*ed on the c«t and extent of
•ervicea (adjusted for regional cost factor*) induded L the miainxr.
n
benefit package aitabliahed by the Teak Force. Altarnatlvely, the
atanda*c cculd be baaed on the cwt of providing current aervlces
mandeted under Medicaid and certt!5 public haalth baiics
Sute* would be required tc contribute their ahare in a lump aum te fur.d
the syr.eai baiad or, the atandard.
Stau* rurrer/Jv apendicg leu thai) the atandard could be require*; to
increaie apeiding up to tbe naxiir.un, or the Federal govammant cculd
decide tc bear the coat of a hold-birmJaa* provialon.
05*-lsr. n-Eatabllah Exce^tior. Procte?
Eatablia-h xasirjunance of effon for each atate, baaad on current spending,
but define an exception proceu baaed on specific criteria. The« criteria
would recognize ttete* that damonaa'ate conaiatent coverage of coat* for
significant and diaprcportionate rumben of individual* who are uniimred.
They wouli aUo raccgnlre ejetraordinary coau rnulting frtsr, high rate*
of morbidity and acuity.
Tbie exception procaas it conceptually 11mlIar to the AIDS CARE (Ryan
White) legiilatior.. That legUlatlon recognized that cenain local
govemnient* are diaproponionately affecud by the AIDS epidemic,
�-2Wainieniric* of Effort
•itab'.lahftd crltcrii for QualiflcatJor baaed on tbe abwlute nurabw of
caAe^ and the mrnber cf ca*« per capita (chack]. It rtcor^ti federal
financia: ra*pontibility tc localltle* for a apeclfic health crUU.
:
An axception procea* would allow the Taak Force tc begin to realize in
goal that the federal fovemment pay for uucompeniate^ coati and care
for the uciua-jred. Many of theae coin in New York City are currently
bcme by local fovemment.
�Bta.ridards/Jiequir«oent» Dtteraiued at ?efieral Laval
2. Kho i s covered. Iirrigrants, regardless oi docunentaticr. status,
and prisoners to be included.
2. Datarsi&atien ef benefit package. Benefit package to be et least
as broad as the Federally Qualified HKO package.
3. Znablin; s e r v i c e s .
That they are. Translation, transpcrtetion, s o c i a l services,
supportive housing,
who q u a l i f i e s for then. These persons vhc gualify f c r f u l l cr
p a r t i a l subsidies f c r coverage should be e l i g i b l e f c r enatling
ser.-ices.
Hov they should be paid. As part of the reirburse-ent rate t c
E s s e n t i a l Ccrjr.unity Providers (either as a r i s k adjustrent paid hy
ar. AH? c r through continuation cf direct payrents).
<. E s s e n t i a l ConuTunity Providers.
C r i t e r i a for deternining who they are. I n i t i a l l y building upon
currer.- desigr.Etions
(FQKC, J-ledicare d-sproport icnate
share
hospitals, EACH hospitals) to designate providers end networks cf
providers
who provide ccr.prehensive
services; to r e d i c a l l y
undferserved pcpulaticns.
Designation or federal approval of state deaignaticts c r i t e r i a .
E. Accountable health plans.
Kandate r i s k adjustment for ECPs.
Kandate recruireatnt that a l l XEPB take percentage of high-risk
patients.
Mandate requirement that a l l XHPs to provide basic benefit
package v i t h nc out-of-pocket costs.
�b. i^ocax ceaitn anaancas [lormtny
HIPCS)
Who governs. Waie up of purchasers - consumers and enployars.
Plus local public health department to put public health issues at
center of recional decision making body and u t i l i z e the
surveillance and data collection capacity of public health
departnents.
What thty are accountable for:
Cost. Through group purchasing, managing competition
eacng AKPs and naintaining a global budget.
Quality. Through requiring and gathering data cn AKPs so
that consuT-iers can make informed choices.
Access. Through co~nunity-rating and prohibitions on AKP
exclusions fcr pre-axisting and other "non-preferred" ccnditicns.
How they v i l l anforce rtquirenents. Mechanises tc ensure
enforcement of federal requirements.
Conditions of large aaployer opt-outs. I f large employers
(rir.ir.u- « 1,000 employees) do net belong to a local health
=
alliance, they rust be required to perform, the sane functions in
regards to cost, access and quality.
". How maintenance of effort i s deternined and what i a required.
current levels of local government contribution and current levels
of local health need must be factored in to either a standard of
effort or to substracticn from requirement.
