Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates’ efforts across the country.

The Pennsylvania Health Access Network (PHAN) is teaming up with Project H.O.M.E, the Housing Alliance of Pennsylvania and the Pennsylvania Health Law Project to address the rising costs among high utilizers in Medicaid through coordinated care in patient-centered medical homes and by providing supportive housing services in Pennsylvania. We recently launched our Housing as Health Campaign to advocate for a statewide approach to patient-centered medical homes for Medicaid beneficiaries with chronic conditions and urge the state to use Medicaid dollars to establish permanent supportive housing services for Pennsylvania’s vulnerable populations. 

As more and more individuals access health care through the Affordable Care Act and Pennsylvania’s newly expanded Medicaid program, it is imperative that we focus on how to reduce costs and improve health outcomes for Pennsylvania’s most vulnerable populations. Lack of coordinated care and access to services that promote health often result in underserved populations turning to costlier forms of treatment instead of continuing the correct path of treatment for chronic conditions. 

With the expansion of Medicaid eligibility on Jan. 1, 2015, many more Pennsylvanians who have experienced chronic homelessness and who live with chronic health conditions have been able to enroll in Medicaid. Pennsylvania’s health plans and providers have an important opportunity to learn about this population’s needs and improve the quality of care and health outcomes. Many new Medicaid beneficiaries in this population have health needs complicated by substance use disorders and challenges related to mental health, trauma and other issues.  

This project is bringing together health, housing and mental health experts and leveraging consumer involvement to urge state policymakers to develop and implement new approaches to health care for vulnerable Medicaid beneficiaries, including requesting federal approval for a waiver. Strategies include engaging the existing consumer advocacy community, raising public awareness, educating policymakers and state Medicaid officials about the need for health system transformation, and working with housing advocates to lift up the benefits to vulnerable Pennsylvanians of supportive housing services. 

A big focus of our work involves engaging consumers from vulnerable populations such as those with substance use disorders, individuals experiencing homelessness and those with chronic health conditions. Through this project community health organizers are working with these targeted populations to help engage them in the campaign. We will help them share their stories about accessing health care with policy makers and the media to advance consumer friendly principles and the need for supportive housing services. Already we had a consumer forum in Philadelphia where three consumers shared their experiences with our patient-centered medical home advisory committee.

We hope our work will create a model for advocates in other states working to address both homelessness and communities with high health needs.

Antoinette Kraus, Director, Pennsylvania Health Access Network

A new report from The Commonwealth Fund demonstrates how Hennepin Health, a Medicaid Accountable Care Organization (ACO) in Minneapolis, Minn. is breaking new ground in creating partnerships to address the range of health and social needs of the most at-risk members in their community. As consumer advocates look at models that address social determinants of health and payment policies that will support such models, this case study is a must-read.

Hennepin County Medical Center has long served the low-income and uninsured community in the Twin Cities and has grappled with how to meet the needs of the most vulnerable, many of whom have needs that go far beyond medical care alone. So, in 2012 they launched a Medicaid ACO demonstration project to create a new model of care for Medicaid beneficiaries who suffer from debilitating mental health problems, chemical dependencies, and other hallmarks of poverty, trauma and social isolation. The ACO includes four partners: the county’s human services and public health department; Hennepin County Medical Center, a public teaching hospital; Metropolitan Health Plan, a county-run Medicaid managed care plan; and NorthPoint Health and Wellness Center, a federally qualified health center. 

Using a care team approach whose members may include physicians, nurses, social workers, a psychologist and a substance use specialist, Hennepin Health was able to reduce ER visits and achieve significant savings. Hennepin’s efforts to identify and engage high-risk patients are key to its success, since the ACO is financially responsible for all of its enrolled members. Patients enrolled in care coordination programs also are given a lifestyle assessment to help staff understand their social challenges.

