State Reform

IN THE STATES: Minnesota Gov. Vetoes Health Coverage Expansion Bill

Joanne Kenen — Wed, 14 May 2008 19:58:00 -0400

Minnesota Gov. Tim Pawlenty has vetoed a health care bill, saying it would expand coverage without doing anything to restrain costs or improve quality, the Star-Tribune reports.The bill had passed the state Senate with a veto-proof margin, but the vote was closer in the House.

The bill would have made more people eligible for MinnesotaCare, the state's subsidized health insurance program for the working poor. It would have covered an estimated 40,000 people.

"The state cannot afford to further expand subsidized health programs without certainty of reform that will control costs," Pawlenty wrote.

Pawlenty noted that the bill would subsidize households with incomes of up to 400 percent of federal poverty guidelines, making eligible a family of four with an income of $84,800. "This is simply too high," he wrote.

The governor said there were parts of the bill that he liked, including promotion of electronic health records, development of medical homes and payment reform for doctors.

The paper had also recently reported that the bill would have started a statewide campaign to reduce smoking and obesity, and would have offered the public data on the quality and costs of doctor and hospital services. The bill was not as far-reaching as measures recommended by advisory panels appointed by Pawlenty and the legislature.

IN THE STATES: Health Reform Wrap-Up

Joanne Kenen — Thu, 08 May 2008 20:16:00 -0400

Lots of health reform activity recently in states. Here's some help in catching up:

Connecticut. The state legislature has approved a Democratic bill permitting municipalities, nonprofits, and small businesses to join the state employee health insurance pool. Unclear whether Gov. Jodi Rell will support it. Some leading Republicans object to a "government-run" health system, while Democrats and labor backers say the greater buying power of the pool will save municipalities money. Not a comprehensive solution but we'll be interested in watching how this plays out.

Alabama. We posted a few weeks ago about Birmingham's plan to cover children—which we confess was a pleasant surprise to us given the state's history, poverty, and health status. Now we see the state has a new $3 million, five-year grant for the University of Alabama's initiative to reduce health disparities among older blacks.

"It's a huge agenda...There's lots of work to be done," said Dr. Richard Allman, who will head the new Deep South Resource Center for Minority Aging Research, noting that the elderly black rural population is growing fast. The program will start with a focus on three areas—how to help families make decisions about nursing home services, social support for patients with chronic heart failure, and cytomegalovirus infections in older blacks.

Minnesota. The legislature has approved a bill that would stop a hospital from using a patient's medical debt history to decide whether to treat the patient. The governor is expected to sign it.

"It hasn't been a problem here yet, but we do know that some companies were working on gathering that information to sell to health care providers," state Sen. Linda Scheid told the Star Tribune.

Under the bill, a health care provider can't share or obtain medical debt information about a patient seeking care until after the care is delivered.

Florida. This is the biggie, and the devil is in the details, which have yet to be figured out.

With nearly 4 million uninsured, Florida has one of the highest rates of uninsured in the nation, a bit more than 20 percent. Republican Governor Charlie Crist pushed hard this year for an affordable alternative health plan that people can purchase in the individual market, and state legislators gave him much of what he wanted.

The plans will be free of most state coverage mandates and regulations, and will be "no frills." And that's what we worry about. We appreciate Crist's effort to act—and the financial limits his state faces. And he's said the plan will cover prescription drugs, screening, even mental health. But for $150 a month,we're not yet sure how comprehensive these benefits can be. Will the young and healthy go for bare bones plans, making prices of more traditional insurance plans even more costly for the older and sicker? The details are going to be decided by the insurers, who will negotiate with the state. Still, we're sympathetic to states who are trying to help people even in economic tough times -- and one reason we're pushing a national comprehensive solution is that we recognize the states can't do it all on their own.

We've read several state newspaper accounts, (Here, among others) and called on an expert who tracks Florida but if our readers have any insights into where the Florida program is likely to go, please free to comment.

IN THE STATES: Californians are Still Dreaming

Joanne Kenen — Mon, 28 Apr 2008 19:26:00 -0400

Apparently, a lot of Californians shared our disappointment when the state's health reform efforts fell apart earlier this year. A new Field Health Policy Survey shows that Californians are none too confident about the future of health care in their state after lawmakers killed Gov. Arnold Schwarzenegger's plan to cover all Californians in January.

