the middle have been flat over the past decade. for lower income americans, they have actually fallen. and even for many higher wage earners below the very top, they have barely risen. so what do we draw from this? americans are working harder, contributing more than ever to their companies' bottom lines and our country's total economic output, yet many are still barely getting by, holding on, not seeing the reports that their hard work should have merited. and where is it all going? well, economists have document how the share of income and

wealth going to those at the very top, not just the top 1%, but the top .1% or the top .01% of the population, has risen sharply over the last generation. some are calling it a throwback to the gilded age of the robber barons. now as secretary of state, i saw all the way extreme inequality has corrupted other societies, hobbled growth, and left entire generations alienated and unmoored. from guatemala to greece to pakistan, i urge them to pay their fair share, to provide services that would be the base on which more of their fellow countrymen and women could climb out of poverty. i addressed governments to address their people and include positive visions for the future. in the middle east and north africa, we saw the explosive results when opportunity and potential are denied for too long.

but one could ask him what does that mean for us? we are not like them? imagine a young single mother trying to raise a family today. after all, there are some 10 million single moms working hard to make it on their own in america today, up from just 3.4 million in 1970. mothers are now the primary or sole breadwinners in nearly 40% of all families. this single mom lives somewhere in our vast metros sprawl, traveling long distances every day to work a low-wage job she is lucky to have. many other young people in her neighborhood are still looking. she works hard, but she knows that her male co-workers tend to make more than she does. it is demeaning, demoralizing, and it sure changes are openly.

she lives in dread of her baby getting sick or some other emergency because, like nine out of 10 workers earning the lowest wages, most of them women, she does not have access to paid family leave, and forget sick days or flexibility or predictability, which is just as important for parents and caregivers. so she relies on a network of friends and family to help care for her kids, but that too is hard. the neighborhood is not like the one she and certainly not the one her mother grew up in. religious and community organizations are weaker. the schools are never good enough. there are few quality affordable childcare options. but she has dreams. she certainly has dreams for her kids. but she does not just face ceilings on her aspirations and opportunities. sometimes it feels as if the floor has collapsed beneath her.

these are the kinds of daily struggles of millions and millions of americans, those fighting to get into the middle class and those fighting to stay there. and it was something of a wakeup call when it was recently reported that canadian middle-class incomes are now higher than in the united states. they are working fewer hours for more pay than americans are, enjoying a stronger safety net, living longer on average, and facing less income inequality. that is not how it is supposed to be. we often think we invented the middle class. so what can we do about it? a lot depends on our leadership

here in washington and across our country. the 1990's taught us that even in the face of difficult, long-term economic trends, it is possible, through smart policies and sound investments, to enjoy broad-based growth and shared prosperity. my husband gave a lecture at georgetown recently where he walked through the numbers. yes, a rising tide really did lift all those. 23 million new jobs were creating about raising the minimum wage, doubling the earned income tax credit. that helped millions of lower income families climb out of poverty. the children's health insurance program changed millions of young lives, and on and on with a balanced budget that resulted in surpluses as far as the eye could see. i remember being on the budget committee in the senate, my very first year with a new administration, making different choices. and the next eight years taught us different lessons about how by policy choices we could turn

surpluses into debt. we can return to rising deficits. that is what happens when your only policy prescription is to cut taxes for the wealthy. and then to deal with the aftermath of a terrible terrorist attack and two wars without paying for them. regulators about their oversight of an entire banking system that operated without can ability. government failed to invest adequately in infrastructure from education, basic research, and then the housing crash, the financial crisis hit like a flash flood. millions of jobs washed away, along with college savings, mortgages, nest egg for retirement, confidence, intangible, in the future. it has been taking years for president obama to get our

economy growing again. but it is growing, and there are reasons to be optimistic about our future. and we know there are tremendous opportunities that we are better positioned to take advantage of than any country in the world, from big data to clean energy to a resurgence of manufacturing, to the dream being realized of energy independence. we are better positioned than anyone to take advantage of these advances. we have the best universities, the most innovative companies, the most creative and flexible, talented workers anywhere. but it will not happen just because we have these assets. we will need some big ideas, like evidence-based decision-making, an old idea that i hope can be restored. [laughter] some of these ideas are as old as america itself, rooted in our values, equality and

opportunity, and most of all we will need to learn again how to work together, how to compromise, how to make pragmatic decisions. in the upcoming midterm elections, americans will have choices to make about which path they want to go down and whether we will make the investments we need in our people. i will leave that discussion to others. but for a lot of us, in the private and nonprofit sectors, we have work to do, too. government does not have a monopoly on good ideas, obviously. and even if it wanted, it could not and should not try to solve all of the problems i itself. we have responsibilities to do what we can. when i left the state department, i joined my husband and daughter at the clinton foundation. i wanted to continue my lifelong work pursuing ways and answers

and solutions that could help more people live up to their own god-given the potential. and i wanted to help try to tear down barriers and crack ceilings that have for too long held back women and men from participating fully in the economy and society. so i thought, what can we do to build on this great work that bill had done and that chelsea was leading, drawing on lessons that really came from my entire life, starting with my work at the study center when i was in the law school, making sure that children are not hobbled from birth, but given more chances to succeed. and it became clear that i could go back to what i had been doing, but unfortunately, it was going back to where we had been in some respects 30, 40 years

ago, rather than picking up the pace of where we had moved toward. i was very struck by how difficult it was for so many children to be successful in school, despite all the education reform that we have done and experimented with over a very long time now. it really did come home to me that part of the problem is that too many of our children are not getting the very early start in those first years that will enable them to take advantage of advances in education. economic pressures on parents translate to less time reading, talking, and even singing with their children. all of these stimulate crucial brain development. by age three, children from low income families have learned half as many words as children from middle and upper income

families. by the time they enter school, they have substantially smaller vocabularies than many of their classmates. experts call this the word gap. it leads directly to an achievement gap. we launched a public action campaign called too small to fail. to give parents the tools and information they need to do their part in beginning to close that word gap. that will give their children the best possible chance in school and later in life. i also thought we needed to keep moving forward on the unfinished business of the 21st century, empowering women and girls here at home and around the world. we started an effort called no ceilings, the full participation project. it has been one to years since the fourth world conference on women in beijing. we spoke with one voice to

declare that human rights are women's rights and women's rights are human rights. we still had only a glass half-full. what we're doing is collecting the best data and research available on the progress women and girls have made in the past two decades, both gains and gaps and making that information accessible to a broad audience. we are also building momentum for the 21st century policy agenda for the full participation of women and girls, including you're in the united states. there have been big changes in our economy and our society and in our institutions, policies, and attitudes have not caught