£. Hov global budget caps are set. Out-of-pocket costs to be
excluded fror global budget caps.
9. Condition of federal support for physician traiaiag. Aggregate
numbers of residency positions, incentives for primary care
programs and disincentives for sub-specialty programs, requirement
that residency programs be fully integrated with essential care
providers for training purposes, and that essential community
providers be covered for training costs.
10. Condition ol federal aupport for mtdical schools. Provisions to
t i e federal funds going to medical schools with production of
primary care doctors, particularly those who serve underserved
populations.
�Clinton Presidential Records
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�TAB 29
Memo on Meeting with National Governors
Associatio n and National Associatio n
of Counties
�Memo on Meeting w i t h
National Governors Association
and
National Association of Counties
�May
To:
John
From:
5, 199 3
Hart
Bonnie
Subject:
Lefkowitz
M e e t i n g s w i t h NGA a n d NACO R e p r e s e n t a t i v e s
May 4,
1993
A t L o i s Quam's r e q u e s t I a t t e n d e d m e e t i n g s w i t h NGA and NACO
r e p r e s e n t a t i v e s t o d i s c u s s two t o p i c s i n v o l v i n g C l u s t e r V I I I ,
which I c o - c h a i r .
The t o p i c s w e r e d e s i g n a t i o n o f e s s e n t i a l
c o m m u n i t y p r o v i d e r s (ECPs) and i n v e s t m e n t i n u n d e r s e r v e d
areas.
The NGA m e e t i n g was a t t e n d e d by Ray S c h e p p a c h , r e p r e s e n t a t i v e s
f r o m V e r m o n t , C o l o r a d o , M i n n e s o t a and S o u t h C a r o l i n a , L o i s , J a n i s
O'Meara o f y o u r s t a f f , and o t h e r Task F o r c e r e p r e s e n t a t i v e s . The
NACO m e e t i n g was a t t e n d e d by Mary Uyeda, Dan M c L a u g h l i n , and
E l l e n Benavides.
A b r i e f summary o f t h e t o p i c s I p r e s e n t e d and
the groups' r e a c t i o n f o l l o w s .
Essential
Community
Providers:
The p r o p o s a l u n d e r c o n s i d e r a t i o n w o u l d c a l l f o r F e d e r a l and S t a t e
d e s i g n a t i o n o f ECPs t o a s s u r e t h a t t h e new s y s t e m m a i n t a i n s and
b u i l d s on " s a f e t y n e t " p r o v i d e r s t h a t s e r v e l a r g e p r o p o r t i o n s o f
low income o r u n d e r s e r v e d
people.
o
T h e r e w o u l d be t h r e e c l a s s e s o f ECPs — c o m p r e h e n s i v e
p r i m a r y care p r o v i d e r s ( e . g . community h e a l t h c e n t e r s ; l o c a l
h e a l t h department c l i n i c s ) ; l i m i t e d s e r v i c e p r o v i d e r s (e.g.
f a m i l y p l a n n i n g c l i n i c s ) ; and h o s p i t a l s .
o
W h i l e t y p e s o f p r o v i d e r s and e x a m p l e s w o u l d be g i v e n i n
l e g i s l a t i o n , t h e a c t u a l l i s t o f t h o s e t o be d e s i g n a t e d F e d e r a l l y
and c l a s s e s t o be d e s i g n a t e d a t S t a t e o p t i o n w o u l d be up t o t h e
HHS S e c r e t a r y .
o
ECPs w o u l d be e l i g i b l e f o r F e d e r a l i n v e s t m e n t i n
i n f r a s t r u c t u r e and s e r v i c e s , s u b j e c t t o p r o g r a m - s p e c i f i c
requirements.
S t a t e s / H e a l t h A l l i a n c e s w o u l d have t h e o p t i o n o f
r e q u i r i n g one o r more p l a n s t o c o n t r a c t w i t h ECPs a t r a t e s no
l e s s t h a n t h o s e p a i d o t h e r p r o v i d e r s f o r t h e same r a n g e o f
services.
S t a t e s / H e a l t h A l l i a n c e s w o u l d be r e q u i r e d t o a s s u r e
t h a t p l a n s r e i m b u r s e ECPs f o r o u t - o f - p l a n use by e n r o l l e d
patients.
o
years
The p r o v i s i o n i s t r a n s i t i o n a l and w o u l d " s u n s e t "
a f t e r f u l l implementation o f insurance reform.
five
Reaction:
NGA was c o n c e r n e d
c
about two aspects
o f t h e ECP p r o p o s a l : .
