Medicaid

HEALTH REFORM: Massachusetts Making Headlines

Allison Levy — Tue, 24 Nov 2009 16:14:00 -0500

As a loyal Bostonian, I don't seem to tire of all the talk of health reform efforts in Massachusetts and enjoy noting our successes. We've gone from a 10.3 percent uninsurance rate before reform, to covering over 97 percent just less than two years later. But passing a law and creating new insurance structures is only part of our success. Massachusetts not only built it -- it figured out how to make people come.

A recent Robert Wood Johnson Foundation study, The Secrets of Massachusetts' Success: Why 97 Percent of State Residents Have Health Coverage, explains why Massachusetts' subsidies have accomplished more than other states. Outreach and enrollment is essential. (Make that effective outreach and enrollment.)

So how did Massachusetts do it?

We'll include a brief refresher at the bottom of this post on components of the Massachusetts system. But we want to look first at how, according to the RWJF study, Massachusetts enrolled so many eligible, low-income residents in health insurance programs:

Within 15 months after implementation, roughly one out of four newly insured state residents received subsidized coverage based on state data about household income, without any need to file traditional application forms. (These enrollees are considered "auto-converted" members.)
A single application form and a single system of eligibility determination served multiple subsidy programs (Medicaid, CommCare, UCP etc.) making enrollment simple and seamless for consumers. The form is processed by a single statewide unit that then informs consumers which program they are eligible to enter.
More than half of all successful applications for subsidized coverage were completed for consumers by community-based organizations and health care providers through the state's "Virtual Gateway" program. As consumers' authorized representatives, the agencies receive copies of state requests for additional documentation needed to establish eligibility. This enables the representatives to educate consumers about procedural requirements and ensure necessary follow-through. This makes the process easier, less costly and generates fewer application errors. (To encourage this, providers do not receive full reimbursement from the state until a patient's application for health coverage is completed.)
Massachusetts initiated an intensive public education campaign.

In light of national and state health reform efforts, policymakers may want to brush up on the Massachusetts health reform model. The Massachusetts approach -- using data already compiled to automatically enroll qualified residents, streamlining and simplifying the application process and launching an education blitz -- did it well.

And here's that promised summary on Massachusetts' coverage:

Medicaid coverage (called "MassHealth") was extended to all children 300 percent of the federal poverty level. (In 2009, the Massachusetts FPL is $18,310 for a household of three and $22,050 for a household of four.)
Massachusetts established a quasi-governmental organization called the Commonwealth Health Insurance Connector Authority ( the "Connector"). It administers the Commonwealth Care and Commonwealth Choice health insurance programs and state health reform laws.
Commonwealth Care provides comprehensive insurance coverage and generous subsidies to adults who are ineligible for Medicaid and whose incomes are at or below 300 percent FPL.
Commonwealth Choice is an insurance exchange that makes affordable health insurance plans available to individuals and small businesses.
Massachusetts instituted an individual mandate (but the mandate does not apply to children and adults with incomes below 150 FPL).
The Health Safety Net program (replacing the Uncompensated Care Pool) pays for uncompensated care.

QUALITY: A Good Beginning for Better Endings

Joanne Kenen — Fri, 06 Nov 2009 16:02:00 -0500

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

The inevitable focus on the politics of health reform, and the disproportionate amount of attention paid to the public plan, sometimes obscures the many ways that the House and the Senate health plans are ambitious. Not perfect. Ambitious. I've heard experts, people I like and respect, say the legislation does "nothing" to advance the cause of quality of end of life care in America. They are wrong. The House and Senate bill each contain measures that would advance that cause -- not fix it completely, far from it, but they will take us important steps in the right direction. It's too soon to know which of these measures - if any -- will survive a final melding of House and Senate legislation. But let's look at them here because, except for the end of life consults which got way too much of the wrong kind of attention, they haven't gotten adequate attention. In an accompanying guest post. Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire, talks about what these changes can mean for his patients and their families.

One of the most damaging myths, or at least misunderstandings, in what passes for our national discourse about health policy is that our culture (and too often our doctors) have trouble talking about end of life care. And when we do talk about it, we don't always know what we're talking about. That confusion in turn fueled the "death panel" chaos of last summer.

An advanced directive -- whether a "living will," a health care proxy or a Physician Order for Life Sustaining Treatment -- does not mean "pull the plug." It does not constitute a license for rationing. It does not obligate you to "give up." It is not irrevocable.

