The Affordable Care Act Implementation and

Family Homelessness

“It’s one thing to approach providers in these systems—already overwhelmed with their own workload—and ask: “Can you also think about homelessness?” But it’s quite another to point out: “Our people are your people. How can we change the way our

systems work to better serve these families?” Alice Shobe, Building Changes Executive Director

Issue Brief #1: Identification of Intersections between Building Changes Work to End Family

Homelessness and Health Care Reform

April 2013

Prepared

for

Building

Changes

1

Table of Contents Purpose ......................................................................................................................................................... 2

Section I: Building Changes—An Intermediary focused on Systems Change .............................................. 2

Vulnerable Family—Defining the Population ........................................................................................... 3

Vulnerable Families, Homelessness and Health Care ............................................................................... 4

Washington Families Fund Systems Change Initiative.............................................................................. 5

Washington Vulnerable Families Partnership ........................................................................................... 7

Role of Philanthropy in Health Care Reform ............................................................................................. 7

The Affordable Care Act and Vulnerable Families .................................................................................... 7

Section II: ACA and Access to Health Care Coverage and Care .................................................................... 8

Overview of ACA’s Medicaid Expansion Provision .................................................................................... 9

Overview of Subsidies to Purchase Health Care Coverage ..................................................................... 10

Essential Health Benefits ........................................................................................................................ 12

ACA Changes to Existing Medicaid Program ........................................................................................... 12

Section III: ACA and Improving Health Care Service Delivery .................................................................... 13

Center for Medicare and Medicaid Innovation ...................................................................................... 13

Health Homes.......................................................................................................................................... 13

Section IV: ACA Implementation Efforts in Washington State .................................................................. 15

Medicaid Expansion in Washington State .............................................................................................. 16

Health Insurance Exchange ..................................................................................................................... 18

CMMI State Innovation Model Initiative ................................................................................................ 19

Health Homes.......................................................................................................................................... 20

Section V: Identification of Connecting Points for Further Exploration ..................................................... 22

Connecting Point 1: Common Beneficiaries of System Reform Efforts ................................................. 23

Connecting Point 2: Common Principles and Vision Guiding System Reform Efforts ........................... 23

Connecting Point 3: Common Change Allies and Targets ...................................................................... 23

Connecting Point 4: Evaluation and Shared Learning ............................................................................ 24

Connecting Point 5: Role of Philanthropy in Health System Reform Efforts ......................................... 24

Next Steps ............................................................................................................................................... 25

APPENDIX A: KEY TERMS AND ACRONYMS ................................................................................................ 26

Alice Shobe quote from Gates Foundation Blog, Our “Aha” Moments in Tracking Washington Families Fund Data, Impatient Optimists, 11/14/12, available at: http://www.impatientoptimists.org/Posts/2012/11/Our-Aha-Moments-in-Tracking-Washington-Families-Fund-Data

2

Purpose In January 2013, Building Changes sought consultative assistance to:

”Identify the intersections between our work to end family homelessness and health care reform, with a focus on how the implementation of the Affordable Care Act affects vulnerable families.

Build on our recent and planned research, evaluation, and systems change work.

Make recommendations for opportunities we should pursue to ensure that vulnerable families benefit from health care strategy or implementation changes at the county and/or state level.”1

In February 2013, Leavitt Partners, LLC2 was selected to complete this work for Building Changes. This issue brief is the first of two to be produced and focuses on identifying the intersections and potential “connecting points” between the implementation of health care reform efforts related to the Affordable Care Act (ACA) in Washington State and the activities of Building Changes related to preventing and addressing the issues of family homelessness. The brief presents information in five sections:

Building Changes Role as an Intermediary focused on Systems Change

Affordable Care Act and Access to Health Care Coverage and Care

Affordable Care Act and Improving Health Care Service Delivery

Affordable Care Act Implementation Efforts in Washington State

Identification of Connecting Points for Further Exploration The second issue brief will further detail the connecting points and as well as opportunities and recommendations for Building Changes to use its intermediary role and systems change expertise to ensure that health care reform benefits vulnerable families in Washington State.

Section I: Building Changes—An Intermediary focused on Systems Change Building Changes has an established history of vision and leadership in bringing community service providers, public agencies, and private funders together in a common effort to address and end homelessness within the State of Washington and at a national level. The success of Building Changes is grounded in its ability to serve as a trusted “intermediary among philanthropy, government agencies, and service providers, seeding and nurturing fundamental change in the way [our] communities collaborate and coordinate efforts to address homelessness”.3

1 Building Changes, Request for Qualifications, Affordable Care Act Implementation and Family Homelessness,

issued January 2013. 2 Leavitt Partners was founded in 2009 by former Utah Governor and HHS Secretary Michael O. Leavitt. Leavitt

Partners advises clients in the practice areas of health care with specific guidance on health reform and government action. 3Building Changes 2012-2014 Strategic Business Plan, p. 2.

3

A central tenet of Building Changes’ intermediary role is to focus on systems change; as conceptualized by the Corporation for Supportive Housing (CSH) and embraced by Building Changes,

“Systems change is a human enterprise, in which the members of a community, its institutions, policy makers, and other stakeholders, collaborate to develop new ways of working together to solve a social problem. These stakeholders mutually agree to apply their resources, authority, technology, ideas, and values to new activities and interventions that result in new practices, policies and funding in the public interest.”4

Building Changes operationalizes its intermediary role through its key activities of grant making, capacity building, policy and advocacy, and evaluation.5

Vulnerable Family—Defining the Population For purposes of this brief, the term “vulnerable family” will incorporate earlier work by Building Changes targeted on the development of emerging strategies to address family homelessness.6 In this work, vulnerable families were defined as families who spend at least 50% of their pre-tax income on their current housing and whose overall income is less than 30% of the Area Median Income (AMI). These families can face losing their housing at any given time due to eviction, family violence or other crises. While exact data on the number of vulnerable families is difficult to report due to data definition and collection differences, estimates from the Building Changes Ending Family Homelessness Policy Paper

4 Ibid. p. 3. [Originally from: “Laying a New Foundation, Changing Systems that Create and Sustain Supportive

Housing,” D. Greiff, T. Proscio, and C. Wilkins, Corporation for Supportive Housing (CSH), 2003.] 5 Ibid.

6 Building Changes (2011), Ending Family Homelessness in Washington State: An Emerging Approach, Executive

Summary Policy Paper, p.11, available at: http://www.buildingchanges.org/library-type/policy-resources/item/458-ending-family-homelessness-in-washington-state-an-emerging-approach-policy-paper-2011

Building Changes’ Key Systems Change Activities: Grant Making – grants to housing and service providers for promising programs and proven solutions

Capacity Building – training and technical assistance to increase skills and knowledge needed to change practices, learn from experience and improve programs

Policy and Advocacy – target policy changes to better coordinate at all levels of government

Evaluation – demonstrate impact by collecting and evaluating data, convening stakeholders to collectively learn from the data, and disseminating findings

4

are that 240,800 Washington State families have incomes below 200% of the poverty level and an estimated 78,500 are vulnerable families. Some of the factors that are associated with vulnerable families moving into the ranks of homeless families include: 1) having no, or a limited social support system that can provide financial or social support when major life events or crises occur, and 2) a lack of access or connection to social programs designed to address economic, social and health needs.7