While s u p p o r t i v e o f the c o n t r a c t i n g o p t i o n , they
"
A
feared
�t h a t u n l i m i t e d r e q u i r e d r e i m b u r s e m e n t f o r o u t - o f - p l a n use
make i t d i f f i c u l t f o r them t o keep t o t h e i r b u d g e t s .
would
o
D e s i g n a t i o n o f h o s p i t a l s as ECPs c o u l d f r e e z e u n n e e d e d
c a p a c i t y i n t o p l a c e -- p a r t i c u l a r l y r u r a l h o s p i t a l s t h a t s h o u l d
c l o s e f o r r e a s o n s o f q u a l i t y as w e l l as e f f i c i e n c y .
NACO p r e p a r e d a w r i t t e n r e s p o n s e w i t h s p e c i f i c
( a t t a c h e d ) and e x p r e s s e d t h e f o l l o w i n g v i e w s :
additions
o
The F e d e r a l g o v e r n m e n t s h o u l d d e s i g n a t e l o c a l h e a l t h
f a c i l i t i e s as w e l l as F e d e r a l g r a n t e e s ; d e s i g n a t i o n o f l o c a l
f a c i l i t i e s s h o u l d n o t be l e f t t o S t a t e s .
o
Concerns a b o u t r e i m b u r s e m e n t f o r o u t - o f - p l a n use (a
p r o v i s i o n t h e y had s u p p o r t e d ) c o u l d be m i t i g a t e d by h a v i n g o n l y
the f i r s t v i s i t r e i m b u r s e d and a l l o w i n g t h e ECP t o a p p e a l t o have
the p a t i e n t t r a n s f e r r e d t o a p l a n i t c o n t r a c t s w i t h i f t h e r e i s a
second v i s i t .
Investment
i n Underserved
Areas:
The p r o p o s a l under c o n s i d e r a t i o n w o u l d i n c r e a s e F e d e r a l
i n v e s t m e n t i n u n d e r s e r v e d a r e a s as f o l l o w s :
o
The i n f r a s t r u c t u r e needed i n u n d e r s e r v e d a r e a s w o u l d be
augmented t h r o u g h s u p p o r t f o r d e v e l o p m e n t o f n e t w o r k s and p l a n s ,
r e c r u i t m e n t and p l a c e m e n t o f s e r v i c e - o b l i g a t e d p r i m a r y c a r e
p r o v i d e r s and i n v e s t m e n t i n o u t p a t i e n t f a c i l i t i e s .
o
S e r v i c e i n i t i a t i v e s would s u p p o r t comprehensive p r i m a r y
c a r e f o r u n d e r s e r v e d u r b a n and r u r a l a r e a s , m i g r a n t f a r m w o r k e r s ,
h o m e l e s s p e r s o n s and u n d o c u m e n t e d a l i e n s ; s c h o o l based c l i n i c s ;
p e r i n a t a l c a r e c e n t e r s and f a m i l y p l a n n i n g c l i n i c s .
o
S t a t e s w o u l d have an expanded r o l e i n needs
p l a n n i n g and n e t w o r k / m a n a g e d c a r e d e v e l o p m e n t .
assessment,
o
Funds w o u l d c o n t i n u e t o f l o w t o S t a t e s , l o c a l g o v e r n m e n t s
and c o m m u n i t y based o r g a n i z a t i o n s as a t p r e s e n t .
E l i g i b i l i t y for
f u n d s w o u l d be b r o a d e n e d so t h a t u s e r - m a j o r i t y g o v e r n i n g b o a r d s
w o u l d no l o n g e r be r e q u i r e d .
T h e r e w o u l d be a d m i n i s t r a t i v e
s i m p l i f i c a t i o n o f a p p l i c a t i o n s and r e p o r t i n g , p a r t i c u l a r l y f o r
l i k e programs s u p p o r t i n g l i k e o r g a n i z a t i o n s .
T h e r e w o u l d a l s o be
a r e p o r t t o Congress e v e r y t h r e e y e a r s on m a g n i t u d e o f need,
recommended f u n d i n g l e v e l s and c o n s o l i d a t i o n / e l i m i n a t i o n o f
programs.
o
E x i s t i n g S t a t e and l o c a l
continue.
