Community Benefits: A Tool for Universal Access, Quality Care and Public Accountability

by Cindy Maxey

Traditionally, one of the major roles of hospitals and other health care institutions has been to contribute to the health of the community at large. The services a hospital provides to address unmet community health needs are called community benefits.

Community benefits are, more broadly, the unreimbursed goods, services and resources provided by healthcare institutions to address community-identified health needs and concerns, particularly those of people who are traditionally uninsured and/ or underserved. These may include such services as:

• free or sliding scale care
• community-oriented wellness and health promotion programs
• sponsorship of programs for the homeless or other vulnerable groups
• support of public health programs
• transportation services for elderly, disabled or low-income patients
• provision of free or reduced cost prescription drugs to patients unable to pay full price.

In the last ten years, hospitals have faced increased marketplace competition, as well as revenue cuts from Medicaid, Medicare and managed care. Tighter bottom lines have threatened community benefits. Further, many hospitals have made little effort in the past to consult with people in their communities to determine what benefits to offer and how to deliver these services.

In order to improve how hospitals use limited resources to address community needs and to improve hospital-community relationships, UHCAN Ohio has joined the community benefits movement. We are working in several communities in Ohio to assist neighborhood residents and members of underserved communities to organize around unmet health care needs and work with their local hospitals to meet these needs. As well as directly working in several communities, we are providing technical assistance to other groups. Examples of working community benefits efforts include the Immigrant (and Limited English Proficient) Health Care Access Coalition in Cleveland and the Language Task Force in Columbus, the Dental Task Force and Free Care Committee in Columbus, and nascent efforts in the Glenville and Buckeye neighborhoods of Cleveland. The Community Partnership for Affordable, Accessible Health Care is a coalition of groups working to improve community relationships with MetroHealth Hospital in Cleveland and to hold the hospital accountable to the neighborhoods it serves.

Typically we begin by interviewing community leaders about unmet health care needs they perceive and which they are motivated to work to eliminate. We then gather a group of people with similar interests to form a task group, identify initial goals and then decide how we want to address those needs. We may do a community health needs assessment survey before approaching the local hospital. Groups sometimes take on concerns which extend beyond community benefits and find themselves working with government officials to improve benefits or change other laws affecting community health.

UHCAN Ohio is not alone in this work. Groups are working on community benefits throughout the country. Fourteen states have community benefits laws, regulations or guidelines. Some apply not only to hospitals, but also to insurers and HMOs. Community benefits are an important way to maximize use of community health resources to address the biggest needs, as well as to improve relationships between hospitals and communities in the pursuit of greater health care change.

If you are interested in starting a community benefits process in your community and would like more information, or if you would like to join an on-going campaign, contact Cindy Maxey, field organizer, in Cleveland (216-241-8422) or Cathy Levine, policy director, in Columbus (614-253-4340).

Why Ohio Should Expand Health Coverage to Working Families

1. Many working families cannot afford insurance.

• Over 40 percent of families with incomes between 125-150 percent of the federal poverty level are likely to be uninsured.(1)
• The average wage of people who left welfare for work in Ohio is $8.65 an hour, or 125 percent of the federal poverty level for a family of three.(2)
• Most entry level jobs either don't offer health benefits, or the employee can't afford the coverage.

2. Families need support as they move from welfare to work.

• Forty-nine percent of women in the U.S. leaving welfare are uninsured one year later.
• Health coverage helps stabilize parents in entry-level jobs and improves long-term employment.

3. Families without health insurance risk health and financial problems.

• Two out of 5 uninsured Ohioans delayed or avoided health care in 1998.(3)
• Uninsured Ohioans are twice as likely as insured Ohioans to use emergency rooms4 -- the most expensive care and not meant as preventative care.

4. Insuring working families saves money for everyone.

• Uninsured people pay more when they get care and many face medical bankruptcies.
• Parents with untreated illness miss more work, costing employers money.
• Ohio hospitals have had uncompensated care from uninsured patients with incomes above poverty level rise $80 million between 1997-1999.
• Costs of the uninsured are passed onto the public.

5. Covering parents helps kids get care.

• Providing health coverage for parents increases enrollment of low-income children.(5)
• Covering children is a top priority for Governor Taft's administration.

6. Medicaid for Working Families is great coverage at a bargain.

• If Ohio expands Medicaid for working families, the federal government may pay $.71 of costs when the state pays $29.(6)
• Medicaid covers doctors' visits and preventative care, keeping parents and children from needing more expensive hospital care.