Vulnerable Families, Homelessness and Health Care It is well documented that a lack of health insurance is one of the key structural causes of homelessness amongst individuals and families. Building Changes has long recognized the critical role that access to health care services plays in addressing issues surrounding homelessness for individuals and families. In its report, “Ending Family Homelessness in Washington State: An Emerging Approach” published in 2011, it further recognized the opportunities that the Affordable Care Act presents. A major recommendation in this report was to “improve health and stability for vulnerable and homeless families and align healthcare reform policies with their needs”.8 Envisioned was a realigned and refocused health care delivery system with greater focus on prevention that “could bring health care providers into a community network of services and supports for vulnerable and homeless families.”9 The potential for the ACA to boost efforts to prevent and address homelessness has been increasingly recognized by providers, advocates, and researchers in the homeless service system and in the health care system.10 A separate Building Changes’ policy brief dedicated specifically to health care, expanded upon the anticipated health care transformative efforts that would occur with ACA implementation. These efforts include redesigned health care organizational and governance models such as accountable care organizations (ACOs), payment models and service delivery strategies, such as patient-centered health homes, and the potential through these efforts to organize a “safety net healthcare system”.11 Such a system was viewed as having “the potential to be a new and significant stabilizing force for vulnerable and homeless families while helping better manage the growth in healthcare costs for this complex population”.12

7 Corporation for Supportive Housing (2012), Ending Family Homelessness: National Trends and Local System

Responses, available at: http://www.buildingchanges.org/images/documents/library/2012%20CSH-NAEH%20White%20Paper%20Ending%20Family%20Homelessness.pdf 8 Building Changes (2011), Ending Family Homelessness in Washington State: An Emerging Approach, Executive

Summary Policy Paper, p.11. 9 Ibid. p.9

10 As examples, see National Health Care for the Homeless Council, Health Care Reform and Homelessness, 2012

Policy Statement available at: http://www.nhchc.org/wp-content/uploads/2011/09/Health-ReformHomelessness-012.pdf and Center for Health Care Strategies, Inc. (2012), Medicaid Financed Services in Supportive Housing for High-Need Homeless Beneficiaries: Emerging Options available at: http://www.chcs.org/usr_doc/SH_Medicaid_Bz_Case_081712_final.pdf 11

Building Changes (2011), Ending Family Homelessness in Washington State: Healthcare Policy Brief, available at: http://www.buildingchanges.org/library-type/policy-resources/item/456-ending-family-homelessness-in-washington-state-healthcare-policy-brief-2011 12

Ibid. p. 8.

5

The connections between vulnerable families, housing and health care was also highlighted in a statewide convening of government, philanthropy and private sector leaders held in October 2011. “Silos to Systems: Solutions for Vulnerable Families” focused attention on the multiple and complex needs of vulnerable families and was premised on the belief that “no single system has the resources, expertise, capacity, or responsibility for coming up with solutions on its own.”13 Participants in this convening echoed earlier calls for coordination between housing and supportive services policy makers and providers and health care policy makers and providers. New collaboration opportunities presented by the ACA and health care reform were specifically called out.

Washington Families Fund Systems Change Initiative In 2004, Washington State initiated its first statewide, public-private effort to provide resources for the provision of “services” within a “housing with services” approach to confronting family homelessness. Initial funding from the State Legislature, matched with private funding, officially launched what became the Washington Families Fund (WFF). To navigate the new world of managing blended public and private dollars, the decision was made to seek an intermediary organization that could provide the flexibility of a nongovernmental entity while also providing strong fiscal stewardship and accountability. Building Changes was selected as the initial intermediary and has continued in that role ever since.14 With support from the Bill and Melinda Gates Foundation, Building Changes launched the Washington Families Fund (WFF) Systems Initiative in 2009. Through this initiative, King, Snohomish, and Pierce Counties are engaging in system level reforms to reduce family homelessness.

13

Building Changes, Silos to Systems: Solutions for Vulnerable Families, Summary Report January 2012, available at: http://www.buildingchanges.org/library-type/reports/item/472-silos-to-systems-solutions-for-vulnerable-families-summary-report 14

Building Changes (2012), Creating and Leading Washington State’s First Public-Private Partnership to Reduce Family Homelessness: The Washington Families Fund (2004-2009), available at: http://www.buildingchanges.org/library-type/best-practice-reports/item/371-creating-and-leading-washington-state’s-first-public-private-partnership-to-reduce-family-homelessness-the-washington-families-fund-2004–2009

“This will not be easy. Healthcare homes and ACOs will quickly learn that if they have a patient with major depression and diabetes, they will not be able to help her manage her diabetes until they help her get her depression under control. Add to this scenario the facts that the patient is the head of household of a family, has lost her job, is experiencing domestic violence, and she and her children are on the brink of homelessness. It is even more unlikely that she will be able to manage her diabetes unless she receives a full set of services and supports to achieve safety, housing stability, and treatment for her depression.”

Building Changes, Healthcare Policy Brief, 2011, p. 8

6

At the core of the WFF Systems Initiative is specific reform efforts focused on the implementation of five “pillars” or practices to reforming systems serving homeless families. These efforts align with Building Changes’ overall approach to ending homelessness.

1. Coordinated Entry: A common point of entry into the system that includes a universal assessment protocol to match families to needed resources;

2. Prevention: Resources that either divert families from entering shelter or that stabilize housing situations for families who are at risk of homelessness;

3. Rapid Housing and Other Housing Resources: A system for quickly placing families who enter shelter into permanent housing, often with short-term rental assistance;

4. Tailored Services: Services that provide for flexible, coordinated, and customized support to ensure that families are matched with the services needed to become residentially stable and self-sufficient; and

5. Economic Opportunity: Services such as education, job training, and other employment preparation and support that help families become and stay residentially stable and self-sufficient.

A key strategy deployed by the counties participating in the WFF System Initiative is “collaboration and coordination among the providers and other stakeholders that provide resources to support each of the pillars”.15 Particular focus is placed on integrating housing assistance with core public programs assisting individuals and families such as Temporary Assistance for Needy Families (TANF), Medicaid, subsidized early learning/child care, and child welfare as well as education and employment assistance. The WFF Systems Initiative is undergoing a rigorous longitudinal process and outcome evaluation being conducted by Westat.16 In their 2012 interim evaluation report, Westat highlighted significant progress being made in all three counties along with recommendations to maximize the system change potential of the initiative. Among the recommendations was to make further connections to additional “mainstream” systems including health and behavioral health.17 This recommendation stemmed from data collected on the initial families participating in the Systems Initiative. Across the three participating counties, 13% of families reported “poor functioning” with respect to their physical health and 24% with respect to their mental health; 80% of the families have one or more indicators of a mental health need and 24% had a positive screen for a substance abuse issue. Fifteen percent had experienced hospitalization for a mental health issue and 21% had experienced an inpatient stay related to substance abuse at some point in their lives. The rate of insurance coverage for these families was slightly lower than that for the overall Washington State non-elderly population18; 82% had a source of health care insurance with 73% enrolled in Medicaid.19

15

Westat (2012), WFF Systems Initiative Evaluation: 2012 Interim Report, available at: http://www.buildingchanges.org/library-type/evaluation-results/item/518-washington-families-fund-systems-initiative-evaluation-2012-interim-report 16

For more information on Westat, see: http://www.westat.com/index.cfm 17

Ibid. 18

The state insured rate for the non-elderly population as a whole is 83.9%. 19

“WFF Systems Initiative Data: Understanding Families’’ Residential (In)Stability, Human Capital, Service Needs and Access” presented by Deb Rog, Westat and Margaret Woley, Building Changes, October Family Homelessness Strategy Convening, Oct. 29, 2012 Available at: http://www.buildingchanges.org/library-type/evaluation-results/item/541

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The most prevalent unmet health care need was for dental services with 56% of the household heads reporting an unmet dental need, followed by 13% reporting an unmet physical health need and mental health need each. Of particular note in the WFF System Initiative data, is the large percent of families that have incurred debt due to medical bills; 86% of all the families had accumulated debt. Medical bills were a source of debt for 39% of those families and the average amount of medical debt exceeded $7,000.20 Home mortgage was the only source of greater debt for these families.

