Safety net sys­tems step up care for im­mi­grants barred from cov­er­age un­der ACA

Modern Healthcare - - NEWS - By Steven Ross John­son

While the Af­ford­able Care Act cut the num­ber of unin­sured by about 32%, mil­lions of im­mi­grants don’t qual­ify for the law’s cov­er­age ex­pan­sions. They still have few op­tions for pri­mary care.

Peo­ple liv­ing in the U.S. with­out au­tho­riza­tion can’t buy health in­sur­ance from the ACA’s ex­changes and aren’t el­i­gi­ble for Medi­care, Med­i­caid or the Chil­dren’s Health In­sur­ance Pro­gram. Even law­ful res­i­dents who have lived in the U.S. for less than five years can’t get Med­i­caid or CHIP. Lo­cal gov­ern­ments in ar­eas with large num­bers of new im­mi­grants have stepped up to be­come their health safety net.

Lo­cal health of­fi­cials see ex­pand­ing pre­ven­tive, co­or­di­nated pri­ma­rycare ser­vices to un­doc­u­mented im­mi­grants as an ef­fec­tive means of achiev­ing ef­fec­tive pop­u­la­tion health man­age­ment by en­sur­ing eq­ui­table health out­comes for the en­tire pop­u­lace.

“The fu­ture is not about keep­ing in­di­vid­u­als healthy, it’s about keep­ing the pop­u­la­tion healthy,” said Dr. Ram Raju, pres­i­dent and CEO of NYC Health & Hos­pi­tals, the coun­try’s largest pub­lic health­care sys- tem, which serves roughly half a mil­lion unin­sured pa­tients. “You can­not keep one part of the pop­u­la­tion healthy be­cause they have ac­cess to health­care be­cause of their in­sur­ance, and then the other part of the pop­u­la­tion can­not get health­care be­cause they don’t have in­sur­ance.”

In 2014 New York Mayor Bill De Bla­sio launched Ac­tionHealthNYC, a pro­gram aimed at pro­vid­ing ac­cess to pre­ven­tive care for the city’s roughly 345,000 res­i­dents who are unin­sured due to their im­mi­gra­tion sta­tus.

And ear­lier this year NYC Health & Hos­pi­tals launched its own five-year ini­tia­tive to de­velop a co­or­di­nated model to pro­vide dis­counted or free care to unin­sured pa­tients that fo­cuses on out­pa­tient, pre­ven­tive ser­vices in an ef­fort to avoid hos­pi­tal­iza­tions and ex­pen­sive treat­ments for other­wise man­age­able con­di­tions.

“It’s eas­ier and cheaper for us to treat them as out­pa­tients and keep them healthy rather than treat them in the emer­gency de­part­ment or as an in­pa­tient, which would cost us a lot more and for which we are not get­ting re­im­bursed,” Raju said.

Raju said it’s too soon to put a num­ber on the sav­ings the pro­gram may reap, but its struc­ture re­sem­bles the sys­tem’s Medi­care ac­count­able care or­ga­ni­za­tion, which has gen­er­ated sav­ings for the past three years.

Other mu­nic­i­pal pub­lic health sys­tems are like­wise bet­ting that pro­vid­ing ba­sic pre­ven­tive health ser­vices now will help achieve long-term sav­ings.

But such ef­forts raise ques­tions about the abil­ity of pub­lic health agen­cies to shoul­der the cost of the ser­vices since fed­eral dol­lars pre­vi­ously ded­i­cated to sub­si­diz­ing un­com­pen­sated care are ex­pected to de­cline over the next sev­eral years.

The ACA calls for a 75% cut by fis­cal 2019 to dis­pro­por­tion­ate-share hospi­tal pay­ments, which re­im­burse safety net hos­pi­tals for pro­vid­ing care to large num­bers of low­in­come pa­tients.

In Cal­i­for­nia, the im­pend­ing loss in DSH funds will be off­set by a Med­i­caid waiver over the next five years. Un­der the waiver, DSH pay­ments will be thrown into a “global pay­ment” in a value- based pay­ment model that en­cour­ages the use of pre­ven­tive care to avoid high health­care uti­liza­tion.