An advanced directive is a tool. Properly used, it is a tool that helps you decide how you want to live out your final days, weeks or maybe even months. It is a tool that helps your doctors know what your wishes are so they can respect them. It is a tool that lets your family know what you want, so they too can respect your values and wishes, and avoid the anguished second-guessing and potential family conflict that ensues when people don't know or can't agree on what is best for an incapacitated loved one. If you want aggressive high tech care, a ventilator and a feeding tube and all that is offered in an advanced ICU, you can state that. If you want a DNR you can state that. And if you want something in between those options, you can say that too. (And we do so wish that the move to change the terminology eventually catches on, so that instead of Do Not Resuscitate, or DNR, we talk about Allow a Natural Death, or AND).

The House kept in its bill the VOLUNTARY advanced directive consult provision.(The word VOLUNTARY appears at least five times.) Basically, this means that Medicare will reimburse doctors for taking the time to talk to an elderly patient about what he or she may face medically and how he or she wants to confront it. Right now, there are all sorts of built-in disincentives -- cultural, emotional, legal and yes financial -- against having that conversation. The incentives lie in the other direction: Doctors, and ERS and ICUs are all reimbursed for giving you the aggressive care, and aggressive care is often the default form of care. Maybe our system should make sure you want it.

In addition, the House bill (Section 240) requires health plans in the new insurance exchanges make available to beneficiaries information about end of life planning and the option (Repeat after me: The Option. Not the requirement. The Option) to complete an advance directive or, in accordance with state law, a Physician-Order for Life-Sustaining Treatment (Not Life Terminating Treatment. You can repeat that a few times too.) The bill explicitly states this "shall not promote suicide, assisted suicide, euthanasia, or mercy killing." It also explicitly states that the provision "shall not presume the withdrawal of treatment and shall include end-of-life of life planning information that includes options to maintain all or most medical interventions."

The Senate left that out of the Finance bill. But the Senate bill does incorporate some -- not all -- of what's been on the wish list of hospice and palliative care doctors and nurses and social workers and chaplains for years. For instance, a number of states have been individually seeking Medicaid waivers so that seriously ill children can get hospice for 12 months instead of six -- and that they can also get concurrent, curative care. In other words, as a parent, you don't have to choose between say, chemotherapy, and all the support and symptom management and family assistance of hospice. The Finance bill would wipe out that lengthy, cumbersome, bureaucrat, financially-restrictive waiver process. All seriously ill children in Medicaid in any state could get concurrent curative and hospice care. It isn't that expensive, and it is so badly needed.

And it's not only kids who benefit. The Finance bill sets up a 26-site hospice concurrent care demonstration project in Medicare, so adults too in these test programs can have both curative and hospice care. Some earlier tests and research suggests that this isn't just going to improve the quality of care for people with advanced and life-threatening illnesses, it's actually cost effective. Given a better and gentler continuum of care, without having to make the stark either/or choice of hospice, people often end up gradually shifting the balance as their disease progresses. It is their choice. But their choice is often less aggressive care toward the end.

The concurrent care model, says Jon Keyserling, vice president of public policy and communication at the National Hospice and Palliative Care Organization, "lets you meet patients where they are." The NHPCO and other trade and advocacy groups have a longer list of programs they'd like tested, but Keyserling noted that legislation can be monumental or incremental -- and in some ways, health reform 2009 is both. The sweep of the whole bill is monumental; some components are incremental. But they are a start, and they can be built upon.

The House and/or the two Senate bills do include numerous provisions that have the potential to improve care for seriously ill people (and even nibble around the edge of the long-term care crisis -- which isn't addressed head-on by the current health reform bills). This post is long enough, so we won't go into detail here. But the bills include things like advanced medical homes for people with chronic disease, iniatives to reduce hospital readmissions, bundled payments, transitional care benefits (paying hospitals to do a better job of moving a patient from one care setting to another), assorted quality measurements, pilot programs to improve home-based (as opposed to institutional) care, even a new research initiative on undertreatment of pain. All these steps, whether they survive in a final bill this year or become part of the "building on" agenda for the future, mean paying attention to, and talking about, and doing something about, the needs of the old, the frail, the seriously ill and the vulnerable among us. Our grandparents. Our parents. And someday, ourselves. It's the one thing we all have in common.