Washington Vulnerable Families Partnership Building on the collaborative public-private-philanthropy successes of WFF, the most recent initiative to maximize the expertise of Building Changes as an intermediary is the Washington Vulnerable Families Partnership. Through a partnership among Building Changes, the Department of Commerce and the Department of Social and Health Services (DSHS), and with financial support from the Bill and Melinda Gates Foundation, was launched in the fall of 2012 and seeks to align strategic plans, policy, and resources related to housing, homelessness and poverty to achieve significant and long-lasting community and system-wide change.

Role of Philanthropy in Health Care Reform In part due to the rich dialogue across a wide spectrum of stakeholders and across the public, private, and philanthropic sectors during the development of the health policy initiatives outlined above, the Health Philanthropy Partners (HPP) of Washington State was formed in 2012. HPP operates as a coalition organization under the leadership of Empire Health Foundation21; its stated purpose is “to collectively influence a rapidly changing health care system. Member organizations recognize that government plays a central role in directing systemic change, but believe that private foundations can add great value due to their ability to flexibly target funds to specific needs.”22 Building Changes participated with HPP in some of its initial efforts and continues that participation as the coalition further defines the collective impact they want to achieve and strategies to most effectively accomplish that impact.

The Affordable Care Act and Vulnerable Families The Affordable Care Act contains numerous provisions that are designed to affect all aspects of health care system reform, including requiring individuals to purchase insurance, reforming private insurance markets, promoting innovative ideas to contain costs, improving the quality of health system performance, and expanding public programs. The following two sections of this issue brief provide a general summary of key ACA provisions that will both impact and offer opportunities for vulnerable families. Specific implementation strategies being pursued in Washington State are described beginning on page 15.

20

Ibid. 21

Empire Health Foundation is an independent, nonprofit grant-making foundation that serves seven counties in eastern Washington, for more information see: http://empirehealthfoundation.org/ 22

Additional information on Health Philanthropy Partners can be found at their website: http://hppwa.net/

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Section II: ACA and Access to Health Care Coverage and Care Reducing the number of uninsured individuals in the United States by providing access to affordable health care coverage lies at the heart of the ACA. The percent of the United States non-elderly population (age 0-64) that is uninsured is 17.9%; within the Washington State population 16.1% are uninsured.23 The uninsured population is comprised predominantly of individuals in working families with low or moderate incomes:

Over 75% are in employed households

38% have incomes below the federal poverty level (FPL) - $23,550 for a family of four in 2013

90% have incomes below 400% FPL - $94,000 for a family of four in 201324 Individuals of color are over represented in the uninsured population. While the uninsured rate amongst non-elderly Whites is 13%, the rate for Hispanics is 32%, for American Indian/Alaskan Natives 27%, for Blacks 21% and for Asians/Pacific Islanders 18%.25 Lack of insurance coupled with limited financial resources serves as a major barrier to receiving needed health care and can result in severe consequences. “The uninsured … are less likely than those with insurance to receive preventive care and services for major health conditions—which leads to more serious health problems for many and significantly higher mortality rates.”26 When the uninsured do seek care it often results in large medical bills, which in turn leads to significant debt placing additional stress on families with already limited incomes. The ACA seeks to provide access to affordable health care coverage and services for the current uninsured population through two primary health system reforms—expansion of Medicaid eligibility to those with incomes below 133% FPL27 and the provision of federal subsidies to assist those between 100% and 400% FPL to purchase health insurance coverage through a health insurance exchange. Of particular note, ACA coverage expansions offer “… an important opportunity to increase coverage among communities of color and advance efforts to achieve greater equity in health coverage.”28 It should also be noted that nearly 20% of the uninsured are non-citizens, including both individuals who are lawfully present and those who are undocumented immigrants.29 Legal immigrants who have resided in the country for less than five years and undocumented immigrants are currently ineligible for federally funded health coverage and remain ineligible under the ACA.30 Addressing how to best meet the health care needs of this population post implementation of the ACA warrants further exploration.

23

U.S. Census Bureau, 2011 American Community Survey 24

Kaiser Family Foundation (KFF) (Sept. 2012), Five Facts About the Uninsured Population, available at: http://www.kff.org/uninsured/upload/7806-05.pdf 25

Kaiser Commission on Medicaid and the Uninsured (KCMU) (March 2013), Health Coverage by Race and Ethnicity: The Potential Impact of the Affordable Care Act, available at: http://www.kff.org/minorityhealth/upload/8423.pdf 26

Ibid. p. 1. 27

Current Medicaid income disregards are replaced by a 5% income disregard, which makes the effective income eligibility level 138% FPL. 28

Ibid. 29

Ibid. 30

Ibid.

9

Overview of ACA’s Medicaid Expansion Provision Under current law, Medicaid is primarily provided to low-income children, parents, pregnant women, seniors, and persons with disabilities—and each group has different income eligibility criteria and standards. As originally enacted in ACA, the Medicaid expansion provision changed the Medicaid program by requiring states to expand eligibility to a new population (low-income childless adults), and to raise the mandatory income eligibility level for other adult populations (jobless and working parents) to 133% FPL effective January 1, 2014. This represented the single largest eligibility expansion since the Medicaid program was implemented in 1965.31 However, as part of the Supreme Court’s decision on the constitutionality of the ACA issued in June 2012, the Court ruled that, as written, the Medicaid expansion provision violates the Constitution. In response, the Court stipulated that the federal government is precluded from withdrawing a state’s existing Medicaid funds based on the state’s refusal to comply with the expansion. The Court’s final ruling on the Medicaid provision effectively allows states to choose whether to participate in the Medicaid expansion. Determination of income for individuals who qualify for Medicaid under expansion will be based on the Modified Adjusted Gross Income (MAGI) standard, which differs from the categorical eligibility determinations of the traditional Medicaid program and is more aligned with calculation of income for Internal Revenue Services (IRS) income tax filing purposes. Once standard income deductions are applied, persons with income below 133% FPL, who are not otherwise eligible for Medicaid, will qualify for the expansion program. The law also includes a 5% income disregard, making the effective income rate 138% FPL.32 Based on 2013 poverty level thresholds, this means that individuals with annual income up to $15,856 and a family of four with income up to $32,499 will potentially be eligible for Medicaid.33

31

Medicaid and the State’s Health Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline, Congressional Research Service (August 19, 2010). 32

In the current Medicaid program, a state determines the gross income and resources of the applicant, and then deducts certain items which may be disregarded (e.g., earned income, child care income, etc.). Under the expansion, most current income disregards are replaced by a 5% income disregard. 33

U.S. Dept. of Health & Human Services, 2013 Poverty Guidelines available at: http://aspe.hhs.gov/poverty/13poverty.cfm

Medicaid Expansion:

What ACA Offers/Mandates:

States have the option to expand Medicaid eligibility to all individuals whose income falls below 133% FPL. The federal government will fund 100% of the cost to cover this expanded population for first 3 years (2014-2016) and a minimum of 90% of the cost thereafter.

Implications for Vulnerable Families: Majority of vulnerable families will be eligible for Medicaid as a stable source of health insurance.