up. women make up half the u.s. labor force, but they are largely concentrated in lower wage positions. women hold three quarters of all jobs that rely on tips, like waiters, bartenders, hairstylists -- which pay even less than the average minimum wage. across the board, women are paid less than men for the same work. here is part of what is happening below the surface, as a result of this slowdown in progress. american women, with the least education, less than high school education, and the lowest incomes, are actually living shorter lives today than their mothers did. shorter lives than women in any other major industrialized country. the only other place where we have seen such a reversal in life expectancy was among russian men after the collapse of the soviet union. there is no single explanation as to why life expectancy is declining. but it correlates with unemployment and economic

stress. that is not what we should expect from ourselves. with the best medicine, most advanced technology. it is not something we should be satisfied with. the third area i want to focus on at the clinton foundation is helping young americans struggling to make headway in this tough economy. that is something i have been working on and committed to for decades. we saw similar problems back in the 1980's, when i served on a workforce training commission organized by the wt grant foundation and the national center for the economy. the problems have grown more complex as the economy has changed. nearly 6 million young people are out of school and out of work. that is almost one in every six. for young people of color, things are even harder. if you do not have a college degree or did not graduate from

high school, most stores are not open, no matter how hard you not. think about what that means. it is not just about missing a paycheck or going without benefits, like health care, when young people cannot find work, they miss out on a crucial period of personal and professional growth that reverberates for decades in lower wages and lost opportunities. those first jobs -- i certainly remember my first job -- that is where you learn skills, even if it is just showing up on time. that is where you build networks and gain confidence and experience the dignity of work and responsibility. if you miss out on all of that, frustration, rejection, and poverty gives you a much less positive outcome. and the rest of your family and community and society. economists say our youth unemployment crisis could cost

america roughly $20 billion in lost earnings over the next decade alone. there is no doubt that the biggest cause of youth unemployment is an economy that is not generating enough demand despite the recovery. we need to keep growing and investing in the building blocks of the 21st century. this is sometimes overstated. but it is true that to get a good job, you have to in our economy have some form of specific skills and proven work experience. and not just a strong work ethic that was a ticket to the middle class for my parent. many young americans do not have these qualifications and i would argue that it starts at the very beginning and goes all the way through their schooling. they do not get the job experiences that they need outside of the classroom. they do not know what is expected of them. when skills training is available, too often it is

disorganized, it does not actually exist, or is it for industries that are shrinking. we need to do more to sync up young people workforce training programs and employers looking to hire. as part of the clinton foundation effort, we are reaching out to businesses big and small and really trying to drill down on what their actual needs are and why what they have tried before has not worked. and how we can do a better job in a public, private partnership to resolve these difficulties. apprenticeships, partnerships with community colleges, cross sector collaborations, forward-looking companies that recognize that molding the talent pool for the future is good for them. that is an investment worth making. take the gap. it recently raised its bottom wages. it has lots of experience hiring and training young americans, many for the first jobs. they have partnered with many nonprofits to provide job training and paid internships. to underserved youth who might

not otherwise make it through their doors. most of the young people who complete the program go on to become full-time gap employees. or consider corning. famous for supplying the gorilla glass for the iphone. to stay on the cutting edge, they need a steady pipeline of high skilled talent. they have invested in internships that help students explore careers and they are providing on-the-job apprenticeships in their factories. at the clinton global initiative annual conference in denver next month, we are assembling a network of businesses willing to step up, expanding hiring, training, mentoring, hopefully to create a virtuous ripple throughout the economy.

engaging with others in the business community and beyond to encourage more partners to come off the sidelines. for some to use some of that cash that is sitting there waiting to be deployed. to help build training infrastructures that will help entire industries. to help use supply chains as force multipliers. to work with schools, nonprofits, unions, and elected officials. to coordinate everyone who has a legitimate, sincere interest in moving forward together. we will be announcing more details about that in the meeting in denver. this is a long-term challenge. we cannot wait for government, which seems so paralyzed and unfortunately at a time when we could be racing ahead. we cannot wait because we have a rising generation of young

people. the so-called millennial generation. they are optimistic, tolerant, creative, generous as a cohort. they have so much potential, so much to contribute. they can be the participation generation, the innovation generation -- not a lost generation. because we have not tended to what social supports they need in order to make their mark. now, working with my husband and daughter at our foundation, our motto is that we are all in this together. which we totally believe you read we believe in the american dream. we believe in social mobility. we believe that what worked for my mother or for bill's mother, these horatio alger rags to riches stories, these are still possible. this is what has fueled the idea of america. that is what is part of what has always made this country great. the chance that anyone of us could move forward, no matter

where we came from. that we can achieve so much. that there is no limit on what can be achieved with big talent and big ideas. but if you look at american history, there is another story to tell about how upward mobility really works. in part, this is the complement to the rugged individualist story that we all know so much about and some of you have lived. it is about communities that are ecosystems of opportunities. as eric schmidt knows, the personal computer revolution needed more than one or two people in a garage. it needed silicon valley. networks of public and private universities, investors, competitors, collaborators. it needed state and local governments that invested in the future and human potential. it needed a culture of risk taking and creativity.

this story about the link between strong communities and the american dream goes very deep. one of the first great observers and chroniclers of america was alexis de tocqueville. he traveled across the new country of ours in 1830's, learning everything about this radical idea called democracy. and the men and women who made it work. he was amazed by the social and economic equality and mobility he saw here, unheard-of in the aristocratic era. and by what he called, our habits of the heart. the everyday values and customs that set americans apart from the rest of the world you read it found a nation of joiners, clubs, congregations, civic organizations, political parties, groups that bound communities together and invested those famous rugged individualist and the welfare of their neighbors. this made the democratic experiment possible. talk about a big idea. those early americans were volunteers and problem solvers. they believed that their own self-interest was advanced by

helping their neighbors. like benjamin franklin, they formed volunteer fire departments because if your neighbor's house is on fire, it is your problem too. middle-class women went into the most dangerous 19th-century slums to help children who had no one else standing up for them. americans came together, inspired by religious faith, civic virtue, common decency -- to lend a hand to those in need. and to improve their lives and their communities and that made our democratic experiment possible. it made america an exceptional nation. i believe with all my heart that is still true. we see that where the fabric of community is strong even today, places with a vibrant middle class, two-parent families, good schools unions, churches, civic organizations, places integrated across class and racial lines, that is where we still see upward mobility in america.