(1) Employee Benefits Research Institute.
(2) Ohio Department of Job and Family Services.
(3) Ohio Family Health Survey, from the Ohio Department of Health.
(4) Id.
(5) Center on Budget and Policy Priorities, September 2000.
(6) This is the federal/state match if Ohio gets a waiver to use unspent CHIP funds to expand family coverage.

Coalition Pushes for Expanded Access

The majority of Ohio's 1.7 million uninsured are low-income working adults. The Ohio Family Coverage Coalition, comprised of human services agencies, provider associations, and nonprofit organizations, has developed a two-pronged proposal for expanding access to care in the upcoming Ohio budget.

(1) Expand Medicaid to families up to 150 percent of the federal poverty level (FPL): During the last budget, the coalition won an expansion of family coverage to poverty level ($17,050 for a family of four). Growing data show that many families with incomes below 150 percent FPL are unlikely to receive employer-sponsored coverage. Ohio can cover parents for less money, because Ohio is eligible for a waiver to use unspent federal Child Health Insurance Program (CHIP) funds to cover parents. Under the waiver, Ohio would pay only 29 percent of the costs; the federal government would pay the rest.

Three states -- New Jersey, Rhode Island and Wisconsin -- recently received waivers to offer health insurance coverage to parents of children eligible under CHIP or Medicaid program. New Jersey will cover parents up to 200 percent FPL; Rhode Island, up to 185 percent FPL; and Wisconsin, 185 percent FPL.

(2) The second prong of the Family Coverage proposal is to provide $5 million per year to community health centers providing primary care to people regardless of ability to pay. For people who do not qualify for Medicaid (particularly non-disabled adults without children), health centers keep people healthy and at work.

The Family Coverage Coalition has produced two "White Papers" on their proposals. View them at the UHCAN Ohio web site <www.uhcan.org/ohio>.

The coalition seeks organizational endorsements and people around the state to participate in grassroots education of legislators and the public. Contact Cathy Levine at the Columbus office, (614)253-4340.

In Memoriam

Doris Brennan, a passionate advocate for people with disabilities, died December 18, 2000. The executive director of LEAP (Linking Employment Abilities and Potential) in Cleveland, Ohio, Doris served the disabilities community as leader, mentor, and sister. She was an expert on social security issues and the relationship of health coverage to work.

Doris was a founding member and trustee of UHCAN Ohio's board. She was also a friend. We are grateful for her presence among us and for her contribution to health care justice. We will miss her.

Families Regain Medicaid

In late December 2000, close to 130,000 Ohioans received special temporary Medicaid cards, good for 3 months. Cardholders have 3 months of comprehensive health care, including doctor's visits, hospitalization, dental, vision and mental health care.

Those reinstated will also receive short applications to apply for continuing coverage. Both working parents and children are now eligible with higher incomes: parents with incomes up to100% federal poverty ($17,050 for a family of four); children with incomes up to 200% poverty. However, even those temporary cardholders not currently eligible for Medicaid may use the cards without fear of having to pay for services.

"The Medicaid reinstatement is a great opportunity for working families to get needed health care," said Gene King, managing attorney for Ohio State Legal Services Attorney and UHCAN Ohio Board member. Gene coordinated the team of legal services attorneys and other advocates that negotiated the Medicaid reinstatement.

Those reinstated lost Medicaid between November 1997 and April 2000. Both those reinstated and thousands of other former Medicaid beneficiaries are also eligible to apply, under certain circumstances for payment of past medical bills incurred after they were terminated from Medicaid.

Spread the Word!
Unfortunately, the state is unable to contact over 30,000 people who have moved since losing Medicaid. Further, the state is doing no media outreach. Anyone who thinks they might be eligible for Medicaid reinstatement should call the state's special toll-free Ohio Family Medical Project hotline: 1-800-221-1560. Anyone who is on the list and notifies the state during the year 2001 will receive 3 months of free Medicaid.

People who receive the 3-month Medicaid cards should be encouraged to apply for continuing benefits. People are now eligible with higher incomes, but it is also easier to apply (less paperwork, no office visits).

For more information or to schedule a presentation for a community organization, call Cathy Levine, 614-253-4340.

Columbus Language Task Force Receives Grant

The Language Task Force, coordinated by UHCAN Ohio, has received a $111,000 grant from Access HealthColumbus, a community partnership to assure access to health care. Under the grant, part of AHC's strategy to improve cultural competency of health providers, LTF agencies will create a centralized pool of trained medical interpreters. By providing hospitals and other providers with 24-hour access to trained medical providers, this project will improve the numbers of Limited English Proficiency (LEP) patients who receive appropriate health care. The project also includes a Policy Committee that will develop community standards for medical interpreters, explore certification for interpreters, and seek Medicaid payment of interpreters.