Challenges: Assuring vulnerable families are aware of and have access to Medicaid; implementing health care delivery strategies that meet their needs; ensuring stable long-term funding for expansion.

Opportunities: Using housing and service systems to connect vulnerable families to Medicaid; convening housing/social service and health care systems to share information, identify common goals and develop strategies and practices to better coordinate services for vulnerable families.

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The federal government will provide 100% funding for the cost of care for the newly eligible Medicaid population for three years (2014‒2016). After 2016, the funding will gradually be reduced to 90% by 2020 and is expected to hold at 90% thereafter. States are responsible for covering the percent not paid by the federal government, as well as their traditional share of the administrative costs of providing coverage to the new population. It is important to note, however, that the new federal match rates only apply to the “newly eligible” or those who do not qualify for Medicaid under the traditional Medicaid categories. If a person applies for Medicaid after 2014, and is found to be eligible for the traditional programs, the state will only receive the regular match rate for the new enrollee (Washington’s FY2012 match rate is 50%, meaning the federal government pays 50% of medical costs and the state pays the remaining 50%).

Overview of Subsidies to Purchase Health Care Coverage Starting in 2014, individuals and families with incomes between 100% and 400% FPL who are not eligible for other affordable34 coverage will be eligible for a federal premium subsidy for purchase of insurance coverage through a qualified health insurance exchange. The amount of subsidy an individual will receive is based on two key factors: 1) the cost of a specified level of insurance plan,35 and 2) the individual’s income. Subsidies will be calculated to assure that the cost to purchase the specified level of insurance plan does not exceed a set percentage of income adjusted for family size. The income levels and percentage caps are:

Health Insurance Premium Subsidies

Income Level Premium as a % of Income

Up to 133% FPL 2% of income

133-150% FPL 3-4% of income

150-200% FPL 4-6.3% of income

200-250% FPL 6.3-8.05% of income

250-300% FPL 8.05-9.5% of income

300-400% FPL 9.5% of income

34

If an individual is offered employer-sponsored coverage but is not enrolled in the coverage and if the individual’s required contribution toward the plan premium would exceed 9.5% of their household income, or if the plan pays for less than 60%, on average, of covered health expenses, then the individual is determined to not have access to minimum affordable coverage. 35

Defined plan is the second lowest cost “silver plan” in the exchange; a silver plan provides all defined essential health benefits and on average pays 70% of the cost of covered benefits.

11

To assist qualified individuals in accessing health insurance coverage, a central feature of the ACA is the creation of health insurance exchanges—marketplaces in which consumers shop for, compare, and enroll in health insurance plans. States are provided the option to establish a state-based exchange, but for states that decline that option, the federal government will establish a federally based exchange to provide access to health plans for individuals in those states.36 Health insurance exchanges are required to coordinate the administration and provision of benefits with the state Medicaid and Children’s Health Insurance Program (CHIP) Programs and any other state administered health programs.37 Federal funding has been available to fund the design and development of state based exchanges and their initial year of operation (2014); the ACA provides that by 2015, exchanges must be self-supporting. Recognizing that simply creating an exchange would not be sufficient to encourage participation of eligible individuals, and that some individuals may experience difficulties in utilizing this new technological approach to seeking health insurance, the ACA also included provisions requiring state and federal health insurance exchanges to establish a Navigator program.38 Navigators will be responsible for:

Conducting public education activities to raise awareness of plans provided on the exchange;

Providing complete, fair, and impartial information during enrollment, including availability of tax credits;

Facilitating health plan enrollment;

Providing referrals for enrollees who have grievances, complaints, or questions regarding enrollment or coverage; and

Providing information in a culturally and linguistically appropriate manner.39

Federal funding is prohibited to be used to cover the cost of exchange navigator services; however, concerns have arisen that during the initial implementation of exchanges there will be insufficient resources to support assisting the large number

36

KCMU (April 2010) Explaining Health Reform: Questions About Health Insurance Exchanges 37

Affordable Care Act § 1331 (c) (4): Coordination with Other State Programs 38

Affordable Care Act § 1311 (i): Navigators 39

Ibid.

Health Insurance Subsidies:

What ACA Offers/Mandates:

Individuals with incomes between 134% and 400% FPL will be eligible for financial support to purchase health insurance through a one-stop, on-line insurance exchange or marketplace. Plans must cover 10 essential health care benefits.

Implications for Vulnerable Families: Provides greater health insurance stability for low and moderate-income families to assist with on-going or crisis health care needs and minimize health care related financial debt.

Challenges: Assuring that individuals are aware of and access insurance and subsidies through the exchange; undocumented immigrants and legal immigrants of less than 5 years remain ineligible; adult dental and vision care is not an essential health care benefit.

Opportunities: Using housing and service systems role as Navigators and In-Person Assisters to connect individuals to coverage through the exchange.

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of individuals who will be seeking benefits. To address this concern, the federal government has made additional grant funding available through September 2015 for in-person assisters; “assisters will be allowed to help consumers file applications, obtain eligibility determinations, report changes in status, compare coverage options, and select and enroll in qualified health plans.”40

Essential Health Benefits In order to address access to “care” in addition to coverage, the ACA included provisions for the establishment of a baseline comprehensive package of items and services that all small group and individual health plans must provide effective January 2014. This package is referred to as Essential Health Benefits (EHB). Ten categories of services41 comprise the EHB:

1. Ambulatory services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment42 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care

All 10 categories must also be offered in the Medicaid benefit package provided to the expansion population.

ACA Changes to Existing Medicaid Program While the Supreme Court ruling allows states to opt out of the Medicaid expansion, other ACA provisions affecting existing Medicaid eligibility and application processes remain mandatory and were developed to increase the participation of eligible individuals in the program. National estimates are nearly one-third of currently eligible individuals are not enrolled in Medicaid.43 A major reason cited for non-enrollment is the complexity of current eligibility rules and processes. As such, specific provisions focus on simplifying and streamlining Medicaid applications and determination of eligibility44 including:

Requiring use of a standard application form for both Medicaid and the health insurance exchange so individuals are informed of and screened for both coverage options;

40

Families USA (Jan. 2013), Filling in Gaps in Consumer Assistance: How Exchanges Can Use Assisters available at: http://familiesusa2.org/assets/pdfs/health-reform/How-Exchanges-Can-Use-Assisters.pdf 41

Affordable Care Act § 1302 (b) (1): Essential Health Benefits 42

The ACA expands the requirement to comply with federal behavioral health parity provisions to individual and small group plans effective in 2014. 43

KFF (Sept. 2012), Five Facts About the Uninsured Population 44

The simplified application and eligibility determination provisions do not apply to Medicaid applicants or recipients who qualify based on age (age 65+) or disability.

13

Simplified income calculation methodologies;

Elimination of consideration of any assets;

Use of paperless electronic processes to verify eligibility (income, citizenship, etc.); and

Providing for continuing eligibility for 12 month periods. The net result of these changes will be increased enrollment in Medicaid, even in a state that chooses not to expand eligibility. This group of enrollees is often referred to as the “woodwork population”; in Washington State they are referred to as the “welcome mat population”. Education and outreach to this population through existing housing and service providers, especially coordinated entry systems, will be needed to inform them of the ACA changes and encourage their participation.