Last year, I had the privilege of sitting in on a team meeting at the Coordinated Care Center at Hennepin. Seeing this person-centered model at work, with all medical, social and behavioral issues being discussed by team members who exhibited high mutual regard for the expertise each brings, was truly inspiring. The Commonwealth report concludes that this is a model that can be replicated elsewhere, but doing so requires: a long-term investment; that state Medicaid agencies look at risk adjustment for social determinants of health, both in quality measures and payment models; and a community-wide approach to providing compassionate care for the most vulnerable high-need populations.



Thanks to the Affordable Care Act (ACA), 20 million people have gained health insurance coverage, creating a pathway to better health. However, holding on to that coverage is not always easy and barriers remain for many consumers. Even with the ACA, low-income individuals and families remain at risk of losing their coverage or cycling between different types of coverage—known as churn. Changes in income, employment status or family composition may all result in churning between types of coverage and/or becoming uninsured.

New research on churn

Earlier this month, a new study published in Health Affairs demonstrated the effect of churn across three different states: Kentucky, Texas and Arkansas. Each state has taken a different approach to coverage: Kentucky implemented a straight Medicaid expansion, Texas chose not to expand Medicaid and created a coverage gap, and Arkansas implemented a premium support model that uses its Marketplace to deliver coverage to newly eligible consumers under 138 percent of the Federal Poverty Line (FPL). The data yield interesting results that require further inspection.

The good news is that churn is not as bad as originally predicted. Only a quarter of consumers surveyed experienced a change in their coverage over the last 12 months; prior research estimated that 50 percent of consumers would experience a coverage change in a calendar year. When we look a little closer, some interesting themes emerge. For example, churning was roughly twice as common among those with Marketplace coverage or non-group private coverage, compared to those with Medicaid−consumers mostly cited job changes as the reason for these coverage changes. Additionally, some populations appear to cycle off of coverage more than others. For example, women and younger adults experience coverage changes more than men and older adults, on average. Furthermore, churn is less common among Latinos than among whites.

Churn Illustration 2

Figure 1. Illustration of Churn and Some Data Highlights.

Addressing churn should be a priority.

While the ACA moves us toward increased opportunities for coverage, challenges remain for individuals maintaining coverage. Clearly, churn has serious health impacts on low-income people. When cycling in and out of coverage, people are forced to switch plans that result in changes in their doctor, disruptions in medical care, interruptions in patient-provider relationships and complications with access to medications. At least 13 percent of those who churned had to change at least one provider, 22 percent skipped doses or stopped taking prescription medications and 29 percent reported an overall harmful effect on the quality of their health care. Those who churn with gaps in coverage experience the worst health outcomes as they delay seeking routine care, skip needed treatments or stop taking prescription medications altogether. These findings affirm that mitigating gaps in coverage is vital to better health outcomes and that states need to do more to ensure continuity of care for those who transition between coverage types.

Finally, there are the financial implications for states. The administrative costs associated with dis-enrollment and re-enrollment is much higher than the costs associated with enrollment procedures and processing for new enrollees. States also incur increased costs associated with overuse of emergency rooms for minor health conditions by individuals with gaps in coverage as well as costs associated with unmet health needs that become exacerbated when people go without needed treatment.

Some states are making progress.

Churn is driven by a multitude of factors. For that reason, policy solutions must be tailored to a state’s specific challenges. A number of states have taken actions to minimize the frequency and adverse effects of churn on low-income individuals and families. However, many states do not proactively report data to identify and monitor churn and its impacts—particularly on people of color.

As we contemplate next steps to build on the progress of the ACA, there is an opportunity for consumer advocates to work with their state policymakers and stakeholders to develop a model for estimating churn and a plan of action to support consumers in keeping their coverage. As we approach the Fourth Open Enrollment Period, enrollment specialists have an important role to play in helping consumers understand their insurance options, responsibility to enroll and how to keep their coverage. Stay tuned for upcoming resources!