it is not about average income. researchers point to cities with similar affluence that have markedly different rates of economic mobility. it is not about race. like and white residents of a city like atlanta have local port mobility. it is about all of these other factors that add up. it suggests that investing in our neighborhood institutions, strengthening community bonds have to be part of our strategy for reducing inequality, increasing mobility, and renewing the american dream. it is not just about money. as important and critical factor that is. it is about how we live with one another, how we treat and look out for one another. it is about how we see one another. how we organize ourselves, what we value. whether in this atomized age we can still come together to solve

our problems the way the early americans did, that is the big question we face. we now spend most of our time talking to people who agree with us. big sort has happened. that is a we are comfortable with. we do not really want to hear from the other side, no matter what side we are on. that is what makes compromise a difficult. because we do not put ourselves any longer in anyone else's shoes. why are some people across the political divide believing what they believe? holding their values so strongly against what we believe to be right? we do not get back into a conversation that cuts across all those lines that divide us. it will be very difficult to tackle the economic and social problems that stand in the way of moving away from inequality toward greater equality, economically and socially. but i believe that the time has

come. the time for us to begin not only a conversation, but a serious effort by which big ideas will renew america for our sake, for our children, and yes, for a future grandchildren. it will not surprise you to hear me say, it i think it really does take a village. thank you very much. [applause] >> a discussion on the state of community health centers. the naacp marks the 60th anniversary of the brown versus board of education decision. another chance to see hillary clinton.

on the next washington journal, president and director counsel of the naacp legal defense and educational fund looks at the versus board of education case on its 60th anniversary. president of the foundation for individual rights in education discusses issues related to the practice of free speech on college campuses. atbal economic editor looks whether -- whether there are financial bubbles looming in the economy. we will take your phone calls and you can join the conversation on facebook and twitter. live at 7:00urnal eastern on c-span. >> can you remember who first influenced you to think about issues, think about government? mother.ther and my

i put it in a book called "17 traditions." children insed four a factory town in new england. it was conversation around the dinner table. there was no looking at tv or listening to radio. we talked and they challenged us, in a nice way, and asked us questions and joked with us. the bottom line was, freedom requires civic responsibility. you cannot just say, i want freedom. most people think they are free because they are personally free. you can buy the own clothing, make their own friends, go wherever they want, eat whatever they want. that is not mean they are civically free. you have to engage in democracy. if you do not use your rights, you will lose your rights. >> ralph nader sunday night at 8:00.

alliance reform panel discussion assessing the state of community health centers. new findings from a 2013 survey of health centers which provide care to underserved communities. this is just under two hours. >> good afternoon. i'm with the alliance for health reform. you to theelcome program on how well prepared federally qualified health centers are four major health system changes that are afoot.

they are one of those essentials . it is a collection of letters. whatever it is, you have to know what it means to be able to negotiate the next one hour and 45 minutes. reliably that there are some differences between democrats and republicans on health policy issues. melissa told me this. during his tenure in office. congress has funds for those centers in the affordable care in additionstimulus

to the regular -- and now we have the coverage expansion underway that is bringing in new customers, new challenges, to these federally qualified centers. they face fiscal and uncertainties. they help some of the most vulnerable people. today we are going to take a close look at the experiences of fqhc's and take a look at the broader issues facing all of them. federaland for that health quality decisions will have to say in how these get met. nearly a century old , and now a strong

washington presence to promote the public good, we are pleased , the vicelinda abrams president in charge of the program on health care delivery system reform. fortunately a nationally known expert in this field, and a leader in putting together the new survey by the 's being released today. you have material on that. well, linda back to the chair. i'm looking forward to have you frame the issues. >> thank you very much. i think the alliance and all of you for being here today.

in our primary care safety net in the united states. were 12002, there federally qualified health centers serving more than 21 million patients. the majority of the patients are uninsured or publicly insured. thanyou look at them, more 84% of the patients are in under 200% of poverty. low incometing our and middle income patient population. the affordable care act has the potential to increase demand for 's because's fqhc

they target low and middle income americans. the commonwealth fund conducted a survey in 2013, and it is a leaders. fqhc viewsed them about their on what they perceived to be some of the challenges in 2014 with a new coverage provisions taking effect. it did ask them to purport on the current shortages and a number of other questions about their current capacity. what we're releasing today is to briefs from this national survey. we had a 60% response rate. and had the university

six percent response back to in terms the capacity of the personnel. by way quickly, just saying that when we ask the health center leaders about what they perceive to be some of the challenges in 2014, a number of them are concerned about physician shortages. and orbital whelming majority, as you can see. physician assistants. this is their perceived concern. this is last summer. it is not of as of right now. this is what keeps them up at night. when we did ask them, tell us fort budgeted positions whom there were vacancies. positions that you have budgets for, a majority report that there our shortages of

primary care physicians. are reporting current shortages. a couple of things about that. ofy also report shortages mental health providers, as well as bilingual personnel. survey, a national survey, in 2009, in as many of you may know, if you follow the , shortageser issues are a long-standing concern. it is not a new problem. compared to 2009 it is consistent. this is something to note. there are shortages. it is not necessarily wars. wor that for what it is th. the anticipated

influx of new patients as result act, andfordable care in light of the concerns about s arenal shortages, fqhc' working on ways to prepare for new patients. whether it is hiring and training staff for insurance coverage, or than half of them are working on integrating behavioral health. many are working more than a third on clinical staff. concerns, bute they are working on trying to address them. as i said in addition to the thesenel issues, we asked health center leaders to report on capacity in terms of information technology. what we found was that we saw more in terms of the adoption of electronic health records, a

huge increase, a tremendous increase where it was 40% of health centers reported that they had and the hr in place. having theust about wires and the hardware in their sights. it is about using them. from tracking lab results, preventative care reminders, alerts, if there is a medication interaction, a number of things. whether or not you can sort patients from medication. number of the percent of fqhc's that have advanced capacity. there is an increase from a we saw in 2009 ammann from 30% to

85%. that is not to say that this was easy. as any of you know who look at information and technology adoption in health care, and you look at whether it is big practices or health centers, a lot of them talked about challenges. such as the training of the staff, the cost of maintaining them. and, the usefulness of some of these templates to manage the entire population. they are not just the population of patients, but across the community. there are certainly challenges. have, in the briefs that are being released today, featured it of that will we see thatile there is this perception and

eirw it concern about th personal capacity and ability to retain their staff, we also ask about the ability of access. we found that there was good access. this is reporting what you yourntly can offer patients. 62% of our health center said receivey can usually telephone advice after hours. over half can receive care either same day or next day. obtain specialist procedures for medicaid patients. there is definitely some work to do and an ongoing issue of ground access to specialty care. what does this mean? thisre doing see you increase? pretend in terms

of personnel issues? i want people to walk away with the sense that health centers are a critical part of the safety net. we do expect them to see more patients. they will continue to need help to attract primary care providers and other clinical personnel to those centers. ,t is maybe about the personnel but the new models of care their working on, such as expanding telemonitoring, that is another way of expanding incapacity and working in teams. , the trust fund is set to $11 million in the affordable care act. in 2015. to expire

we just need to ask ourselves adequater not there is support, continued support for health centers, and whether they have stability to meet the need of new patients and expanded patients. they will continue to see the remaining uninsured. proportion have substance abuse issues. a lot of this is being addressed through the health and home provision of the affordable care act. i think the other thing that is no question, the adoption of -- is impressive. funding,eted federal that has been focused on community health centers has made a difference.