Section III: ACA and Improving Health Care Service Delivery

Center for Medicare and Medicaid Innovation The ACA created the Center for Medicare and Medicaid Innovation (CMMI) within the Center for Medicare and Medicaid Services (CMS) with an expressed purpose to test “innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care” for recipients of Medicare, Medicaid, and CHIP.45 Among the major health care innovations that CMMI is currently in various stages of testing are efforts to promote accountable care organizations, testing of payment methods that reward quality and value of services as opposed to volume of services, transformation of primary care practice, and coordination of care for individuals who are eligible for both Medicare and Medicaid. The CMMI announced its State Innovation Models (SIM) initiative in the fall of 2012.46 SIM is targeted towards large scale systems change, designed to test “whether new payment and service delivery models will produce superior results when implemented in the context of a state-sponsored State Health Care Innovation Plan” and based on the belief that “because of the unique powers of state governments, Governors and their executive agencies, working together, with key public and private stakeholders and the Centers for Medicare & Medicaid Services can accelerate community-based health system improvements, with greater sustainability and effect, to produce better results for Medicare, Medicaid, and CHIP beneficiaries.”47 To receive funding, states must develop and submit a State Health Care Innovation Plan detailing the comprehensive and system-wide reforms they will implement. Washington State developed and submitted an Innovation Plan which is described further on page 19.

Health Homes Section 2703 of the ACA provides states with a Medicaid State plan option to receive enhanced federal financial support48 for the provision of health home services to eligible children and adults with chronic conditions. This provision became effective on January 1, 2011 and is designed to further efforts to

45

Affordable Care Act § 3021 (a); for more information see: http://innovation.cms.gov/about/index.html 46

See: http://innovation.cms.gov/initiatives/State-Innovations/ 47

CMMI, SIM request for proposal, available at: http://innovation.cms.gov/Files/x/StateInnovation_FOA.pdf 48

States that secure approval of a Health Home SPA are eligible for federal match of 90% for authorized health home services for the first 8 quarters.

14

improve health care access, quality and efficiency through a health home service delivery model. The model must provide comprehensive and coordinated medical, behavioral health, and social supports and services. Health home services for which enhanced federal funds are available include:

Comprehensive care management;

Care coordination and health promotion;

Comprehensive transitional care from inpatient to other settings, including appropriate follow-up;

Individual and family support, which includes authorized representatives;

Referral to community and social support services, if relevant; and

The use of health information technology to link services, as feasible and appropriate. Washington State will be seeking approval of a 2703 Health Home State Plan Amendment as a central component of its health care reform efforts.

Innovative Models and Health Homes:

What ACA Offers/Mandates: Funding is provided to public agencies, health care providers, and communities to develop and test new approaches to financing and delivering health care. The health home model recognizes that health and social service needs are interrelated and the need for greater service and integration across medical, behavioral health and social services; a central component of health homes is comprehensive care management.

Implications for Vulnerable Families: Families facing complex health and social service needs can choose a health home to assist them in receiving and integrating a range of services and supports across systems and places them at the center of care planning and decision making.

Challenges: Operationalizing “comprehensive care management” and the assessment, referral, and service coordination mechanisms that will be required at the local and state level.

Opportunities: Greater coordination of health and social services at all levels can prevent individuals from “falling through the cracks” between systems, identify and address gaps in care, avoid duplication of services and costs, and result in improved health outcomes on an individual and population level.

15

Section IV: ACA Implementation Efforts in Washington State The State of Washington has been actively engaged in implementation of the ACA since immediately following its passage in 2010. These efforts were begun under the Gregoire Administration and continue under the administration of Governor Jay Inslee. House and Senate members from both parties have sponsored and secured passage of several major pieces of legislation in the past two sessions that provide both statutory authority and appropriations to support implementation. Additional statutory and budgetary provisions are under consideration in the 2013 legislative session.49 Implementation of health care reform efforts addressed in this issue brief requires efforts by four entities and a tremendous amount of coordination across their efforts. The entities and their major responsibilities are reflected in the following chart:

Responsible Entity Key Implementation Responsibilities (Medicaid Expansion, Exchange, Delivery System)

Health Care Authority (single state Medicaid agency)

Design and implementation of Medicaid expansion policy, process, fiscal, and operational requirements Collaborating with the Governor’s Office and DSHS in convening public and private providers and stakeholders and leading efforts to design and support the implementation of innovative health care delivery system reform efforts

Department of Social and Health Services Modification of existing Medicaid eligibility determination systems to match new streamlined and simplified eligibility rules. Collaborating with the Governor’s Office and HCA in convening public and private providers and stakeholders and leading efforts to design and support the implementation of health care delivery system reform efforts

Health Benefit Exchange (public-private partnership)

Design, development and operation of the health insurance exchange

Office of the Insurance Commissioner (statewide elected official)

Development of requirements, approval of and oversight of insurance plans to be offered through the health insurance exchange

49

Enacted legislation will be detailed more fully in the next issue brief which will be produced after the scheduled end of the 2013 Session.

16

Medicaid Expansion in Washington State While the 2013 Legislature has yet to make a final budgetary determination authorizing the expansion of Medicaid eligibility, all indications are that the final 2013-15 Biennial Budget will include this authorization. Medicaid expansion was recommended in Governor Christine Gregorie’s original 2013-15 budget proposal, released in December 2012, and has been further endorsed by Governor Jay Inslee in his Budget Priorities for a Working Washington released on March 28th. House and Senate Democratic and Republican leadership have publicly expressed support for the expansion and it is included in the initial budgets passed by both chambers. With respect to implementation of the Medicaid expansion, as lead implementation agency, HCA has expressed the following goals:

Leverage new federal financing opportunities to ensure that the Medicaid expansion is sustainable

Maximize use of technology to create a consumer-friendly application/ enrollment/ renewal experience

Maximize continuity of coverage and care as individuals move between subsidized coverage options

Reform the Washington way—comply with, or seek waiver from, specific ACA requirements related to coverage and eligibility, as needs are identified50

Who is likely to be included in the Medicaid expansion population in Washington? Estimates are that 16.1% of the Washington State non-elderly population is uninsured including approximately 97,200 children/youth age 0-18 and 948,300 adults age 18-64.51 Similar to the uninsured in the United States as a whole, Washington’s uninsured are individuals with low to moderate income:

40% have incomes below 138% FPL

17.2% have incomes between 139 and 200% FPL

29.7% have incomes between 200 and 400% FPL

12.8% have incomes above 400% FPL52 Most, if not all, uninsured vulnerable families will be eligible for Medicaid after 2014. Differences in how median income and poverty levels are defined and calculated prevent a direct comparison in estimates. However, based on the 2012 estimated state median income for Washington of $56,44453, a family making 30% of median income ($16,933) would likely fall below 138% FPL.

50

50

HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee (Jan. 18, 2013), available at: http://www.hca.wa.gov/documents/legreports/011813_house_health_medicaid_expansion.pdf 51

U.S. Census Bureau, 2011 American Community Survey 52

HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee Jan. 18, 2013. 53

See http://www.ofm.wa.gov/economy/hhinc/medinc.pdf

17

For the 40% of Washington’s uninsured population that have incomes below 138% FPL, it is helpful to differentiate them into two groups. A portion of this population would be eligible for Medicaid under the current program—this group is referenced as “currently eligible but not enrolled”. The remainder will be eligible under the Medicaid expansion and are referenced as “newly eligible”. Current estimates for these two populations, and their expected enrollment rates, are reflected in the following chart from the Health Care Authority.

