1. Sponsored by National Governors Association Center for Best Practices Health Resources and Services Administration Agency for Healthcare Research and Quality Enhancing the Safety Net Through Data-Driven Policy January 7, 2004 Richmond, VA February 12, 2004 Salem, OR February 19, 2004 Tallahassee, FL February 20, 2004 Phoenix, AZ

2. What is a “Safety Net?” Loose patchwork of providers (institutions, clinics, and physicians’ offices) who deliver a disproportionate share of health care to those who fall outside the medical and economic mainstream, regardless of their ability to pay for those services Source: Institute of Medicine. America’s Health Care Safety Net: Intact But Endangered (Washington, DC: National Academy Press, 2000).

3. What Are Safety net Services? Emergency/trauma services Dental services Major medical/ surgical services Maternal & child health services Mental health services Long-term care services Primary care services Substance abuse treatment Vision care services Other services

4. Who Relies on the Safety Net? Vulnerable groups Special needs Uninsured, underinsured Uninsured, underinsured » Working poor (unaffordable, not offered) » Working poor (unaffordable, not offered) » Unemployed, poor (non-Medicaid) » Unemployed, poor (non-Medicaid) » Children not covered under parents’ plan » Children not covered under parents’ plan Medicaid beneficiaries Medicaid beneficiaries Immigrants, migrant workers (legal, undocumented) Immigrants, migrant workers (legal, undocumented) Racial, ethnic groups Racial, ethnic groups Homeless individuals Homeless individuals Veterans Veterans Prisoners, parolees Prisoners, parolees Chronically ill Chronically ill Physically disabled Physically disabled Severely mentally ill Severely mentally ill People with communicable diseases People with communicable diseases » HIV/AIDS » HIV/AIDS » Tuberculosis » Tuberculosis People with substance use disorders People with substance use disorders Underserved areas Cities and suburbs Cities and suburbs Rural areas Rural areas Municipal, state boundaries Municipal, state boundaries Neighborhoods Neighborhoods Medically underserved areas Medically underserved areas Source: Institute of Medicine. America’s Health Care Safety Net: Intact But Endangered (Washington, DC: National Academy Press, 2000).

5. Who Delivers Safety Net Services? Public, community, and teaching hospitals Emergency departments, acute care facilities Emergency departments, acute care facilities Inpatient Inpatient Ambulatory care clinics Ambulatory care clinics Community Health Centers Local health departments Private practitioners School-based health centers Indian Health Service Veterans Administration Private, specialty hospitals Others Source: Institute of Medicine. America’s Health Care Safety Net: Intact But Endangered (Washington, DC: National Academy Press, 2000).

6. Who Pays For Those Services? FederalStateLocal Medicaid (Title XIX) Medicaid (Title XIX) » DSH payments » DSH payments » EPSDT payments » EPSDT payments » Major teaching hospital » Major teaching hospital Medicare (Title XVIII) Medicare (Title XVIII) » DSH payments » DSH payments FQHC payments FQHC payments BPHC financing BPHC financing » Section 330 grant » Section 330 grant » Rural Health Outreach » Rural Health Outreach » Rural telemedicine » Rural telemedicine MCH Block Grant (Title V) MCH Block Grant (Title V) Ryan White CARE Act Ryan White CARE Act Indirect Medical Education Indirect Medical Education Medicaid (state share) Medicaid (state share) SCHIP SCHIP Indigent medical assistance Indigent medical assistance High-risk insurance pools High-risk insurance pools Special population subsidies Special population subsidies Special needs subsidies Special needs subsidies Rural health grants Rural health grants » Obstetrical programs » Obstetrical programs Migrant dental programs Migrant dental programs Capital assistance grants Capital assistance grants Public health services Public health services » Immunizations » Immunizations University teaching programs University teaching programs WIC supplemental nutrition WIC supplemental nutrition Special capital assistance Special capital assistance Physician service contracts Physician service contracts Indigent medical assistance Indigent medical assistance Other public health programs Other public health programs Other Traditional insurance Traditional insurance Managed care contracts Managed care contracts Out-of-pocket payments Out-of-pocket payments Service contracts Service contracts Foundation grants Foundation grants Local contributions Local contributions Manufacturers’ indigent drug program Manufacturers’ indigent drug program Proceeds of sales and services Proceeds of sales and services Source: Institute of Medicine. America’s Health Care Safety Net: Intact But Endangered (Washington, DC: National Academy Press, 2000).

7. Phase One Goals What are our safety net policy priorities? What are the most pressing unmet health care needs of people in our state? What are the most pressing unmet health care needs of people in our state? How many people are affected? Why? How many people are affected? Why? What data are relevant, available to inform these priorities? Populations Populations Providers Providers Funding streams Funding streams Geographic variation Geographic variation Evaluate the usefulness of the AHRQ safety net data books

8. Phase One Activities Site visits to each state AHRQ document on data-driven policy Leverage technical assistance (as needed) Identifying and securing available, needed safety net data Identifying and securing available, needed safety net data Compiling, interpreting safety net data Compiling, interpreting safety net data Work done primarily at state and local agency levels

9. Phase Two Goals What policy options are available to address those unmet health care needs? What have other states done to address similar challenges? What have other states done to address similar challenges? What outcome(-s) do we want to result? What outcome(-s) do we want to result? What data are available to inform those policy choices? Who will it impact? Who will it impact? How much will it cost? How much will it cost? What is the net costs/benefit of potential remedies? What is the net costs/benefit of potential remedies?

10. Phase Two Activities Leverage technical assistance (as needed) Prioritizing critical needs and concerns Prioritizing critical needs and concerns Exploring policy options, resources, and strategies Exploring policy options, resources, and strategies Learning from experiences and best practices of other states Learning from experiences and best practices of other states Governor’s office more involved

11. Definitions and Priorities What is the policy problem? Data What data are available to support policy decisions? Assessment What do the data say about the current state of affairs? Action What policy options are supported by the data? Developing Data-Driven Capabilities to Support Policymaking Who are the stakeholders?

12. Definitions and Priorities What is the policy problem? Data What data are available to support policy decisions? Assessment What do the data say about the current state of affairs? Action What policy options are supported by the data? Articulating a common definition of the safety net Clarifying current concerns and priorities Understanding what questions need to be answered

13. Definitions and Priorities What is the policy problem? Data What data are available to support policy decisions? Assessment What do the data say about the current state of affairs? Action What policy options are supported by the data? Assembling a matrix of available data sources Determining available measures Identifying need for new or additional data Inventorying current and past initiatives

14. Definitions and Priorities What is the policy problem? Data What data are available to support policy decisions? Assessment What do the data say about the current state of affairs? Action What policy options are supported by the data? Analyzing data Clarifying the limitations of current knowledge Disseminating findings

15. Definitions and Priorities What is the policy problem? Data What data are available to support policy decisions? Assessment What do the data say about the current state of affairs? Action What policy options are supported by the data? Evaluating the impact of past and current initiatives Estimating short- and long-term impacts Recommending policy options

16. Questions & Technical Assistance (http://www.nga.org/center/safetynetdemo/) http://www.nga.org/center/safetynetdemo/ Robert J. Burns Policy Analyst Health Policy Studies Division National Governors Association Center for Best Practices Hall of States, Suite 267 444 North Capitol Street, NW Washington, DC 20001-1512 (202) 624-7729 fax: (202) 624-5313 email: rburns@nga.org rburns@nga.org