Implementing Health Reform in the District of Columbia
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Stephanie Akpa

Stephanie Akpa, Equal Justice Works Fellow

In September of last year, I joined Legal Aid as an Equal Justice Works Fellow.  My project focuses on ensuring that African Americans in the District, a group that experiences disproportionately negative health outcomes, have access to quality health care.  One aspect of my project involves advocating for policies that advance the health care interests of the low-income African-American community.  With health reform underway in the District, I have had a unique and exciting opportunity to participate in the implementation of key provisions of the Affordable Care Act.

Legal Aid focuses on two primary features of the Affordable Care Act, often called the ACA or Obamacare, which President Obama signed into law on March 23, 2010:  (1) Medicaid expansion and eligibility determination, and (2) the creation of the DC Health Benefit Exchange.  As part of the ACA, states must decide whether to expand Medicaid to low-income childless adults. Although the District had provided coverage to this population even prior to the passage of the ACA through a program called the DC Healthcare Alliance, childless adults were previously ineligible for medical assistance in most states.  In conjunction with Medicaid expansion, the ACA changes Medicaid rules for determining household income and size.

The ACA also requires that states create Health Insurance Exchanges, virtual marketplaces where individuals and small businesses can compare and enroll in health plans.  Think Travelocity for health insurance.  Exchanges will also determine whether households or members of households are eligible for Medicaid, tax credits (which reduce the cost of premiums through the Exchange), and other subsidies.  Essentially, Exchanges will act as one-stop shops for federally-funded public health insurance and private health insurance.  Open enrollment will begin for health plans through Exchanges on October 1, 2013 and coverage will begin on January 1, 2014.

The expansion of Medicaid and creation of the DC Exchange touch upon the very heart of my project, as the vast majority of Legal Aid’s clients are eligible for Medicaid or other forms of medical assistance.  Although implementing health reform provides many opportunities to improve upon the existing process for obtaining and accessing health care in the District, these opportunities also present challenges.  One challenge will be ensuring that individuals who currently receive Medicaid do not lose coverage as a result of the process for determining Medicaid eligibility.  Additionally, the District must work to ensure continuous access to insurance coverage for individuals with fluctuating incomes—for example, individuals who transition from Medicaid to private insurance or vice versa.  The District must also provide sufficient staffing for the agencies that currently run the its medical assistance programs, as well as agencies that will oversee the Exchange, so that it can continue to meet the needs of the current Medicaid and medical assistance population even as the District implements health reform.  These are just a few of the issues that must be addressed for the Exchange to be successful in the District.

My project has allowed me to take an active role in articulating the concerns listed above and participating in the implementation process.  As part of my advocacy work, I have attended the District’s Health Reform Implementation Subcommittee meetings on Medicaid Eligibility and Expansion.  In October 2012, I worked with my Legal Aid colleagues to submit comments on the new process to determine eligibility for Medicaid.  Our comments addressed the potential negative impact of this new process on single-parent households and victims of domestic violence.  Last month, I testified before the DC Council’s Committee on Health on the implementation of the District’s Exchange, applauding the Executive Board for its efforts to engage stakeholders and noting Legal Aid’s concerns with implementation.  I also participate or will participate in a few short-term working groups designed to produce recommendations for how the District’s Exchange will operate, and anticipate potential problems before they arise.  And I was recently appointed to serve on the Consumer Assistance and Outreach Advisory Committee, a long-term committee that will focus on the District’s programs to provide education, outreach, and enrollment assistance to those seeking health insurance coverage.  In addition to this advocacy work, I will design and facilitate training sessions to educate community-based organizations and District residents about important aspects of health reform in the District.

All in all, the goals of my project and health reform are the same—ensuring that every District resident, regardless of income or ethnicity, has access to quality affordable health care.

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