Report on Workforce Shortage Solutions

The Healthforce Center at UCSF has released the final report of a three-part series on primary care workforce in California. The first two reports analyzed the current supply and future need of primary care providers, which revealed that the demand for full-time equivalent primary care clinicians in California is projected to increase by 12 percent to 18 percent between 2016 and 2030. These reports also showed that Latinos, African Americans, and Native American clinicians remain largely underrepresented. The most recent report, Strategies for Expanding Primary Care Capacity in California, analyzes current policies and practices that target these challenges and identifies strategies to alleviate the workforce shortage in California. The report categorizes these strategies into four main categories and defines effective short-term and longer-term strategies, as summarized in the table below:

What are the Needs of California for Behavioral Health Providers?

Our colleagues at UCSF's Healthforce Center have written a report analyzing California's looming Behavioral Health Workforce Shortage. The report forecasts that if current trends continue, California will have 41 percent fewer psychiatrists than needed and 11 percent fewer psychologists, licensed marriage and family therapists, licensed professional clinical counselors and licensed clinical social workers than needed by 2028. Additional behavioral health professionals will be needed to care for Californians with unmet needs for behavioral health services.

“This affects everybody with a behavioral health condition, particularly those with severe mental illness,” said Janet Coffman, associate professor in policy at University of California-San Francisco and one of the authors of the report, “California’s Current and Future Behavioral Health Workforce.”The report also found that there aren’t enough Latino and African-American psychiatrists and psychologists relative to those patient populations in California.  (From Capitol Public Radio interview, retrieved from UCSF healthforce blog 3/1/18)

To read the full report, please go to https://healthforce.ucsf.edu/publications/california-s-current-and-future-behavioral-health-workforce.

What are the Consequences for California of Congress Not Taking Action on CHIP?

From the Desert Sun newspaper:

 

Are tens of thousands of California kids about to lose their health care?

Elizabeth Aguilera, CALmatters Published 3:55 p.m. PT Dec. 20, 2017 | Updated 3:56 p.m. PT Dec. 20, 2017

 

When Alice Mayall rushed her daughter Hannah to the hospital for a head injury after a water polo tournament a few years ago, she didn’t think twice about whether she could afford it. Her daughter was covered by the Children’s Health Insurance Program.

Mayall is a self-employed psychologist in Livermore, in the Bay Area, and the mostly federally funded program has helped her get through tough economic times over the years by insuring her twins. It has kept her kids healthy when she needed to give up work hours to be at home with her son Owen, who is autistic.

“What ends up being an ongoing issue with any of these publicly funded programs is the uncertainty, especially with what is going on right now,” she said.

She was referring to the question of whether Congress will reauthorize funding for CHIP, a program that covers more than 1.3 million California children, including hers, but now hangs in the balance. Federal funding expired in September, and state officials are considering what to do if Congress doesn’t act soon—perhaps this week. Coverage for about 32,000 residents is at risk most immediately.

CHIP has benefited from bipartisan support since its inception in 1997, and lawmakers from both sides of the aisle in Washington say they want to renew it. But there’s been disagreement over where the money should come from, and Congress has lately been focused on the tax overhaul.

CHIP covers children and pregnant women in families that earn too much to qualify for Medi-Cal, the federal and state health care program for California’s lowest-income residents, but not enough to afford private insurance. These families earn between 108 percent and 266 percent of the federal poverty level, up to about $65,000 for a family of four, depending on the children’s ages.

Without congressional action, California expects its federal funds to run out by early January, if not sooner, leaving state officials to figure out how to make up the difference, which could involve taking money from other programs.

“It’s a Sophie’s choice we shouldn’t have to make,” said Anthony Wright, executive director of Health Access California, which advocates for consumers. “Part of the evil genius of this is that the cuts show up at the state level and forces state lawmakers to make tough choices.”

California received $3.1 billion from the federal government for the program for the last federal fiscal year, which ended Sept. 30. Those funds make up 88 percent of the costs, said H.D. Palmer, spokesman for the Department of Finance. The state picks up the rest, about $734 million.

Families in some other states have begun receiving notices that their insurance is going to end. But not in California.

When California expanded Medi-Cal under the Affordable Care Act in 2014, it rolled in nearly all CHIP recipients for administrative purposes. The state agreed with the federal government to keep them enrolled through September 2019.

