Advocacy for Federally Qualified Health Centers and Medicaid Expansion Copyrighted
June 5, 2017
City of Dubuque Consent Items # 7.
ITEM TITLE: Advocacy for Federally Qualified Health Centers and
Medicaid Expansion
SUMMARY: City Manager transmitting information about the significant
changes to the health care system that will impact all 1 ,400
community health centers across the country and over 25
million people health care centers serve and
recommending approval to send letters to Senator Charles
Grassley and Senator Joni Ernst advocating for health
centers.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Approve
ATTACHMENTS:
Description Type
Advocacy for Federally Qualified Health Centers and City Manager Memo
Medicaid Expansion-MVM Memo
Staff Memo Staff Memo
Senator Grassley-Advocacy Letter Supporting Documentation
Senator Ernst-Advocacy Letter Supporting Documentation
THE CITY OF Dubuque
fta B E I 11p y
Masterpiece 012 the Mississippi 2007.2012«2013
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Advocacy for Federally Qualified Health Centers and Medicaid Expansion
DATE: May 25, 2017
Public Health Specialist Mary Rose Corrigan is transmitting information about the
significant changes to the health care system that will impact all 1,400 community health
centers across the country and over 25 million people health care centers serve.
Mary Rose Corrigan recommends City Council approval to send letters to Senator
Charles Grassley and Senator Joni Ernst advocating for health centers.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Crenna Brumwell, City Attorney
Cindy Steinhauser, Assistant City Manager
Teri Goodmann, Assistant City Manager
Mary Rose Corrigan, Public Health Specialist
THE CITY OF Dubuque
ci
DUB E I I III a I.t I
Masterpiece on the Mississippi 2007-2012-2013
TO: Mike Van Milligen, City Manager
FROM: Mary Rose Corrigan, Public Health Specialist
SUBJECT: Advocacy for Federally Qualified Health Centers and Medicaid Expansion
DATE: May 25, 2017
INTRODUCTION
Congress is in the midst of considering significant changes to our health care system
that will impact all 1,400 community health centers across the country and the over 25
million people heath centers serve. The House narrowly passed its bill, the American
Health Care Act (ANCA), on May 4th, and now the Senate has begun developing its
own legislation.
BACKGROUND
As it is currently drafted, the AHCA could profoundly roll back Medicaid while at the
same time doing nothing to avert the "primary care funding cliff' - a 70% cut in funding
for health centers - this would also mean the elimination of key healthcare workforce
programs - all slated to occur on September 30, 2017. Combined, both of these actions
will severely impact health centers and hinder their ability to care for more than 25
million patients for whom they are often the only source of high quality, comprehensive
and integrated care. Previous estimates from the Congressional Budget Office (CBO)
estimated that the bill would lead to the loss of coverage for 24 million people, including
14 million Medicaid beneficiaries, by 2026.
For over 50 years, health centers have worked with Members of Congress on both
sides of the aisle to improve the quality of health care, lower costs, and increase access
to comprehensive health services in nearly every community. Now is the time to take
action to tell your Senators to protect Medicaid and take bipartisan action to avert the
health center funding cliff before they vote on the American Health Care Act. Act now to
support America's Health Centers and stand up for the 25 million patients they serve!
Crescent Community Health Center served over 6,000 unique patients in medical and
dental departments in 2016. If the federal legislation to fund Medicaid and health
centers is not enacted before the end of September, we may lose this valuable resource
to our community.
RECOMMENDATION
Crescent Community Health Center is requesting advocacy for health centers by
sending letters to our Iowa senators.
REQUESTED ACTION
Sign the attached letters of support.
2
Masterpiece on the Mississippi
Senator Charles Grassley
135 Hart Senate Office Building
Washington, DC 20510
Dear Senator Grassley:
Dubuque
*****
All -America City
11 111
2007 • 2012 • 2013
City Manager's Office
City Hall
50 West 13th Street
Dubuque, IA 52001-4805
Office (563) 589-4110
Fax (563) 589-4149
TTY (563) 690-6678
ctymgr@cityofdubuque.org
www.cityofdubuque.org
May 25, 2017
Iowa's Community Health Centers are united in our commitment to work with
policymakers at all levels of government to move our health care system toward one
that is more affordable, accessible and equitable for all patients in our state. We deeply
appreciate the support and leadership you've shown on behalf of health centers in Iowa
and nationwide during your time in the Senate.
