Leslie Graham, President and CEO of the Primary Care Coalition
On February 20th, PCC submitted written testimony to the State legislature in support of SB705, the Access to Care Act with amendments. Senate Bill SB705 (and its companion House Bill HB728) remove requirements for those using the Maryland Health Benefits Exchange for the purchase of qualified health insurance plans to provide proof of their legal residency status. Conceptually, this opens the purchase of health insurance on the Benefits Exchange to some of our most vulnerable families and neighbors, our undocumented residents.
We support SB705 and HB728 knowing that this legislation is unlikely to create any immediate change for the population we serve—people whose incomes are too low to purchase their own health insurance policies without financial assistance for the monthly premium costs. Currently the State budget and federal policies would not include subsidies for these individuals and families even if these Bills pass.
Which begs the question: Why do we support these Bills?
First, it is an important step of recognition that these families and individuals have been previously excluded from State-led health insurance programs, including the Health Benefits Exchange. Yet, like all residents of Maryland, they work, raise families, and need healthcare.
Second, SB705 and HB728 recognize that health insurance gives people a path to getting care early and regularly, such as seeing a primary care provider. This benefits both the individual and the State - improving health and quality of life for the individuals and reducing cost of care within Maryland by preventing advancement to more expensive disease states and emergency room use or costly hospitalization.
Currently, hospitals bear the direct burden as Uncompensated Care, but as a community, we all eventually feel the effects. We feel them when uncompensated hospital care drives up all insurance premiums, and when we wait longer for emergency care because conditions that could have been treated in outpatient clinic practice were not.
Montgomery County’s own Delegate Cullison (D-19) was very clear when presenting HB728 to the Health and Government Operations Committee that it was not designed to be an end point. It was designed to be a move toward it. We take the same view.
As Delegate Cullison and panelists from state health agencies made clear in House committee testimony, the explicit purpose of this legislation is to provide all Marylanders with access to the best available consumer tools for purchasing insurance coverage. Tools that help people analyze plan options, as well as navigation support in multiple languages.
The current legislation would not provide any subsidies to make purchasing health insurance plans viable for low-income individuals or families. We still support its recognition of the need participants in PCC programs like Care for Kids and Montgomery Cares face, and its creation of a framework for meeting that need, should funds for premium assistance become available.
In House debate before the Bill passed, Delegate Fisher referenced ongoing challenges with primary care supply as a reason not to approve the Bill, according to Maryland Matters, arguing that adding more demand to an already stressed system was “ridiculous.” The good delegate is not wrong that sufficient healthcare supply remains a pressing challenge—hence, our work with the Nexus Montgomery Regional Partnership and community partners on workforce capacity—but limiting our immigrant neighbors’ options for coverage is not the answer.
Resources may be constrained; our problem-solving potential should not be. This legislation is not a one-and-done solution to healthcare access, but it is part of the solution. More importantly, it’s a part we can reasonably accomplish this session.
To: The Honorable Pamela Beidle (Chair), and Members Senate Finance Committee
From: Leslie Graham, President & CEO, Primary Care Coalition
Date: February 20, 2024
Subject: Support - SB705 Access to Care Act
The Primary Care Coalition (PCC) administers a variety of programs including Montgomery Cares and Care for Kids—Montgomery County's principal health safety-net programs—which provide primary care, specialty care, behavioral health, and access to medications uninsured adults and children. The PCC strongly supports the intent of the Access to Care Act based on our experience operating access to care programs for low-income, uninsured residents of Montgomery County.
Maryland’s percentage of uninsured residents has decreased from 10.2% in 2013—just prior to Affordable Care Act coverage expansions—to 6.0% in 2022, according to KFF analysis of American Community Survey data. Despite that progress, KFF estimated that more than 350,000 Marylanders remained uninsured in 2022. The reasons for being uninsured vary, but for many thousands of Maryland residents, those reasons are linked to immigration status. Some are legally present in the United States but do not meet the 5-year residency requirement to qualify for Medicaid, some have complicated statuses, such as asylum seekers with pending immigration cases. Others are undocumented and ineligible for Medicaid or Qualified Health Plan Subsidies. All need healthcare.
In fiscal year 2023, the Montgomery Cares program served 22,963 adults and the Care for Kids program served 8,648 children, all low-income, uninsured residents of Montgomery County, mostly immigrants, from over 75 countries. These individuals and families reflect the range of immigration barriers to accessing affordable health care. These programs are publicly subsidized with county general funds, privately managed by a 501c3 nonprofit (Primary Care Coalition) and run in partnership with independent safety-net health centers, four hospital systems, individual specialty care providers, and the Montgomery County Department of Health and Human Services.
