1. WHAT DOES HEALTH REFORM MEAN FOR CABRINI CLINIC & FOR OUR PATIENTS? The Patient Protection & Affordable Care Act (ACA)

2. WHAT IS THE ACA? HOW WILL ACA HELP THE UNINSURED? WHO WILL REMAIN UNINSURED AFTER 2014? HOW WILL ACA AFFECT OUR PATIENTS & OUR CLINIC? WHAT DO WE NEED TO DO TO PREPARE FOR ACA? OUTLINE

3. ACA: What are some of the Benefits? Medicaid eligibility will be expanded to childless adults and to 133% of FPL Above 133% of FPL, low and middle income people and small businesses will get subsidies to make insurance affordable Children can stay on parents plan until 26 years old No lifetime or annual caps No denials based on pre-existing conditions No co-pays or deductibles for preventive care 80% of premium must be spent on enrollees Insurance companies have to justify rate increases

4. Some free clinics receive liability coverage for their volunteer health professionals through the Federal Tort Claims Act (FTCA). ACA makes FTCA more attractive to free clinics by extending that coverage to board members, officers, employees, and individual contractors, but not to the clinic entity itself. Does ACA help Free Clinics?

5. ACA: What are some of the Barriers? The Supreme Court ruled that States can opt out of Medicaid Expansion Political target Critical shortage of Primary Care Providers, especially PCPs who accept Medicaid The rising cost of health care

6. January 1, 2014, 30 million (of 53 million) uninsured will be eligible for coverage Eligibility for Medicaid will increase from 35% of Federal Poverty Level in MI to 133% of FPL across the nation Childless adults will be eligible This will help many of the patients we serve. How will ACA help the Uninsured?

7. 2012 Federal Poverty Levels 2013 FPLIndividualFamily of 4 100%$11,490$23,550 MI - 35% $ 4,022$ 8,243 133% $15,282 $31,322 400% $45,960 $94,200

8. Timeline for ACA 2010 2012 2011-2014 2014 President Obama signed ACA into law. Implementation is over the next few years. The Supreme Court ruled that Medicaid Expansion is optional for the states. Planning and implementation at federal and state levels. Numbers of uninsured continue to grow. Up to 30 million will become eligible for coverage, either through Medicaid expansion or the exchanges.

9. Timeline for ACA contd. 2014-2019 2019 Eligible persons will be enrolled in Medicaid and other programs beginning Oct. 1, 2013. The numbers of uninsured will gradually decline. The newly insured will try to find a medical home, but face a critical shortage of Primary Care Providers, especially PCPs accepting Medicaid. The number of uninsured will level off to those who are not eligible for coverage through ACA, approximately 29M persons.

10. THE SUPREME COURT OF THE USA RULED THAT EXPANSION OF MEDICAID IS OPTIONAL, STATE BY STATE. GOVERNOR SNYDER RECOMMENDS MEDICAID EXPANSION FOR MICHIGAN, BUT THE STATE LEGISLATURE TOOK IT OUT OF HIS BUDGET. FREE CLINICS NEED TO ADVOCATE FOR MEDICAID EXPANSION IN MICHIGAN AND OTHER STATES Medicaid Expansion is Critical!

11. Even with Medicaid Expansion, who will remain uninsured? Undocumented immigrants Naturalized citizens here < 5 yrs. Choose to pay the penalty rather than acquire insurance Eligible but unenrolled Coverage is not affordable In between coverage, due to income change Those <133% of FPL in states that opt out of M/A expansion Citizens who cannot pull together the documentation required to apply And where will they find care?

12. ACA: Implications for Free Clinics Many uninsured clients of our free clinic may be eligible for Medicaid Our clients will need help through the transition Potential negative impact on our donors and volunteers? Potential negative impact on our relationship to area hospitals? We need to re-evaluate our mission and services, and educate our community on the impact of ACA.

13. VT, WI, and MA received federal waivers to expand Medicaid for uninsured. What happened to free clinics in these states? None closed; in fact volume continued to grow. Free Clinics helped enroll and navigate patients through the changes. Patients moved in and out of coverage as their income changed, e.g. with seasonal jobs. They required a lot of help navigating the system. PCP shortage, especially of PCPs who will accept Medicaid, resulted in some free clinics providing care to Medicaid patients but not billing. Dental Care and Rx Assistance remain huge gaps in service. What is the experience of free clinics in states where most of the uninsured received coverage?

14. What Questions Should We Be Asking? Will Michigan opt for expansion of Medicaid? What will be the impact of the ACA on our clinic? How many of our patients will receive insurance coverage under ACA? Where will they find care? Who will remain uninsured in our community? Will our clinic be needed post-2019? Whom will we serve? What do we need to do to prepare for ACA changes? What options are open to us for the future? Are we eligible to be a FQHC, and should we consider becoming or partnering with a FQHC? What if ACA is not implemented? Other questions?