Health centers are bound, both by our mission and by federal statute, to care for any
patient who walks through our doors, regardless of insurance status. Also, by statute,
health centers must be located in underserved and low-income urban and rural areas
with few other options for care -- and must provide a broader range of comprehensive
primary and preventive health care services. Health centers have a solid and long track
record of improving health outcomes in these areas while at the same time lowering
costs for the nation's overall health system. In 2015, our network of 14 health center
organizations provided high-quality, comprehensive primary and preventive care at 71
locations, to nearly 189,000 Iowans, including children and veterans. At Crescent
Community Health Center in Dubuque, 6,263 patients made almost 19,000 dental and
medical visits in 2016. On behalf of these patients, we offer below both our concerns
with the health-related legislation that passed the House in May, and our
recommendations and principles for health reform moving forward.
We urge you to take these recommendations into the coming deliberations with your
colleagues, and ask that you work together with us in the coming weeks and months to
ensure any and all legislation considered by the Senate meets these principles.
Concerns with the American Health Care Act
On May 4th, the U.S. House of Representatives passed H.R. 2192, The American
Health Care Act, by a very narrow margin. Like health centers nationwide, we have
Service People Integrity Responsibility Innovation Teamwork
significant concerns about the potential impact of the House legislation on our patients,
and on our capacity to deliver care. In particular, we are most concerned about the
following aspects of the House bill:
1. Medicaid Per -Capita Cap/Block Grant. In Iowa, 57% of health center patients
are covered by Medicaid and over 65% of our patients live at or below 100% of the
federal poverty level. Crescent Community Health Center in Dubuque is similar to Iowa,
and also serves 33% uninsured and 185 veterans. The House legislation would put that
coverage at risk for a significant number of our patients by capping the federal portion of
Medicaid spending. Regardless of whether the cap is determined on a per -capita basis
or on a statewide basis, this change represents an enormous shift of risk to state
governments already hamstrung by significant budget challenges. More importantly,
because federal Medicaid contributions would grow more slowly than health care costs,
states would be forced to either to raise taxes or to make increasingly dramatic cuts to
covered benefits, beneficiary eligibility, and provider payments.
2. Rollback of Medicaid Expansion. For the low-income Iowans health centers
serve, the expansion of Medicaid coverage to individuals with incomes below 138% of
the Federal Poverty Level has literally been a life-saving policy change. The House bill
would undo the progress made since 2014, forcing our patients into much more limited
coverage (see concerns below with tax credit proposals) or into becoming uninsured.
Medicaid expansion has also allowed Iowa's health centers to bolster our capacity and
to offer a more comprehensive range of services (like behavioral health and substance
abuse services) to our patients. Reversing the Medicaid expansion will mean that the
150,000 Iowans who lose Medicaid coverage will lose access to critical specialty care
services, and increasingly will return to seeking care in emergency rooms, ultimately
leading to higher costs and poorer health outcomes.
3. Change in Tax Credits for Purchase of Private Insurance. Both the Affordable
Care Act and the House -passed AHCA legislation call for tax credits to individuals to
assist in the purchase of private insurance. We are concerned that the AHCA would
shift this credit away from one based on income and geography toward one determined
based almost exclusively on age. For the low-income, elderly and/or rural patients who
represent the bulk of those we serve, this would pose a major barrier to the affordability
of coverage for our patients, which would lead inexorably to poorer health outcomes for
our patients and increased costs for the system.
4. Weakening Covered Benefits and Consumer Protections. The late addition of
the Meadows -MacArthur amendment to the House bill would allow insurers to once
again discriminate against individuals with pre-existing conditions, by allowing state
waiver of so-called "community rating" requirements that no patient be charged more for
insurance based on health status. This will cause our patients who are most in need of
coverage to face the greatest challenge in affording it. The bill would also allow waivers
of the Essential Health Benefits package, meaning insurers could offer plans that don't
Service People Integrity Responsibility Innovation Teamwork
cover many basic services, including many which health centers are required to provide.
Health centers already encounter many patients who we would consider
"underinsured"—as providers open to all, this leads to significant strain on the federal
investments Congress and the Administration make in our system of care. The
Meadows-Macarthur provisions would only make this problem worse.
