How the Affordable
Care Act Affects Safety Net Clinics in KC
The impact of the fully-implemented Affordable Care Act (ACA)
will include a reduction in the total number of uninsured people and an increase in the numbers covered by Medicaid. There
will remain a substantial number of people, mostly non-elderly adults, who will lack insurance and there will likely also
be a large number who despite having insurance will continue to have difficulty accessing services due to costs of the co-pays
and deductibles of available insurance plans. Projections are that the Safety Net Clinics in Kansas City will continue to
serve the uninsured and underinsured poor. The Robert Wood Johnson Foundation’s brief on the ACA states “Safety net programs and providers that serve the uninsured…(may) adjust their policies and structures
to best serve the needs of the many millions who remain uninsured even after the ACA is fully implemented.”
Kansas City Safety
Net Clinics provide health care services to the poor, many of whom are uninsured or have Medicaid/Medicare coverage. Most
(>90%) of the uninsured are adults and the great majority of the uninsured are poor. The Kaiser Family Foundation (KFF)
calculated uninsured rates among nonelderly nondisabled adults with incomes at or below 250% of the federal poverty level
(FPL*) to be 87% in Kansas and 88% in Missouri. Using census data from 2008, the Mid-America Regional
Council (MARC) reported the number of uninsured poor (< 200% FPL) in the 6 county KC metropolitan area (Jackson, Platte,
Clay in Missouri and Wyandotte, Leavenworth, Johnson in Kansas) to be nearly 128,000; another 96,000 uninsured
with incomes over 200% FPL. More than 190,000 people were covered by Medicaid. This population of over 400,000 vulnerable
adults is the primary group served by the KC Safety Net Clinics which include Federally Qualified Health Centers (FQHC) and
non-profit sliding scale fee and free clinics and is expected to grow during the months leading up to implementation of the
ACA. In 2009, the major KC Safety Net Clinics provided 267,000 visits, and are estimated to have provided services to up to
30% of this vulnerable population.
<200%||Un-insured >200%||Medicaid||Vulnerable||SNC Visits|
Projections are that the ACA will expand some insurance coverage to many of these 400,000 vulnerable metropolitan
residents through a quilt knit together with three types of blocks: 1) Increased coverage under Medicaid – for adults
up to 138% of FPL, 2) Increased coverage through private insurance paid through employer mandates and 3) increased coverage
through private insurance paid by individuals and supplemented with income-based subsidies.
The ACA will lower the uninsured rates in Kansas and Missouri by about half. According
to the Robert Wood Johnson Foundation’s (RWJ) report on the impact of ACA, Missouri and Kansas are considered high subsidy
impact states. Our states have a higher than average proportion of the population that make over 138% and less than 400% of
FPL. Our states will be subsidizing a larger proportion of state residents than most states. That may result in a larger group
of underinsured persons depending on the affordability of the insurance plans.
Impact CalculationsExtrapolating the RWJ figures to the 1.7 million residents of Metropolitan Kansas City and
using current estimates for rates of unemployment (expected to rise) and numbers of persons living in poverty (also expected
to increase), conservative estimates of safety net- eligible residents in the metro area include the following: 128,000 not
currently on Medicaid and with incomes under 200% FPL, plus up to an additional 96,000 with incomes under 400% FPL (this group
will be subsidized to purchase health insurance) – totaling 224,000. There are also 190,000 who are now receiving benefits
RWJ has projected these uninsured would
fall into five groups post- ACA. Projections for the metropolitan area:
- 38% to 42%
or up to 95,000 will be newly eligible for Medicaid, not enrolled.
- 14% to 19%
or as many as 43,000 will be undocumented and uninsurable (about half of these people would have emergency services only covered
by the Sixth Omnibus Budget Reconciliation Act – SOBRA = Medicaid.)
- 14% to 18% or up to 42,000 would not have an affordable insurance option and are uninsurable. They would be exempt
from the individual mandate. Most of these individuals are likely to be older and with low incomes.
- Up to 9% or 20,000 will be eligible for subsidies to assist with insurance purchase.
- About 16-19% or 43,000 with incomes > 400% FPL will not qualify for subsidies, but will be subject to the individual
mandate to purchase health insurance through their employers.
- Uninsured - These figures represent an overall shift to subsidized
and other types of insurance coverage for all but about 85,000 individuals. This reduction in the total number of uninsured
will likely be off-set by an increase in the number of poor with private insurance who are underinsured and in need of affodable
- Medicaid Coverage- Expanding Medicaid coverage may
mean the Safety Net CLinics will not be the only resource for health services for Medicaid-covered patients and may compete
with more private physicians for the estimated 285,000 patients
- Private Insurance-
It is expected that the types of non-Medicaid insurance coverage that will be available for the poor
even with subsidies may carry higher co-pays and deductibles, thus rendering these insurance plans ineffective for covering
the out-patient care for the poor that is provided through Safety Net Clinics. The number of underinsured individuals will
likely increase substantially, although the numbers are difficult to project without more data on insurance plans.
