What's New with HCFO - February 9, 2007 (Print All Articles)
Universal Coverage—One State at a Time
With roughly 46 million Americans uninsured, increasing healthcare costs, and a new Democratic Congress with an eye on healthcare, state-based universal coverage proposals are on many states’ legislative agendas for 2007. Governors from California and Pennsylvania have unveiled proposals to expand coverage in their states, while Massachusetts, Vermont, and Maine are in the process of implementing coverage plans. The move toward state-based universal coverage may have been prompted by the failed national effort in the 1990s; state coverage expansions offer solutions that an overhaul of the entire U.S. system could not. State policymakers can design individual programs that fit the unique characteristics of their populations and their healthcare delivery systems. They can structure financing mechanisms to meet the needs of individuals, employers, providers, and insurers in their state. Structure & Financing of State Initiatives State Coverage Initiatives, a national program of the Robert Wood Johnson Foundation, recently published its annual State of the States. This year’s edition includes a review of key features of state-based coverage reforms.1 The structure and financing of the reforms that are currently in place, and in development, are in many ways as unique as the states themselves. Medicaid expansions, premium subsidies, tax incentives, employer and individual mandates, and offset payments are some of the mechanisms that states are using to design universal coverage plans. For example, under the new initiative in Massachusetts, “Commonwealth Care,” residents must enroll in a health plan by July 1, 2007 or risk loss of their personal tax exemption. The state’s employers share the healthcare burden with its employees by making a “fair and reasonable” contribution toward insurance coverage. Overall financing of the initiative will come from federal matching funds, general fund revenues from the state, and individual and employer contributions.2 Vermont’s “Catamount Health,” with its goal of covering 96 percent of state residents by 2010, will use a combination of financing mechanisms, including a tobacco-product tax, federal funds based on a Medicaid waiver, enrollee premiums, and an employer assessment.3 Maine’s “Dirigo Health,” which has led the way in state-based coverage reforms, is unique in its voluntary nature. Maine’s residents, who have no access to large employer-based health insurance, are now able to obtain coverage under DirigoChoice, a subsidized plan offered by the state’s largest carrier, Anthem. In a project jointly funded by the Robert Wood Johnson Foundation’s HCFO program and The Commonwealth Fund, James Verdier, J.D. and Debra Lipson of Mathematica Policy Research, Inc. are examining DirigoChoice. The research team is not only assessing the program’s potential ability to be replicated in other states, but also examining which features are attractive to small businesses and the satisfaction of enrolled employers with the program.4
Efforts by individual states to develop universal coverage programs offer one solution to the intractable problem of the uninsured. Many of these efforts are predicated on projected cost savings from reducing the need for costly catastrophic services or uncompensated care. Despite the obvious benefits of state-based health insurance, implementing these plans has its challenges. A large influx of previously uninsured individuals into the healthcare system could burden the system and lead to reduced access to care and diminished quality in the short term. Moreover, many may find that the financial demands are prohibitive. For example, while some employers in Massachusetts are hopeful that that the new insurance law will help reduce premiums, other employers are concerned that they may not be able to financially support the influx of new enrollees in the heath plans they offer.5 In addition, individuals who are currently insured may have to purchase additional coverage to meet Massachusetts’ minimum standards.6 Even since the launch of Dirigo Health, Maine has continued to explore long-term funding