O t h e r S t a t e and l o c a l
matches of F e d e r a l funds would
c o n t r i b u t i o n s w o u l d be o p t i o n a l .
�R e a c t i on :
NGA v;ould p r e f e r t h a t a l l funds flow- t h r o u g h S t a t e s , or
S t a t e s be able t o request a u t h o r i t y over a l l funds.
NACO p r e f e r s t h a t funds f l o w as a t p r e s e n t .
see f u n d i n g c o n t i n g e n t on l o c a l p l a n n i n g .
cc:
L o i s Quam; J a n i s 0"Meara
that
They would l i k e t o
�Clinton Presidential Records
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marker by the William J. Clinton Presidential Library Staff.
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indicated below.
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�TAB 30
P o l i c y Statement of Watts Health Foundation
�Policy Statement of
Watts Health Foundation
�WATTS HEALTH FOUNDATION, INC.
Policv Guidelines; National Health Care Reform
February 22, 1992
I.
INTRODUCTION
The reformation of the American health care system is a policy whose time has come.
Restructuring the way mainstream health care systems provide and expend the cost of medical
services, is fast becoming a top domestic priority for the 1990s. Over the past two years a
number of health care reform proposals have been introduced in the Califomia Legislature and
Congress, ranging from minor tinkering to comprehensive national health insurance. Inasmuch
as these proposals establish the framework for what is expected to be a broad-ranging state and
national debate on the scope and structure of a reformed health care system, they both require
and deserve scrutiny and comparative review. In particular, these plans must be evaluated for
their impact on low-income, rural and urban, ethnic minorities and medically underserved
Americans ~ who are the most isolated from our current health care system and who stand to
gain the most from any efforts to improve access to care.
The Watts Health Foundation, Inc. (WHF), firmly believes that all Americans have a right to
health care. Such a premise, directs WHF to address issues of access and health care reform
as they relate to urban health on the front-lines. In discussing urban health in Califomia, and
to a larger extent the nation as a whole, a focus on improving the health status of ethnic
minorities is emerging. Over the past 20 years, some groups have made significant gains in
improving their health status indicators (i.e., life expectancy, infant mortality, etc.), while many
ethnic minorities, and African-Americans in particular, have not shared in those gains. Despite
the sophisticated medical technology available in the United States and the escalating level of
resources committed to health care spending, millions of minorities still do not have access to
basic health care services.
Based on the WHF's experience and history, the development of any type of health care reform
without serious analysis of urban-based populations will fail. An effective plan will not occur
unless all Americans can be assured real access to comprehensive primary and preventive health
services, regardless of where they live, the type of insurance they have, their health or
socioeconomic status, or other relevant characteristics that act as barriers to health care.
The purpose of this paper is to initiate discussion on a state/federal level regarding health care
reform issues as they relate to ethnic communities within urban-based settings. The WHF has
developed this policy paper to outline key issues and principles necessary to enact a meaningful
state and/or national health care proposal that can assure equitable access to health care for all
Americans, especially for disenfranchised populations. It is imperative that elected and
appointed officials representing urban cities maintain an aggressive position in support of health
care reform, and take a leadership role in a full and informed debate on its design and
implementation.
�H.
WATTS HEALTH FOUNDATION, INC.
WHF is a non-profit health service organization founded in 1967 to provide innovative, low-cost,
high quality health care to residents of Watts. WHF has a proven track record in effectively
serving the poor, the uninsured, the underserved and special populations. WHF prides itself on
its innovation, creativity and "going that extra mile" in providing services to a population that
has been traditionally overlooked by mainstream health care systems. Today, WHF is uniquely
composed of two operational systems that have garnered wide praise and have been models for
organizations nationwide: Community Health Programs, which focus on operating WHF's
federally qualified health centers; and United Health Plan, the organization's federally qualified
Health Maintenance Organization.
Through its Community Health Programs, WHF has evolved to become one of the largest
private providers of primary health care in Los Angeles County, annually serving over 100,000
clients with more than 250,000 encounters a year. WHF serves primarily individuals who have
been increasingly disenfranchised by the mainstream health systems -- "vulnerable populations"
like the poor, the elderly, the immigrants, the addicted, the homeless, the chronically and
terminally ill, and those without health insurance. With the support of a network of government
and private grants, WHF serves these patients through an unique array of programs (over 30
programs) that have been woven together into a comprehensive service network. The population
CHP serves is approximately 45 percent are African Americans, 45 percent are Latinos, and the
remaining 10 percent are Anglos and Asian Pacific Islanders.