Note: Analysis forecast assumes full take up rate and the ACA was in effect in 2011. **Includes individuals who have access to other coverage (e.g. employer sponsored insurance). Sources: The ACA Medicaid Expansion in Washington, Health Policy Center, Urban Institute (May 2012); The ACA Basic Health Program in Washington State, Health Policy Center, Urban Institute (May 2012); Milliman Market Analysis; and Washington Health Care Authority for Medicaid/CHIP enrollment. From: Washington State Health Care Authority, Health Reform Implementation Presentation, available at: http://www.hca.wa.gov/hcr/me/Pages/stakeholdering.aspx

The expected enrollees from the “currently eligible but not enrolled” and “newly eligible” populations differ in key demographic characteristics. The currently eligible but not enrolled population is younger, predominantly children and adult parents, while the newly eligible population is overwhelmingly adults and typically childless adults.54 55 As indicated in the following chart, health status also differs slightly between the currently eligible but not enrolled and newly eligible populations in Washington State.56

54

HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee Jan. 18, 2013. 55

KCMU (April 2010), Expanding Medicaid under Health Reform: A Look at Adults at or below 133% of Poverty 56

HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee Jan. 18, 2013

0

200

400

600

800

1000

1200

CurrentEnrollees

Currently Eligiblebut Not Enrolled

Newly Eligible Eligible forSubsidies in the

exchange

2012 2014 2014-2017

Current and Projected Medicaid Enrollment

Total Eligible

Likely to Take Up

Currently Enrolled(Medicaid)

Currently Enrolled(CHIP)

Ind

ivid

ual

s (i

n t

ho

usa

nd

s)

1.16 million current enrollees

545,000 currently eligible but not enrolled

494,000 newly eligible

Exchange Take Up Est. (2013) 2014 - ~280,000 2015 - ~344,000 2016 - ~408,000 2017 - ~471,000 532,000 total eligible

78,000 250,000 471,000

18

Washington State Uninsured Population with Incomes below 138% FPL

Expected to Enroll in Medicaid

Currently Eligible/Not Enrolled Newly Eligible

Number Percent Number Percent

AGE:

0-18 49,115 63% 5,512 2.2%

19-24 2,400 3.1% 80,037 32%

25-44 23,281 29.9% 75,553 30.2%

45-64 3,117 4% 89,206 35.6%

HEALTH STATUS:

Excellent to Good 58,726 75.4% 180,407 72.1%

Fair to Poor 19,187 24.6% 69,901 27.9%

Source: HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee (Jan. 18, 2013)

Health Insurance Exchange Washington State was among one of the first states to enact legislation authorizing the creation of a state-based health insurance exchange with SB 544557 in 2011. The exchange was created not as a state agency, but rather as a “public-private partnership” governed by an 11-member Board.58 Additional legislation enacted in 2012, ESSHB 2319,59 provided further guidance for operation of the exchange as well as regulatory provisions pertaining to insurance plans that will be available on the exchange and the benefits they will provide. Statutory provisions covering the on-going source and amount of financing for operation of the exchange after 2015 will be enacted in 2013.60 The official name adopted for Washington’s exchange is the Washington Healthplanfinder and it is designed to be “…an easily accessible, online marketplace for individuals, families and small businesses to compare and enroll in qualified health insurance plans.”61 Washington Healthplanfinder is scheduled to begin operation and accept applications October 1, 2013; plan coverage will begin January 1, 2014.

57

Available at: http://apps.leg.wa.gov/documents/billdocs/2011-12/Pdf/Bills/Senate%20Passed%20Legislature/5445-S.PL.pdf 58

For current Board membership, see: http://wahbexchange.org/board/ 59

Available at: http://apps.leg.wa.gov/documents/billdocs/2011-12/Pdf/Bills/Session%20Laws/House/2319-S2.SL.pdf 60

HB 1947: Concerning the operating expenses of the Washington health benefit exchange 61

Washington Healthplanfinder FAQs, available at: http://wahbexchange.org/about-the-exchange/frequently-asked-questions/

19

As discussed earlier in this brief, Washington Healthplanfinder is required to coordinate its operation with the state Medicaid and CHIP programs. The interface between the new exchange and Washington Connections, the current web-based avenue for applying for state benefits including Medicaid and CHIP, is one of the implementation challenges facing the Exchange and how it is addressed will have a significant impact on vulnerable families and all low-income individuals. The more seamless the interface, the greater likelihood individuals will have of actually being connected with the coverage they are eligible for. The Health Benefit Exchange is currently seeking qualified entities to serve as “In-Person Assister Lead Organizations organized by county service areas or by specified target populations”.62 In-Person Assisters are scheduled to be available when Washington Healthplanfinder begins accepting applications on October 1, 2013. These Lead Organizations and the individuals/entities they engage or contract with to perform in-person assistance services will be a critical link to assuring vulnerable families are informed of and connected to Washington Healthplanfinder.

Who is likely to enroll in health insurance through Washington Healthplanfinder? As previously noted, 16.1% of the Washington population under age 65 is uninsured and 40%, including most vulnerable families, have incomes that will qualify them for Medicaid. An additional 46.9% of the uninsured have incomes between 138% and 400% FPL making them eligible for insurance subsidies through the exchange.63 The State has estimated that 532,000 individuals will be eligible for federal subsidies to assist them with purchasing insurance on the exchange. Of that number, current estimates are that 280,000 will enroll in coverage through the exchange in its first year (2014) rising to 344,000 by 2015, 408,000 by 2016 and 471,000 by 2017.64

CMMI State Innovation Model Initiative Washington State, with support from Health Philanthropy Partners, submitted a State Health Care Innovation Plan65 through the CMMI State Innovation Model (SIM) process in September 2012. In its proposal, the State sought to strengthen and expand quality collaboratives that have been developed as a part of its health care reform efforts and to convene health care payers, providers and stakeholders across the state to further efforts to meet what has been referred to as the “Triple Aim” challenge of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care”.66 On February 21, 2013, Washington State was notified that it was one of three states selected to receive a “pre-testing” award of $1 million from CMMI.67 Funding will be used to more fully develop and re-

62

For all procurement documents see: http://wahbexchange.org/health-benefit-exchange-procurements/ 63

HCA, 2014 Medicaid Expansion Progress, presented to House Health Care and Wellness Committee Jan. 18, 2013 64

Washington State Health Care Authority, Health Reform Implementation Presentation, available at: http://www.hca.wa.gov/hcr/me/Pages/stakeholdering.aspx 65

See: https://docs.google.com/a/empirehealthfoundation.org/file/d/0BGwHpCq3bGLc3hCUnhEcWZfVGM/edit?pli=1 66

Ibid. Submittal letter of Governor Chis Gregoire. 67

6 states (Arkansas, Maine, Massachusetts, Minnesota, Oregon and Vermont) received model testing funding ranging from $33 to $45 million for the next 42 months. The other states receiving pre-testing funds were Colorado and New York. 16 additional states received design funding to initiate development of their State Health Innovation Plans.

20

submit the Washington State Health Care Innovation Plan for future model testing funding. The Health Care Authority announced selection of a consultant68 to lead the efforts to update the Health Care Innovation Plan. The update process provides an opportunity for a wide range of stakeholders as well as public and private partners to provide input between April and September of this year.69 This opportunity can and should be utilized to assure the needs of vulnerable families are recognized, understood, and addressed.