and cost containment methods. On January 29, 2007, the Blue Ribbon Commission on Dirigo Health Reform delivered a report to the governor with recommendations on how to financially strengthen the plan. The Commission proposed increased taxes on cigarettes, alcohol and snacks, as well as the development of employer or individual mandates.7 California Governor Schwarzenegger is facing challenges even as his proposed plan to cover the uninsured is in its development phase. One component of the plan’s financing, fees levied on employers, hospitals and physicians, has raised concerns by those constituencies.8 Moreover, California’s population of 6.5 million, including a large immigrant population, presents a unique challenge in that state. Future Policy Developments The National Conference of State Legislatures reports that, “Health reform will remain a priority this year. Several states—including Illinois, Colorado, Louisiana, Maine, Maryland, New Mexico and Washington—have commissions charged with creating recommendations for expanding coverage and reforming health care. Political leadership in other states including California, Colorado, Florida, Indiana, Ohio, Oregon, Minnesota, New Jersey and Wisconsin are poised to act in 2007.”9
Evaluation of Maine's Dirigo Health Reform James M. Verdier, Ph.D., Mathematica Policy Research, Inc. Monitoring the Early Experience with Federal Health Insurance Tax Credits
Sustaining Individual Health Insurance Markets Under Community Rating and Open Enrollment Joel Cantor, Sc.D., Rutgers, The State University of New Jersey Expansion of the Evaluation of the Effects of New Jersey's Individual Health Coverage and Access Programs
Katherine Swartz, Ph.D., Harvard School of Public Health The Dynamics of Health Insurance Coverage: 1996 to 2000 Studies of the Working Uninsured, Their Dependents and Insurance Reform on Their Behalf Linda Blumberg, Ph.D., The Urban Institute Patterns of Individual Coverage Andrew F. Coburn, Ph.D., University of Southern Maine The Fishing Partnership Health Plan: A Model for Reducing the Numbers of the Working Uninsured Stephen M. Davidson, Ph.D., Boston University Evaluation of State Initiatives to Expand Health Insurance Among Small Businesses
Uninsured in America: Individual and Community Factors Barry Saver, M.D., University of Washington
Benefits and Challenges
Time will tell whether the benefits of state-based universal coverage will outweigh the challenges. Momentum from states’ efforts could also lead to a national plan providing health insurance for all or, as recently proposed by the Administration, a joint state/federal effort, the President’s “Affordable Choices Initiative.”10 Congress is also exploring legislation to provide federal support for state coverage initiatives.11 Regardless of the structure, affordability and sustainability will be the key drivers behind any viable plan to make health care coverage a staple of every American’s life.
Other Related HCFO Research:
Karen Pollitz, M.P.P., Georgetown University
Evaluation of Reforms of the Market for Individual Health Insurance Coverage in New Jersey
Gail A. Jensen, Ph.D., Wayne State University, Institute of Gerontology
1 http://statecoverage.net/pdf/StateofStates2007.pdf
2 Ibid.
3 Ibid.
4 http://www.hcfo.net/grantees/grant.asp?GrantNo=58012&searching=Yes
5 “Massachusetts Law Threatens Bottom Line of Not-For-Profit Health Providers,” Kaiser Daily Health Policy Report, January 18, 2007. See also, AP/Long Island Newsday, “Many Businesses Fear Health Care Costs, January 20, 2007. http://www.newsday.com/business/nationworld/wire/sns-ap-health-care-business,0,6108052.story
6 The Boston Globe, “200,000 May Need to Get More Insurance,” January 30, 2007.
7 http://www.maine.gov/tools/whatsnew/index.php?topic=Portal+News&id=29304&v=article-2006
8 The Washington Post, “Talk of Universal Health Care Grows,” January 20, 2007.
9 http://www.ncsl.org/programs/health/h-primary.htm#2007
10 The Washington Post, “President to Propose Shifting Health Funds to States,” January 22, 2007.
11 CQ HealthBeat, “Lawmakers Unveil Bill that Would Help Fund State’s Efforts to Cover Uninsured,” January 17, 2007.
Grantee Spotlight - Jeanene Smith, M.D.