5. Overall Impact on Coverage. The Congressional Budget Office has estimated
that the original version of the House bill would cause 24 million Americans to lose
coverage within ten years. Yet every health center clinician and staff member can attest
to the difference having health insurance makes in the lives of our patients—in terms of
their personal and family security, access to specialty care, and likelihood to seek the
cost-saving, primary and preventive care services we offer. Our nation can do better.
Principles and Recommendations for Health Reform
Iowa's health centers serve on the front lines of a changing health care system. We
share your belief that our system can be improved dramatically --specifically toward
becoming a more equitable, accessible and affordable one for all patients in need, while
driving efficiency and promoting high-quality, high-value care. To that end, we offer the
following principles and recommendations to help guide your work on any effort to
reform the health care system moving forward.
1. First, do no harm – do not eliminate coverage for any American in your
proposal. This should be the guiding principle of your work – to at least sustain both the
number of people covered by insurance and to maintain the accessibility, affordability
and quality of that coverage for every American.
2. Maintain a strong and viable safety net through Medicaid. Medicaid and
health centers work synchronously to ensure that our patients have access to
affordable, high-quality care and reliable and predictable coverage. Health reform
legislation should build on successes within Medicaid, not simply shift the burden of
operating and financing the program to the states. Specifically, we cannot support
proposals to place caps on the federal share of Medicaid payments or to institute broad
block grants, or attempts to roll back the federal commitment to Medicaid expansion.
3. Strengthen Medicaid's connection to health centers. Medicaid not only
covers nearly half of health center patients, but it is also the largest revenue source,
accounting for 44% of health center revenue nationwide. Yet health centers deliver
significant return on investment. Within Medicaid, this is especially true – a recent 13 -
state study found that health center Medicaid patients had 24% lower total costs of care
when compared to similar patients cared for in other settings – in Iowa this cost savings
increases to 27%. This record of success is due largely to the unique Federally
Qualified Health Center Prospective Payment System (FQHC PPS)—a bundled
payment designed by Congress to ensure health centers can fully treat the whole
patient, while not diverting other federal investments intended to support care for the
Service People Integrity Responsibility Innovation Teamwork
uninsured. Congress has since implemented similar payment systems for health centers
in Medicare, CHIP, and Exchange coverage, and replicated it for other key safety net
providers. Any proposals related to Medicaid must preserve and build upon this
successful system.
4. Strengthen tax credits, minimum benefits and consumer protections in the
individual marketplace. Several Senators have already indicated a desire to enhance
the system of tax credits called for in the House bill to improve affordability for low-
income patients. We strongly support changes in this direction. Further, it is critical that
any final legislation ensure individual market plans cover a minimum set of essential
health benefits, and either maintain or strengthen protections afforded to the millions of
patients with pre-existing conditions.
5. Sustain and grow direct investments in health centers and the primary care
workforce. For decades and through bipartisan administrations, Congress has
consistently seen the value in growing the federal investment in the health center
system of care. The Trump administration has continued that support, calling
investment in health centers one of the "highest priorities" in its March budget
document. Yet, a crisis looms for every health center in Iowa and around the nation with
the scheduled expiration of the Health Centers Fund at the end of September. We
strongly urge you to sustain and grow this and other key federal investments in primary
care on a long-term basis, by acting well ahead of the September deadline to extend
funding for Health Centers, the National Health Service Corps and the Teaching Health
Centers Graduate Medical Education program for at least five years.
Given the urgency of this discussion, we would like to discuss these concerns with you
in person at your earliest convenience. We have asked representatives from the Iowa
Primary Care Association to work with your office to coordinate that visit, and are willing
to meet here in Dubuque, Iowa or in Washington, DC. We deeply appreciate the
opportunity to offer these recommendations and stand ready to work with you and your
colleagues to develop health policy proposals that improve both our overall system and
the lives and health of those we serve.
Michael C. Van Milligen
City Manager
MCVM:Ih
cc Mary Rose Corrigan, Public Health Specialist
Service People Integrity Responsibility Innovation Teamwork
THE CITY OF
Masterpiece ,
„
iece on the Mississippi
Dubuque
AH -America City
II 11
II
2007 • 2012 • 2013
Senator Joni Ernst
111 Russell Senate Office Building
Washington, DC 20510
Dear Senator Ernst:
City Manager's Office
City Hall
50 West 13th Street
Dubuque, IA 52001-4805
Office (563) 589-4110
Fax (563) 589-4149
TTY (563) 690-6678
ctynigr@cityofdubuque.org
www.cityofdubuque.org
May 25, 2017
Iowa's Community Health Centers are united in our commitment to work with
policymakers at all levels of government to move our health care system toward one
that is more affordable, accessible and equitable for all patients in our state. We deeply
appreciate the support and leadership you've shown on behalf of health centers in Iowa
and nationwide during your time in the Senate.
