Health Care Access and Workforce Issues

1. Health Care Access and Workforce Issues A Colorado Perspective April 11, 2012 IPHY 2500: Perspectives in Health and Medicine

2. Today’s Discussion • Being uninsured is an important barrier to care. • Health insurance is just one part of the equation; health workforce is critical. • Health reform provisions aim to address coverage and workforce issues.

3. What is CHI? CHI is the most trusted and leading source of credible health information for Colorado leaders. Our insight is used to: • Inform policy • Contribute to effective implementation • Support state efforts to improve health

4. Our Focus: Stakeholder Communities

5. What determines health?

6. Health Care Expenditures Comprise a Growing Sharing of Our Economy

7. Barrier #1: Financial

8. If Colorado Were Represented by a Room of Six People . . .

9. If Colorado Were Representedby a Room of Six People… About 1 of 6 Coloradans, or 16%, is uninsured. About 4 of 6 Coloradans, or 71%, are adequately insured. About 1 of 6 Coloradans, or 13%, is underinsured. Source: 2011 Colorado Health Access Survey

10. The Importance of Access

11. Table 3.1. Reasons the uninsured reported for lacking health insurance, Colorado, 2009 and 2011 Why Coloradans are Uninsured. . . Source: 2011 Colorado Health Access Survey

12. Cost Matters:Health Insurance Premiums Compared to Other Economic Indicators

13. The Skewing of Health Expenditures

14. If Colorado’s Uninsured Population Was Represented by a Room of 50 People… One figure represents ~15,000 uninsured Coloradans. Adult without dependent children (18-64) Key: Child (0-17) Parent(18-64) Older adult (65+) Source: CHI analysis of the 2010 American Community Survey

15. Age Matters: Uninsured Coloradans by Age Source: CHI analysis of the 2008-09 Colorado Household Survey and the 2011 Colorado Health Access Survey

16. Why Do Kids Have the Lowest Uninsurance Rates? • More generous Medicaid/CHP+ eligibility • 2/3 of uninsured Colorado kids are eligible for Medicaid or CHP+ but not enrolled • Recession:

17. Place Matters:Uninsured Coloradans by Region, 2011

18. Income Matters:Poverty Correlates with Uninsurance Uninsured Rates by Income as a Percentage of Federal Poverty Level, Colorado, 2009 and 2011 1818 Source: CHI analysis of the 2008-09 Colorado Household Survey and the 2011 Colorado Health Access Survey

19. Underinsured Coloradans by Region, 2011 • 19

20. Coloradans Without a Usual Source of Care, 2011

21. What is the Safety Net? • They offer care to patients regardless of their ability to pay for those services; and • A substantial share of their patient mix is uninsured, have Medicaid, or other vulnerability risk factors. Institute of Medicine. 2000. America’s Health Care Safety Net: Intact but Endangered

22. Colorado’s safety net landscape Colorado’s Safety Net Landscape

23. Barrier #2: Provider Availability

24. Health Care Workforce

25. Range of Providers Investment, skills Cost, access

26. Lifecycle of a Health Care Provider C U Later!

27. Finding a Provider: A Long Wait for Some • “Our single limiting factor is recruiting providers. It’s really frustrating and it’s hard to find family physicians…Typically it takes us about a year to recruit one provider.” • -Janet Fieldman, CFO of Pueblo Community Health Center SOURCE: CHI analysis of 2011 Colorado Health Access Survey data PHOTO: Health Policy Solutions

28. Count ‘Em Up How many physicians does Colorado have? NOTES: Colorado providers include practicing/working providers only. SOURCES: Peregrine and CHI analysis of DORA licensure data and 2010 Colorado Advanced Practice Nurse Survey and 2010 Colorado Physician Assistant Workforce Survey

29. Pending Retirements NOTES: Colorado providers include practicing/working providers only. SOURCES: Peregrine and CHI analysis of DORA licensure data and 2005 Colorado Physician Workforce Survey 2010 Colorado Advanced Practice Nurse Survey and 2010 Colorado Physician Assistant Workforce Survey

30. Primary Care Needs of the Future Demand Shortage in 2025:1,034 FTE Supply SOURCE: Colorado Health Institute Primary Care Supply & Demand analysis

31. Is Anybody Here? Licensed physicians per 1,000 population NOTE: Note that providers may work less than full time or not at all. SOURCE: Active licensed Physicians from the Colorado Department of Regulatory Agencies, Jan 3, 2011. Population data from State Demography Office, February 12, 2010

32. Keeping Healthy: Primary Care • SOURCE: Starfield B. (1998). Primary care: balancing health needs, services, and technology. New York: Oxford University Press.

33. $pecialty Choice Wages are 36%-48% greater than for primary care SOURCE: Leigh, JP, et.al. (2010). “Physician Wages Across Specialties.” American Medical Association 170(19):1728-1734.

34. A Provider Who Accepts Your Insurance 54% Do not accept new Medicaid patients SOURCE: Fryer, GE, et al. (1998). “Personal and educational background predictors of physician practice profiles: The case of Colorado.” Evaluation and Programming Planning 21(3): 307-314.

35. Where From Here? Health Reform and the Road Ahead

36. An Important Distinction U.S. HR 3590 Health Reform Alpaca PPACA (or The ACA)

37. An Important Caveat

38. The Road Ahead: Access and Affordability

39. Table 3.1. Reasons the uninsured reported for lacking health insurance, Colorado, 2009 and 2011 Why Coloradans are Uninsured… Source: CHI analysis of the 2008-09 & 2011 Colorado Health Access Survey

40. . . . and How Health Reform Addresses These Issues Reason for being uninsured What does health reform do? Medicaid expansions, premium credits and cost-sharing subsidies, insurance regulations Cost of health insurance is too high Working family member is not offered or eligible for health insurance Employer mandate, small employer tax credit Insured family member lost job or changed employers and lost health insurance Portability of coverage; high risk pools Medicaid expansions, continuous eligibility for Medicaid Lost eligibility for Medicaid or CHP+

41. . . . and How Health Reform Addresses These Issues Reason for being uninsured What does health reform do? Have pre-existing medical condition and cannot obtain health insurance Temporary national high risk pool, prevent denials for pre-existing conditions Do not know how to get health insurance Insurance Exchanges and Education surrounding individual mandate Do not need health insurance Individual Mandate and Employer Mandate

42. Colorado, Post-Health Care Reform Uninsured after HR implementation Uninsured Before HR implementation 800,000 258,000 214,000 153,000 175,000

43. Medicaid, CHP+, and Subsidies in 2014

44. The Individual Mandate and Affordability Source: CHI analysis of 2008-09 COHS Source: CHI analysis of the 2011 Colorado Health Access Survey

45. Shopping for Insurance and the Cereal Aisle Why do we need to organize this marketplace?

46. What is a Health Insurance Exchange? A health insurance exchange is an organized marketplace for customers to shop for health insurance based on price and quality. Like a or for health insurance. It also provides a level playing field for plans to comply with the new consumer protections and benefit requirements.

48. Other Access-related Health Reform Provisions • Physical infrastructure • The ACA allocates $11 billion to FQHCs • Electronic infrastructure

49. Who will still be uninsured? • “The reality is that really only 92% of Americans will be covered…If you think everyone is going to have health insurance, they’re not, even if this bill [The ACA] is implemented perfectly.” • Former Sen. Majority Leader Bill Frist

50. The next frontier: Access to long-term care SOURCE: Colorado State Demography Office, population estimates, 2000-2030