there are still gaps. they are not exclusive to fqhc 's. access.as patient patient portals, patient access to records. there is still more work to do. these are just conclusions and implications from our survey. our panel is going to be talking about a broader range of issues. i'm excited to hear them. these will be some of the questions for us to benefit and consider in terms of projecting what they see as the projecting coverage expansion, and how the investments have affected their operation, challenges they see moving forward, and what can officials do to make it easier for them to fulfill their mission, and successfully meet the needs of their patients. i didn't do this alone.

i would like to recognize my colleagues at the commonwealth fund to help analyze and write these briefs. also, a technical expert panel who provided a valuable guide to the commonwealth fund as we developed the survey. i will pass it back to you. >> thank you. a bit of housekeeping before we get our speakers. ofre are a treasure trove materials in your packets on this subject. including, a list of some things that aren't in your packets but if you go online, you can pick the link to get to each of those. schedulesbiographical of each of our speakers that will provide background on who they are, there will be video recording of this briefing

available on the alliance website at allhealth.org. that will allow you to peru's every word that you have heard. every word that you have heard. microphones where you can -- there are microphones were you can voice your question at the appropriate time. -- briefings on topics, and speakers that will serve your purposes. if you are tweeting, and we would encourage you to tweet, #healthcenters

will do that. we're going to start with leighton ku. he is a professor at george washington university. he directs the policy of health research there. he is one of the leading experts in coverage for vulnerable populations and medicaid, and the health care safety net, which will serve him well in conveying to you information on the topic at hand today. we have asked him to identify 'se major issues facing fqhc in this time of rapid expansion. us to share with you and some of the insights from his examination of what has been happening in massachusetts with health centers since its

expansion in 2006. welcome back. happy to have you wilth us. .> thank you thank you for having me. i realize the title sounds dire. feelings to me that my has been about committee health centers for a long time in the tv show macgyver, you find yourself in a pit with alligators, and you think this is the end, and then somehow the hero pulls out a ballpoint pen and bubblegum, and there is a thread, and he figures a way to save the day. in the end, i'm often impressed that they are amazingly resourceful and ingenious through good leadership and managed to make what seems at dire situation into a happy ending. certainly that is what i hope.

what i'm going to talk about today is a few points. insurance expansions are leading to an increase in the demand for primary care services. health centers play a central role in filling that need. they continue to insure the uninsured. another thing that is important is that they can help reduce medical expenditures. there are some areas where things are unclear. whether the relationship is the new health insurance exchanges is a little murky. medicaid expansions, health centers, and will help them expand their capacity. there are some worries about a potential funding cliff after 2015. this is a slide that shows what happens in massachusetts before and after chapter 58, the big health insurance reform.

was of the federal response designed to emulate what happened in massachusetts. after that time, massachusetts serve another 200,000 people. they stepped up to take on capacity. in addition, during that time, the patient's uninsured and health centers fell from 36% to 20%. they are still surveying uninsured patients. it is around four percent. but the fact that there was growth in medicaid, in that yellow patch, commonwealth, really led to the ability to expand capacity. not only were they called safety net providers, they were a safety valve for the system. one of the reasons we think this is a good thing, health centers

provide care to people who would have difficulty getting that, the evidence suggests they actually save money. this was the study that we did that basically looked at what were the annual medical expenditures for people who would the community health centers versus those who did not. expenditure,ical total ambulatory care, they were one quarter less for people who went to health centers. they can have a profound effect in helping to bend the cost group down providing better primary care to people who just wouldn't get it. one of the new landmark parts of the affordable care act are the creation of the health exchanges. as well as medicaid expenditures -- expansions. act, the affordable care qualified plans that operate

under the exchanges must contract with essential community providers. see hc's are some of those. -- chc's are some of those. negotiating with the payments are for the community health centers. it is not clear how many health centers have obtained contracts with qualified health plans, therefore let them serve the patients of the health centers, and the anecdotal information suggests that the payment rates are often low, below the rates they expected to get. which are actually pretty good for health centers. one of the things of this leaves as an additional problem, many of the insurance plans, patients have relatively high deductibles. health centers will subsidize scale.er a sliding pay

they may have a privately insured patient but they have to underwrite the care. it is like this person is a complicated care patient. -- uncompensated care patient. they have a patient who is insured. little bit about health center financing, and on -- one hand the steady this myth of people to sleep, they are the core funding for health center funding. however, health centers get funding from a variety of sources, of which medicaid is the largest source. together and work to improve capacity of the uninsured and low-income patients. 340, they help fill

in gaps that are left by insurance payments that are not adequate. most insurance payments and health centers are less than the actual cost of providing care. health centers provide a relatively rich set of packages, including social services, enhance services, and help needy patients. the grand end up supporting the uninsured and insured patients. what has happened in the affordable care act is it was anticipated there would be a need to build up the infrastructure of committee health centers to serve patients who are low income patients, and areas that were underserved across the country. it built a mandatory funds under a trust to supplement the regular appropriations. those trust funds expire at the end of 2015. what this means is there is a funding clip that will begin in 2016.

if they aren't increase, there could be some serious issues. michelle will also talk about this. medicaid expansions play a big role. and byll add revenue, doing this, health centers not only serve more medicaid patients, but more uninsured patients, more exchange patients. that inhe net fx is addition to this, this is where things work together. half the states aren't spending medicaid. half are not. if more states expanded medicaid, health centers would be able to serve more patients. so, this is from the analyses colleagues of mine did recently that looked at the 2012 caseloads in medicaid. they found that people who were currently being served as

uninsured patients in medicaid, 2.3 million of them appeared to be eligible for the opt out. or the healthd insurance exchanges in the state that are expanding medicaid. the thing that is important is the black section. 1.1 million people who will be eligible if the state had expanded medicaid. if the state does not expand medicaid, these people will remain uninsured. uncompensatedin care patients. they will have a problems getting specialty care melinda was talking about in her prior presentation. the others will be eligible for the premium subsidies under the affordable care act for the exchanges. many of them will get health insurance coverage. on the expansion state, all

those 2.9 million will be eligible for either the health insurance exchange subsidies or medicaid. there is the potential for them to get coverage. >> i want to wrap up and talk about a we think this has in terms of implications for our ability to serve people. as melinda mentioned, in the last official day that we have available, there were 21 million patients being served and health centers in 2012. what this graph shows is a comparison. the blue bars are the states that we think are expanding medicaid. the yellow are the green bars that we do not think are expanding medicaid. our current projection is that based on funding for 2014, the number patient that can be served is more like 25 million. we will be able to pick up around 4 million additional patients and health centers. that will clay long way in serving the primary care needs

of newly insured people. if the grant funding level is low, that is if the appropriations do not compensate for the loss of the mandatory funds, these caseloads could plummet. the third bar says that in 2020 e would expect 20 million patients could be served. getting close to 6 million patients that are served this year would not have service, would not get care in 2020. of the low grant levels. on the other hand, if grant funding continues to grow, not as readily as recently, but a modest growth rate after 2015, we could it to the point where health centers will be serving 35 million patients.