The remaining 32,000 are in families with slightly higher incomes—up to $79,000 for four—and would no longer be eligible for any publicly funded coverage if CHIP, which in California used to be called Healthy Families, were eliminated. This group includes recipients in three county programs, in San Francisco, Santa Clara and San Mateo Counties, said Anthony Cava, spokesman for California’s Department of Health Care Services.

If the state decides to continue covering them, its options include absorbing all of the costs or helping the families pay for insurance on the Obamacare exchange, according to Wright.

What it would cost to cover the majority of the 1.3 million recipients if Congress demurs is unclear. Palmer noted that the state could be on the hook for the entire $3.1 billion that Washington had been providing if California is required to maintain most of its current coverage, or the federal government could agree to pay half, as it does for regular Medi-Cal patients.

“The worst-case scenario is that the kids still stay in Medi-Cal and we do the 50/50 match,” said Democratic state Sen. Ed Hernandez of Azusa, chairman of the Senate Committee on Health. “I believe we need to make sure these children are insured. I can’t imagine that we would not make up the difference.”

The Legislature anticipated a cut in the federal funding and budgeted an extra $396 million for CHIP through June 30, which could allow the program to limp along until the next budget is worked out in mid-2018, Hernandez said. Gov. Jerry Brown will give the Legislature his proposal for that budget by January 10. It is likely to contain possibilities for CHIP funding, especially if Congress’ intentions remain murky, Palmer said.

Hernandez said that if the state has to fund the program, “then something else has to suffer.”

The state could reduce the cost by altering eligibility requirements for adults, lowering payments to doctors, hospitals and other health care providers or changing the menu of benefits, said Kelly Hardy, senior managing director of health policy at Children Now, a research and advocacy organization. She said none of those are great options.

However, she said, “the state has made a commitment toward a culture of coverage. I would be really surprised if the state went back on that promise.”

 

What is happening with the Affordable Care Act's Cost Sharing Reduction payments?

The Trump administration has recently announced that it will not fund subsidies for lower-income consumers known as Cost Sharing Reduction (CSR) payments.

This is a complicated issue and President Trump appears to have made this move in order to under cut the Affordable Care Act.  In a statement from Covered California, Peter Lee explained that "These CSR payments don’t go directly to eligible Covered California members, instead health insurance companies lower the costs of some out-of-pocket expenses for eligible Californians, and then the insurers get reimbursed for that expense. "    While President Trump has been able to suspend these payments due to the fact that they are not automatically budgeted each year, in actuality for many people below 250% of the Federal Poverty Level, particularly in high cost states such as California, the Federal cost sharing subsidy cut will trigger an increase in premium support. This is because the Affordable Care Act rule that people should not pay more than a specific percentage of their income for health insurance costs still stands.

Covered California has announced that its members will not see any change in their health costs for the remainder of 2017 and published rates for 2018 Covered California for 2018 will not be affected. 

"Because the surcharge will only be applied to Silver-tier plans, nearly four out of five consumers will see their actual monthly premiums stay the same or decrease, since the amount of premium assistance they receive will also rise.

 

The effect of the federal government’s decision is something like this: Insurers get less money for helping low-income people with out-of-pocket costs on silver plans; premiums on silver plans increase more to compensate; and that forces the federal government to increase all APTC based subsidies to make sure people can still afford insurance."

However, Covered California had previously raised premiums to account for some of the uncertainty of the Federal government's actions.
 

 

 

 

 

 

 

 

 

What is the Fiscal Funding Cliff?

While community health centers have bipartisan support in general, we are facing a 70% cut in funding to grants to Federally Qualified Health Centers if Congress does not act by September 30, 2017.  These grants provide basic funding for health centers to allow them to serve everyone, without regard to ability to pay.  Most of Congress does not want the funding to expire, but time is getting short and many other issues are getting their attention. We need to ask them to act NOW! 

This is the link to a short video explaining the funding cliff:  https://www.youtube.com/watch?v=OKBVyvhJJnw&feature=youtu.be

How You Can Help

Please go tohttp://www.hcadvocacy.org/takeaction to complete some simple communications with your legislators.

