On October 4, the Health Care Council of Chicago, in collaboration with Foxglove Alliance and the Union League Club of Chicago’s (ULCC) Health and Life Sciences Subcommittee, hosted an in-person event about the future of Medicaid expansion in Illinois. A panel of experts discussed the development and implementation of policies to expand Medicaid in Illinois, challenges to enable access to affordable and equitable care, and how providers and policymakers can continue to collaborate to transform the health care system and deliver high-quality care to all Illinois residents.
David Smith, Founder and CEO, Third Horizon Strategies
Panelists: Dan Fulwiler, CEO, Esperanza Health Centers
Cristal Gary, Chief Advocacy Officer, Ascension
Doug O’Brien, Interim President and Executive Director, Rush University Medical Center
Steph Willding, CEO, CommunityHealth
In the News PANELISTS DISCUSS BARRIERS TO IMPROVING CARE FOR ILLINOIS’ MEDICAID POPULATION | Health News Illinois | 10.6.2022 | Article here
FGA HC3 ULCC Illinois Medicaid Expansion Panel | Foxglove Alliance | Post here
David Smith (DS): In 2020, Illinois became the first state to expand Medicaid coverage to undocumented noncitizens. The state policy specifically extended coverage to those 65 and older who would otherwise qualify for Medicaid if not for their immigration status. Lawmakers lowered the age limit to 55 in 2021 and passed a bill this year to lower the age limit even further to 42 years old. Let's talk about these programs – Health Benefits for Immigrant Adults (HBIA) and Health Benefits for Seniors (HBIS) – and how they are/aren’t providing access and coverage to more people in Illinois.
Stephanie Willding (SW): The immigrant population was concerned and apprehensive about enrolling in a government program specifically for the undocumented. With time, that has changed, particularly with the involvement of organizations like CommunityHealth and Esperanza, whose staff are known and trusted by the community. People now seem more eager to enroll and a significant number of people are now eligible for this program. For CommunityHealth, that constitutes about half of our entire patient population. Increased enrollment also increases the paperwork process. Unfortunately, the investment to increase staffing to support this increased enrollment was not a priority. However, CommunityHealth is grateful for partners like Esperanza, who deployed their staff to support the enrollment process.
Dan Fulwiler (DF): Esperanza is a Federally Qualified Health Center (FQHC) which are facilities designed to serve everyone regardless of ability to pay. About 70 percent of Esperanza’s patients have insurance, and about 30 percent are uninsured. About 90 percent of our patients are Hispanic. Nearly half of our Hispanic adult population is uninsured, usually because they are undocumented.
We were extremely excited when we found out about the HBIS program; it turned out that about 500 – 600 of our patients were eligible. We began outreach to people, having our front desk staff talk to qualified patients to engage and help enroll them. When HBIA rolled out, the task became more difficult. Esperanza serves about 50,000 patients a year, of which about 30 percent are uninsured. Nearly half of the uninsured population are between the ages of 42- 65, bringing the total number of eligible patients to approximately 6,000 eligible patients. Enrollment became a heavy lift for our existing staff. Since this was a critical KPI measurement for us – it has positive implications on health outcomes and the bottom line – we hired six additional staff members to support benefits enrollment. Thus far, they are enrolling about 100 people a week. Although many of these enrollees are “undocumented,” the state does require extensive documentation to process their enrollment. Once we have gathered all of their information and completed the enrollment process, it has been life-changing for the patients and our team.
DS: What kinds of documentation are the states looking for? And how is participation in this kind of program shifting the economics for Esperanza?
DF: The program to us is worth several million dollars a year. We estimate it adds about $3 million to our bottom line, which is a positive shift. In terms of documentation, a patient needs to provide everything one would to apply for Medicaid: proof of residency, proof of income, number of family members and co-dependents, and so on. All of these pieces can be difficult for our patients to provide, as some of them may not have a driver’s license, or they may not have gotten the state/city ID that they are eligible for as an undocumented person, in which case they have to provide bills. In some cases, these bills are usually being paid by someone else, so they may not have their name and address on them. It is all these little things that make documentation processing difficult and complicated.
DS: Illinois is one of the only states that has systematically checked all the health care coverage expansion boxes. That said, what other communities are still having eligibility challenges being able to access some form of medical benefit? Having worked with Ascension, what problems are you all running into around the access-coverage issues? Where do you still see opportunity in the state?
Cristal Gary (CG): Illinois now provides coverage for everyone, with the exception of the undocumented population between the ages of 21-42. There is so much that the state is doing well, and I think subsequent governments will continue to chip away at this gap to ensure everyone has coverage. However, coverage doesn’t necessarily mean access.