Jeanene Smith is the administrator of the Office for Oregon Health Policy & Research (OHPR), which serves as the policymaking body for the Oregon Health Plan. Smith has also served as assistant clinical professor for the Department of Family Medicine at Oregon Health & Sciences University. Smith’s published and policy-related work has focused primarily on healthcare benefit design, cost-sharing strategies for Medicaid populations and quality of care in new, emerging models. In 2004, Smith took the lead on a HCFO grant, which examined the impact of benefit reductions and changes to the Oregon Health Plan, Oregon’s Medicaid program. The study was conducted by a unique collaborative of Oregon’s policy and health services research community, the Oregon Health Research and Evaluation Collaborative (OHREC). Researchers from the OHPR, Portland State University (PSU), and the Oregon Health & Science University (OHSU) set out to determine how increased cost sharing and benefit reductions would impact access to preventive care and the economic viability of Oregon’s Medicaid adult “expansion” enrollees. Drs. Neal Wallace (PSU) and John McConnell (OHSU) explored the effect of imposing co-payments and eliminating benefits on patterns of service use and expenditures. In addition, Drs. Robert Lowe (OHSU) and McConnell examined differences in emergency department utilization before and after plan changes. The researchers concluded that the imposition of co-payments did not reduce expenditures under the Oregon Health Plan. While use and expenditures fell for prescription drugs, expenditures for all other medical services increased, including increased use of inpatient and hospital outpatient care. An examination of the elimination of behavioral health benefits showed that individuals who lost methadone treatment coverage had significantly increased expenditures, driven primarily by increased inpatient admissions. There was also an abrupt and sustained increase in emergency department use following the plan cutbacks and a disproportionate impact on patients’ chemical dependency diagnoses. The researchers’ findings suggest that benefit design changes and cost-sharing strategies may have impacts within a Medicaid population that are different than what might be expected in a commercial population. “We believe findings from this work will inform Medicaid programs nationwide as they consider increased copays and cost sharing structures,” says Smith. Smith received her M.D. from OHSU and her M.P.H. from the Oregon Masters in Public Health Program. She has more than 15 years of clinical experience, including a year long rotation at the Alaska Native Medical Center and two years working for the Urban Indian Health Clinic. For more information on research by the OHPR, contact Jeanene Smith at jeanene.smith@state.or.us or go to the Office’s website at http://egov.oregon.gov/DAS/OHPPR/OHREC/index.shtml For more information on the Medicaid program impacts of increased cost sharing, contact Neal Wallace, Ph.D. at PSU, nwallace@pdx.edu, or John McConnell, Ph.D. at OHSU, mcconnjo@ohsu.edu. For more information on the impact of cost sharing structures on emergency department use, contact Robert A. Lowe, MD, MPH at OHSU, lowero@ohsu.edu. 
New HCFO Grant Announced
Title: Study of the Effects of High-Deductible Health Plans on Families with Chronic Conditions
Grantee Institution: Harvard Pilgrim Health Care, Inc.
Principal Investigator: Alison Galbraith, M.D.
Grant Period: February 1, 2007 - July 31, 2009
Paragraph Summary:
This project will analyze the impact of high-deductible health plans on families who do not have a choice in health plans. The researchers will examine the effect of high deductibles on family health care decision making strategies, unmet health care needs, and the financial burden for families relative to that of traditional plans. They will also explore whether one family member’s health or resource use influences that of other family members, particularly when one member has a chronic condition. The objective of the project is to inform policymakers about the potential advantages and disadvantages of high-deductible plans for families dealing with chronic conditions, especially when they have no choice in health plans.
Spotlight on Grantee Publication
Joel C. Cantor, Sc.D., professor and director, Center for State Health Policy, Rutgers University, is the co-author of an article titled, “The Adequacy of Household Survey Data for Evaluating the Nongroup Health Insurance Market” that appeared in an early online issue of HSR. The article describes HCFO-sponsored research examining the accuracy of household survey estimates of the size and composition of the population covered by nongroup insurance.
Current HCFO grantee publications and recent grant findings will be regularly featured in the results section of our Web site.
This Month in the News
Paul Ginsberg, Ph.D., president of the Center for Studying Health System Change, was quoted in a January 22, 2007 article in the Pittsburgh Post-Gazette that examined the recent launch of RevolutionHealth.com, a Web site that hopes to cater to the growing phenomenon of consumer-driven health care. Ginsburg cautioned that “they’re talking about tying together a lot of different services, most of which no one has been very successful in developing.”
Stephen Parente, Ph.D., associate professor in the Carlson School of Management at the University of Minnesota, was featured in a January 29, 2007 Government Health IT article that examined the development and funding for the National Health Information Network (NHIN). The article summarizes a meeting of experts to discuss further development, including finance options for NHIN. Parente noted that “planning for the NHIN has focused too much on the national network and not enough on the potential users of the network, especially individual doctors.”
Robert D. Reischauer, Ph.D., chair of the HCFO National Advisory Committee, and president of The Urban Institute, was featured in a January 25, 2007 Washington Post article that examined the health care proposals President Bush introduced in his State of the Union address. Reischauer described Bush’s proposal to provide a tax deduction for purchasing health insurance in the individual market as “tilting the playing field toward this very flawed market.”