it can make a big dent in meeting the primary care needs of patients across the country. the last two bars show what happened in the states they're not expanding medicaid. increasesat furthermore the capacity of couldstates that actually reach 36 million more patients. this would make a big difference in those states they're not expanding patients to meet the needs of medicaid patients in the uninsured patients. health centers can go a long way to meeting the primary care needs of a vulnerable income patient. that is very much at risk if the mandatory funds are not replaced in some manner in 2016. thank you. >> thank you. if all we hear from our next speaker, i would like to mention that the briefing is being carried live on c-span 3.

you can tell your colleagues about it by e-mail so that they can tune in if you would. i would remind anyone who was watching on c-span 3 the they can follow along including with the speaker by looking at them website.lth.org's you can get a better sense of what is being presented right here. we are going to turn to a couple of folks who have an intense familiarity with the challenges and chances to help. they run them. vernitaernie to todd -- todd. she knows her way around the world of nonprofit organizations. in is a long-term consultant a range of management issues. she faces many changes at heart

city, including a diverse population and managing services that melinda was talking about. we are delighted you could join us today. >> thank you for giving up your friday afternoon. 24, i amompare us to jackie bauer. keep that in mind. we are not all things to all people. a little bitshare about comprehensive overview of community health centers. they gave me 600 seconds. i will do a little bit of a synopsis of the slides you saw.

hopefully, when you go home and you are making -- giving input to those funding and policy decisions, you will have something to look back on. the presentation will get started. to share a little bit about hard city, we are in indiana, -- heart city, we are in indiana. the center sees about 2000 people a year. it represents 20% of our city's population. we are a safety net provider serving a large group of folks within the community. we have the requisite medical, dental, you puerile health, and an on-site pharmacy -- behavioral health, and an on-site pharmacy. we are opening a second clinic on june 3. we were able to do that thanks in part to a grand during the

affordable -- to a grant during the affordable care act. that since the press release went out to our community, we received 15-20 calls a day from people who are trying to get access and who need care. this is before we ask the hospitals to open the gate. folks,ey are referring the 3500 number will fill up the cleats. -- fill up quickly. 47% of low income families do not have access to a primary care provider and that low income is $44,000 for a family of four. or less. a little bit about our patient population, i think it mirrors many of the slides that melinda showed earlier. we do have a very large medicaid accusation. -- ahalf of our patients

very large medicaid population. serve a very diverse patient population. it is one of the more diverse communities when it comes to hispanic and latino families, largely due to the rv industry and the opportunity for work in that area. we got the dubious distinction in 2009 of having the highest unemployment rate in the country, prompting a visit from the president. recovery looks different, jobs with the front. -- jobs looks different. automation.tim to it does not look like it did before. the thing i would point out to you is 44% of our patients are kids under the age of 12. while the need for access still exists for adults, what we're finding as we have a large

patient population of children because there are very few medicaid providers. needs to be updated. i am so proud to announce that yesterday, indiana governor announced the expansion or desire to expand access to low-income families. i did not say he expanded medicaid. he would be very happy with me for that. he did expand access to low-income families using what we have now, the healthy indiana plan. there are some financial obligations for the folks involved, we believe it is a , after ai believe quick review of something that was released yesterday, that it is a good compromise between fiscal responsibility and access to care for the families who are the most vulnerable.

if you're doing a basic plan, no actual monthly premium, but you have a co-pay on every service. the mobile -- the more robust plan includes a monthly premium based on family size and income. we will be interested to see how indiana response during the public comment period and hopefully be ready to provide care for those families starting january of 2015. what we know is that increased access is going to place capacity challenges. we are the only safety net provider, and many do not take medicaid. the compensation rate is comparable to hip. the heart of my presentation is a little bit about primary care

and the patient centered medical home. the increased need for the primary care provider to be the asper of knowledge and data well as the person that helps the patient navigate through what can be a complex health care system. if you live in it, you understand it. if you need to access it, it can be tough to understand. we implemented electronic medical records to be able to guide the patience to the referrals they needed and to be able to bring together and reconcile the information so that somebody had a big picture of what was going on. say our use of technology, we were one of the health centers in 2009 that it just started the electronic health record implementation. we went from a practice -- in

2011, we went live with the electronic medical record. what we learned quickly is it is not a panacea. ge commercial were all of the specialists are in the audience. it is a great system, it does help you, but with the lack of other providers having electronic medical records technology, it is a little antisocial. we have information, but the information is not coming back to us. the other thing i would tell any of my colleagues and all of you who are impacting policy, buying the system is just the first of 100 costs. getting the hardware and software is important and keeping it maintained in providing support -- on a paper record system, circle, circle, circle, if your computer goes down, it it is a very different

world. you may be able to go back to the circling on a paper, but someone is responsible for putting all of that information back into the electronic medical record so that we are still keeping that information. i would also say that not many providers have adopted yet. has, and wespital are fortunate to have built an interface with them, that there are three hospitals that patients utilize in our community. meaningful use of the dhr does not equate to better outcomes. this is a shared responsibility. we can become more efficient and effective and have better information, that it is a partnership with the patient to myate to better outcomes for not simply an alert or the ability to function more effectively. slide,share much on the but a talks about meaningful

use, which is some of the financial incentives available to all health care providers who adopt electronic medical records. there is more information. we are doing the medicaid 5 iningful use, which is 63 incentives. providers, on new the former workplaces have attested to some portion of meaningful use. they do not come to us with the ability to generate the level of incentive for any new provider. bit about the money, because i know everybody cares about that, we were able to get about a $55,000 grant from the federal government for the implementation of patient portal management or tracking software. if you look at the yellow line,

that is the amount we have invested in ehr since we started in 2009. it is costly. we need folks to know that going forward. -- it is not as easy as wi-fi, so that is self-explanatory. the i.t. challenges, the biggest one is personal cost 10 to be the highest for all health centers, but i can guarantee you they are not high because we have a lot of i.t. experts on staff. those of folks we utilize are part of our care teams, their clinical related. not having that expertise in-house makes it difficult for us to deal with the myriad of changes as well is to make sure the system is as robust as it can be so that we are always ready to move forward. the maintenance and support

.osts i will end with a couple of things about delivery system improvements using the ehr. we were very fortunate to have received a level three patient centered medical home designation from the national committee on quality assurance. we are darn proud of that because we had to work very poor -- very hard to do that. how are we better serving our patients? what are we doing that is making a difference? the medical community can create patients who are dependent, who believe they go in and you tell them what to do and they go home . if they don't get better, it is your fault. it is a team concept and the patient is at the center of that . some of the things we are talking about, improvement for a chronic disease patients are

understanding you have to meet them where they are. reasonable care plans, they have to have things that are acceptable to them. i hear a lot about, reach out to your patience and do text messaging. our patients say look, i have a limited amount of minutes. when you recognize, you have to know your audience and who you are dealing with. you have to be willing to meet them where they are, not where you want them to be. these are some of the things we are working on as far as the delivery system. up, soseconds have been i will end with these three slides that show a percent of the patients are typically considered multiple chronic positions. 20% of our patients have more than one chronic disease. talkingwhat we're about. think about it.

