HomeMy WebLinkAboutMinutes 10-12-2010 APPROVED 11/16/2010
MINUTES
ORANGE COUNTY BOARD OF COMMISSIONERS
JOINT WORK SESSION With BOARD OF HEALTH
October 12, 2010
5:30 p.m.
The Orange County Board of Commissioners met for a joint work session with the
Orange County Board of Health on Tuesday, October 12, 2010 at 5:30 p.m. at the Southern
Human Services Center in Chapel Hill, N.C.
COUNTY COMMISSIONERS PRESENT: Chair Valerie P. Foushee, and Commissioners Alice
Gordon, Pam Hemminger, Barry Jacobs, Mike Nelson, Bernadette Pelissier, and Steve Yuhasz
COUNTY COMMISSIONERS ABSENT: Alice Gordon
COUNTY ATTORNEYS PRESENT:
COUNTY STAFF PRESENT: County Manager Frank Clifton and Clerk to the Board Donna S.
Baker (All other staff members will be identified appropriately below).
BOARD OF HEALTH MEMBERS PRESENT: Christina Harlan, Carol Haggerty, Michael
Carstens, Tony Whitaker, Anissa Vines
BOARD OF HEALTH MEMBERS ABSENT: Susan Elmore, Matthew Kelm, Michael Wood Paul
Schelminski and Christopher Cooke
HEALTH DEPARTMENT STAFF PRESENT: Rosemary Summers, Director
1. Introductions
Introductions were made.
2. Message from BOH Chair
Anissa Vines, Board of Health Chair, said that tonight they want to focus on health care
reform. She said that the BOH felt it was important for to talk to the County Commissioners
about health care reform and the BOH would like feedback from the Board of County
Commissioners in this regard and how this will affect the strategic plan for the Health
Department. She said that N.C. released its prevention plan and Orange County is already
addressing three of the risk factors — diet and exercise, risky sexual behavior, and tobacco
usage.
3. Overview Patient Protection and Affordable Health Care Act ( ACA)
Health Director Rosemary Summers made the PowerPoint presentation.
Joint Board of Health
Board of County Commissioners Meeting
October 12, 2010
Slides Courtesy of
NC Institute of Medicine
Why Focus on Population Health?
■ North Carolina ranks 37th in overall health status and 40th in premature deaths in 2009
(with "1" being the state with the best health status).
■ North Carolina ranks in the bottom third for many health indicators including:
•Adults who are current smokers (371)
•Obese adults (41st)
•Air pollution (361h)
•4-year graduation rate (371)
■ North Carolina cannot "treat" its way to health
Overview of "Health Care Reform"
- Opportunities provided by the Patient Protection and Affordable Care Act (ACA)
o Underlying reasons for health reform
o Coverage expansion
o Other ACA provisions
o Prevention and wellness
o Cost containment and financing
Underlying Reasons
►Estimates of the uninsured:
•Recent Census numbers showed approximately 1.7 million non-elderly uninsured in NC
(2009)
•23% of Orange County adults under 65 uninsured
►Lack of health insurance impacts on a person's health
•People who are uninsured are less likely to receive preventive services, more likely to end up
in the hospital for preventable conditions or late stage cancer, and more likely to die
prematurely
•Lack of insurance coverage affects a family's financial security
Overview Elements
- By 2014, the bill requires most people to have health insurance and large employers
(50+ employees) to provide health insurance — or pay a penalty.
o Builds on our current system of public coverage, employer-sponsored
insurance, and individual (non-group) coverage
- New funding for prevention, expansion of the health workforce, long-term care services,
increasing the healthcare safety net, and improving quality
Expansion of Public Programs
- Expands Medicaid to cover all low-income people under age 65 (including childless
adults) with incomes up to 133 FPL (begins FY 2014)
o States must maintain current income eligibility for children in Medicaid and CHIP
until 2019
o Beginning 2014, special outreach requirements to vulnerable populations
- Enhances Medicare preventive services
Essential Benefits Package
- HHS Secretary will recommend an essential healthcare benefits package that includes
a comprehensive set of services:
o Hospital services; professional services; prescription drugs; rehabilitation and
habilitative services; mental health and substance use disorders; and maternity
care
o Well-baby, well-child care, oral health and vision services for children under age
21
o Recommended preventive services with no cost-sharing and all recommended
immunizations
o Mental health parity law applies to qualified health plans
Individual Mandate
- Citizens and legal immigrants will be required to pay penalty if they do not have
qualified health insurance, unless exempt.