Improving access to care for these neighbors is not just about doing the morally right thing. It is also a choice with broad community benefits. These individuals and families and the overall healthcare system are best served through early prevention and treatment, preferably in primary care settings. Yet, low-income uninsured residents will delay preventative treatment due to cost and often delay treatment for potentially more serious illness as well, hoping the issue will resolve itself. Access to health insurance provides access to primary care.
Indeed, when PCC, local hospital emergency departments, and the Montgomery County Department of Health and Human Services partnered on the Emergency Department (ED) to Primary Care Connect program from 2009 to 2011, referring and connecting uninsured ED patients to safety-net primary care clinics reduced potentially avoidable future utilization. In an era of very long ED wait times statewide, avoiding unnecessary visits is imperative to make space for patients who need emergency care.
PCC has also invested in the analysis of the expected value return on investment associated with improved access to care for uninsured patients. The results suggest improved participation in economic life associated with access to primary and preventive health care for our uninsured neighbors. Diabetes control alone was associated with a return of $11.56 for every dollar invested in Montgomery Cares in FY22, while hypertension control saw an estimated return of $3.45 per dollar spent. Those returns reflect savings from anticipated decreases in absenteeism, lost productivity while at work for the employed population, early workforce exits due to disease-related disability, and lost productivity due to mortality.
The proposed legislation is not enough to solve the uninsurance problem in our state. But it is an important step in recognizing the role all Marylanders play in realizing health and prosperity goals for our state. Future legislative efforts should designate funding within the Maryland Medicaid program to expand coverage to undocumented immigrants below 138% FPL.
Based on our experience serving immigrant populations in Montgomery County, we recommend the following amendments to ensure access to care for all of our “Qualified Resident” neighbors:
Evaluate approaches for providing premium assistance and cost sharing reductions for “Qualified Residents” with or without a federal 1332 waiver.
Codify involvement of trusted community-based organizations in program implementation and allocate resources to provide patient application assistance to address linguistic and cultural barriers to navigating the healthcare system for “Qualified Residents;” and consider measures to assure consumer protection for participating “Qualified Residents” who may be wary of participating in government-run programs either as a result of their experiences in countries of origin or due to concern that use of such a program would impact their future immigration proceedings.
The Primary Care Coalition is strongly supportive of the intent of this legislation and is more than happy to share information and perspectives based on our years of experience administering health care access programming for our immigrant neighbors.
Sincerely,
Leslie Graham
President and CEO
Primary Care Coalition
On February 20th, PCC submitted written testimony to the State legislature in support of SB705, the Access to Care Act with amendments. Senate Bill SB705 (and its companion House Bill HB728) remove requirements for those using the Maryland Health Benefits Exchange for the purchase of qualified health insurance plans to provide proof of their legal residency status. Conceptually, this opens the purchase of health insurance on the Benefits Exchange to some of our most vulnerable families and neighbors, our undocumented residents.
We support SB705 and HB728 knowing that this legislation is unlikely to create any immediate change for the population we serve—people whose incomes are too low to purchase their own health insurance policies without financial assistance for the monthly premium costs. Currently the State budget and federal policies would not include subsidies for these individuals and families even if these Bills pass.
Which begs the question: Why do we support these Bills?
First, it is an important step of recognition that these families and individuals have been previously excluded from State-led health insurance programs, including the Health Benefits Exchange. Yet, like all residents of Maryland, they work, raise families, and need healthcare.
Second, SB705 and HB728 recognize that health insurance gives people a path to getting care early and regularly, such as seeing a primary care provider. This benefits both the individual and the State - improving health and quality of life for the individuals and reducing cost of care within Maryland by preventing advancement to more expensive disease states and emergency room use or costly hospitalization.
Currently, hospitals bear the direct burden as Uncompensated Care, but as a community, we all eventually feel the effects. We feel them when uncompensated hospital care drives up all insurance premiums, and when we wait longer for emergency care because conditions that could have been treated in outpatient clinic practice were not.
Montgomery County’s own Delegate Cullison (D-19) was very clear when presenting HB728 to the Health and Government Operations Committee that it was not designed to be an end point. It was designed to be a move toward it. We take the same view.
As Delegate Cullison and panelists from state health agencies made clear in House committee testimony, the explicit purpose of this legislation is to provide all Marylanders with access to the best available consumer tools for purchasing insurance coverage. Tools that help people analyze plan options, as well as navigation support in multiple languages.
The current legislation would not provide any subsidies to make purchasing health insurance plans viable for low-income individuals or families. We still support its recognition of the need participants in PCC programs like Care for Kids and Montgomery Cares face, and its creation of a framework for meeting that need, should funds for premium assistance become available.