There are incentives for primary care for those Safety Net Clinics that choose to accept
Medicaid and Medicare insurance plans up to $66,000 for implementation of electronic medical records through Medicaid or Medicare
for those providers with high Medicaid and Medicare ratios in their practices. The Meaningful Use incentives are through the Health Information Technology for Economic and Clinical Health (HITECH)
Act which is part of the American Recovery and Reinvestment Act of 2009 (ARRA) and are closely associated with ACA due to
the changing demographics predicted. More safety net clinics will be accepting Centers for Medicare and Medicaid Services
payments due to the ACA changes and may be expected therefore to access the incentives.
However, it is not likely that the non-FQHC safety net clinics will meet the criteria for these funds. These
are not practice-based, but provider- based incentives.
Ironically non-federally qualified health center safety net providers
who see a high proportion of uninsured are penalized for their charity. FQHC’s are allowed to count uninsured patients
in their Medicaid figures. But, other Safety Net Clinics will not likely meet the required ratios for payment of these substantial
incentive payments because the uninsured must be included in the denominator of total patients, but may not be counted as
part of the Medicaid numerator when calculating the percentages of Medicaid in a practice. Thus most Safety Net Clinics that
offer the uninsured services will not have providers who are eligible for these incentive payments. Also many of the Safety
Net Clinic providers are volunteers and therefore any payments to these providers may not go to the Safety Net Clinic, but
to another type of practice site.
Safety net systems may require changes to business plans and revenue streams. Shifting from providing services solely
to uninsured and developing billing procedures and policies to serve Medicaid/Medicare and the underinsured will be a challenge
for some Safety Net Clinics.
concerns are that the safety net may be prematurely removed due to donor over-confidence in ACA coverage for vulnerable populations.
Continued funding for safety net services is critically important.
Populations served through the Safety Net
Clinics are not simply vulnerable due to lack of insurance, or poverty alone, but carry a higher burden of social problems.
Safety Net Clinics provide a spectrum of supportive services in addition to direct health services. These services are not
generally “billable” through insurance sources and will require continued subsidies from donors.
ACA will likely
push some clinics to change business plans, diversify revenue sources and extend eligibility to underinsured impoverished
populations including those with Mediciad, Medicare or other third pary payment sources. The majority of the underinsured
are the working poor with incomes at or below the federal poverty level. Lower income and sicker adults are most at-risk for
having inadequate insurance coverage.
*Federal Poverty Level- What is it? Click here to find out.
Not "socialized medicine"- that's the VA.
Just paid by the public- like Medicare.
Expand this coverage, allow buy-in by individuals or employers and that is Universal Health Care.
Learn more about Medicare For All...
What happens day in and day out, to
those people who do not have insurance, is that they suffer. And yes, some actually die because they don’t have insurance.
Because- we, the American society choose not to provide care for them.
- just ask these folks:
FHC patient who lost the use of his arm and ability to walk normally when his spinal stenosis went untreated until there were
serious consequences. (http://www.swbfhc.org/id72.html)
The family of the FHC patient- a man whose health plan cardiologists
delayed treatment (money saved gave them points which increased their pay) until he a) progressed so he could not work and
b) lost his insurance after losing his job and finally c) entered charity care and had an emergency cardiac bypass which failed
and then they were told he did not qualify for a transplant- ONLY BECAUSE HE LACKED INSURANCE COVERAGE. He died in his mid-forties
three days after the failed bypass.
A woman, and FHC patient who lost 3/4 of her blood volume, not
once, but twice due to fibroid tumors in one year. She was not provided the definitive treatment (a hysterectomy) because
the abnormally large menstrual flow stopped. She was given a transfusion and thus "stabilized"- sent home to wait
for the next heavy flow and the next emergency room visit and the next transfusion.
and literally thousands of other Americans every year.
Check out these articles:
Care Without Coverage: Too Little Too Late ...
- Institute of Medicine
Physicians for a National Health Policy reported: "Dr.
David Himmelstein, study co-author and an associate professor of medicine at Harvard, remarked, “The Institute
of Medicine, using older studies, estimated that one American dies every 30 minutes from lack of health insurance. Even this
grim figure is an underestimate — now one dies every 12 minutes.” http://www.pnhp.org/news/2009/september/harvard_study_finds_.php
It appears, that in order to actually provide for these and tens of thousands of uninsured poor who
are our neighbors, we need Medicare for all.