Sara Rosenbaum, Ph.D., professor at the George Washington University School of Public Health, was featured in a January 12, 2007 Akron Beacon Journal article that discussed a town hall meeting at Rainbow Babies and Children’s Hospital in Cleveland. The article describes the educational meeting to inform parents about SCHIP and Medicaid. Rosenbaum, the program moderator, cautioned attendees at the meeting that “those interested in seeing that kids are insured should keep an eye on the congressional debate to make sure money for SCHIP isn’t taken from Medicaid.”
New Findings Briefs Explore Medicare Prescription Drug Plans and Regional PPOs
“A Sustainable Future? The Role of Premium Subsidies in Medicare Prescription Drug Plans“
In July 2004, HCFO funded research to provide early and timely information on entry, enrollment, and risk selection of Medicare prescription drug plans and regional PPOs. A research team based at Boston University School of Public Health explored adverse selection in PDPs, the entrance of PPOs into regional markets where health maintenance organizations (HMOs) already exist, and the introduction of PDPs and PPOs in markets where HMOs did not have a presence. Simulation models show that in general, PDPs will be stable, regardless of adverse selection, and that premium support of these programs will ensure viability.
“Regional PPOs in Medicare: What Are The Prospects?: How Do They Contain Rising Costs?”
One of several new types of Medicare health plans that became available for the first time in 2006, regional Medicare preferred provider organizations (PPOs) promised to import the successful commercial PPO model to the Medicare market. Policymakers anticipated that regional PPOs could provide access to comprehensive coverage (including for prescription drugs) at affordable costs to all Medicare beneficiaries. This Findings Brief summarizes recent research and experience related to regional Medicare PPOs and assesses the prospects for this type of health plan in the near future.
New HCFO Issue Brief
Medical Malpractice: Strengthening the Evidence Base
Vol. IX, No. 8
December 2006
The myriad of issues associated with medical malpractice have been hotly debated. Despite continued attention, most policy proposals are based on research findings facing important drawbacks—data limitation and disparate methodologies. Missing and inaccurate data and poorly designed studies lead to inconsistent findings, which have made the malpractice debate vulnerable to exaggerated and invalid claims and ideological rhetoric. Another significant barrier to successful malpractice reform is the failure of researchers and policymakers to be clear about which malpractice problem they are trying to address, since different problems can require very different solutions. In an off-the-record discussion conducted by HCFO, researchers and policy experts reviewed the state of the evidence and explored whether and how research results support or call into question a variety of proposed policy solutions.
New NCHS Summary Data on Nursing Homes Available For Researchers and Policy-Makers
The
The NNHS is a periodic survey providing data on nursing homes, nursing home residents, and their care. The 2004 NNHS collected data about 13,600 residents in 1,174 nursing homes from a nationally representative sample. A telephone survey of 3,017 nursing assistants from 582 nursing homes was conducted as a supplement to the NNHS, and was designed to obtain information on factors that may influence the direct care workforce shortage. Summary data tables describing characteristics of nursing home residents and nursing assistants will be available shortly. To receive updates on NNHS products and release dates, subscribe to the Long-Term Care Listserv http://www.cdc.gov/nchs/about/major/ahcd/long_term_care_listserv.htm.
To conduct analyses using the 2004 NNHS public use data files, see http://www.cdc.gov/nchs/nnhs.htm.
The NNHS is one of a family of surveys known collectively as the National Health Care Surveys. For more information on the long-term care, inpatient care, ambulatory surgery, and ambulatory medical care components of the National Health Care Surveys, please visit www.cdc.gov/nchs/nhcs.htm.
Public Health Systems Research Article of the Year and Student Scholarships
PHSR Article of the Year:
The Article of the Year recognizes the best scientific work that the field of PHSR has produced and published in 2006. Using either qualitative or quantitative techniques, articles must present, analyze, and comment on new data or synthesize and analyze data that have already been collected. The selection will be based on the article's contribution to the understanding of public health systems; provision of new insights to the field of PHSR; and potential to advance the field and/or challenge current thinking.
The awardee will receive complimentary registration for both the PHSR Interest Group Meeting and the AcademyHealth Annual Research Meeting, travel assistance, and a $1,000 cash award.
To nominate an article for this award please click here.
