DISTRICT of COLUMBIA PRIMARY CARE
ASSOCIATION
Washington, DC  

April 2000

        §       Background

The DC Communities in Charge partnership is stepping onto a moving train.  The Robert Wood Johnson Foundation's Communities in Charge request for proposals was announced just as the District's newly elected Mayor Anthony Williams put forth a sweeping plan to reform the way the District uses its public health dollars.  Mayor Williams suggested redirecting all the Disproportionate Share and District Subsidies for healthcare services into purchasing Medicaid insurance.  The proposal argued that DC could insure all but 3% of DC's low-income residents this way.  In the midst of the ensuing vigorous discussion, the DCPCA organized around 70 people and institutions to develop a response to the Communities in Charge proposal.  The DCPCA wrote the grant using the Mayor's Medicaid reform numbers because they were the focus of the discussion.  Policy makers and the healthcare community were unprepared to analyze the sweeping nature of the changes, the Mayor's comprehensive reforms were not included in the budget.  However, the plan put a spotlight on the inadequacies of our current public health system, and Medicaid expansions continue as the District debates its overall strategy for public health reform.

The Mayor requested that the Council join him in forming a Health Commission with representatives from the Mayor, the Council, Healthcare and Community.  The Commission has worked for four months to look at the healthcare status of District residents and is developing strategies to improve the public health through comprehensive reform.  In the beginning of February the Commission will release its legislative recommendations for the upcoming budget year.

Five members of the Commission have been invited to serve on the Task Force to ensure that the Communities in Charge will build on the work of the Commission.  The Commission, and other efforts underway, will provide the foundation for CIC.  The 21-member Task Force will meet bi-monthly (with committees meeting in alternate months) for the first year, with the goal of presenting a legislative agenda in February of 2001.  Three co-chairs will provide Task Force Leadership:

• Dr. Ivan Walks, Commissioner of the Department of Health, will serve as the Mayor's representative

• Dr. Gary Dennis, Chief of Neurosurgery, Howard University Hospital, will serve as the Community Chair.

• Council member Sandy Allen will serve or appoint a Co-Chair Council representative.

The Task Force will serve as the coordinating agent to develop a "community intelligence quotient" regarding healthcare reform options, develop leadership and direction to decide among options, and build the political will to see the decisions implemented.  

The Communities in Charge Task Force is independent of the DCPCA Board of Directors.  Representative communications open between the Board and CIC.  The Executive Director of the DCPCA will serve as a Task Force participant and Committee participant, but will not be a voting member of either.  DCPCA will provide staffing that includes a fulltime staff person to coordinate the project, project leadership and administrative support.  DCPCA will continue to support the project with grant management, resource development, communications and other efforts.  

There will be three committees:  Financing, Delivery and Accountability.  Staffing will be provided by RWJF funding and other DCPCA funding efforts.  In addition, staff will work with leadership to connect projects like Kellogg Community Voices and RWJF Covering Kids to support the committees and develop consumer involvement and voter education strategies.

Financing Strategy

DC will use Medicaid expansion as the major vehicle for reform for many reasons, including the national importance of Medicaid, the structure is in place for expansion, and District policy makers are comfortable with Medicaid expansion.

It is likely we will also develop a free care pool of some type as an interim step because Medicaid has many, many internal problems to resolve before expansion will be effective in improving health outcomes.  

Outreach Strategy

The consumer outreach strategy is being developed and funding is reserved for execution of the plan.  The Executive Director of a consumer Medicaid Advocacy organization will chair the Delivery Committee and will be responsible for ensuing consumer involvement in the Task Force.  An outreach strategy will be developed as the project progresses.

Delivery System

DC Communities in Charge is as concerned about delivery as it is about insurance.  Our delivery system is fragmented; prevention, primary care and home-based services are inadequate both in quality and quantity.  A large amount of uncompensated care is provided in emergency rooms, making it difficult to secure tertiary and non-emergency hospitalizations to the uninsured.

Through related projects DCPCA is working to secure funding for developing standards of care for primary care and helping our community providers meet those standards.  We are working with the Department of Health because they will need to build the capacity to monitor the providers once standards are in place.  We have not yet tackled long-term care problems, which will need to be included because DC's population is aging.  We are using CIC to bring those communities, and others into the healthcare reform process.  In addition to the healthcare providers, Medicaid's ability to contract for and/or provide outreach, enrollment and re-certification must be improved if reform is to succeed.

The Mayor and the City Council have a rocky relationship:  Both are relatively new to their emergency roles in a revitalized DC government.  We will work carefully to ensure that both are included in the process.  Constant communication will help maintain success.

Race and income divisions in the city are real and powerful:  We are an urban center that has an African-American majority (65%-70%) of the population, a white minority (25%-30%) and a large international immigrant community (5%-10% most of whom are Latino).  This complicates reform.  Strict attention to diversity in leadership and participation is critical.

DC advocates are inexperienced:  The DCPCA is one of the new emerging community organizations that have professional advocacy staff.  Healthcare reform, with its complex funding and delivery options is demanding.  In addition to the lack of staff experience, healthcare leaders are new to reform generally.  CIC will be bringing new voices to the table, like consumers and corporate DC, which means we will need to help people grasp complex issues quickly.

DC is emerging from many years of little government accountability:  The lack of capacity at the Department of Health, the Income Maintenance Administration, and the Office of Contracting and Procurement must be considered when planning implementation.