Back in 2013, Massachusetts became the first state to use a full managed care approach under the CMS-sponsored Financial Alignment Demonstration. This demonstration, known as One Care, serves people with disabilities ages 21-64 who have both Medicare and Medicaid and seeks to provide better care at lower cost. Since the launch, advocates from the disability community have regularly voiced the need for the public reporting of outcome data. And, nearly three years later, that day has arrived! Results from One Care’s first year (October 2013-December 2014) are now available! 

While the evaluation did not reveal any big surprises, and findings are only from the first demonstration year, having the data to back up claims of successes and challenges is critical as our health care system shifts more and more toward integrated models of care for people with complex needs, utilizing various innovative payment mechanisms. A few key takeaways of note from the evaluation:

  • One Care enrollees had a lower 30-day readmission rate compared to non-enrollees.
  • There are opportunities to further improve beneficiary education and engagement. For example, focus groups convened to obtain participant feedback suggest that many beneficiaries were not aware of the formal complaint and appeals processes or available resources to assist them with problems.
  • It’s important to ensure stable financing structures and adequate payments. The evaluation reports that One Care plans experienced losses during the first year, noting that Medicare and Medicaid capitation rates were inadequate to cover new costs associated with care coordination, additional benefits offered, and administrative start-up costs of the demonstration.
  • With the large number of beneficiaries being enrolled during passive enrollment phases, One Care plans reported their greatest difficulty was reaching enrollees, including many who are homeless or without a stable address.
  • The Long-Term Services and Supports (LTS) coordinator role, while widely supported and very much needed, was difficult to implement due to ill-defined roles and responsibilities, which led to inconsistencies and confusion in implementation. The plans and community-based organizations found it difficult to strike the right balance between flexibility and structure for the LTS coordinator role.
  • Participants reported unmet needs for oral/dental care and substance use disorder services.

Though many of these early challenges have been largely addressed, there is still additional work to do both in Massachusetts, which extended the demonstration for another two years, and elsewhere. It will be important to take these early findings and use them to continue to improve One Care. Other states with ongoing demonstrations may also find much of interest within this report, as they work to refine their projects to provide maximum benefit to participants.

And, to continue the virtuous cycle of quality improvement, we eagerly await further demonstration evaluations out of CMS!


Today, Community Catalyst’s Center for Consumer Engagement in Health Innovation submitted comments on the proposed regulations updating the Program of All-inclusive Care for the Elderly (PACE) model. The regulations proposed by the Centers for Medicare and Medicaid Services (CMS) represent the first major update to the PACE program in a decade. PACE is a team-based program available to nursing-home eligible people over age 55 with Medicare or Medicaid, or both (in some states, only Medicaid beneficiaries are eligible). The program’s goal is to keep participants in the community in which they live rather than a nursing home or other care facility. PACE does this by coordinating care and connecting members to many specialists and other providers, as well as to a range of services and supports in the community to provide a well-integrated care experience. Despite evidence showing PACE participants have significantly lower rates of hospital, nursing home, and emergency department utilization and lower overall rates of inpatient days, both the numbers of PACE programs and the level of enrollment has remained relatively small.

To address some of these challenges, CMS is proposing a number of improvements including operational flexibilities, particularly around the Interdisciplinary Team (IDT) that is so central to the benefits of the PACE model. For example, the integration of community-based providers as primary care providers (PCPs) and expansion of the professions which would qualify as PCPs to include nurse practitioners and physician assistants are both steps in the right direction. The ACA has enabled CMS to explore and promote new models of care via demonstrations to integrate care for some of the most high-need, high-cost consumers. Our comment letter urges that some of this work, including the PACE program, be integrated into the work of the Medicare-Medicaid Coordination Office within CMS.

In general, the Center is supportive of the proposed regulations and believes it is important to build upon the lessons learned from PACE’s successes over the past four decades and expand these to other integrated models of care. In our comments, we urge CMS to make building awareness of this model more of a priority and in the final regulations, to encourage provisions that will allow for greater expansion of the number of PACE programs across the nation.