Contact your Members of Congress and ask them to Support Health Centers in the FY18 annual appropriations process:

 

Senate Again Proposes ACA Repeal: Timeline as of 7/25/17

 

Last Friday – Senate Parliamentarian released her list of guidance on provisions that she believes do not comply with budgetary guidelines.  This does not mean that these provisions are struck automatically from the bill, a Point of Order needs to be made on the floor for the provisions to be stripped.  Should these provisions be struck, it will make the bill even harder to pass.  Her list includes:

  • The provision removing Planned Parenthood from the Medicaid program for a year
  • The provision prohibiting individuals from using their tax subsidies to purchase insurance plans that cover abortions
  • The 6-month waiting period penalty for a lapse in insurance coverage
  • Payment of the Cost-Sharing Subsidies to Insurers
  • The “Buffalo Bailout”- the provision that limits the ability of NY State to require counties other than NY City to contribute funding to the state Medicaid program
  • Still to come:  Parliamentary guidance on Cruz amendment

 

Monday, 4 pm – Senate is back in session; there should be more information from Senators about how they are feeling at that point

 

Tuesday Senator McConnell plans to hold a vote on a Motion to Proceed (likely to be early in the day), but nobody knows exactly what they will be proceeding to.   Procedurally, it looks like they will be proceeding to the House-passed American Health Care Act and then an “amendment in the nature of a substitute” will be offered.  The substitute could be either:

  • H.R. 1628, the Obamacare Repeal Reconciliation Act of 2017;
  • Revised Better Care Reconciliation Act (BCRA) w/out Cruz amendment; or
  • Revised BCRA w/Cruz amendment.
    • Possibility of adding $200 billion to help states handle the Medicaid expansion population

  

Tuesday/Wednesday/Thursday

  • If MTP passes, then there will be 20 hours of debate (10 hours for Rs/10 hours for Ds)
  • During the debate, Republicans will offer their substitute amendment and other changes and Democrats will make Points of Order to strip non-germane provisions from the bill)
  • After 20 hours elapses, they will have the amendment vote-a-rama – as many amendments germane to the budget process and budget-neutral can be offered as desired, as long as the Senators are there to offer them (each amendment takes up about 15 minutes and they go all night)

 

Friday or early in the week of July 31 – vote on final passage

  • Right now it does not look like they have put together a package that can get 50 Republican votes; if Senator McCain remains absent, their math is even harder.
  • If it looks like the bill is going to pass, the House could stay in session to consider it immediately

 

July 28 (?) – August recess begins for House

 

August 14 (?) – August recess begins for Senate

(From California Health Advocates(7/25/17)

San Francisco's "Getting to Zero" Initiative and HIV Pre-exposure Prophylaxis (PrEP)

San Francisco's Getting to Zero initiative aims to make San Francisco the first city to achieve the UNAIDS goals of eliminating new HIV infections, deaths due to HIV/AIDS, and stigma against people living with HIV by 2020. It relies on a three-prong strategy of expanded access to PrEP; (see below for a description)  rapid initiation of antiretroviral therapy, or ART; and engaging and retaining HIV-positive people in care. At a report presented on World Aids Day, December 1, 2016, progress was celebrated, along with a recognition that San Francisco still has far to go, particularly since there are still significant disparities between populations.

"HIV Pre-exposure Prophylaxis , or PrEP , is a critical component of the Getting to Zero strategy for ending the HIV epidemic in San Francisco. PrEP is a co - formulated pill (emtricitabine/tenofovir[Truvada®]) taken daily and can reduce the risk of HIV transmission by over 90 %. PrEP complements other proven HIV prevention options, such as reducing the number of partners , consistent use of condoms, needle and syringe exchange, and suppressing viral load through use of HIV medication among those who are HIV infected. Current surveillance data estimates 12,500 SF residents on PrEP." (www.sfdph.org).

The San Francisco Department of Public Health has published a handy two page information sheet regarding PrEP.  Please see the link here https://www.sfdph.org/dph/files/newsMediadocs/2016PR/AskAboutPrEPandHelpSFGettoZero12012016.pdf as well as Project Inform's detailed chart about how to get PrEP, which can be found at http://www.projectinform.org/pdf/PrEP_Flow_Chart.pdf. 