Health centers are bound, both by our mission and by federal statute, to care for any
patient who walks through our doors, regardless of insurance status. Also, by statute,
health centers must be located in underserved and low-income urban and rural areas
with few other options for care -- and must provide a broader range of comprehensive
primary and preventive health care services. Health centers have a solid and long track
record of improving health outcomes in these areas while at the same time lowering
costs for the nation's overall health system. In 2015, our network of 14 health center
organizations provided high-quality, comprehensive primary and preventive care at 71
locations, to nearly 189,000 Iowans, including children and veterans. At Crescent
Community Health Center in Dubuque, 6,263 patients made almost 19,000 dental and
medical visits in 2016. On behalf of these patients, we offer below both our concerns
with the health-related legislation that passed the House in May, and our
recommendations and principles for health reform moving forward.
We urge you to take these recommendations into the coming deliberations with your
colleagues, and ask that you work together with us in the coming weeks and months to
ensure any and all legislation considered by the Senate meets these principles.
Concerns with the American Health Care Act
On May 4th, the U.S. House of Representatives passed H.R. 2192, The American
Health Care Act, by a very narrow margin. Like health centers nationwide, we have
Service People Integrity Responsibility Innovation Teamwork
significant concerns about the potential impact of the House legislation on our patients,
and on our capacity to deliver care. In particular, we are most concerned about the
following aspects of the. House bill:
1. Medicaid Per -Capita Cap/Block Grant. In Iowa, 57% of health center patients
are covered by Medicaid and over 65% of our patients live at or below 100% of the
federal poverty level. Crescent Community Health Center in Dubuque is similar to Iowa,
and also serves 33% uninsured and 185 veterans. The House legislation would put that
coverage at risk for a significant number of our patients by capping the federal portion of
Medicaid spending. Regardless of whether the cap is determined on a per -capita basis
or on a statewide basis, this change represents an enormous shift of risk to state
governments already hamstrung by significant budget challenges. More importantly,
because federal Medicaid contributions would grow more slowly than health care costs,
states would be forced to either to raise taxes or to make increasingly dramatic cuts to
covered benefits, beneficiary eligibility, and provider payments.
2. Rollback of Medicaid Expansion. For the low-income Iowans health centers
serve, the expansion of Medicaid coverage to individuals with incomes below 138% of
the Federal Poverty Level has literally been a life-saving policy change. The House bill
would undo the progress made since 2014, forcing our patients into much more limited
coverage (see concerns below with tax credit proposals) or into becoming uninsured.
Medicaid expansion has also allowed Iowa's health centers to bolster our capacity and
to offer a more comprehensive range of services (like behavioral health and substance
abuse services) to our patients. Reversing the Medicaid expansion will mean that the
150,000 Iowans who lose Medicaid coverage will lose access to critical specialty care
services, and increasingly will return to seeking care in emergency rooms, ultimately
leading to higher costs and poorer health outcomes.
3. Change in Tax Credits for Purchase of Private Insurance. Both the Affordable
Care Act and the House -passed AHCA legislation call for tax credits to individuals to
assist in the purchase of private insurance. We are concerned that the AHCA would
shift this credit away from one based on income and geography toward one determined
based almost exclusively on age. For the low-income, elderly and/or rural patients who
represent the bulk of those we serve, this would pose a major barrier to the affordability
of coverage for our patients, which would lead inexorably to poorer health outcomes for
our patients and increased costs for the system.
4. Weakening Covered Benefits and Consumer Protections. The late addition of
the Meadows -MacArthur amendment to the House bill would allow insurers to once
again discriminate against individuals with pre-existing conditions, by allowing state
waiver of so-called "community rating" requirements that no patient be charged more for
insurance based on health status. This will cause our patients who are most in need of
coverage to face the greatest challenge in affording it. The bill would also allow waivers
of the Essential Health Benefits package, meaning insurers could offer plans that don't
Service People Integrity Responsibility Innovation Teamwork
cover many basic services, including many which health centers are required to provide.