“It sets up in­cen­tives for sys­tems to pro­vide care be­yond just emer­gency

“You can­not keep one part of the pop­u­la­tion healthy be­cause they have ac­cess to health­care be­cause of their in­sur­ance, and then the other part of the pop­u­la­tion can­not get health­care be­cause they don’t have in­sur­ance.” DR. RAM RAJU Pres­i­dent and CEO NYC Health & Hos­pi­tals

ser­vices,” said Mi­randa Di­etz, a re­searcher at the Uni­ver­sity of Cal­i­for­nia at Berke­ley’s Cen­ter for La­bor Re­search and Ed­u­ca­tion. Di­etz coau­thored a re­cent re­port that pro­files the work of county health­care pro­grams in San Fran­cisco and Los An­ge­les that pro­vide care to un­doc­u­mented res­i­dents.

Cal­i­for­nia Gov. Jerry Brown signed leg­is­la­tion this year to al­low nonci­t­i­zens, re­gard­less of im­mi­gra­tion sta­tus, to buy health in­sur­ance on the state’s ACA ex­change with­out sub­si­dies. That, how­ever, will re­quire a fed­eral waiver.

Pro­vid­ing health­care to peo­ple who don’t have per­mis­sion to be in the coun­try has been a con­tentious is­sue for years. Crit­ics ar­gue the ser­vices in­vite more il­le­gal im­mi­gra­tion and are an un­fair use of pub­lic funds.

Unau­tho­rized res­i­dents made up about 12% of the na­tion’s 33 mil­lion unin­sured in 2014, ac­cord­ing to a sta­tis­ti­cal anal­y­sis pub­lished on web­site FiveThir­tyEight.

Scru­tiny of the costs of pro­vid­ing health­care for them has in­creased in re­cent months amid anti-im­mi­grant rhetoric from Repub­li­can pres­i­den­tial nom­i­nee Don­ald Trump. One of the ar­gu­ments against il­le­gal im­mi­gra­tion is the eco­nomic bur­den on the health­care sys­tem, but re­searchers have found that bur­den is of­ten ex­ag­ger­ated. Health ex­pen­di­tures for nonci­t­i­zens from 1999 to 2006 were 50% lower on av­er­age per capita than ex­pen­di­tures for U.S. cit­i­zens, ac­cord­ing to a 2010 study in Health Af­fairs.

Ad­vo­cates of pro­vid­ing care to this pop­u­la­tion con­tend it’s a mat­ter of com­mon sense, par­tic­u­larly in the states where their num­bers are con­cen­trated. Cal­i­for­nia, Illi­nois, New York and Texas are home to about 55% of all un­doc­u­mented im­mi­grants.

The lead­ers of pub­lic health sys­tems see the ser­vices as part of their long-stand­ing mis­sion to de­liver care to pa­tients re­gard­less of their abil­ity to pay.

“We think it’s the right thing to do,” said Dr. Jay Shan­non, CEO of the Cook County Health & Hos­pi­tals Sys­tem in Chicago. The sys­tem pro­vides be­tween $400 mil­lion and $500 mil­lion a year in un­com­pen­sated care to the county’s unin­sured, which in­cludes an es­ti­mated 200,000 un­doc­u­mented res­i­dents. In Septem­ber, county of­fi­cials ap­proved a pro­gram to al­low unin­sured res­i­dents who do not qual­ify for Med­i­caid and earn up to 200% of the fed­eral poverty level to get ac­cess to pri­mary-care ser­vices.

The pro­gram is slated to launch by next year with ini­tial costs ex­pected to be about $2 mil­lion.

“These in­di­vid­u­als are res­i­dents of our county,” Shan­non said. “They pay taxes in our county, and be­cause they are part of the pop­u­la­tion, they con­trib­ute in a mean­ing­ful way to the health sta­tus or lack of health sta­tus in our county.”

One of the ar­gu­ments against il­le­gal im­mi­gra­tion is the eco­nomic bur­den on the health­care sys­tem, but re­searchers have found that bur­den is of­ten ex­ag­ger­ated.

AP PHOTO

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