The organization's HMO, United Health Plan, started in 1973 with an emphasis on the Medicaid
population, but has evolved to include Medicare and employer-based markets. In Califomia,
United Health Plan is the tenth largest HMO and is the second largest HMO serving Medicaid
beneficiaries. United Health Plan has nearly 85,000 members throughout the greater Los
Angeles area. The dominate market remains those most vulnerable to issues of access and
quality care, Medicaid recipients, which represents 69% of the membership. The Medicare
market represents 16%, and the traditional (employer-based) commercial sector represents
14.5% of the membership.
The WHF mission, which includes its family of organizations and programs, is dedicated to
building and maintaining individual, group, and community health and well-being, within a
patient driven/quality focused environment. The successful integration of community health
center services with the benefits of a managed care operation (i.e., UHP), has allowed WHF the
ability to provide a multitude of services and to compete on many levels. Furthermore, WHF's
unique array of community focused and managed care products has prepared the organization
to be a key part of the solution to the health care delivery and cost containment debate of the
1990's and the 21st century. Given the WHF's history, structure and mission, the organization
is compelled to share its experiences and knowledge, and become actively involved in the
formulation of a national and/or state focused health care reform plan.
�While there is now clearly a chance to solidify and expand theroleplayed by organizations such
as the WHF in reforming the U.S. and/or state health care system, WHF's sense of community
responsibility compels the organization to speak out about the need for health services and their
value to urban-based communities. Therefore, the following discussion items represent
recommended guidelines and principles for key representatives of legislative and administrative
bodies, in developing responsible and effective health care policies and programs that will touch
all disenfranchised urban communities.
m.
THE "URBAN" CHALLENGE
Although, the nation, state and local governments are giving greater attention to serving the
uninsured and poor, there is a serious void and lack of participation from ethnic communities.
Organizations who serve populations that represent the largest proportion of the uninsured and
poor, who are primarily based in urban cities, are not being sought as a viable resource. The
health reform debate, in many instances, is being lead by politicians, bureaucrats and private
corporations who have had little, if any, direct experience in serving the uninsured. The
challenge is to insure that urban-based organizations who have traditionally served the uninsured,
underinsured and publicly supported individuals, become active participants in the health care
reform debate. As the major for-profit health insurance agencies, hospitals, private providers,
HMOs and corporations continue what is increasingly perceived as a self-serving debate on their
rightful role in a reformed health care system, elected and appointed officials have a clear moral
imperative to represent the collective needs, values and voices of their urban constituents.
IV.
GENERAL POLICY GUIDELINE AND PRINCIPLES
In developing and/or reviewing the multitude of national and state Health Care Reform
proposals, the Watts Health Foundation, Inc. believes the following policy guidelines are
essential in establishing an effective plan. It is hoped that these principles will serve as a
benchmark for assessing the various debates. While it is unlikely that any single plan will meet
or exceed the criteria that underlie these principles, it is hoped that the evaluative process will
yield a composite set of responsive provisions. Provisions which would represent the "greatest
good" for the populations in the most need of a reformed health care system, and who will be
at great risk and jeopardy to our society and its national budget, if such needs continue to go
unmet.
A.
Structure/Administration
1.
To the extent possible, the plan should be federally administered with state
flexibility. The state's role should be under federal guidance and oversight. If
a portion of the plan is state-administered, designated requirements, such as
eligibility, minimum benefits, cost sharing, provider reimbursement and cost
containment requirements should be uniform and federally mandated, to ensure
consistency across all jurisdictions.
�2.
B.
The plan should include a process to ensure the equitable allocation of resources
based on need through a structured mechanism that includes community
participation in planning and decision-making.
Financing
1.
2.
State or local funding should be reasonable, based on relative state income, and
should not exceed current state health financing levels.
3.
C.
The plan should be progressively financed, including use of income-related taxes
(such as general revenues or payroll taxes); and, corporate tax payments or
required employer contributions. Further exploration is needed to study the
feasibility of assessing surcharge fees to designated sources, i.e., hospital
inpatient services, insurers, etc. Tobacco, alcohol taxes and other appropriate
taxes should also be increased, with revenues dedicated to national health care.
Consumer costs should be reasonable and income-related.
Eligibility and Enrollment
1.
To the extent possible, the plan (whether in a mixed or multi-payer system)
should ensure universal coverage and access to care for all Americans.