Health centers already encounter many patients who we would consider
"underinsured"—as providers open to all, this leads to significant strain on the federal
investments Congress and the Administration make in our system of care. The
Meadows-Macarthur provisions would only make this problem worse.
5. Overall Impact on Coverage. The Congressional Budget Office has estimated
that the original version of the House bill would cause 24 million Americans to lose
coverage within ten years. Yet every health center clinician and staff member can attest
to the difference having health insurance makes in the lives of our patients—in terms of
their personal and family security, access to specialty care, and likelihood to seek the
cost-saving, primary and preventive care services we offer. Our nation can do better.
Principles and Recommendations for Health Reform
Iowa's health centers serve on the front lines of a changing health care system. We
share your belief that our system can be improved dramatically—specifically toward
becoming a more equitable, accessible and affordable one for all patients in need, while
driving efficiency and promoting high-quality, high-value care. To that end, we offer the
following principles and recommendations to help guide your work on any effort to
reform the health care system moving forward.
1. First, do no harm – do not eliminate coverage for any American in your
proposal. This should be the guiding principle of your work – to at least sustain both the
number of people covered by insurance and to maintain the accessibility, affordability
and quality of that coverage for every American.
2. Maintain a strong and viable safety net through Medicaid. Medicaid and
health centers work synchronously to ensure that our patients have access to
affordable, high-quality care and reliable and predictable coverage. Health reform
legislation should build on successes within Medicaid, not simply shift the burden of
operating and financing the program to the states. Specifically, we cannot support
proposals to place caps on the federal share of Medicaid payments or to institute broad
block grants, or attempts to roll back the federal commitment to Medicaid expansion.
3. Strengthen Medicaid's connection to health centers. Medicaid not only
covers nearly half of health center patients, but it is also the largest revenue source,
accounting for 44% of health center revenue nationwide. Yet health centers deliver
significant return on investment. Within Medicaid, this is especially true – a recent 13 -
state study found that health center Medicaid patients had 24% lower total costs of care
when compared to similar patients cared for in other settings – in Iowa this cost savings
increases to 27%. This record of success is due largely to the unique Federally
Qualified Health Center Prospective Payment System (FQHC PPS)—a bundled
payment designed by Congress to ensure health centers can fully treat the whole
patient, while not diverting other federal investments intended to support care for the
Service People Integrity Responsibility Innovation Teamwork
uninsured. Congress has since implemented similar payment systems for health centers
in Medicare, CHIP, and Exchange coverage, and replicated it for other key safety net
providers. Any proposals related to Medicaid must preserve and build upon this
successful system.
4. Strengthen tax credits, minimum benefits and consumer protections in the
individual marketplace. Several Senators have already indicated a desire to enhance
the system of tax credits called for in the House bill to improve affordability for low-
income patients. We strongly support changes in this direction. Further, it is critical that
any final legislation ensure individual market plans cover a minimum set of essential
health benefits, and either maintain or strengthen protections afforded to the millions of
patients with pre-existing conditions.
5. Sustain and grow direct investments in health centers and the primary care
workforce. For decades and through bipartisan administrations, Congress has
consistently seen the value in growing the federal investment in the health center
system of care. The Trump administration has continued that support, calling
investment in health centers one of the "highest priorities" in its March budget
document. Yet, a crisis looms for every health center in Iowa and around the nation with
the scheduled expiration of the Health Centers Fund at the end of September. We
strongly urge you to sustain and grow this and other key federal investments in primary
care on a long-term basis, by acting well ahead of the September deadline to extend
funding for Health Centers, the National Health Service Corps and the Teaching Health
Centers Graduate Medical Education program for at least five years.
Given the urgency of this discussion, we would like to discuss these concerns with you
in person at your earliest convenience. We have asked representatives from the Iowa
Primary Care Association to work with your office to coordinate that visit, and are willing
to meet here in Dubuque, Iowa or in Washington, DC. We deeply appreciate the
opportunity to offer these recommendations and stand ready to work with you and your
colleagues to develop health policy proposals that improve both our overall system and
the lives and health of those we serve.
Sincerely,
Michael C. Van Milligen
City Manager
MCVM:Ih
cc Mary Rose Corrigan, Public Health Specialist
Service People Integrity Responsibility Innovation Teamwork