The survey, commissioned by the California Wellness Foundation, found that voters are even more worried now (quite possibly because as the economy worsens, people get more nervous about health costs and job-related insurance). For instance, 59 percent are "very concerned" about not being able to pay all of the costs for a major illness or surgery, up from 48 percent in late 2006. Other findings:

58 percent report being very concerned about having to pay more out of pocket for their health insurance coverage (up from 40 percent).
57 percent are very concerned about either not having or potentially losing their health care coverage (up from 48 percent).
59 percent are very concerned about the possibility of their insurance provider canceling or severely limiting their coverage due to a health condition.
51 percent are very concerned about not having access to quality doctors and health care services (up from 40 percent).

Field reported that three times as many Californians expect the health care system to be worse in five years as think it will be better. The poll found no consensus, however, on whether the solution lies in Sacramento or Washington. The poll of 1,202 registered voters was conducted March 12-30.

The voters were asked specifically about the state's health reform package—including how to pay for it. After hearing a description of the main provisions of the plan Schwarzenegger negotiated with state legislative leaders, more than seven out of ten (72 percent) approved overall. In addition, large majorities backed these specific components:

84 percent favored requiring health insurance companies to offer coverage to anyone without regard to their health condition.
78 percent supported providing state tax credits to moderate-income people if they need to buy health insurance in the open market.
77 percent endorsed the idea of providing state-subsidized health insurance coverage to low-income adults.
73 percent favored an "employer mandate," which would require all employers to help pay for their employees' health coverage on a sliding scale, with larger companies paying more and smaller companies paying less.
68 percent supported the idea of an "individual mandate," that would require all Californians to have a minimum level of health coverage either by purchasing it themselves or by obtaining it through an employer or government agency.

The toughest part of expanding coverage is often how to pay for it, but by large margins (70 percent or more) the California voters surveyed approved of all these funding mechanisms: getting the uninsured to pay more themselves (depending on family income); requiring employers to provide a minimum contribution toward their workers' health coverage, and increasing cigarette taxes by $1.75 per pack. The only unpopular item on the fiscal menu: increasing hospital fees by 4 percent. More than three in four voters opposed that.

We can't predict when health reform will return to policymakers' agenda in California; obviously we don't expect the governor to try again tomorrow. But as the voters made clear, the problem isn't going away. But as voters' concerns about the future intensify, it may be easier next time around to reach consensus on solutions—whether in Sacramento or Washington.

IN THE STATES: Unintended Consequences in (the Other) Washington

Joanne Kenen — Fri, 18 Apr 2008 15:04:00 -0400

A new policy magazine and online site called Miller-McCune took a look at the debate about individual mandates. The article argued that Barack Obama and Hillary Clinton aren't really that far apart on health policy (one reason, perhaps, that they haven't been arguing about it as much recently). As New America's Len Nichols was quoted as saying, mandates don't necessarily have to be the first step but you do have to get everyone in the system to make it work. Otherwise sick people buy policies, healthy people take their chances, costs go up, the system gets creakier and creakier.

We all know about the financial problems Massachusetts is facing with its plan to cover everyone. Less well-known is the experience of Washington state which introduced a version of "guaranteed issue" (when insurers have to sell to everyone, sick or well.) Insurers were not allowed to reject more than 8 percent of applicants. The state did not, however, require everyone to be covered. The result was huge premium increases.

"In a year that some individual rates rose by more than 40 percent, Washington insurers amassed a record $1.4 billion surplus. Lawmakers responded in March with a bill restoring the state's authority to regulate individual rates, in effect opening the door to price controls, but they did not impose a mandate," the Miller-McCune report said.

We're encouraged when states experiment with reform; some initiatives succeed and the rest of the country can learn from them. But state reform also has limits, as the Washington state experience shows. They could not impose a mandate, which would have made their market with guaranteed issue work better, because they do not have the money for subsidies to make insurance affordable for all. Just one more reason that we're convinced that the best approach is a comprehensive national reform, with ample room for state variation so that local conditions can fit within federal parameters and guarantees.