IN THE STATES: There's More Than One Brady in New England

Allison Levy — Wed, 21 Oct 2009 16:06:00 -0400

In the world of state health reform, Vermont often plays the Jan to Massachusetts' Marcia. However, preliminary evaluations suggest that other states and policymakers would do well not to ignore New England's favorite middle child. My colleague previously wrote about Vermont's most recent legislative action on health reform passed in May of 2006. Now, a study published by the Robert Wood Johnson Foundation this week updates us on Vermont's achievements. Here are some of the successes from the Year 1 Interim Report:

Universal health care legislation met its goal of significantly increasing the number of insured Vermonters. Between 2005 and 2008, the percentage of insured Vermonters between the ages of 0 and 64 increased by 2.4 percent -- from 88.8 percent to 91.2 percent. Insurance coverage expanded faster in Vermont than in any other New England state during this period.
Vermont's health reform legislation created the Catamount Health Insurance Program, providing subsidized coverage to Vermont's uninsured with incomes below 300 percent of the federal poverty level. As of April 2009, Vermont was just shy of reaching the enrollment goal of 8,800 people.
Participation in public health plans increased significantly once health reform was enacted; many of the new enrollees were previously eligible for coverage but may not have known. The increase is attributed to successful outreach campaigns. There was a 5.5 percent enrollment increase in traditional Medicaid and a 21.0 percent enrollment increase in Vermont's Health Access Program for childless adults.

Vermont's early accomplishments provide a few lessons for other states to consider as their own health reform efforts come to fruition:

Stakeholder collaboration -- get all the key players (government, providers, insurers, business and consumers) on the same page.
Federal assistance may be necessary for sustainability -- Vermont will not be able to continue its current programs -- unless new sources of revenue are located -- without the continued support of the federal government.
Keep it simple -- lawmakers need to continue to address basic barriers and challenges to program enrollment.
Health system-level improvements are necessary -- lawmakers need to address underlying inefficiencies in order to make system-wide improvements in prevention, disease management, costs, and quality of care.

As Vermont demonstrates, health care reform is an ongoing process. It takes continued analysis and adjustments to make lasting improvements and changes to the health care system.

IN THE STATES: Pay for Performance in Medicaid

Meredith Hughes — Thu, 01 Oct 2009 14:00:00 -0400

We've written often about misaligned incentives in the US health care system -- we pay for quantity of care instead of paying for quality. We've seen high-performing health systems across the nation work to reverse this trend -- and succeed in bringing down costs and improving quality. It is possible for the U.S. health care system to become a value-based purchaser, to move toward pay for performance (healthier patients getting the right treatment at the right time) rather than fee for service (paying for more and more tests and procedures, regardless of whether or not they help the patient). So we're glad to see states taking steps toward pay for performance by including it in their Medicaid contracts.

According to a 2007 study sponsored by the Commonwealth Fund, half of all states currently operate some kind of pay for performance initiative in Medicaid. Researchers conducted a survey of state Medicaid directors and found that 85 percent of the states planned to incorporate some form of pay for performance program within the next five years.

The most common type of pay for performance program in Medicaid is managed care or primary care case management (PCCM), according to the report. The goal of PCCM is to encourage patients to foster a relationship with a primary care provider, so that patients get more comprehensive, coordinated care. Patients can stay healthy (or healthier) with affordable preventive care visits and stay away from costly emergency rooms. According to the Children's Health Insurance Research Initiative, states are free to use regular fee-for-service or PCCM under Medicaid and SCHIP. About half of states use PCCM, and about 30 percent of kids in SCHIP are getting care through a primary care case management.

The Commonwealth Fund report offered examples of some problems and solutions encountered by state Medicaid officials:

Alabama is offering reimbursement increases tied to provider participation in a program using technology to improve monitoring of chronic diseases. HIT also has the potential to reduce data collection costs, which should facilitate P4P expansion into less traditional venues.

The Oregon Health Care Quality Corporation, involving state government, health plans, medical groups, insurers, purchasers, providers, and consumers, is working to incorporate standardized performance measures into their P4P activities.

Several Medicaid directors were concerned that P4P activities might impinge upon beneficiaries' access to care by causing providers to leave the Medicaid program or limit the number of Medicaid beneficiaries in their practices. This concern is shaping some of the approaches taken in pay-for-performance programs, particularly in states with large rural or sparsely populated areas. For example, South Carolina is offering increased reimbursement to providers who agree to establish a Medicaid medical home.