Health Homes Washington State’s efforts to implement health homes predated the enactment of the ACA. Efforts by the State Legislature, the Department of Health, HCA, and DSHS in 2008 and 2009 laid the groundwork for a broader scale implementation, including a learning collaborative to assist primary care practices seeking to transition to a health home model as well as the development of innovative payment models to support the health homes. Based on the success of these developmental steps and the passage of the ACA, SB 5394 was enacted in 2011. Under this legislation, contracts for Medicaid, Basic Health, and Public Employees health benefits are required to “…include provisions in contracts that encourage broad implementation of primary care health homes”.70 The targeting of health home services on “enrollees with complex, high cost, or multiple chronic conditions” was also authorized.71 HCA and DSHS have been working collaboratively to design a comprehensive and coordinated approach to providing health home services for all high need populations. Extensive stakeholder input and involvement during 2011 and 2012 resulted in the development of HealthPath Washington, a comprehensive blueprint to achieve the vision of true integration of care across health and social services.

68

Consultant retained by HCA is Karen Merrikin; for announcement see: http://www.hca.wa.gov/Releases/HCA%20selects%20Karen%20Merrikin%20as%20leader%20for%20the%20Innovations%20Model%20Grant.pdf 69

HCA contract K739, Exhibit B—Statement of Work, See: http://www.hca.wa.gov/rfp/K739/Consultant%20for%20Health%20Care%20Delivery%20System%20Reform%20Plan.pdf 70

SB 5394 Final Bill Report, p. 2. Available at: http://apps.leg.wa.gov/documents/billdocs/2011-12/Pdf/Bill%20Reports/Senate/5394-S%20SBR%20FBR%2011.pdf 71

Ibid.

Integrated Care: MUST:

Be delivered by teams that coordinate medical, behavioral, and long-term services and supports

Be provided by networks capable of meeting the full range of needs

Emphasize primary care and home and community-based service approaches

Be based in organizations that are accountable for costs and outcomes

AND MUST:

Provide strong consumer protections that ensure access to qualified providers

Respect consumer choices in the supports they receive

Unite consumers and providers in eliminating use of unnecessary care

Align financial incentives to impel integration of care. Source: DSHS/HCA, HealthPath Washington: Medicare and Medicaid Integration Project, presented to House Appropriations Subcommittee on Health & Human Services (February 6, 2013)

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Implementation of the Medicaid health homes under Section 2703 of the ACA described earlier is being coordinated with the implementation of health homes for seniors and disabled individuals who are dually eligible for Medicare and Medicaid under a separate ACA option that Washington has also been selected to participate in.

Health homes will be phased in across the state based on “health home network coverage areas” which consider, among other factors, the need for and current efforts to integrate services at the local service delivery level.72 Within each area, “qualified health homes” will be competitively selected to deliver health home services either directly or through contracts with appropriate providers. The first area to implement health homes will be Pierce County, with implementation scheduled for July 2013. Qualified health home providers selected for Pierce County (Coverage Area 4) include United Healthcare of Washington, Inc., United Behavioral Health (Optum Pierce), Community Health Plan of Washington, and Coordinated Care Corporation.73 Requests for Proposals for qualified health homes to serve Coverage Area 5 (Clark, Cowlitz, Klickitat, Skamania, and Wahkiakum Counties) and Coverage Area 7 (Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walls and Yakima Counties) are currently being solicited.74

A map reflecting all health home network coverage areas is available at http://www.hca.wa.gov/documents/health_homes/HHNetworkCoverageAreas.pdf and reproduced below.

72

DSHS/HCA, HealthPath Washington: Medicare and Medicaid Integration Project, presented to House Appropriations Subcommittee on Health & Human Services. February 6, 2013 73

See: http://www.hca.wa.gov/pages/rfp.aspx 74

For a complete schedule see: http://www.hca.wa.gov/Documents/health_homes/HHReleaseSchedule.pdf

22

As with any new model of service delivery, it will be critical to evaluate outcomes for individuals served by health homes and essential to clearly define desired outcomes and associated performance measures. Legislation currently working its way through the 2013 Legislature calls on the HCA and DSHS to establish and incorporate processes outcomes and performance measures related to health care service coordination into their contracting.75

Section V: Identification of Connecting Points for Further Exploration An initial examination of the intersections that are emerging between Building Changes’ work to end family homelessness and health care reform has revealed five “connecting points” that warrant further exploration.

75

HB 1519, Establishing accountability measures for certain health care coordination services.

CONNECTING POINTS

Building Changes

Intermediary Role

Washington

Families Fund (WFF)

WFF Systems

Change Initiative

Washington Vulnerable

Families Partnership

Health Reform Implementation

in WA State

Medicaid Expansion

Health Insurance Exchange

Health Homes

Common Beneficiaries

Common Vision/Principles

Common Change Allies & Targets

Focus on Evaluation & Shared Learning

Developing Role of Philanthropy

23

Connecting Point 1: Common Beneficiaries of System Reform Efforts The obvious common denominator of system change efforts by both Building Changes and health care reform in Washington is the individuals and families who face economic, social, and personal hardships that bring them into contact with public and private services and are vulnerable to homelessness. These individuals and families are touched and impacted by reform efforts seeking to prevent and end homelessness as well as health care reform efforts. Maximum positive impact is possible if these efforts are complementary and coordinated. Done well, these efforts present great opportunities for vulnerable individuals and families. Done poorly, or in an uncoordinated manner, they can pose great risks. Breaking down silos within existing health and human service systems only to create new ones between them will prevent vulnerable individuals and families from accessing needed services and runs the risk of reducing the effectiveness of overall system change efforts. Drawing upon its experiences with other reform efforts addressing vulnerable families and proven strategies such as coordinated entry, Building Changes can play a pivotal role in making sure vulnerable families and their needs are recognized and represented in health care reform policy discussions and implementation efforts. Encompassed in this must be attention to vulnerable families who will remain ineligible for publicly funded health care benefits due to their citizenship and immigration status and continuing to seek the most effective ways to meet their health care needs.

Connecting Point 2: Common Principles and Vision Guiding System Reform Efforts There are clear areas of similarities in the approaches to system reform employed by both Building Changes and state health care reform leaders and participants as well as the theories of change on which they are based. While different terminology may be used, common elements include:

A focus on prevention

Coordinated entry into and seamless transitions within service continuums

Comprehensive assessment of personal, economic, and social needs of vulnerable individuals and families

Services and service delivery approaches that allow for tailored or individualized services and timely access to right services at the right time and at the right levels

Process and outcome focused evaluation of reform efforts to inform policy, practice, and resource allocations

Connecting Point 3: Common Change Allies and Targets The success of Building Changes in achieving system change is in part due to its willingness to seek and to accept help from “allies” who have a common recognition of the need for change and are willing to collaborate in drawing attention to that need and advocating for action. The allies that Building Changes seeks to connect with include organized philanthropy, housing and service providers and the people they serve, as well as policy and advocacy agencies and coalitions. Increasingly, those ally relationships have expanded beyond the traditional realm of housing and homeless service providers to mainstream

24

public agencies providing public assistance benefits (TANF, Basic Food, early learning and child care), child welfare services, as well as education and employment services. As noted earlier, there is an emerging recognition of the need to expand even further to form ally relationships with agencies and providers that provide health and behavioral health services. As health system reform efforts are evolving, there is a growing recognition that traditional allies in the health care system—primary care practitioners, specialists, health clinics, hospitals—will be insufficient to achieve the broad scale reform that is envisioned. Reaching beyond the borders of traditional health care systems must include outreach to and participation by the same set of traditional and emerging allies that Building Changes has relied on in its system change work. Building Changes is uniquely positioned and can assist in convening and making connections between housing, social service and health care providers at a community, regional, and state level and facilitating efforts to identify common and complementary system change agendas.