Subsidies to Individuals
- Refundable, advanceable premium credits will be available to individuals with incomes
up to 400% FPL on a sliding scale basis
o Individuals not eligible for subsidies if they have employer-based coverage,
TRICARE, VA, Medicaid, or Medicare
o North Carolina's median household income in 2008
Sliding Scale Subsidies (table)
Employer Responsibilities
■Employers with 50 or more full-time employees required to offer insurance or pay penalty
(Sec. 1201, 1513, amended Sec. 1003 Reconciliation)
■Employers with less than 50 full-time employees exempt from penalties. (Sec. 1513(d)(2))
•Employers with 25 or fewer employees and average annual wages of less than $50,000 can
receive a tax credit. (Sec. 1421, Sec. 10105)
■ Orange County has approximately 2,991 employers with less than 50 employees.
Health Benefits Exchange
- States will create a Health Benefits Exchange for individuals and small businesses.
o Limited to citizens and lawful residents who do not have access to employer-
sponsored or governmental-supported health insurance and to small businesses
- Exchanges will:
o Provide standardized information (including quality and costs) to help
consumers choose between plans
o Determine eligibility for the subsidy
Health Benefits Exchange (HBE)
■"No wrong door approach" between Medicaid and HBE (Sec. 1311, 1411, 1413)
•Individuals who apply for health insurance through the HBE will have their eligibility
determined for Medicaid; those who apply for Medicaid will have their eligibility determined for
HBE subsidies
■Patient navigators to help link individuals to Medicaid or private insurance through HBEs
Income Eligibility for Subsidized Insurance (2010, 2014) (table)
Safety Net Overview
■ Federally qualified health centers: Appropriate a total of $9B over five years for
operations, $1.5B for construction and renovation (FY 2011-2015) (Sec. 10503, Sec.
2303 of Reconciliation)
■ School based health centers: Appropriates $50M in each FY 2010-2013 (Sec. 4101,
10402)
■ Funding authorized, but not appropriated for other safety net organizations
■ New requirements for charitable 501(c)(3) hospitals: (Sec. 9007, 10903)
•Must conduct a community needs assessment and identify an implementation strategy; have
a financial assistance policy; provide emergency services; and limit charges to people eligible
for assistance to amounts generally billed
Long-Term Care
- Establishes a national voluntary insurance program to purchase community living
assistance services and supports (CLASS) financed through payroll deduction
- New Medicaid state options to expand home and community-based services
Prevention and Wellness: Overview
- Federal government providing more funding to support prevention efforts at national,
state, and local levels
o Grant funds will be made available for prevention, wellness and public health
activities
o Some of the focus areas include: healthy lifestyle changes, reduction and
control of chronic diseases, health disparities, public health infrastructure,
obesity and tobacco reduction, improved oral health, immunizations, maternal
and child health, worksite wellness
Prevention and Public Health Fund
■ National Prevention, Health Promotion and Public Health Council (Sec. 4001)
■ Prevention and Public Health Fund to invest in prevention, wellness, and public health
activities (Sec. 4002)
•Appropriates $500 million in FY 2010, $750 million in FY 2011, $1 billion in FY 2012,
$1.25 billion in FY 2013, $1.5 billion in FY 2014, and $2 billion in FY 2015 and each fiscal
year thereafter
•May be used to fund programs authorized by the Public Health Service Act and for
prevention, wellness, and public health activities
•Half of this funding will be used for health professional workforce training
Examples of New Prevention Activities
- Expands access to clinical preventive services in Medicare and private plans (with no
cost sharing)
- Public-private partnership to support health promotion outreach and education
campaign
- Some example of grants for prevention and wellness:
o Maternal, infant, and early childhood home visiting programs
o Personal responsibility education
o Diabetes prevention
o Dental caries management
Prevention:
Competitive Grants
- Community transformation grants
o To be used for the implementation, evaluation, and dissemination of evidence-
based community preventive health activities to reduce chronic diseases,
prevent the development of secondary conditions, address health disparities,
and develop evidence based effective prevention programs
o Available to state and local government agencies and community-based
organizations
o Activities may focus on healthier school environments, active living
communities, access to nutritious foods, chronic disease, worksite wellness,
healthy food options, and reducing disparities
o Authorizes funds necessary. May be funded by the Prevention and Public
Health fund.