an uninsured patient who finally access the care has probably delayed going to see about it. by the time they do get to us, we are dealing with more complex disease states. relief that isic the presentation. ,e thought it was simplistic the seven steps, you will be a better care. this is what it actually looked like. every step generated 15 more steps and 15 more questions and things we had to do. being jackie bauer, we did it. i will leave you with this. this is what our staff says to themselves every day, this is why we exist. one who has health has hope. one who has hope has everything. that is why we believe community health centers make such a

difference in the communities that we serve. thank you. >> excellent. she who has the quicker -- the quicker has everything -- the clicker has everything. it will now be an instrument in the hands of brooks miller. the only ceo the center has had in its 11 years of existence. mr. miller has 30 years of health care experience. he is using all of it as he -- has center expands to meet the needs of the uninsured. he does have a high volume of business in his center. he is trying to meet the needs of the uninsured, medicaid beneficiaries, other vulnerable groups and he is trying to help us learn a little bit more about that. let's thank you. i appreciate the opera -- >>

thank you. i appreciate the opportunity to be here today. i have 30 years experience. when i was invited to attend to this comment they ask for me to summarize that within five minutes. most of my staff would say that is three minutes too long, but we will see what we can do. joseph, had the opportunity to do an internship with our national association and i commend the association. they represent us very well. really do a great job. i had the opportunity to talk to joe and i said, i have been invited to attend the alliance for health and do a presentation. he said, i had the opportunity to go to some of that last year and that is the real deal. he quickly followed that up by, why did they ask you? [laughter]

this might be the intermission time for you today. if you need to get up, this could be it. michelle would follow-up. always a pleasure for me to -- it has been a wonderful career. i moved to springfield, missouri , and that is in the southwest corner of the state. when i first got to springfield, we were a new start row graham and i had -- program and i had the opportunity to operate out of the back of my pickup truck. there was a lot of opposition to our program when we first established, we turned in three previous grant applications. when i got to springfield, i felt that it may be limited. i opened our first health care unit in a strip mall.

five years ago, we moved into the facility that is shown on your screen. that building is 70,000 square a full arrayides of services. we are very blessed. care, behavioral health, and oral health services. we have a dynamic program that is operated through that center and it is the largest in the state of missouri and it done in conjunction with the greene county and springfield health departments. thate very proud of relationship and affiliation. this building was a blighted factory will be bought it. it had about a third of a roof. it was a tractor part distribution center. it sat centrally to the population that we chose to serve. years, we had the

opportunity to expand it once again. there you go. -- we willhe process be expanding that piece of property or that clinic. we will be relocating our family practice, urgent care, ba bureau health into the bill -- behavioral health into the building. jordan valley is somewhat divided evenly between primary care and oral health. the reason for a large part of has beenss and growth the emphasis he placed on oral health from the very beginning. we will have a total of 120 exam ,ooms, central sterilization and expanded pharmacy.

have our own surgery center where we do a significant amount of oral surgery on a daily basis. we also have a pediatric residency program that is operated in conjunction with lutheran medical center at of new york. -- out of new york. we are in our second year of that program. we also have a mobile program, we have five mobile units. three of these particular tracks, which are single exam rooms and optometry. we have two large vehicles where we operate our oral health programs from. we service 21 schools outside of springfield. springfield has a population of

250,000, but once you get out of our direct city and into our five-county service area, it becomes very rurial. we've been able to develop this very robust program. also work with the county jails and nursing homes, which prevents a hardship for that. i will also say that we have three satellite clinics. one came online in 2009. hollister and republic clinics will, on this year and are part of the funding. have 4-8 medical exam rooms and 4-8 dental rooms. since moving into the new building, and that is some most accurate information, you can

see the number of users within our program. what we anticipate to the affordable care act will transpire to additional users of our programs as well. 2013. a slight dip in in speaking to my staff, we have numerous excuses why that occurred. haveer, in fairness, we had a significant transition of medical providers during the past year, which did a tribute to that as well as some service changes. we do anticipate that we will be back on a growth rate. this is an extremely important slide and i draw your attention

to this. this is where jordan valley is a little bit different. our total grant income only makes up nine percent of our budget. routinely, across our programs, that is a small amount of funding. i am very proud of that in one degree, but you can see we have generated revenue that is the blue cycle, which is medicaid. things that really that well heme is talked about funding of health centers, it can not only be about the grant. there are -- many of the new start programs, the

reimbursement methodology that many of us live on and developer programs around. we need to be consistent in our theage that how important revenue stream is. let me go quickly to the next slide and show you that medicaid for us is 60%. we ever get into medicaid expansion, this will go down and we anticipate by going onto the exchanges, this 12% is going to increase. that is where our additional revenue should come from. to ancern with that is degree, health centers are being pushed into a private sector model rather than a community health model and i truly do believe that the focus for the

treatment of disadvantaged patients is very different depending upon your social economic class. -- socioeconomic class. one thing i want to show you is that our revenue is just short .f $29 million a year so far, we are privileged to be carrying a 1.2% margin. it is about $347,000. it is always good to be in the black, putting that into perspective, our two-week payroll is about $430,000 a year. you can see that we operate on a are ahin line and there lot of variables that impact us on a daily basis. we have not passed medicaid expansion in the state of missouri, we have been the beneficiary of a significant amount of resources.

been awardedhad four new sites. very positive things are taking place. that will bring us up to 27 health centers in the state of missouri. something that we are working with. concern, i think it is an excellent philosophy for patient care. my concern is the expense related to it. i think it is important for children to be within this model and that they have access to all of these different support services. once again, it is very labor-intensive and very expensive and we have to be willing to make the investment. missouri was the first state

that began participation with the medical home. our state primary care association is very aggressive and progressive. we leverage $1 million of our resources to obtain $9 million to the affordable care act to implement this program. mistake.ne little ipa,ba, we which -- the the independent practice .ssociation it builds on the medical home model, which is integrated. the wonderful thing is that allows us to come together as health centers and contract for , health with hmos

insurance programs, and things of that nature. we have 330,000 lives in a group -- in that group in that system and that is a for-profit company that has been established. workforce development, reimbursement models, competition with the private sector, patient responsibility. we cannot sell that too short. program accountability. we need to be accountable for the increase that is expected. most importantly is the uncertainty. missouri has not expanded in ourd at this time and session concludes at 6:00 tonight so we continue to make calls to see if there is any changing of that. we do not anticipated. it is unfortunate that we are coming down to the last day to determine whether we will have expanded medicaid are not.