2.
The plan's enrollment procedures should be simple, and forms should be simple
and easy to understand and complete. Furthermore:
•
enrollment applications should be available in the work place and various
community agencies (including health centers and other key providers);
•
assistance should be provided in accessible community settings, with
special assistance for those with no or limited English reading, writing or
speaking skills;
•
federal and state enrollment forms should be streamlined to complement
the specific needs of each jurisdiction, and to the extent possible, be
standardized.
3.
If a portion of the plan is state-administered, coverage should be easily
transferrable across state lines.
4.
Individuals with pre-existing conditions should be eligible for enrollment, with
minimum waiting periods.
�D.
Benefits
1.
Basic benefits should be uniform for all individuals and should include at least:
primary health care services;
inpatient/outpatient physician and hospital care;
emergency medical and health services;
full maternity and newborn/infant care, including delivery;
routine pediatric/well-child exams, including all immunizations;
periodic screening diagnosis and treatment services for children;
preventive services for adults (i.e., pap, mammogram, colorectal, etc.);
diagnostic lab and x-ray services;
preventive and restorative dental care services and supplies;
prescribed pharmaceutical;
vision and hearing screening and prescribed eyeglasses;
family planning services and supplies;
mental health and substance abuse services.
2.
3.
E.
The plan should include supplemental benefits for populations with special needs
(such as long-term chronic physical, developmental or mental health conditions,
including children, homebound adults or frail elders), either directly or by
continuing publicly assisted programs for eligible populations.
If the plan places amount, scope and duration limits on designated benefits, the
limits should be reasonable and should not apply to primary, preventive or
maternity care.
Patient Cost Sharing
1.
The plan's coverage should be affordable for all Americans, and should avoid
creating financial barriers to care. This means that:
a.
Premiums should not exceed 20 percent of the cost of coverage, and
should be reduced or eliminated for low-income Americans;
b.
Deductibles and co-payments should be reasonable, with a family limit
and should also be reduced or eliminated for low-income persons; and
deductibles and co-payments should be waived entirely for essential
maternity, pediatric and preventive services; and
A maximum out-of-pocket limit should be set for patient cost-sharing,
based on a percentage of annual income for low-income Americans.
�2.
P.
The plan should include provisions making the purchase of coverage affordable
for small employers and those who are self-employed.
Provider Participation and Reimbursement
1.
2.
The plan should recognize and provide financial incentives for organizations and
providers serving large numbers of low-income or underserved Americans,
including disproportionate share hospitals and community health centers, as well
as the special costs of providers serving inner-city urban and rural (especially
sparsely populated) areas.
3.
G.
Provider reimbursement rates should, in general, be reasonable and, in a multipayer system, should be uniform for all payers (public or private).
The plan should recognize and cover the services of key practitioners (including
nurse practitioners, nurse mid-wives, physician assistants, dental hygienists,
nutritionists, clinical psychologists and social workers) at least in certain
organizational settings, such as community health centers.
Resource Development
1.
The plan should provide direct financial support for the development, staffing,
and operation of community-directed comprehensive primary care systems in all
areas with medically underserved Americans.
2.
The plan should support health professional education and training programs
(including nurses, physician assistants, dentists, nutritionists, health education
specialists, and social workers), either directly or through reimbursement. Any
such support should be targeted on preventive and primary care training and
focused on assuring a sufficient number of providers for medically underserved
areas.
3.
Increase the supply of urban-based providers, especially ethnic minorities to
medically underserved areas. State and national elected bodies should support all
efforts directed toward training minority primary care providers who want to
serve in underserved areas. These efforts are critical to counter the financial and
social costs of medical specialization and to increase the availability of providers
for underserved communities.
4.
Establish linkages between allied health professional training and residency
programs and local health centers to provide community-based training
experiences for students and residents.
�H.
Cost Containment and Quality Assurance
1.
2.
J.
The plan should establish nationwide uniform billing forms and procedures for all
payers, and standardized reporting and data collection requirements (including
data on coverage, enrollment and utilization, sufficient to evaluate the plan's
effectiveness in making care accessible to all Americans, and particularly the
medically underserved).
The plan should include a system for developing uniform quality of care standards
and reporting requirements, with strong consumer/community involvement, and
with appropriate consideration of providers serving large numbers of urban, lowincome or "hard-to-serve" persons.
Tort Reform
1.
V.