Prevention: Worksite Wellness
► Worksite wellness initiatives
•CDC to provide technical assistance, consultation, tools, and other resources in evaluating
wellness programs offered by employers of all sizes (Sec. 4303)
•Grants to encourage small businesses (100 employees or fewer) to offer comprehensive
workplace wellness programs (Sec. 10408)
.Authorizes $200 million for the period of FY 2011-2015
•Employers can have wellness programs that include requirements that enrollees satisfy health
status factors (i.e., tobacco cessation or weight) if the financial consequences (reward or
penalty) do not exceed 30% of the cost of employee-only coverage (or 30% of family coverage
if dependents participate)* (Sec. 1201)
Prevention Research
and Evaluation
- Funding for research to optimize the delivery of public health services.
o Research shall include examining evidence-based practices relating to
prevention, with a particular focus on high priority areas as identified by the HHS
Secretary in the National Prevention Strategy or Health People 2020, and
comparing community-based public health interventions in terms of
effectiveness and cost.
- HHS Secretary must ensure that all publicly-funded health programs, surveys, and
reports collect data on race, ethnicity, sex, primary language, and disability status and
that data be collected at the smallest geographical level possible (effective no later than
March 23, 2012)
o Authorizes such sums as necessary through FY 2014
- HHS Secretary will evaluate the effectiveness of federal health and wellness initiatives.
Congressional Budget Office (CBO) Projections
■ Covers 92% of all nonelderly residents (94% of legal, nonelderly residents)
•Would cover an additional 32 million people (leaving 23 million nonelderly residents uninsured
by 2019)
■ Expansion of insurance coverage and new appropriations included in PPACA will cost
$938 billion over 10 years.
•However, with new revenues and other spending cuts, PPACA is estimated to reduce the
federal deficit by $124 billion over 10 years.*
4. Discussion
Annissa Vines said that there will be a lot of things coming from the reform that the
Health Department will have to think forward on.
Commissioner Yuhasz asked about money available for prevention programs. He
asked about the anticipation of Orange County's share of State-distributed revenues. He
thinks that the Health Department will have to take more responsibility for prevention
programs. He asked if Orange County will get sufficient money from the State to fulfill those
responsibilities.
Rosemary Summers said that it is unclear. Based on past performance, she would say
that the money will not be sufficient. She said that when the State looks for a county that can
improve a program, it often looks to Orange County to be able to do that. She thinks that
Orange County will be able to get demonstration grants that are testing evidence-based
programs. None of the funding will be permanent, but it is all within the prevention area.
There is no infrastructure support mentioned in the reform to maintain those prevention
programs. She said that the thought is probably that the prevention programs will result in less
high-cost hospital admissions, and the money saved will be turned into prevention "dollars."
She does not know how this will occur, but that is the thought. Prevention is not a
reimbursable service.
Frank Clifton said that there is a need to be cautious as to how to proceed since the
problem is much bigger than Orange County.
Chris Harlan said that they cannot rest decisions on a purely business mind. There will
always be people in the community who need service who will never be able to pay for it. A lot
of these people will be seeking health services in health departments and community health
centers. There has to be a balance with the reimbursable services.
Commissioner Pelissier said that her concern is regarding the sliding scales —to expect
someone at the poverty level to pay up to 8% for insurance and medical needs is
unreasonable. She made reference to Medicaid and asked if there are any provisions in the
healthcare reform to require more providers to serve Medicaid and Medicare patients. This is a
huge problem now.