COVERAGE: The Big Picture in the Bay State

Joanne Kenen — Tue, 08 Apr 2008 19:32:00 -0400

"Who said it would be easy?" That headline on the Boston Globe's editorial about the Massachusetts health care for all initiative is as wise as it is simple. We often mutter something similar ourselves when we look ahead to the enormous task of fixing the whole country's health care: "If it were easy, we'd have done it already."

We have naturally watched with interest as Massachusetts lawmakers and officials work to close the fiscal gaps (estimated at about $100 million) and develop accurate assessments of future demand as they strive to make sure that everyone in the state has health insurance. The Globe didn't hone in on the financial details today, focusing on the big picture. Although Massachusetts had a relatively low uninsured rate before the reform bill was enacted two years ago this week, it is a high-cost state and enrollment in subsidized insurance plans has been much higher than expected. And it is nearly impossible for a state to fix all the problems on their own, particularly how we pay for and deliver health care, without a systemic nationwide approach. (Hear that Washington?)

But Massachusetts, for all its challenges, has blazed the trail. "While the success of this initiative is not assured, Massachusetts should be proud of accomplishing so much, so quickly," the Globe wrote. According to the editorial, at least 342,000 people had enrolled in insurance plans as of the start of this year, and two in three of them are being subsidized because they are just above the poverty line.

Reform didn't happen because politicians finally decided the time was right (although of course it would not have happened without them). Reform happened because a coalition, both broad and deep, demanded it. It included businesses, health insurers, hospitals, unions, healthcare advocates, and political leaders. "They now need to figure out ways to control costs, maintain quality, and get new money into the system when absolutely necessary," the Globe said, calling on the coalition to "reenergize" itself to preserve its gains and sustain them into the future. We've got our fingers crossed.

IN THE STATES: Alabama City to Cover All Children

Joanne Kenen — Fri, 04 Apr 2008 15:41:00 -0400

Birmingham, Alabama, has announced an ambitious program to cover the city's 5,000 uninsured children through a mix of public-private partnerships blending public funding, philanthropy and an arrangement with a local children's hospital planning a major job-creating and revenue-producing expansion.

The plan isn't a comprehensive solution to all the health problems in the state—Alabama ranked 42 in CQ's 2008 Health Care State Rankings—but screening and covering young people is a sensible step.

Mayor Larry Langford said the city will put up $150,000, and the Blue Cross Blue Shield of Alabama's Child Caring Foundation will match the funds. Eligible low-income children will be enrolled in Medicaid or the state's All Kids program; others will get care through the foundation, the Birmingham News reported.

"It's wrong that we allow these children to go unprotected. It's wrong that we make mothers and fathers worry every day about something as basic as health care,” Langford said.

The city worked out a deal with the Birmingham Children’s Hospital. The paper reported that the hospital could get up to $20 million from the city toward a $450 million expansion. The city will share some of the eventual tax revenue (anticipated from job creation and construction) with the hospital, and the hospital will do health screening and care for the city’s kids. The plan must be approved by the City Council.

IN THE STATES: National Governors Association Workshop on Benefit Packages in Health Reform

Julie Barnes — Fri, 28 Mar 2008 14:59:00 -0400

What should be included in a health care benefit package? Balancing access to comprehensive benefits with cost is tricky business, and this dilemma is increasingly evident as many states try to cover more residents with limited access to financing.

We took this issue on the road yesterday and participated in an important discussion with state policymakers at the National Governors Association's "Defining Benefit Packages in Health Reform" meeting in Philadelphia.

There were at least three main points we took away from this conversation:

Financing health care must be a shared responsibility between the federal government, state government, individuals and sometimes employers, if it is to be affordable;
Determining the minimum set of required benefits is a value-based, community discussion that lends itself to regional differences;
Providing access to and incentives for preventative care is the most important goal of many state reforms.

We kicked off the program with two state officials, Susan Besio, Director of Vermont Health Care Reform Implementation and Susan Cooper, Commissioner, Tennessee Department of Health. We examined the innovative solutions to the uninsured problem in their states, as well as the lessons learned from reform proposals in Arkansas, Indiana, California and Massachusetts. The lessons from the states will serve us well in our national discussion about what services to offer, which cost-sharing solutions have the best chance of success, and how coverage can be used to improve the health care of all Americans.

