Memo for fiscal year 2017, updated 2016-04-11

[Archived] Can staff provide some analysis regarding the Health Care coverage gap and Health Fair/Clinic proposal presented to City Council at the March 14, 2016 budget public hearing?

The “Mayor’s Special Advisory Panel on the Health Care Needs of the Uninsured” provided a report last year that detailed the challenges associated with those Alexandrians who remain in the healthcare coverage gap. Since that time, members of the committee have approached the City with a request for $250,000 to partner with Neighborhood Health to begin to fill that gap. Can staff provide some analysis of the request that has been made, as well as these alternatives/questions?

Dan Hawkins and Richard Merritt, Chairman and member of the Mayor’s Special Advisory Panel on the Health Care Needs of the Uninsured in Alexandria, propose the establishment of a public/ private partnership called ALEXCARES for the purpose of improving access to essential health services for some of the neediest and most economically disadvantaged individuals in the City of Alexandria who continue to be denied Medicaid coverage by the Virginia General Assembly. The request is for a minimum investment of $250,000 from the City for each of the next three fiscal years for the establishment of ALEXCARES. According to the proposal, an additional $100,000 to $150,000 will be forthcoming each year through community fundraising efforts, the sources of which are not identified in the proposal. The initiative has four key components:

  1. A "bridge" funding program (AlexCARE) to improve access to primary care services for the most vulnerable and at high-risk segment of the City's very low-income (below poverty), non-elderly adult (ages 18-64) (many are "the working poor") Medicaid "gap" population.

    AlexCARE would be administered through Neighborhood Health (Alexandria's community health center) in accordance with eligibility and reimbursement requirements determined by Neighborhood Health and approved by City Council. (As a guideline, low-income, non-elderly adults without a routine source of primary care and who suffer from a serious chronic illness or who are at moderate-to-high risk of developing serious chronic health conditions should be considered among those in "great need".) The advisory panel expects approximately 700 patients could be served during the first year of  AlexCARE. This initiative was not proposed by Neighborhood Health, who has requested an alternative use of funds. 
  2. Financial assistance to Neighborhood Health for the establishment of a part-time, satellite clinic is to improve access to primary care services for uninsured, non-elderly adults in up to two areas of the City that are particularly underserved, also not requested by Neighborhood Health.
  3. An annual public/private sponsored one-to-two day Community Health Clinic each Fall for the non-elderly, low-income uninsured population in Alexandria. The Community Health Clinic would be held with the help from the National Association of Free and Charitable Clinics, which has a local match listed of $40,000. 
  4. The creation of a Special Advisory Body by City Council to develop a plan of action by the end of 2016 in response to growing evidence that access to affordable and accessible specialty care is problematic within the City of Alexandria, especially for low-income, uninsured residents, and that serious and unacceptable health disparities and outcomes exist within the City's low­ income population.

The request for $250,000 includes $175,000 for primary care at Neighborhood Health, $50,000 for specialty care at Neighborhood Health, and $25,000 for the health fair/clinic, which would require $25,000 from other sources to match the City’s $25,000 contribution. 

Subsequently, Neighborhood Health is requesting a supplement of $87,878 for an additional 0.5 FTE Family Nurse Practitioner or a Physician to serve additional 1,300 health care visits by a minimum of 600 additional adults. In FY 2015, 75% or 32,058 visits of all Neighborhood Health were City residents, greater than current capacity at Casey and two East Glebe centers. These additional patients would receive comprehensive high quality primary care, including medical care, labs, low or no cost medicines, care coordination, and as needed dental care and mental health services available to all patients.

Staff recommends that, instead of a health fair, any additional resources that might be directed for access to clinical care should be to support Neighborhood Health’s request for organizational infrastructure and for their acquiring expanded, consolidated space for Neighborhood Health to serve Alexandrians who lack access to clinical care. Conducting a health fair would drain resources from these necessary efforts and/or from services that are mandated by the Code of Virginia and/or are in alignment with the City's Strategic Plan. 

Additionally, Advisory Panel members from the Public Health Advisory Commission, the Partnership for a Healthier Alexandria, and the Northern Virginia Health Foundation voted against holding a health fair or clinic based on a number of reasons: non-sustainability, diversion of resources, health fairs not being a substitute for a medical home, financial and opportunity costs (i.e., the resources needed to organize and mount health fairs are better directed to increase the capacity of nonprofits that currently serve Alexandria’s uninsured), health fairs having no to very limited impact on addressing health insurance coverage, the limited impact a one day event would have on the health of Alexandrians, the uncertainty of the feasibility of uninsured Alexandrians being able to attend the event, false expectations of access to health care for those who are most vulnerable, the lack of comparisons of the cost of a health fair to other strategies to address healthcare for the uninsured, and concerns about health fair operations such as expertise of volunteers and others who are providing screenings. 

The options for organizations and residents interested in health fairs include collaborating with entities that already conduct such events (e.g. Neighborhood Health, Alfred Street Baptist Church, etc.). Options for addressing clinical and support services for the uninsured include supporting and enhancing existing nonprofit safety net providers (i.e. Neighborhood Health, the Department of Community and Human Services, Alexandria Health Department, and INOVA Alexandria). 

Staff does not recommend this proposal because health fairs are not sustainable and they are not a solution to lack of access to clinical care. Clients served at a health fair will not have established deserve doctor-patient relationships and will not have a medical home at the end of the event. 

Staff are also not willing to support a proposal that does not have support of our local health serving agencies who have actually voiced their disagreement with this approach.

Is it accurate that a cigarette tax increase of 7 cents could produce about $50,000 annually in revenue as a budget offset? 

Increasing the cigarette tax by 7 cents will generate an additional $66,000 over the FY 2016 projected revenue. Increasing the cigarette tax by 6 cents would generate $43,000.

Some of the uninsured, particularly children, are otherwise eligible for FAMIS or Medicaid. Could the City play a greater role in encouraging full participation in those programs? What would the cost of those efforts be?

Currently DCHS does limited outreach through education at events and by outreach and application access at the Health Department.  A full-time employee to provide outreach would cost approximately $53,107 a year.             

The City currently provides an on-going appropriation to Inova Alexandria Hospital. Given the reductions expected in uncompensated care due to the advent of the Affordable Care Act, can Inova absorb some of the impact of these remaining uninsured in partnership with the City? Could that be negotiated as part of the proposed Memorandum of Understanding (MOU) with the City?

The City and Inova Alexandria Hospital are currently in the process of negotiating a memorandum of understanding (MOU) which will address the indigent care and other services provided to Alexandrians. 

What would be the estimated cost for the City to provide local subsidies for the uninsured (those with too much income to qualify for Medicaid/FAMIS/CHIP, but too little to qualify for Exchange subsidies) to purchase coverage on the Federal Exchanges?

Currently DCHS has 14,742 individuals enrolled in Medicaid and children comprise 9,485 of that number. According to State estimates, based only on poverty figures, 9,911 children could be eligible. Alexandria is reaching a significant number of the poverty estimate for children (the estimate includes children under 200% of the federal poverty level). The City does not have figures on what part of the population falls between Medicaid and the federal exchange.

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