Rosemary Summers said that there are no provisions at this time, but the reimbursable
rates will be higher in this model. Hopefully, this will entice more providers to serve these
patients. North Carolina, through the Community Care Network System, has a managed care
model for Medicaid patients. Patients do not have to agree to be in the managed care area,
but most patients are ok with it. Patients still get to select their preferred provider. This will be
like an HMO for Medicare and Medicaid patients and this will be converting the payment to a
per-member per-month reimbursement, rather than a reimbursement for services over time.
Anissa Vines said that they may need to talk about some changes in terms of facilities,
such as Piedmont Health Services. There is language in the reform about these types of
facilities.
Frank Clifton said that part of the issue is that when the State gets in a financial pinch,
they always lower the Medicaid reimbursement rates. He asked if there were opportunities for
more significant formulated partnerships within the community such as UNC and Piedmont
Health Services so that there is not a competitive market.
Rosemary Summers said that she has had several discussions with Piedmont about
collaboration and several other Health Directors. There was a very cordial discussion and
everyone agreed to bring finance officers to talk in a more structured way. There are
collaboration models, but the county lines bring challenges.
Tony Whitaker said that he wanted to try and get a sense from the Board of County
Commissioners about the priorities.
Commissioner Hemminger said that the Board has not had a formal discussion about
this yet. One of the priorities is to open a full-time clinic in the southern part of the County.
She said that preventive health is definitely a priority and the Board of County Commissioners
is waiting to hear from the BOH since they are on the front lines of healthcare.
Chair Foushee echoed what Commissioner Hemminger said and said that the Board of
Health should develop a strategic plan and then it can be better able to tell how the Health
Department will be impacted by the reform.
Commissioner Hemminger said that when the Board of Health came to the Board of
County Commissioners for dental equipment, the Board of County Commissioners was able to
respond, so the BOH needs to continue to bring needs forward.
Frank Clifton said that it is apparent that the County is unlikely to purchase the
Hillsborough Commons site. There is a lease arrangement there. He said that this does not
address health facility needs, and as they move forward it is going to be incumbent on the
County to provide health services since it is limited in facilities. He thinks that this discussion
about facilities needs to be elevated.
Dr. Carol Haggerty, a public health dentist, said that consolidation of resources is an
important part of long-term delivery of sustainable care. A dental clinic that stays empty two
days a week is a terrible drain on resources. Regarding prevention, she said that prevention
dentistry is portable and cheap.
Commissioner Pelissier said that there are two levels of priorities —the ideal level and
the actual dollars in reality. She said that this is probably always going to be shifting. The
County Commissioners need guidance from the BOH about the priorities and the needs. She
made reference to mental health and said that she hopes that with the reform that it could be
made more seamless to access mental health services.
Commissioner Jacobs made reference to priorities and said that there has been
discussion with Rosemary Summers and UNC Hospital about a possible partnership at
Waterstone in Hillsborough. He thinks that this would have an impact on what services the
County needs to carry and what would be feasible in the partnership.
Rosemary Summers said that Orange County has a unique opportunity with the health
science schools at the University— Dentistry, Public Health, Pharmacy, Medicine, and Nursing
are all on the campus. This is the only hospital in the state with all of those in the same
university system. She said that those five schools are going to be incredibly impacted by the
need to boost the work force. There is not enough of any kind of healthcare professional to
provide those services right now with this reform as it rolls out. She would like to develop an
academic health center in partnership with these schools and she had a conversation with
representatives from the schools, who all said that they would be happy to sit down and look at
the options. She said that this is a natural partnership.
5. Closing Remarks
Anissa Vines said that there are many challenges ahead and she appreciated
Commissioner Pelissier's comments about the dollars. She said that the reality is that it may
not be very different in 2014 than it is now financially. She said that the plans need to be
based on what is realistic as well as what would be ideal. She thanked the County
Commissioners for listening.
The meeting was adjourned at 6:51 PM.
Valerie Foushee, Chair
Donna S. Baker, CMC
Clerk to the Board