The vast majority of Medicaid directors reported that their priority in operating pay-for-performance programs is to improve quality of care rather than reduce costs. Some states are targeting specific aspects of care, such as the overuse of emergency department services. Maine's Physician Incentive Program ties 30 percent of a performance bonus to emergency department utilization.

A caveat from Commonwealth: Though quite a few states have implemented some kind of pay for performance program in Medicaid, the study found very few states actually conducted any followup studies to evaluate how well P4P was working.

HEALTH REFORM: Addressing the Gender Coverage Gap

Joanne Kenen — Mon, 21 Sep 2009 17:58:00 -0400

A year ago, we posted on a report by the National Women’s Law Center on how the current health care system hurts women. Among the many flaws:

Health insurers can reject women applicants for gender-specific reasons (including, in some states, classifying domestic violence as a preexisting condition).
Many insurance policies in the individual market don’t cover maternity.
Women pay more for insurance than men the same age.

Sen. Baucus's office today put out a list of reasons for why his proposed Finance Committee bill helps women. Among them:

Better access to affordable coverage.
Medicaid expansion for poor women.
Women won't pay more than men, just because they are women.
More focus on prevention, screening and wellness (including eliminating copays for certain services under Medicare).
Smoking cessation programs for pregnant women.
Medicaid coverage for free-standing birth centers.

Marcia Greenberger, co-president of the center said that while the proposal needs to be strengthened, "it ends insurance discrimination that women face in the individual market... and ensures health plans cover certain basic health care needs, including maternity coverage."

(I recieved the Baucus statement in an email, it's not on the commitee website yet, but check back later.)

COVERAGE: Matching Benefits to Needs

Allison Levy — Thu, 17 Sep 2009 17:07:00 -0400

As policymakers put the final touches on health care legislation that would expand coverage to millions of Americans, it is important that they ask themselves, "Coverage for what?"

Two new reports from the Georgetown University Health Policy Institute and the Kaiser Family Foundation tackle this question head on, looking at health coverage for children and individuals with special needs. Both groups require specialized care. The reports analyzed how insurance coverage differs between a benchmark private plan and public programs. Read the full reports, respectively, here and here.

Their key findings, from last week's discussion, Matching Health Benefit Packages to Health Needs: Key Issues to Consider in Health Reform, are interesting:

Individuals with Special Needs and Health Care Reform:

The medical needs of individuals with special needs are diverse, complex, specialized and life-long
Medicaid offers comprehensive coverage with little or no cost-sharing
The typical private plan falls short in providing necessary long-term services and support for individuals with disabilities and chronic conditions

Children and Health Care Reform:

Children have unique health care needs (e.g. vision, dental, hearing) that are often limited or excluded from private plans. Appropriate health care can help children avoid preventable and serious conditions as well as promote nutrition and physical activity.
Even families with relatively healthy children will face high medical bills under a typical private insurance plan
Children with special needs face coverage gaps and high medical bills under private coverage; often families will put off children's preventive care
Medicaid fully covers children's acute care and long-term needs with limited or zero cost sharing

While private plans offer generous benefits for acute problems, the public plans are better able to accommodate individuals with long-term conditions, children and low-income families/individuals. Yet while benefit packages in Medicaid may be more comprehensive, funding issues can create significant barriers to care.

Clearly one size does not fit all in health care. Which is why we are pleased that reform proposals in Congress place such an emphasis on creating more options for Americans to get the health care coverage they need.

QUALITY: When Medicaid Gets Health Right

Joanne Kenen — Thu, 09 Jul 2009 15:20:00 -0400

We've written in the past about the North Carolina Medicaid Medical Home model, and its success in providing high quality care to vulnerable populations while saving money. The Kaiser Foundation's Drew Altman focuses on Community Care of North Carolina in his latest commentary. We aren't going to rehash the program here, (read our earlier posts or this Kaiser issue brief) but we were interested in what he identifies as the "few big messages to take away from this experience." The emphasis is ours:

One is the evidence that basic delivery changes have the potential to make a difference and produce savings. This is not cutting edge or controversial comparative effectiveness research or complex payment reform; it's basic, sensible care management with the delivery system and data system changes necessary to make it happen. I suspect a number of variations on this approach could be effective depending on local circumstances. The key is providing a usual source of care and truly managing care for those who need it most, whether that is called "primary care case management" as it was 25 years ago, or an "enhanced medical home" as it is in North Carolina.