Ascension Illinois is a health system serving Chicagoland and Chicago Suburbs. We have 10 acute care hospitals; four specialty hospitals, and we primarily serve Medicare and Medicaid patients. There are about 30 percent of commercial patients within the system, and we also serve some undocumented patients. Since the rollout of this program and the growth in Medicaid, particularly during the pandemic, we have seen the number and percentage of undocumented patients we serve to go down. We have helped to enroll just under 800 individuals into the HBIA/HBIS programs. And the data we have suggests that this is having an impact on our bottom line. We have important partnerships with FQHCs and free clinics like Communityhealth because we want our patients to be able to access more ongoing supportive care, including access to regular preventative and primary care services. We need to start thinking more about what it means to care for people who have coverage but do not entirely access it, are underinsured, or have difficulty paying for certain types of care. These are meaningful conversations, but I think that’s the direction we need to go regarding policy conversations.
DS: Coverage is great, and it economizes the capacity to organize resources around families that need them. Access is a whole different ball game. It’s almost like coverage is the easy part. We are not doing great at facilitating access to everything from a primary care physician to addiction services to an endocrinologist. What are the tenets of that conversation, and who will start it?
CG: This is a conversation that isn’t specific to HBIA or HBIS, it is a conversation affecting all of us and is very real. It affects everyone, particularly uninsured individuals who may not have attractive insurance that reimburses at a higher level. There is a huge workforce challenge right now and wait times are ridiculously long. Demand greatly outweighs supply. And that’s not an easy problem to fix right now.
In my role as Chief Advocacy Officer at Ascension Illinois, I am having conversations about what we can do to start addressing the workforce challenge.
Doug O’Brien (DO): We all know the system is fractured. The access issue is system-wide, and so many factors have led to the dysfunction.
We have about 12,000 nursing vacancies in the Chicago metropolitan area we may have about 2,000 - 3,000 nurses available to fill those positions.The pandemic exacerbated this workforce issue and simultaneously made the system value nursing more appropriately. Nurses are getting compensated more appropriately now than before the pandemic, which is a good thing. The problem is that nobody budgeted for it. Nobody could see it coming. Some things have exacerbated the problem among those that have been federal government interventions aimed at reallocating nursing.
Going back to the questions about the conversations we need to be having, we are already having these conversations. I came to Rush from the federal government, and I think we have to look beyond expecting government and policymakers to share their problem-solving wisdom and cure all these ills with us. We need to be innovative within the health care space. We need to roll up our sleeves and develop innovative solutions and partnerships that will change the game.
When I came to Rush, one of the first things I wanted to work on was how to serve the Medicaid population better. Traditionally there are two schools of thought within a health system: 1) folks who are advocates of expanding access and developing social programs and 2) the business folk. These two sides never talk to each other.When we talk about Medicaid, we also talk about equity because that’s where equity lives. And if we are going to really address equity, we need to drill down into how we operationalize that in the context that our health care is currently providing. We can’t be aspirational on either side. People who say we must expand the access, and that’s all that matters, versus people who say we must put more money into the system because we are dying financially. Those are both simplistic and one-dimensional answers. Folks need to sit down and talk to each other about how we do better to coordinate care and ensure that access for patients comes at the right place, at the right time.
I believe that the future to addressing equity and making Medicaid more accessible/functional is for the providers to sit down and collaborate on how care is provided and make sure that there’s a continuum of care starting at the community level. The only way we can drive the outcomes and changes in population health is if the continuum of care collaborates and cooperates. One problem we face is that the system is so disjointed. It is very hard to find those synergies because FQHCs have a different reimbursement structure than hospitals.We literally run into legal impediments for us to sit down and do business together. If we could do that, we could solve many of these problems at the community level, and then they could expand and get some traction.
DS: The mechanisms to have these conversations exist, and we have had them. The problem is that they have rarely yielded much fruit. What do larger institutions, states, counties, and cities need to do differently to show up in those conversations differently?
DO: The financial crisis that we are faced with, coming out of the pandemic, has put a lot of pressure on everyone. I think that one of the things we need to do is get the government to work more collaboratively. We can find solutions if we have a little more leeway from the government, and then they help us make them happen instead of putting up roadblocks.
SW: I think we have a workforce challenge that was not unanticipated. I think it was just accelerated because of the pandemic. I agree that how we collaborate to build cost-efficiency into the entire health care ecosystem is a factor.However, I think that something we are not explicitly mentioning is that we have expanded a Medicaid-like product, but Medicaid reimbursement is pennies on a dollar from private payers. When we talk about structural issues and their impact on access, we are inevitably talking about money. The individuals covered by Medicaid have higher rates of health disparities and higher rates of health conditions, yet we are not putting more funding towards those individuals.
