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|
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 through Medicaid.
RWJ has projected
these uninsured would fall into five groups post- ACA. Projections for the metropolitan area:
to 42% or up to 95,000 will be newly eligible for Medicaid, not enrolled. (These people have been left
out since Kansas and Missouri are not expanding Medicaid. They are very low income and are not covered with the subsidies.)
- 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
- 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 affordable out-patient
- 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. (This is not happening in Kansas and Missouri as the States have not expanded Medicaid
and has left most of these people without an option for insurance. In addition, traditional safety net hospitals are losing
their DSH support for services for the uninsured poor and are expected to reduce the level of care. Therefore more people
will be in need of Safety Net Clinic services.)
- 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...
impact of the Affordable Care Act (ACA) is changing the health insurance marketplace and subsequently more people will
have access to health services throughout the country.
US average costs for individual health insurance prior to the ACA was $491 and is projected to be down to $328 a month for
a midlevel policy (before subsidy). In Kansas City, the KC Business Journal reports that adults age 50 will pay between $285
to $460 per month plus those earning between 100% and 400% of the Federal Poverty Level (FPL) would be eligible for subsidies
to reduce the monthly premiums, based on a sliding scale, to between 2% and 9.5% of their income.
HOWEVER, about 5.2 million adult Americans fall into the coverage gap created by the refusal of 26 states
to implement the Medicaid Expansion portion of the ACA. (Kaiser Family Foundation; Galewitz, 10/16).
The ACA provided for Medicaid to cover everyone below 138% of the Federal Poverty Level. When the Supreme Court
separated Medicaid expansion from the rest of the Act and left it to the States to decide, Kansas and Missouri “opted
It is estimated about one-half of the 200,000 uninsured low-income individuals in the KC
metropolitan area will not qualify for Medicaid or for subisidies.These low-income adults will have no viable options for insurance coverage. Medicaid in Kansas covers parents
with incomes under about 30% of the FPL or $267/month and in Missouri, Medicaid the eligibility is set at 18% of FPL.
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