Health Care for Low-Income People in the District of Columbia

Barbara Ormond, Linda Blumberg, John Holahan,David G. Stevenson, Susan Wallin, Joshua M. WienerHEALTHCARE FORLOW-INCOMEPEOPLE IN THEDISTRICT OFCOLUMBIA THE URBAN INSTITUTEBarbara OrmondLinda BlumbergJohn HolahanDavid G. StevensonSusan WallinJoshua M. WienerHEALTHCARE FORLOW-INCOMEPEOPLE IN THEDISTRICT OFCOLUMBIA Copyright ©1999. The Urban Institute. All rights reserved. Except for shortquotes, no part of this book may be reproduced or utilized in any form or byany means, electronic or mechanical, including photocopying, recording, orby information storage or retrieval system, without written permission fromthe Urban Institute Press. AcknowledgmentsSupport for this paper was provided by TheRobert Wood Johnson Foundation and theUrban Institute. The authors would like toacknowledge the cooperation of the members ofthe District of Columbia health care communitywho gave generously of their time and insights.Without their help this paper would not havebeen possible. ContentsOverview of the District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Government Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Economic Landscape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Washington’s Medicaid Program: Overview. . . . . . . . . . . . . . . . . . . . 7Medicaid Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Washington’s Medicaid Expenditures Comparedwith States’ Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Medicaid Growth Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Medicaid Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24The PCCM/HMO Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24The Mandatory HMO Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Proposals for Expanding Medicaid Eligibility . . . . . . . . . . . . . . . . . . . . . 31The Safety Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35The Public Safety Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35The Private Safety Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Threats to the Safety Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Long-Term Care for the Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Policy Environment for Long-Term Care . . . . . . . . . . . . . . . . . . . . 46Home- and Community-Based Services. . . . . . . . . . . . . . . . . . . . . . 48Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Challenges for the Future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Health Care forLow-IncomePeople in theDistrict of ColumbiaAs in many areas of the country, low-income people inWashington, D.C., face a number of challenges in obtaining healthservices delivered in a timely manner, in an appropriate setting, andwith attention to continuity and quality of care. One barrier isfinancial; nearly 30 percent of nonelderly D.C. residents below 200percent of the federal poverty level (FPL) are uninsured. Anotherbarrier is availability; many economically depressed sections of thecity are underserved by health care providers. Hospitals and clinicsthat serve the poor are experiencing some financial strain as com-petition among hospitals for paying patients continues to increaseand Medicaid payments are held in check. The District’s Medicaidprogram has for many years paid facilities relatively generous rates.In an effort to control what many perceive as a bloated programbudget, the city has adopted new fee-for-service payment method-ologies and instituted managed care reforms. From a fiscal per-spective, the effect of these changes and others on the budgetappears favorable; however, the outcome for safety net providersand Medicaid recipients remains to be seen. Some observers areoptimistic that access to providers—whether traditional safety netproviders or providers who mainly serve a commercially insuredpopulation—and continuity of care for t