In House debate before the Bill passed, Delegate Fisher referenced ongoing challenges with primary care supply as a reason not to approve the Bill, according to Maryland Matters, arguing that adding more demand to an already stressed system was “ridiculous.” The good delegate is not wrong that sufficient healthcare supply remains a pressing challenge—hence, our work with the Nexus Montgomery Regional Partnership and community partners on workforce capacity—but limiting our immigrant neighbors’ options for coverage is not the answer.
Resources may be constrained; our problem-solving potential should not be. This legislation is not a one-and-done solution to healthcare access, but it is part of the solution. More importantly, it’s a part we can reasonably accomplish this session.
To: The Honorable Pamela Beidle (Chair), and Members Senate Finance Committee
From: Leslie Graham, President & CEO, Primary Care Coalition
Date: February 20, 2024
Subject: Support - SB705 Access to Care Act
The Primary Care Coalition (PCC) administers a variety of programs including Montgomery Cares and Care for Kids—Montgomery County's principal health safety-net programs—which provide primary care, specialty care, behavioral health, and access to medications uninsured adults and children. The PCC strongly supports the intent of the Access to Care Act based on our experience operating access to care programs for low-income, uninsured residents of Montgomery County.
Maryland’s percentage of uninsured residents has decreased from 10.2% in 2013—just prior to Affordable Care Act coverage expansions—to 6.0% in 2022, according to KFF analysis of American Community Survey data. Despite that progress, KFF estimated that more than 350,000 Marylanders remained uninsured in 2022. The reasons for being uninsured vary, but for many thousands of Maryland residents, those reasons are linked to immigration status. Some are legally present in the United States but do not meet the 5-year residency requirement to qualify for Medicaid, some have complicated statuses, such as asylum seekers with pending immigration cases. Others are undocumented and ineligible for Medicaid or Qualified Health Plan Subsidies. All need healthcare.
In fiscal year 2023, the Montgomery Cares program served 22,963 adults and the Care for Kids program served 8,648 children, all low-income, uninsured residents of Montgomery County, mostly immigrants, from over 75 countries. These individuals and families reflect the range of immigration barriers to accessing affordable health care. These programs are publicly subsidized with county general funds, privately managed by a 501c3 nonprofit (Primary Care Coalition) and run in partnership with independent safety-net health centers, four hospital systems, individual specialty care providers, and the Montgomery County Department of Health and Human Services.
Improving access to care for these neighbors is not just about doing the morally right thing. It is also a choice with broad community benefits. These individuals and families and the overall healthcare system are best served through early prevention and treatment, preferably in primary care settings. Yet, low-income uninsured residents will delay preventative treatment due to cost and often delay treatment for potentially more serious illness as well, hoping the issue will resolve itself. Access to health insurance provides access to primary care.
Indeed, when PCC, local hospital emergency departments, and the Montgomery County Department of Health and Human Services partnered on the Emergency Department (ED) to Primary Care Connect program from 2009 to 2011, referring and connecting uninsured ED patients to safety-net primary care clinics reduced potentially avoidable future utilization. In an era of very long ED wait times statewide, avoiding unnecessary visits is imperative to make space for patients who need emergency care.
PCC has also invested in the analysis of the expected value return on investment associated with improved access to care for uninsured patients. The results suggest improved participation in economic life associated with access to primary and preventive health care for our uninsured neighbors. Diabetes control alone was associated with a return of $11.56 for every dollar invested in Montgomery Cares in FY22, while hypertension control saw an estimated return of $3.45 per dollar spent. Those returns reflect savings from anticipated decreases in absenteeism, lost productivity while at work for the employed population, early workforce exits due to disease-related disability, and lost productivity due to mortality.
The proposed legislation is not enough to solve the uninsurance problem in our state. But it is an important step in recognizing the role all Marylanders play in realizing health and prosperity goals for our state. Future legislative efforts should designate funding within the Maryland Medicaid program to expand coverage to undocumented immigrants below 138% FPL.
Based on our experience serving immigrant populations in Montgomery County, we recommend the following amendments to ensure access to care for all of our “Qualified Resident” neighbors:
Evaluate approaches for providing premium assistance and cost sharing reductions for “Qualified Residents” with or without a federal 1332 waiver.
Codify involvement of trusted community-based organizations in program implementation and allocate resources to provide patient application assistance to address linguistic and cultural barriers to navigating the healthcare system for “Qualified Residents;” and consider measures to assure consumer protection for participating “Qualified Residents” who may be wary of participating in government-run programs either as a result of their experiences in countries of origin or due to concern that use of such a program would impact their future immigration proceedings.
The Primary Care Coalition is strongly supportive of the intent of this legislation and is more than happy to share information and perspectives based on our years of experience administering health care access programming for our immigrant neighbors.
Sincerely,
Leslie Graham
President and CEO
Primary Care Coalition
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