PHSR Student Scholarships:
The Student Scholarships recognize graduate students who demonstrate potential to contribute to the field of PHSR through promising research. Scholarship recipients will receive $500 to be put towards registration and travel to attend AcademyHealth's Annual Research Meeting (ARM) and the PHSR Interest Group (IG) Annual Meeting, June 2-5, 2007 in Orlando. Additionally, students will have an opportunity to present their research during the PHSR IG Meeting's poster session.
Masters or doctoral students engaged in research that shows potential to advance our understanding of public health systems are encouraged to apply. The Student Scholarships strive to highlight the diversity of research interests that constitute PHSR— from inquiries into the relationship between the built environment and public health, to food safety, chronic disease, and emergency preparedness.
To apply for this award please click here.
International Health Study Tours – Spaces filling quickly; Register Today!
United Kingdom, April 28-May 4
Join AcademyHealth as we set out for an unprecedented opportunity to stimulate new ways to think about specific health policy issues and learn from international experts that are grappling with similar challenges. Partnering with the National Health Service (NHS) Confederation, the first tour will be to the
View the Web site for more on registration fees, a preliminary agenda, and travel information. A maximum of 15 participants will be accepted. Register early to reserve your place.
Next Stop~Germany, October 13-19
AcademyHealth 2007 Annual Research Meeting (ARM)
June 3-5 * Walt Disney World Swan and Dolphin *
Registration Now Open
Abstracts submitted for the 2007 ARM are under review. Notifications will be sent by March 23.
ARM Preliminary Agenda Available Online
So far, about half of the program has been identified and is available online. The call for abstracts peer review process will determine the content of the remaining sessions. Check out the agenda-at-a-glance and session schedule.
Keynote Speaker
David Cutler, Otto Eckstein Professor of Applied Economics and Dean for the Social Sciences at Harvard University and author of Your Money Or Your Life: Strong Medicine for America's Health Care System.
ARM Preliminary Agenda Available Online
So far, about half of the program has been identified and is available online. The call for abstracts peer review process will determine the content of the remaining sessions. Check out the agenda-at-a-glance and session schedule.
Keynote Speaker
David Cutler, Otto Eckstein Professor of Applied Economics and Dean for the Social Sciences at Harvard University and author of Your Money Or Your Life: Strong Medicine for America's Health Care System.
David Cutler, Otto Eckstein Professor of Applied Economics and Dean for the Social Sciences at Harvard University and author of Your Money Or Your Life: Strong Medicine for America's Health Care System.
Building Bridges: Making a Difference in Long-Term Care
2007 Colloquium
Saturday, June 2
Orlando, FL
Join The Commonwealth Fund and AcademyHealth on Saturday, June 2 in Orlando for the fourth Building Bridges: Making a Difference in Long-Term Care Colloquium. This event is part of a strategic initiative that brings together policy leaders, providers, consumer advocates, researchers, and funders around critical issues in long-term care. This is a unique opportunity for stakeholders to exchange information, debate the issues, seek solutions, and identify where additional research is needed.
The 2007 Colloquium will focus on two issues:
Conflicting Incentives for Long-term Care: Medicare and Medicaid
David Grabowski, Ph. D., at Harvard Medical School’s Department of Health Care Policy will prepare a background paper and explore the sometimes conflicting incentives within the Medicare and Medicaid programs in terms of the provision and financing of long-term care, as well as the implications of those incentives for quality, financing, and ultimately policy. Grabowski will synthesize what is known, develop a research agenda, and identify methodological concerns and obstacles to building an evidence base to inform the policy debate.
Preparedness for Long-term Care
This year’s colloquium will feature a new forum format designed to stimulate discussion among an expert panel and colloquium participants. The goal of this facilitated discussion will be to engage the dynamic panel in a discussion of issues related to long-term care planning. In addition, the facilitatorwill elicit the experts’ and colloquium participants’ sense of which issues were most important to policymakers and practitioners, as well as where research efforts should be focused. Following the colloquium, AcademyHealth will prepare an issue brief synthesizing the discussion and outlining research and policy agendas.
The meeting will be held on Saturday, June 2 from 8:30 a.m. until 4 p.m, in conjunction with AcademyHealth's Annual Research Meeting in Orlando, FL.
For more information on AcademyHealth and The Commonwealth Fund, see www.academyhealth.org and www.cmwf.org.
Inquiries can be directed to Christal Stone at 202.292.6765 or ltc@academyhealth.org.