Connecting Point 4: Evaluation and Shared Learning Evaluation is one of the key strategies employed by Building Changes in its system change work. Independent process and outcome evaluation accompanies all initiatives and is thoroughly embedded in all grant making activity of the organization. Evaluation efforts often form the basis for convening stakeholders to receive and collectively learn from the data and findings and to use that learning to improve future strategies and activities. Evaluation of process and outcomes is also embedded in implementation of health care reform. The ACA as well as Washington State law and policy calls for rigorous evaluation of the impact of new health care policies, benefits, and delivery systems at the individual and system levels. It will be critical to know whether efforts in fact have increased access to coverage and care amongst the uninsured and if that coverage and care impacts individual and population health outcomes and results in most effective resource utilization. Design and implementation of health care reform evaluative efforts, particularly related to vulnerable families, could benefit from the rich and deep expertise and experience of Building Changes.

Connecting Point 5: Role of Philanthropy in Health System Reform Efforts Major philanthropic entities, the Bill and Melinda Gates Foundation chief among them, have invested significant resources in Building Changes to support their system change efforts. Successful execution of those efforts has garnered Building Changes tremendous respect and trust within the broader Washington State’s philanthropic community. Building Changes increasingly serves as the “linking pin” between philanthropy and public agencies engaged in aligned system reform efforts. Recent examples of such efforts include the Washington Families Fund System Initiative and the Washington Vulnerable Families Partnership. The formation of Health Philanthropy Partners was in part generated by Building Changes and offers yet another possible avenue for serving in a “linking pin” role as state and local public agencies encourage and support involvement of the philanthropic community in health care reform implementation efforts.

25

Next Steps The second component of this project to be completed by June 30, 2013 will focus on further defining and delineating the specific gaps, opportunities, and points of leverage that exist in each of the Connecting Point Areas. Monitoring of action by the 2013 State Legislature related to health care reform as well as that of federal authorities will continue and be integrated into defining opportunities and leverage points. Additional information gathering and analysis as well as internal and external stakeholder interviews will be used to address the following questions and formulate recommendations to Building Changes leadership.

1. Is there alignment between Building Changes’ role as an intermediary and the gaps and opportunities related to the connecting points between health care reform implementation and efforts surrounding family homelessness?

2. If there is alignment: a. What are the specific needs and most effective avenues for this work to follow? b. Who would sanction Building Changes serving in this role and how should that best be

executed? c. What resources will be needed and available to support Building Changes in this role? d. What are the most strategic points of leverage? e. Who are the critical stakeholders and decision makers? f. What other entities are also playing intermediary roles in related system reform efforts

and how should coordination occur?

3. If there is not alignment with a direct intermediary role by Building Changes: a. What other entities have the capacity and willingness to assume that role? b. What role, if any, should Building Changes play in encouraging that to happen? c. What role, if any, should Building Changes assume in assisting alternative intermediaries

meet the identified needs?

4. Regardless of whether Building Changes seeks to assume a lead intermediary role, what is the most advisable continuing role for the organization in relationship to Health Philanthropy Partners and other current or future philanthropic community engagements in health care reform implementation?

26

APPENDIX A: KEY TERMS AND ACRONYMS ACA - Affordable Care Act: Public Law 111-148 enacted March 23, 2010; also referred to as national health care reform ACO - Accountable Care Organization: group of health care providers that provides coordinated care to an assigned population of patients; characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care. ACOs are accountable to their patients and payers for delivering quality, cost-effective health care AMI – Area Median Income: median household income for a specific metropolitan or non-metropolitan area Behavioral Health: mental health and/or substance abuse prevention, treatment and recovery services CMMI - Center for Medicare and Medicaid Innovation: entity created by the Affordable Care Act for the purpose of testing innovative health care payment and service delivery models in the Medicare, Medicaid, and the Children’s Health Insurance Program CMS - Center for Medicare and Medicaid Services: federal agency within U.S. Department of Health & Human Services responsible for administration of Medicare, Medicaid, and Children’s Health Insurance Program EHB – Essential Health Benefits: 10 benefit categories established in the Affordable Care Act and all associated state and federal regulatory provisions including cost-sharing limits and compliance with the federal Mental Health Parity and Addiction Equity Act76 FPL - Federal Poverty Level: income level issued annually by the Department of Health and Human Services and used to determine eligibility for certain programs and benefits HealthPath Washington: State plan detailing the strategic design and implementation approach for integrating medical, behavioral health and long term services and supports for seniors and disabled who are dually eligible for Medicare and Medicaid Heath Home Network Coverage Area: Geographic regions established by the state for implementation of health homes; implementation will be phased in statewide through this regional structure Health Home or Primary Care Health Home: (WA State Statutory Definition) coordinated health care provided by a licensed primary care provider coordinating all medical care services, and a multidisciplinary healthcare team comprised of clinical and nonclinical staff.77

76

ACA Section 1302(a) 77

Revised Code of Washington §74.09.010(8)

27

Health Insurance or Benefit Exchange: an online marketplace where individuals, families and small businesses can compare and purchase health insurance as well as access premium subsidies and public programs such as Medicaid In-Person Assister: a key component of the consumer service function associated with a health insurance exchange; will assist individuals learn about, apply for and enroll in appropriate health insurance coverage MAGI - Modified Adjusted Gross Income: adjusted gross income as calculated under the federal income tax, plus any foreign income or tax-exempt interest received [Adjusted gross income under federal income tax system is an individual’s income less various adjustments and is calculated prior to any itemized or standard deductions, exemptions and credits are applied.]78 Median Household Income: amount which divides households into two segments with one-half earning less and one-half earning more than the amount Multidisciplinary health care team: (WA State Statutory Definition) an interdisciplinary team of health professionals which may include, but is not limited to, medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers including substance use disorder prevention and treatment providers, doctors of chiropractic, physical therapists, licensed complementary and alternative medicine practitioners, home care and other long-term care providers, and physicians' assistants.79 Premium and Cost-Sharing Subsidies: funding to assist low to moderate income individuals purchase insurance coverage through a health insurance exchange80 Primary Care: Health services that cover a range of prevention, wellness, and treatment for common illnesses Primary Care Provider: (WA State Statutory Definition) a general practice physician, family practitioner, internist, pediatrician, osteopath, naturopath, physician assistant, osteopathic physician assistant, and advanced registered nurse practitioner81 QHP - Qualified Health Plan: health plan certified as meeting all state and federal requirements to offer health insurance on a health insurance exchange including coverage for all essential health benefits82

78

Kaiser Commission on Medicaid and the Uninsured, Explaining Health Reform: The New Rules for Determining Income under Medicaid in 2014 (June 2011) available at: http://www.kff.org/healthreform/upload/8194.pdf 79

Revised Code of Washington §74.09.010(13) 80

Kaiser Family Foundation, Explaining Health Care Reform: Questions About Health Insurance Subsidies (July 2012) available at: http://www.kff.org/healthreform/upload/7962-02.pdf 81

Revised Code of Washington §74.09.010(16) 82

ACA Section 1301(a)

28

Vulnerable Families: families who are potentially at risk of homelessness due to family earnings that are less than 30 percent of the Area Median Family Income and spending more than 50 percent of pre-tax income on housing WFF - Washington Families Fund: a public-private partnership providing funding for supportive services and stable housing for families experiencing homelessness Washington Healthplanfinder: official name of Washington State’s health insurance exchange83 “Welcome mat” or “woodwork” population: Individuals who are eligible for Medicaid based on current eligibility policy but who have not submitted an application or enrolled

83

See http://wahbexchange.org/