 

 

 

 

 

 

 

 

 

 shows that the number of new HIV diagnoses fell 17 percent in 2015, to 255, the lowest level since the start of the epidemic. The total number of deaths due to all causes among people living with HIV also fell, by about 10 percent, to 197. About 40 percent of those deaths were due to HIV/AIDS-related causes.

 

And San Francisco continues to do a better job than the U.S. as a whole in moving people through the continuum of care, from HIV testing to linkage to care to initiation of treatment to viral suppression.

But there are still notable disparities. African-Americans are the only group for whom new HIV diagnoses are stable or rising rather than declining, and blacks are more likely to be diagnosed late and less likely to be promptly linked to care. African-Americans accounted for 17 percent of all new HIV diagnoses in San Francisco in 2015, despite making up about 6 percent of the city's population.

Dr. Albert Liu of the DPH reported on behalf of the Getting to Zero PrEP committee that the city recently launched a social marketing campaign – "Our Sexual Revolution" – to encourage gay and bisexual men of color and transgender women to consider daily Truvada (tenofovir/emtricitabine) for HIV prevention.

San Francisco has taken the lead on access to PrEP. Informal estimates suggest that 6,000 to 10,000 people in the city may be taking Truvada for PrEP. However, to date major PrEP providers, including the San Francisco AIDS Foundation's Magnet program at Strut and Kaiser Permanente, have primarily served white and Latino gay men.

 

Rapid treatment

Dr. Oliver Bacon of UCSF and the HIV Division at SFGH gave a progress report from the Getting to Zero Rapid committee, which aims to get people newly diagnosed with HIV on antiretroviral treatment as soon as possible – ideally the same day.

Currently the median time from diagnosis to initiation of care is seven days and the time from starting care to treatment initiation is six days. Altogether, the time from diagnosis to reaching an undetectable viral load is 69 days – down from 131 days in 2013.

"Physicians around the city are quite willing to do rapid ART," Bacon said. "One of the major barriers to [rapid ART] is insurance status. If you have Medi-Cal or public insurance it's very easy to get rapid ART in San Francisco, but if you're eligible for commercial insurance or are uninsured, it's actually much more difficult."

The city has created the first directory of Rapid providers who can start ART right away, as well as an insurance navigation guide.

Reporting from the retention and re-engagement in care committee, Edwin Charlebois, Ph.D., from UCSF's Center for AIDS Prevention Studies, said that the city has received renewed funding from the MAC AIDS Fund for a linkage demonstration project. A pharmacy working group is exploring whether pharmacists can help identify people at risk of falling out of care.

Stigma is harder to measure than the number of people on PrEP or the length of time to viral suppression, but Austin Padilla from the stigma committee said the goal for the next year is to establish metrics.

 

HIV among young and old

A member of the audience asked where young people fit into the Getting to Zero plan.

According to the latest HIV Surveillance Report from the Centers for Disease Control and Prevention, young adults age 25-29 are the only age group to see an increase in new HIV diagnoses in 2015. In San Francisco this age group accounts for 23 percent of new diagnoses, while those age 18-24 account for 13 percent.

Liu said that the PrEP committee has identified youth as a high priority and the city is talking about establishing a fund to provide PrEP for young people. Oliver noted that Larkin Street Youth Services was one of the first to sign on to the rapid ART program.

The Getting to Zero meeting concluded with a discussion of HIV and aging. According to the DPH annual report, 60 percent of people living with HIV in San Francisco are age 50 and older.

"We quit our jobs, went on disability, and prepared to die – but some of us didn't," said long-term survivor Hank Trout. "Our golden years are turning into tin."

Vince Crisostomo, manager of SFAF's 50-Plus Network, said that housing is the biggest concern of older people living with HIV in San Francisco.

Dr. Monica Gandhi, medical director of the HIV clinic at SFGH, described a new program – dubbed Golden Compass – that will launch in early January at Ward 86. The program will centralize services for HIV-positive people age 50 and older, including cardiology and neuropsychiatric care, exercise and fitness for bone strength, vision and hearing services, and peer support groups.

"So much in HIV started in San Francisco and we need to be on the forefront of HIV and aging," Gandhi said. "As we work toward the [Getting to Zero] goal, we need to make sure people living with HIV are living better."