DF: This has been one of my mantras since the beginning of the pandemic: Medicaid is the perfect example of structural racism. It is a racist system. I hate to say that because it’s my government. In Illinois, I think 54 percent of the people on Medicaid are people of color, which is far higher than the percentage of the state, and yet we pay far less for their care as a society than we do for other people.
That is the definition of structural racism when people of color get less than others. That is very uncomfortable, and I think we must push that. I agree that the private sector has a tremendous amount of work to do on this, but there are certain things that only government can do. People at the Department of Healthcare and Family Services (HFS) are not racist. The HFS also has a workforce problem. They are being very ambitious with all these new programs they are rolling out, but they don’t have the people to implement them.
Audience Question: We ought to be in a place where the managed care organizations (MCOs) in the state are taking a different posture in leadership on how we think about program integrity, reimbursement, and driving alignment in incentives and outcomes. What is the role of the MCOs in all of this?
DF: I don’t believe MCOs are part of the solutions. I think the only thing they can do to be part of the solution is to get us claims data in a much timelier fashion. I think the solution is much more about primary care, and not just more but different primary care. We need to think about the different types of people doing care within our system, such as getting people like community health workers involved in solving problems at an individual level. We have been locked in for too long into paying just for doctors’ services. I am excited to see if value-based care can get us there. I don’t think there are any cost savings in value-based care as the system is underfunded. However, the shift around money and paying for things that are going to be less expensive and can get a more effective outcome is a good thing.
Audience comment: When we talk about providers, we should go back to the source and deal with the problem before it becomes an issue; using the community-level health workforce to engage with community members at an individual and family level. Keep it simple.
DS: There’s nothing that prevents MCOs from funding community health workers. Or supporting mid-level care that goes upstream and prevents adverse outcomes downstream. I think the state could be taking a more assertive posture of leadership in being more compulsory about what gets paid for based on evidence and based on driving care into the communities.
DF: I agree, but the problem is that many considerable costs are driven by issues that can’t be solved on the one-year cycle that many of the MCOs work on.Everything is one year…if you save money this year, you’ll get your money back next year. Many things in health care don’t work that way, for example, mental health doesn’t work that way. Also, the money from pay for performance is so little – 3 or 4 percent – which is not a big enough part of the premium to change that.I think it has to come back to the primary care providers who are considering the long-term benefits to the patients.
DO: I believe institutions like Rush need to forge meaningful operational partnerships with FQHCs, but Dan, I am going to disagree with Dan on the role of MCOs. In Illinois, most of the Medicaid money flows through MCOs. However, it is highly politicized. We have missed opportunities to create meaningful structures for the MCOs and providers to work together. We still do not have a straightforward method to adjudicate claims quickly and appropriately, and it spirals into this political “tennis match’ that is slowing down progress. One thing that the MCOs have in their favor is that they are part of a move to align all our interests in health care better so that outcomes become the primary driver. In practice, it is not perfect, but conceptually that’s where we all want to get, particularly for underserved communities. However, we still have this political environment that makes it difficult for MCOs to do anything meaningful when there is so much uncertainty in terms of cycles that there are judged by, the future of their contracts, etc. Everyone needs to have a seat at the table, and we have to work collaboratively to see improved results.
Audience Question: The point was made that collaboration is necessary what technology do you see linking health systems to FQHCs and community health providers?
SW: As many of you know, all our electronic health records (EHRs) don’t speak to each other, but there are third-party systems that exist.CommunityHealth and Rush have developed a robust referral partnership and collaboration that closes the loop on our work together using products like “Unite Us.” We can provide bi-directional referrals and continue to track those patients after those referrals are completed using ‘Unite Us.”
We collaborate at every level of the organization, from the front desk to clinical staff. It's important to mention that while all these conversations are going on, patients are going without care, so it is essential to find the needed solutions quickly.
Contribution from the audience: The South Side Collaborative is doing something similar, but we are doing it in “Epic.” We are not doing EMR interoperability; just keeping it simple. Its care coordination staff at 13 of our collaborative sites will be on the same “Epic” community cloud-based platform.
DS: Let’s talk about whether the governor of Illinois and you were thinking about re-procurement of Medicaid; what is the one thing that you feel could be addressed by the state in that process?
DF: My one thing would be rates, a very small slice of rates which are behavioral health. Behavioral health is probably the most underfunded part of Medicaid but also the part where we could have the most significant effect.
SW: I agree with rates; Increase primary care reimbursement rates.
CG: I agree with that but also want to see a more significant proportion of the rates tied to health equity. Also, ensure that the MCOs know they are being held accountable for outcomes, one of which is access.
DO: Longer-term stability in the program. Separate out some of the political noise and focus on the long-term operational stability of the program.
DS: Finding reimbursement/payment pathways that don’t have those programs rely on philanthropy or time-limited state programs.