The plan should provide provisions that reduce the pressures on providers to
defensively provide excess services, thus supportive of tort reform, including, but
not limited to: mandatory alternative dispute resolution, limits on non-economic
damages, controls on malpractice insurance loss ratios; and the development of
statutory standards of liability as care protocols continue to emerge.
MANAGED CARE GUIDELINES AND PRINCIPLES
As an HMO, with a twenty-year history and experience with the Medicaid program, we support
state and federal efforts toward transitioning Medicaid beneficiaries into managed care settings.
To the extent that the national health care plan encourages the use of managed care
arrangements, the Watts Health Foundation, Inc. suggests the following guidelines.
1.
Growth in Medicaid managed care should be strategically planned with clear,
articulated health policy goals. Managed care should be viewed as long-term
structural reform, not as a quick budget fix.
2.
Expansion of managed care should take into account the need to maintain "safety
net" providers, especially, Community Health Centers, public and
disproportionate share hospitals, encouraging their continuation as providers to
the Medicaid population.
3.
New managed care arrangements and public systems should allow for the
continued operation and growth of existing managed care organizations who have
demonstrated a historical commitment of serving the Medicaid population.
4.
The methodology for enrolling and assigning beneficiaries into managed care
organizations should be reasonable and fair. The methodology should spread the
�8
risk and avoid one segment of the provider community or managed care
organization having a disproportionate number of high risk/cost beneficiaries.
5.
Medicaid beneficiaries should have accessible and appropriate services. No
beneficiaries should be assigned to a managed care plan or provider, in an urban
area, unless there is a primary care site within reasonable proximity of their
residence.
6.
Medicaid managed care organizations should be required, to the extent feasible,
to utilize providers and staff who can meet the cultural and linguistic needs of the
population they serve.
7.
The plan should support guaranteed eligibility, at least a six month lock-in and
continuous eligibility for beneficiaries that enroll in managed care plans.
8.
The current reimbursement methodology needs to be reassessed. The current
Medicaid Prepaid Health Plan capitation rates are substantially lower than the
commercial fee-for-service equivalent. The plan should support the development
of a reasonable medical cost base capitation rate, based on actual managed care
(not fee-for-service) utilization.
9.
The plan should support the creation of appropriate approaches to meet special
needs. Such assistance is required to establish actuarially-sound capitation rates
and to develop re-insurance and stop-loss provisions. The plan should provide
financial assistance to adequately address catastrophic epidemics like cocaine and
crack babies and AIDS. Additionally, it should analyze the impact on rates of
resource-based relative-value-scale reimbursement and to determine rate-setting
rules for disproportionate share hospitals and community health centers.
10.
All managed care organizations (i.e. PCCMs, PHPs, county-based programs,
etc.) should meet federal and state regulatory standards, such standards should be
streamlined and complement both jurisdictions, particularly in the areas of quality
assurance, accessibility,financialsolvency and administrative accountability.
11.
All managed care organizations should meet quality standards surrounding doorto-door marketing activities. Federal and state entities should explore and
encourage the development of new alternative strategies to replace door-to-door
marketing.
12.
The federal and state's current information systems, program monitoring and
evaluation systems are inadequate to support growing managed care programs.
Medicaid managed care requires skilled and dedicated staff, sophisticated data
collection systems, and data analysis capacity, at the administrative level.
�13.
VI.
Eliminate and/or reassess the federal 75/25 rule. Congress should reevaluate the
75/25 enrollment mix rule, and/or create special exemptions for managed healthcare entities that are operating in economically depressed areas and service a large
number of Medicaid beneficiaries. In principle, the ratio rule should be
abandoned in its entirety and replaced with performance indicators and quality
assurance standards. For possible consideration, a number of existing
performance and quality standards exist within federal and state licensed managed
care systems (i.e., In California, portions of Knox Keene regulations and those
represented in federal regulations for federally qualified HMOs).
CONCLUSIONS
In closing, the U.S. and the state of Califomia must come to grips with the fact that a strong
and productive society will not be realized and maintained if we do not ensure a healthy future
for all Americans, especially those living within the inner-city. Nothing less than a sustained
commitment to the delivery of quality services to ethnic minorities, the poor, the underserved
and uninsured should be acceptable for the country. Therefore, Watts Health Foundation, Inc.
urges all urban-based elected and appointed officials to act as a unified voice that articulates the
health needs of ethnic communities to create a new reformed system of care that meets the need
of those who are at jeopardy of being further disenfranchised in the current debate.