A second message is that Medicaid, often characterized in public debate like other public programs as lagging behind the private sector in its ability to innovate, can be a leader in demonstrating how to improve care and lower costs through delivery system changes.

A third message is about the importance of focusing efforts on the sickest, highest cost patients, because they have the greatest health care needs and account for such a substantial share of health care spending. A small percentage of the U.S. population (five percent) accounts for nearly half of health care spending. If we want to get a handle on increases in spending in Medicare and Medicaid, we will need to do more to reach out to and more effectively manage care for these high cost groups.

Other states are putting some of these lessons to work; Indiana, for instance, has been doing a lot on chronic disease management for its Medicaid population. And some community health clinics, like the Urban Health Plan in the Bronx we wrote about earlier this year, have learned as North Carolina has that you can provide a lot better care to poor people when social workers team up with the medical staff to address the context as well as the complications. That's often not the case, another example of penny wise, health care system foolish.

One last comment. There is a certain amount of urban myth -- I haven't seen it in writing, but I've heard a lot of offhand remarks in health policy settings -- that the North Carolina program is working because it's only treating healthy kids. That's not the case. It's treating some healthy kids -- and it's enabling some kids stay healthy. But it's also treating people with serious chronic illnesses. And it's doing a very good job.

HEALTH REFORM: Let's Make a Deal

Paul Testa — Mon, 06 Jul 2009 18:31:00 -0400

Congress is back in session for what figures to be a frantic month of July. As the House and Senate gear up for a packed schedule of health reform hearings and mark-ups to meet a self-imposed August deadline, the White House has been working very hard to line up support outside the halls of Congress and keep the process moving.

First, there was the much-reported stakeholders' letter to the White House pledging to help slow health care spending by some $2 trillion over 10 years. Then, there was the $80 billion agreement with PhRMA—endorsed by the AARP—to lower costs of prescription drugs and help pay for reform. Just last week, the nation's largest employer, Wal-Mart, in a letter to the president also signed by SEIU and the Center for American Progress, stated that it was open to an employer mandate as part of the shared responsiblity it and other businesses bore for health reform.

Next up—hospitals.

Politico's Carrie Budoff Brown and Chris Frates report that the White House and Senate Finance Chairman Max Baucus (D-MT) are a near a deal with three hospital associations to provide more than $150 billion in savings, over 10 years, for health reform. The savings would come primarily from reductions in current Medicare and Medicaid spending. The key question for the American Hospital Association, the Catholic Health Association, and the Federation of American Hospitals is how quickly such changes would be phased in. Also contentious is the president's proposal to expand the Medicare Payment Advisory Commission's authority to make payment policy decisions. (Now MedPAC makes nonbinding recommendations.) The details are expected to be released later this week, although the timing is tricky with Obama currently traveling abroad.

With Congress ready to dive into health reform weeds that can seem sicker than our backyard (a push mower, it turns out, is an even less effective tool for moving your priorities than reconciliation), agreements like these are important. They illustrate the magnitude of savings that are really possible from health reform. Perhaps even more important, they demonstrate that while we may disagree on a certain provision or component of reform, there's a great deal of consensus on what reform can and should accomplish. And with every stakeholder discussion, town hall, good faith ad campaign, op-ed and public letter supporting reform, however broady defined, that consensus gets harder to break.

Health Reform through History: Part III: Medicare and Medicaid

Kyle Noonan — Thu, 28 May 2009 15:33:00 -0400

Here's the last of our posts this week on health reform history...Then we'll turn our attention back to health reform's future...

Medicare, the government health insurance system that covers all America's senior citizens and many of its disabled, and Medicaid, a federal-state partnership providing insurance to the poor, are two of the great legacies of the Great Society era of the mid-1960's. Medicare and Medicaid cover tens of millions of people and remain giants of the current American social contract. Like the State Children's Health Insurance Program of the mid 1990s, Medicare and Medicaid emerged after a comprehensive reform initiative had failed earlier.

In the 1940s, Congress and President Truman made various attempts to institute national health insurance. A 1947 bill with Republican support (including that of Congressman Richard Nixon) would provide government subsidies for a private nonprofit insurance system with premiums scaled to individual's incomes. (If you include private for-profit insurance companies in the mix, it sounds quite a bit like current coverage proposals.) In 1950, Congress did finally pass, and Truman signed, legislation to provide federal matching grants to state payments for medical care for the poor. This became the forerunner to Medicaid.

