1. Research | Training | Policy | Practice The Legacy of the War on Poverty’s Health Programs for Non-Elderly Adults and Children Barbara (Bobbi) Wolfe June 12, 2012

2. Major Components of the War on Poverty’s Health programs Medicaid – Expanded to Children's Health Insurance Program Neighborhood Health Centers – National Health Service Corp added to attract providers

3. Pre War on Poverty Public sector – – public hospitals, military health care, Public funding for medical research, school health programs, programs to promote maternal and infant health, worker’s comp for health – ~one percent of GDP Private insurance covered < 30% of private health spending. Employers provide as cost of business so tax subsidized.

4. A Picture of Health Differences by Income pre War on Poverty

5. Medicaid Became law in 1965; a Demand side program that provides coverage to eligible persons Joint federal-state program – Federal – minimum benefit package; majority of financial resources (match based on average per capita income in state: range 50-83 percent.) Mandatory groups- single-parent family members, quickly expanded to pregnant women Minimum benefits for children 1967, Early & Periodic Screening, diagnostic and Treatment – State – option to cover additional groups (medically needy) and services and set income-eligibility for mandatory groups (tied to AFDC eligibility). – Major Eligibility Expansions: 1986-pregnant women and infants with income <100% FPL as state option; 1988 mandatory. 1989: expanded to cover up to 133% FPL. & up to age 6. 1990: All children to age 18 up to 100% FPL 2010: ADA – all under 133% FPL

6. Personal Health Expenditures and Medicaid, 1960 to date

7. Core problems with Medicaid – Zero-one nature re eligibility. “Notch” Negative labor market incentive Negative private coverage incentive (increases uninsured) May change use of care in way that influences health – Coverage varies by state: inequality – Crowd-out. – Low reimbursement especially for specialists and oral health providers limits access – Cost of program esp. to states

8. Evaluation tied to core issues – Wisconsin Badgercare Eligibility to 185% FPL, no asset test, family coverage Premiums for higher income families State subsidy for ESI for those eligible for BadgerCare (tied to income) outreach – Outcomes: increased coverage. Evidence that bridged gap between public and private provision. Estimates of crowd out about 25% – Medicaid Managed Care Program- (Kaestner, DuBay and Kenney) evaluate effect of MMC on prenatal care usage and infant health. Find no tie to adequacy of prenatal care ; or health outcomes. – Community Care of NC (KFF study) Medical home model-MDs, hospitals, county health & social service agencies coordinate care. 24/7 access on call Improved care and cost savings.

9. ACA –lessons from Experience of Medicaid Makes eligibility more uniform across states Raises importance of smooth transition from Medicaid to private coverage – Subsidy plan; administration and implementation – Providers who participate Access – will providers participate? Reimbursement Medical or health homes to improve care for chronically ill

10. (State) Children’s Health Insurance Program 1997: SCHIP 2009: CHIP Joint federal state program to expand coverage beyond Medicaid to low income children. extensive leeway to states. – Coverage varies from 160% up to 400% FPL. – Targeted on children but states have option to expand to parents. – Federal government pays Medicaid rate + 15% Issues – low take-up rate, churning enrollment and crowd out.

11. Evaluation Focus on Take-up rates and strategies to increase (2009=84.8%) – Outreach – Simplify enrollment – Longer periods of eligibility Focus on Crowd-out and ways to reduce – Use of waiting periods; lock-outs – Premiums Improvements in coverage for children? – CPS data show drop in uninsured children < 250% FPL while adults increase rate Improvements in access? – Greater utilization if have Medicaid/Chip but disparities continue in quality, and access to specialty care including time to appointment – Managed care networks not serve both Medicaid/CHIP and privates

12. Neighborhood Health Centers Concept: provide health and social services in poor and medically underserved areas and promote community empowerment. Established in 1965 as part of War on Poverty. Slow growth – perceived threat and only benefit those in geographical areas would be served (supply side approach that differed from private insurance.) – Early 19070s only ~ 100. Now 1,124 and under ACA expected to double capacity – 2010 served 19.5 million – 93% < 200% FPL; 72% <FPL FQHC-1989 on – 90% federally qualified; – all can receive cost-based reimbursement from Medicaid and Medicare (since 1989). – FQHC covered for malpractice. – Medicaid accounts for 37% of funding; federal grants 25%, state & local grants 12%

13. CHC - evaluation Most compare CHC to other providers – Quality of care; access; disparities; cost-effectiveness – Mostly favorable Reduced infant mortality rate and low birth weight More up to date on cancer screening than comparable women More pediatric patients have recommended preventive care Lower rate or ambulatory care sensitive hospitalizations Lower cost than comparable care—Medicaid covered CHC patients lower hospitalizations rates and fewer annual hospital days

14. Issues-CHCs Current issue – insufficient funding to serve population – 1985-2006 real / ca appropriations steadily decreased Staffing – Funded vacancies esp. in rural areas Access to specialty services Can they expand to meet expected increase in demand?

15. Measures of Success of These Programs-insurance coverage In 1965, >70% of population had hospital coverage; 67% surgical care but little else. >25% had no coverage. By 1970, 15% had no coverage*. Records of actual coverage only begin in 1982 (earlier count policies.)

16. Indicator of success of Medicaid and S-CHIP on covering children

17. High rates of Uninsured among Non- elderly adults remain

18. Indicator of Success-utilization disparities

19. Indicator of Success – infant mortality rates by race

20. Final thoughts 1.Bulk of evidence clearly suggests that the combination of Medicaid/Chip/CHC /NHSC have increased health insurance coverage, access (as captured by utilization) to medical care for the poor and decreased gaps in health status. 2.ACA if enacted will extend these benefits though clearly major issues remain in terms of actual access to beneficial care 3.It is also clear that evaluations in this area are complicated; beyond asking limited questions (for ex., take-up, crowd out, costs of care, labor market incentives, infant mortality) the profession has not done well at understanding the full benefits of this set of programs 1.Endogeneity of take up of Medicaid and use of CHCs 2.Inaccuracy of numerous measures of health and limited scope of others (mortality, infant mortality) 3.Long term nature of health and effectiveness of medical care. 4.Role of risk taking behaviors/knowledge/exposures with health consequences 5.Difficulty in conducting experiments that might deny coverage or access to care.