FOR MORE INFORMATION, CONTACT:
Dr. Clyde W. Oden
President & Chief Executive Officer
or
Debra M. Ward
Director, Governmental Relations
3405 W. Imperial Highway
Inglewood, Califomia 90303
(310) 671-3465 Extension 382
2/93
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
Q1
�TAB 31
L e t t e r from Mariposa Community Health Center
�L e t t e r from Mariposa
Community Health Center
�05/11/93
14:35
O202 456 7739
WHITE HOUSE
TASK FORCE RM118
0001/002
MARIPOSA
-COMMUNITY"
HEALTH -CENTER
April
5,
1993
Mark Smith/ M.D. and Richard Brown
White House Task Force on Health Care Reform
Old Executive Office Building
Washington, D.C. 20500
Dear Dr. Smith and Mr. Brown:
I would f i r s t l i k e to thank you for the opportunity of meeting
with you and other members of the task force on A p r i l 1st to
discuss issues regarding health care for the underserved i n light
of pending health care reform. I have just a few comments which I
believe are important i n considering service to t h i s particular
population.
I think that i t i s c r i t i c a l that we recognize that merely
providing t h i r d party coverage to low income, underserved
populations w i l l not assure equal access to care, nor as experience
has shown, w i l l i t effectively impact indicators such as low birth
weight, infant mortality, inadequate prenatal care, immunization
rates, etc. P a r t i c u l a r l y for underserved populations, additional
enabling
services, such as transportation, outreach,
case
management, translation, etc., which are usually not recognized i n
traditional
managed
care environments, are e s s e n t i a l for
successfully impacting underserved populations.
Therefore, a
funding mechanism outside of the normal capitation methodology
should be i n s t a l l e d to support the provision of these essential
services to low income populations. I would further recommend that
these services be provided, not at the plan or regional l e v e l , but
as close to the patient as possible, that i s , at the community
level by t r a d i t i o n a l community providers.
As the experience of AHCCCS i n Arizona has demonstrated,
merely providing third party coverage to residents i n underserved
areas w i l l also not contribute significantly to a redistribution of
professional resources to underserved populations.
In Arizona,
only through community and migrant health centers has there been
any meaningful expansion of provider capacity. To assure universal
access to care, i t i s very clear that additional resources must be
garnered to create primary care capacity in underserved areas. The
» r r a m i n p p o r i y r . i t , j r l i r m i n v e i t i l o n employer Ag o u . l i r l n j p . n o n Including Ihe M m j l t . p c w d ^rc e n c o u u g e d t o p i r l l d p . K
�05/11/93
14:35
©202 456 7739
WHITE HOUSE
TASK FORCE RM118
12002/002
Page 2
community and migrant health center model has proven to be
extremely successful and should be u t i l i z e d to accomplish this
task.
From the discussion on Thursday, i t was also very c l e a r that
as successful providers of care to low income, underserved
populations, community health centers have gained unmatched
expertise in this arena and should be assured participation in a
new environment of managed competition.
Health Centers have
demonstrated their a b i l i t y to adapt to new demands countless times
over the past 27 years and certainly have the a b i l i t y to compete i n
any health care environment.
However, funding should be made
available to centers to a s s i s t them in planning and creating the
infrastructure necessary to effectively compete i n a manage care
environment.
F i n a l l y , i t i s my understanding that coverage for uninsured
populations may be phased in over time.
Quite obviously,
traditional
federal support for health care to uninsured
populations must be preserved until a l l Americans have coverage.
As has already been the case in our experience, heightened
awareness of health care has greatly increased the demand for
services by the uninsured, particularly. We expect t h i s demand to
only be further exacerbated by radical changes in the environment.
I would also s p e c i f i c a l l y recommend that additional attention
be paid to how managed competition w i l l be played out i n r u r a l
areas and how undocumented residents w i l l be effected by the new
system.
Once again, thank you for the opportunity to participate in
t h i s exciting process.
Tames R. Welden
Executive Director
�
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Health Care Reform
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2006-0810-F
Description
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
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Clinton Presidential Records
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Briefing Book on Access for Underserved and Vulnerable Populations [8]
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Health Care Task Force
General Files
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2006-0810-F Segment 1
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Box 48
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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Adobe Acrobat Document
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5/5/2015
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42-t-2194630-20060810F-Seg1-048-008-2015
12090749