During the 1950s, expanding health coverate to all temporarily faded as a pressing political concern, reflecting both the enormous expansion of employer-sponsored insurance and the conservatism of the time. But by the late 1950s, pressure grew to expand Social Security to include relief from medical bills for the aged. Because the elderly have the highest medical costs of any group, many seniors were unable to purchase insurance; medical bills were a leading cause of poverty among the elderly. In 1960, outgoing President Eisenhower did sign into law Kerr-Mills, the forerunner to Medicare. That gave grants to states for health care for the aged poor. But it didn't work very well; by 1963, only 28 states were participating.

Though the massive Democratic sweep of 1964 gave President Johnson huge majorities in Congress. Medicare and Medicaid emerged from a compromise between the majority and the Republican minority in Congress. Democrats wanted a mandatory hospital insurance program for the elderly (which became Medicare A) and an expanded federal-state partnership for medical insurance for the poor (which became Medicare B), while the Republicans, supported by the AMA, tried to make it subsidized but voluntary insurance for regular medical bills (which became Medicare B). In the photo above, Johnson signs Medicare and Medicaid into law as Harry Truman and his wife Bess look on.

Still, the huge size of the Democratic majority obscures the importance of Johnson's leadership in passing Medicare and Medicaid. A large portion of those Democrats, including many powerful committee chairmen in both houses, were conservative Southerners and instinctively hostile to expanded social programs. Johnson, the formidable former Senate Majority Leader, had to threaten, bully, and charm members of Congress to shepherd the programs through.

We think President Johnson would have approved of the speed with which the Obama Administration is moving health reform today. As NPR reported in a November story,

...Just moments after a bill to create Medicare got through a key House committee in March of 1965, Johnson sounds like he's in no mood to celebrate. He gets on the phone to demand that legislators keep the bill moving.

"You just tell them not to let it lay around. Do that," Johnson barks.

"They want to, but they might not," he continues. "Then that gets the doctors organized, then they get the others organized. And that damn near killed my education bill. Letting it lay around. It stinks. It's just like a dead cat on the door. When a committee reports it you'd better either bury that cat or get some life in it."

President Johnson did have one huge advantage on Obama: it wasn't the middle of the worst recession in decades and he had a relatively balanced federal budget that gave him room for new spending. Again, from the November 2008 NPR story, Johnson's recorded telephone calls offer insight into the President's approach to budget matters. Below, in a conversation with Vice President Hubert Humphrey:

"I'll go a 100 million or billion on health or education," Johnson said. "I don't argue about that any more than I argue about Lady Bird buying flour. You got to have flour and coffee in your house. And education and health, I'll spend the goddamn money."

Of course today's economic climate is tougher. But Obama has made clear that he too regards health coverage as essential to our nation as coffee was to LBJ.

IN THE STATES: Colorado Expands Coverage and Hospital Care

Joanne Kenen — Thu, 23 Apr 2009 20:41:00 -0400

In what's been hailed as the most significant health legislation in Colorado in some 40 years, Colorado has a new law that will help cover up to 100,000 uninsured people and reduce some of the uncompensated care and cost-shifting that hurts the state's health care system and raises costs for people who are insured. It's an impressive achievement in a time of great economic pressure—one that we hope the folks here in Washington notice.

"At no increased cost to taxpayers, the Colorado Healthcare Affordability Act will allow us to provide critical health services to people who need those services the most," Gov. Bill Ritter said in a statement when he signed it into law earlier this week.

The law needs to get final approval from federal Medicaid officials. The goal is to implement it next spring. Ritter said that the law will provide coverage to about 100,000 and improve access to hospital care for the other 700,000 uninsured. (Colorado had an estimated 800,000 uninsured in 2007, that figure may be rising because of the job losses of the recession.)

The new law will devote $1.2 billion—an estimated $600 million each from hospital provider fees and federal Medicaid matching funds—to support health care for low income people on Medicaid and the state's children's health insurance program. Hospitals will get better reimbursements for treating patients on Medicaid and the Colorado Indigent Care Program (CICP).

Denver's Channel 7 reported that the law garnered bipartisan support during months of negotiations, in part because it will keep health care costs down. When the uninsured get coverage, they get better access to doctors, keeping them out of emergency rooms.

"The most expensive place to treat someone is in the emergency room," Steven Summer, President and CEO of the Colorado Hospital Association, told the station. "What happens is (uninsured patients) go there because they don't have a physician."