the benefit from my office to be able to walk to mulholland see why we put in the struggles -- walk down the hall to see where we put in the struggles that we do. it is not only the work we do on the ground. none of that would be possible without the work that you do. we are very appreciative for that. >> thank you. his last two folks have emphasized to me that they could probably have been part of the last two panels we have put together. ago ona session not long integration of behavioral health into primary care. just on monday with our at commonwealth, we talked about the states that are pursuing the third way of expanding coverage without that dreaded medicaid word.

we have a session coming up on h's.30 looking at pcm we must be doing something right and you may get another invitation. now we will turn to michelle, for thector of research national association for community health centers. michelle has a decades worth of experience doing research and analysis. in the process, offering up the results of that work to the communities directly affected so they can improve their ability to serve. the idea that you can actually use research is a wonderful advancement, it seems to me. thank you for being with us today. >> thank you for having me. i was asked to respond to a lot

of things you heard, especially from brooks and vernita. hopefully, i will be reinforcing a lot of those things. would hope to show, i like to emphasize that help center -- demand for health center care continues to increase. there are still a lot of unmet need out there that extends beyond insurance. i want to echo how much the model actually works. it is designed to remove barriers and generate savings. as you heard from the other panelists, there are some capacity challenges. i will be talking about the support that is necessary to maintain and expand the capacity. challenges,h the

there will be some increasing demand and that is going to shift the payer mix. we will be seeing more medicaid patients, more patients with private insurance plans and also a large number of insured and that does have an impact on revenue cycles. maintaining funding streams is a challenge. health centers have diverse revenue streams and it is essential to maintain those streams for existing capacities, and also we need to think about how we bring in or increase those funding streams so that we are able to expand our capacity. workforce is still a need. we will talk a little bit more about that. complex patients, health centers serve more patients, but we are also serving patients that are really experiencing very entrenched social determinants of health and those have very

significant impacts on their health care outcomes and utilizations of services, things like lower education or lack of safe lacesd, lack of to play and walk and move around, unemployment and so on. patients are very complex. health centers are still very heavily invested in quality improvement activities. hit andd a lot about hiring new staff. last i heard, they do from the bureau, 44 -- data from the bureau, 44% have been recognized officially and the vast majority stages ofoing reaching that recognition. examples of delivery system

infrastructure challenges still to be met, still a need for better integrated care, access to specialty care. regardless of the insurance expansion taking place, there is a continued need for health centers. there is a lot of unmet need out there. demand, a lot of communities out there without access to care regardless of having an insurance card. is not enoughrage to guarantee you access to care. it will always be uninsured patients. -- there will always be uninsured patients. these communities need patience and need care need not just a comprehensive model of care, but need a very accessible model of care that knows how they will meet those specific needs and how to break down barriers.

slide -- it is hard to see up here, but it is one in need -- it is in one of your handout. levelhows at the county what percent of residents are experiencing shortages of primary care physicians. 62 million people across the country do not have access to primary care because of shortages. nothing to do with whether or not they have insurance cards. most of them do have insurance, only about 21% are uninsured. the uninsured are at higher risk of falling this category given where they tend to live. areas. in rural 30% are minority. this is just one manager -- one measure of unmet need. those providers may not be there

to serve all community residents, given their acceptance of certain insurances, the languages they speak, cultural barriers. health centers have higher rates compared to other providers of accepting medicaid patients, medicare patients, uninsured patients, and even new patients. figure, whatlion does that represent? who donumber of people not have access to primary care, specifically because there is no primary care provider to serve them. it is a population to provider count. thank you for asking that. i do want to quickly touch base on the health center model. did i miss a slide? no, i did not. the health center model is rooted in federal law and regulation. health centers are designed to

break down very complex barriers and provide comprehensive services. services that facilitate access to care, services that we call enabling services, home visitation, case management. health centers also work by being customized to fit each individual communities unique needs. they must be run by a governing model that is made up of a majority of patients. of care nots model only explains why they are so successful in improving access to care, but generate significant savings. 24 billion annually.

health center street more uninsured patients than other providers. it is probably obvious at this point. they have more patients with chronic illness as well. i know we have talked a lot about massachusetts. it is a great example of what to expect. i want to emphasize two things. there is still a large number of health center patients in massachusetts that are insured and that rate has been fairly steady. it has not dropped below 21%. the number of uninsured and the percent of state residents without insurance dropped, health centers are serving more of the states uninsured. they served 22% of all of the states uninsured,

suddenly, with insurance expansion, a now serve 38% of the state's uninsured. of course, i want to talk about growing and sustaining health centers. health centers tend to have very slim operating margins. nationally, they hover around zero percent. i want to talk about health center funding because this is another critical piece. ins funding is very critical new communityng health centers and leverage other resources within communities -- within existing communities and also new communities. health centers are facing a iff because of the trust fund in the affordable

care act will sunset soon. it will be a 70% cut in funding. close sides,ve to they would have to lay off staff, it would have to have fewer hours and it will reduce the number of patients they can serve. every community would experience this differently and have to apply the cuts differently. this might be a great question for brooks and vernita. while demand is increasing for care, they are experiencing gaps in other revenue payment. federal funding is critical for supporting the cost of the uninsured and caring for -- covering the full program at health centers provide, it is a community health model and these grant dollars really help health centers expand those models.

it also ensures that health to take on able lot more patients with these federal resources. andaunches health centers two new communities as well. health centers are also experiencing gaps in medicaid reimbursement. they are losing about 20% of their cost that is not being reimbursed. it has not kept up with the cost of care. you heard about some of the issues we are anticipating and already experiencing with the exchange. the bottom line with these that asrty payers is the number and percent of patients who have these forms of insurance increases, or it does not make up for per patient losses. slide --n to my last

let me move on to my last slide. moving on to future issues, to help health centers continue to invest in quality improvement programs and infrastructure. i know i have touched on quite a bit, but these are critical issues. federal funding is still very important, not just about maintaining -- or sustaining the current capacity. we also need to think about how we expand into new communities. workforce issues, programs like the national service corps, also iff.ng a funding cl health centers are also participating in the teaching

health center program that is federally funded and that funding also could expire unless it is renewed. is about program does training providers and getting them to stay in these underserved communities. health centers are able to put these investments into use rare rapidly -- very rapidly and the model is designed to continue to improve care and outcomes and generate cost savings. i want to thank you and i apologize for the brief presentation, but i look forward to questions and answers. you would like to ask a question, there are microphones you can use. there are green question cards in your package that you can fill out and hold up. someone will bring them forward. pending the lineup

getting longer at the microphones, i might take just a moment to ask clarifying question. potentiald about the underpayment in private insurance. medicaid is not known for its high rates and most private insurance, we keep hearing complaints about medicaid shifting costs to private insurance. and you have a shortage of primary care providers in most parts of the country. how is it that community health centers do not have more negotiating clout with private insurance? >> it is not entirely clear that health centers have been able to negotiate. when the health insurance

began, they began rather hurriedly last year. what has happened is that in many cases, insurers said, we already have a contract with you in which we were paying the same rate we would pay a regular primary care dr. and we are invoking that contract that we already have with you. many health centers were never contacted at all, never have the room to negotiate and number locked into rates they thought were only being used for regular private insured patients. this is where things are a little messy and unclear exactly what happened.