For us, it was a good news-bad news meeting. The good news is that there are very creative, dedicated state policymakers who are determined to help their constituents stay healthy and lead productive lives— and are coming up with some truly ingenious solutions to do so. The bad news is that the states have extremely limited resources to accomplish a very large goal. Most policymakers peppered their comments with the adage that "it is better than nothing" in explaining why they couldn't do more than their current reform plan.

We at the New America Foundation Health Policy Program have a renewed sense of responsibility to get the states' message to national policymakers. Federal lawmakers need to pick up the health care reform ball now. They have access to the financing levers—mainly the federal tax system—necessary to cover all Americans and reform the health care delivery system to reduce costs and improve value.

IN THE STATES: Pennsylvania Governor Backs Coverage Plan

Joanne Kenen — Wed, 19 Mar 2008 22:04:00 -0400

Brief update - As expected, the Pennsylvania House did approve a scaled-back version of Gov. Ed Rendell's health coverage plan this week. Rendell has now embraced the compromise and strongly urged the state Senate—which has been more skeptical about the finances—to pass it. As coverage expansion needs to go hand in hand with insurance market reform, particularly to help small businesses and individuals purchase policies, Rendell is also pushing for an insurance package in the House. AP has the details.

Also in Pennsylvania - Patients can now go to a single user-friendly web site- instead of a confusing array of them - to learn about local hospital quality in four key areas: heart attacks, heart failure, pneumonia, hospital-associated infections. The site was developed by the Pennsylvania Health Care Quality Alliance - a coalition insurers, hospitals, doctors and government agencies, the Philadelphia Inquirer reported.

"Our goal has been to work together on a common way of understanding and sharing the quality measures data that providers are already required to report," Carolyn F. Scanlan, president of the Hospital and Healthsystem Association of Pennsylvania, said in a statement.

IN THE STATES: Pennsylvania House Set to Approve Coverage Expansion

Joanne Kenen — Fri, 14 Mar 2008 20:17:00 -0400

Pennsylvania's House is set to approve a scaled-down version of Gov. Ed Rendell's health care plan that would cover about 300,000 Pennsylvanians. The compromise found common ground among several constituencies: low-income families get affordable coverage, the small businesses that employ some of them get grants to help finance health care, and doctors get a 10-year extension of a malpractice insurance subsidy program.

The House gave preliminary approval on Wednesday and is expected to hold the final vote on Monday, with 11 Republicans joining the Democratic majority. The outcome in the Senate, however, is uncertain, the Philadelphia Inquirer reported.

Rendell had initially wanted to provide subsidies to families with incomes up to $62,000 a year—about 800,000 people. The revised version sets the threshold at $42,000—about 300,000 people by 2013. Families would have to pay a small premium, for instance $50 a month for a family of four.

Funding would come from Medicaid, state tobacco settlement money, and the malpractice fund. Coverage would include prescriptions, behavioral health, preventive care, and chronic-disease management—which can often save money if it keeps people out of hospitals and emergency rooms.

Portions of Rendell's intitial proposal were signed into law last year, including a provision that will provide incentives for hospitals to prevent hospital acquired infections beginning in 2009.

IN THE STATES: Oregon's Wheel of Fortune

Joanne Kenen — Thu, 13 Mar 2008 21:50:00 -0400

You often hear that everyone in America gets good health care, even if they are uninsured. Sadly that's not the case. As we noted in a recent policy brief, uninsured people get diagnosed later, die sooner, and the costs get shifted to the rest of us anyway.

In Oregon, one working-age adult dies each day because he or she lacks health insurance. That's the conclusion of Families USA, which has taken national data from the Institute of Medicine and the Urban Institute and broken it down state-by-state.

We looked at the Oregon data because the state has been in the news so much recently because of its health insurance lottery. The state, which in more prosperous times was often at the forefront of health innovation, has seen the number of uninsured creep up to 600,000. The legislature has approved covering low-income families who don't qualify for Medicare or Medicaid. About 130,000 people are eligible but the state only has the money to cover 24,000 of them—and 17,000 of those slots are already full. The state decided the only fair way to fill the remaining slots is by lottery.

"We thought about other options, such as should we try to pick all of the sickest people or the kids or the people with cancer or heart disease," the state's Medicaid director Jim Edge told the New York Times. "But the Feds won't allow that, and there's just no way to guarantee the fairness of that. Why would cancer be more deserving than heart disease?"