For more information, contact Cathy Levine, 614-253-4340.

U2K, Year Two

This last fall, thirteen Ohio candidates for Congress pledged to work for health care for all -- if elected. Six of them are now in Congress. As promised, the committee led by UHCAN Ohio is returning to our representatives to follow up on their commitment made during the national Universal Health Care 2000 Campaign (U2K). In Cleveland, U2K culminated on October 15 with a successful Day of Action for Health Care for All which drew some 300 people and several candidates for congressional and state office.

The post-election follow-up involves letter writing, and focuses on one congressional district for more extensive work. Those in Congress who already are on board in their commitment to working for health care for all will hear from their constituents -- U2K endorsing organizations and other individuals. They will be thanked and asked for their ideas on moving a health care agenda. Ohio's other 13 members of Congress will also receive letters from their constituents, urging them to come on board, on behalf of our country's 43 million uninsured Americans. All will be urged to participate in the bipartisan congressional universal health care task force.

Representative LaTourette (District 19) was the only one of the four representatives in Northeast Ohio who remained silent on the issue of universal health care during U2K. The committee has targeted District 19 (Rep. LaTourette) for "direct action." Watch for a report in the next issue of Update!

Ohio Legislation Highlights

UHCAN Ohio keeps an eye on Ohio health legislation. For more information on pending bills,
either check our website or call the policy director, Cathy Levine, in our Columbus office, (614) 253-4340.
Full texts and summaries of bills are available on the state's website: www. legislature.state.oh.us.

The 124th General Assembly began on Jan. 1, 2001. All pending legislation will have to receive a new number or die. No new bills have been introduced, but the following bill will be introduced soon.

Senator Eric Fingerhut, D-Cleveland, will introduce a bill to create an Assisted Living Program for Ohioans who are eligible for Medicaid. Under current law, Ohioans who are sixty-five or older or disabled and are eligible for Medicaid have only two choices. They can enroll in one of Ohio's home health care options, such as PASSPORT or move into a nursing home. Ohioans who do not need Medicaid have many other options, including assisted living.

"An Assisted Living Program in Medicaid would provide all Ohioans with the same options," said Fingerhut. "Because assisted living is less expensive than nursing home care, an Assisted Living Program would also save taxpayers money. If we save money by allowing people who are able to stay in assisted living to do so, then we should also be able to afford the quality of care we want and need to provide in nursing homes for those who need that intensive level of care."

UHCAN Ohio offers Presentationsfor Providers

UHCAN Ohio and the Language Task Force have received many complaints from community advocates about immigrants saddled with unpaid hospital bills that should be covered by a public program. In response, UHCAN Ohio has prepared a presentation for hospitals and community agencies entitled "Health Care Resources for Immigrants." The program covers Medicaid eligibility for immigrants and refugees, Alien Emergency Medical Assistance (AEMA), HCAP and charity care, as well as requirements under Title VI of the Civil Rights Act of 1994 regarding language access in health care.

Staff trained in the program will enable hospitals to assist immigrants while helping the hospitals increase reimbursements for their services. At its premiere at Columbus' Children's Hospital, the presentation received great reviews.

For more information, contact Cathy Levine.

Health Coverage for Uninsured Immigrants

In 1996, Congress put restrictions on eligibility of immigrants for Medicaid. Most permanent residents who entered the US after August 22, 1996 are not eligible for Medicaid for 5 years, with the exception of people with "refugee" or "asylee" status from the INS. In addition, immigrants living here without documentation are not eligible for Medicaid.

AEMA is available for immigrants not eligible for Medicaid. The Alien Emergency Medical Assistance program, or AEMA, (Ohio Administrative Code 5101:1-39-80) provides Medicaid payment to hospitals for emergency treatment to non-citizen patients who are not otherwise eligible for Medicaid. Even patients who lack documentation of their immigration status are eligible for AEMA.

However, when low-income, uninsured immigrant patients receive non-emergency services, AEMA will not apply. Those patients who are neither eligible for Medicaid nor AEMA may be eligible for the Hospital Care Assurance Program, or HCAP. This is a program created by Ohio law.

HCAP requires hospitals to provide all medically necessary hospital care to people living at or below the federal poverty level (HCAP does not cover physicians or other non-hospital charges). HCAP is available to all Ohio residents, regardless of citizenship or immigration status. By law, signs about HCAP appear in the emergency room, admitting, and other areas of the hospital. Notices about HCAP are also found on hospital bills. However, patients with limited English or who cannot read may not understand those notices, especially when they are in English only.

For more information on Medicaid, AEMA, or HCAP, contact the hospital's billing office; or call UHCAN Ohio, 614/253-4340.