we would expect a little bit more change over time. -- they never had the negotiations. we have heard this from other community providers that they expected the insurers would contact them. in many cases, they never did, but then they said, we already have contracts with you. >> i just want to add, i agree that it is important that it lays out well for health centers, and part of that negotiation, 14% of their patients have had private insurance. that will grow somewhat. in terms of negotiation, when you have several different private managed care contracts

already for a small number of patients, suddenly, that contract that you may be locked payment you are receiving for those fewer patients is going to be that much harder to work with when 10 andents lose -- moves to 50 two 100. 100. something -- and to >> thank you. i would ask the people who come to the microphones to identify themselves. keep your question as brief as you can. cms and nowwith doing some work on the affordable care act. i am interested in hearing from some of the panel members what are your recommendations would be to the federal government and to state governments in terms of

the affordable care act. what are some of the key things that need to be done for this next go round in terms of enrollment? things within the current law that you think need to be addressed at both levels. >> that is a little bit of a loaded question for indiana. due to the significant division -- oferest of appealing keeping the affordable care act, we had a lot of folks who believed erroneous information about what it was going to be. we spent the lion share of our time explaining that there really were not tracking devices going to be put in your arm if you got the affordable care act.

that sounds ridiculous, but some of the information that was being shared was so over-the-top that people were afraid of it. the folks who needed it were afraid of it. been an awareness building. i believe that indiana is expanding access to low income families. is if you have never had insurance, it is a difficult thing to understand. the premiums, the difference between a deductible and why am i paying an additional thing like that? there were those kinds of components that just had to do with insurance that folks really did not -- they had never been a part of it. thank you for terrific and

informative presentation. this question is for the entire panel. what has the experience been out there so far for what you asicipate is going to be regards to individuals who were previously traditional ryan white clients who are moving into medicaid and likely finding their way to other care settings? they arey cases, already serving those patients in many sites. for hivy, not only patients, many other patients who have some serious chronic illnesses, some of them will be

coming into insurance coverage for the first time. hopefully, getting coverage at a health center is a blessing to the extent that it provides them a broad access of care. they will still have the ability to access care at more specialized sites or other places that exist. to people, confusing though. you have been used to getting caret one facility and that facility is not part of the private insurance and it will take some orientation. how can i figure out how to get those care services? someone is privately insured, they would still be able to get certain services from the ryan white centers. it can be confusing to some of the patients. >> did you want to comment on that as well? >> unfortunately, this is where

i believe missouri is behind a lot of places in the nation. as far as ryan white and hiv patients, we see -- we have a very strong program in the someonehat is run by who sits on my board of directors and they have the medical side fairly well down. were we assist mostly is with regards to oral health care services, which are limited in a lot of places. .hat is a two edge sword in 2005, missouri discontinues services to the adult population as far as world health services -- oral health services. on a positive note, missouri passed a reinstatement of those benefits of oral health back the adult population.

has put $45 million towards that effort. should the governor release those funds, it will have a very positive impact, not only for the hiv population, but for those with mental disorders and things that have been separated or taken out of that system. thank you for the panel. a very informative and insightful discussion. i would like to get this issue on the table of integrated health care into primary care and get your views on this issue that no one talks about that is a real deal killer, we live in a behavioralgregated

-- the segregation prevents real integration. -- the big issue on the table that we never seem to be able to address is that ,nder managed behavioral health the providers cannot work and get paid in primary care. how to become to a time when we need to have behavioral health as just another standard medical benefit under health plans? in other words, end segregated

delivery? [inaudible] >> the answer to your question is yes. for me, behavioral health has been one of the very difficult things for me to gain understanding of. care oftenhealth times does not have an end. my frustration, as you try to integrate that into the primary care setting, which i truly do believe that is where it should be, you do not get paid for it. if you have a patient that comes in and sees your primary care provider who recommends they have counseling with a specialist come you get paid for one of those services. forpecialist, you could pay one of those services. it defeats the purpose of an integrated care system.

that is an issue that truly has to be addressed. i do believe that behavioral it is the challenge of the future. as we look at workforce development, there is a real shortage of such. antidepressants, are the most reverently this -- drugs.tly prescribed -- i do not know how we move move forward in a better way. it also has to be addressed on the local level to get medicaid recognized the importance of an integrated system. ,s we push for a medical home and not reimburse for it, you are defeating it. if you go to the exchanges, issues like integration are

things that are pushed to the side. a quick moment of clarification. -- any service that a patient gets, you are paid once. even if you get -- you may only get one payment that is sort of an integrated payment. it discourages them from providing behavioral care as the second service. they would rather have someone come back another day for the mental health services, which is things.icient way to do states have the option to have separate billing, but the majority of states do not implement that system. >> without getting into the weeds, indiana, are primary care

really concerned about this issue and really lobbied our legislature so that they do on her same day -- on our same-day visits for behavioral health for a limited number of brief therapy associated with a medical diagnosis. for families dealing with children with adhd or anxiety or depression, thinks the primary ,are provider can help manage our state listen to that. instead of a saying, we will have to send you home, we went to our state legislature and we were able to get compensated for that. it is a matter of what you do in your states and bringing that to their attention. you have to meet patients where they are. it is not meeting them where they are if we are sending them home. place int system in other states?

that something on the way in a bunch of places? is indiana blazing a path? at one point, i knew, but i've forgotten how many states have same-day billing. emily johnson would know, but i think she has left. >> it is increasing. under the health home provision of the affordable care act, we are seeing new and other creative ways of trying to more rigorously integrate within primary care or on the community mental health side, some states have amendments for their community mental health programs to flesh out their primary care

for the severely mentally ill. i am not saying it is not an issue, but there are a lot of innovation going on across the country. >> institute of social medicine and community health. it sounds like there are lots of reasons to look at community health centers as a laboratory for experimentation and how to dress -- in how to address the unique needs of patients with status,me, minority disproportionate amount of social determinants of poor health. and yet there is a lot of variation among the centers, as we saw based on the payer mix that their clientele represents.

my question is a research question. have you, michelle, focused enough on differences among the centers so that you can make recommendations for health care policy at the state and federal lessons yout the have learned and how to deliver effective care to the population that is primarily the recipients of services and community health centers can be translated into standards of care for medicaid, quality standards in insurance in you are not if being reimbursed with a grant from