Improving Coverage and Access:  An Overview of State Activities
This presentation is the property of its rightful owner.
Sponsored Links
1 / 42

Improving Coverage and Access: An Overview of State Activities Donald Cohn, Associate PowerPoint PPT Presentation


  • 72 Views
  • Uploaded on
  • Presentation posted in: General

Improving Coverage and Access: An Overview of State Activities Donald Cohn, Associate AcademyHealth December 7, 2006. State Coverage Initiatives (SCI ). An Initiative of The Robert Wood Johnson Foundation Direct technical assistance to states

Download Presentation

Improving Coverage and Access: An Overview of State Activities Donald Cohn, Associate

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Improving coverage and access an overview of state activities donald cohn associate

Improving Coverage and Access: An Overview of State Activities

Donald Cohn, Associate

AcademyHealth

December 7, 2006


State coverage initiatives sci

State Coverage Initiatives (SCI )

  • An Initiative of The Robert Wood Johnson Foundation

  • Direct technical assistance to states

    • State specific help, research on state policy makers’ questions

    • Convening state officials

    • Web site: http://statecoverage.net

    • Coverage Matrix

    • Publications

  • Grant funding


State role in the health system

Payer

Regulator

Provider

Public Health

State Role in the Health System

  • Medicaid/SCHIP

  • State Employees & Retirees Coverage

  • High-risk pool

  • Uninsured

  • Underinsured

  • Oversight of health insurance market

  • Oversight of providers

  • Oversight of facilities

  • Prevention

  • Health performance


Drivers of state health reform efforts

Drivers of State Health Reform Efforts

  • Health insurance becoming increasingly unaffordable for working families

  • Increasing numbers of uninsured

  • Some states beginning to emerge from fiscal crisis

  • Lack of national consensus


Health care premiums outpace worker s wages health coverage increasingly unaffordable

Health Care Premiums Outpace Worker’s Wages = Health Coverage Increasingly Unaffordable

* Estimate is statistically different from the previous year shown at p<0.05.

^ Estimate is statistically different from the previous year shown at p<0.1.

Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).

Data: KFF/HRET Survey of Employer-Sponsored Health Benefits: 1999-2006.


Improving coverage and access an overview of state activities donald cohn associate

Health Insurance Coverage Changes Among Working-Age Adults, 2000-2004

17.9

20.6

5.6

5.8

8.6

10.5

67.9

63.1

Note: Data taken from Kaiser Commission on Medicaid and the Uninsured/Urban Institute, Health Insurance Coverage in America, 2004 Data Update. November 2005.


Reasons why 3 4 million employees lost insurance between 2001 and 2005

Reasons Why 3.4 Million Employees Lost Insurance Between 2001 and 2005

Employee Take-Up Decline

27%

Employer Sponsorship Decline

48%

Loss of ESI Dependent Coverage—11%

Employee Eligibility Decline—14%

Note: Data taken from “Changes in Employees’ Health Insurance Coverage, 2001-2005”, Kaiser Commission on Medicaid and the Uninsured, October 2006.


Percent of adults ages 18 64 uninsured by state

Percent of Adults Ages 18–64 Uninsured by State

1999–2000

2004–2005

NH

NH

ME

WA

NH

VT

ME

WA

VT

ND

MT

ND

MT

MN

MN

OR

NY

MA

WI

OR

MA

NY

ID

SD

WI

RI

MI

ID

SD

RI

WY

MI

CT

PA

WY

NJ

CT

IA

PA

NJ

IA

NE

OH

DE

IN

NE

OH

NV

DE

MD

IN

IL

NV

WV

UT

VA

IL

MD

CO

DC

WV

UT

VA

KS

MO

KY

CA

CO

DC

KS

MO

KY

CA

NC

NC

TN

TN

OK

SC

AR

OK

AZ

NM

SC

AR

AZ

NM

MS

GA

AL

MS

GA

AL

TX

LA

TX

LA

FL

FL

AK

AK

23% or more

HI

HI

19%–22.9%

14%–18.9%

Less than 14%

Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006


Improving coverage and access an overview of state activities donald cohn associate

WA

NH

ME

VT

MT

ND

MN

OR

WI

NY

MA

ID

SD

MI

RI

WY

CT

PA

IA

OH

NE

DE

NV

IN

IL

MD

UT

VA

CO

DC

CA

KS

MO

KY

NC

TN

OK

AR

SC

NM

AZ

AL

GA

MS

TX

LA

FL

States Vary in Employer Coverage

Quartile Rank

Less than 50 %

50% to 53 %

54% to 59 %

More than 59 %

Adapted from Kaiser Family Foundation

Source: Urban Institute and KFF estimates from 2005, 2006 CPS supplement


Different strategies to improve coverage and access

Different Strategies to Improve Coverage and Access

  • Comprehensive approaches

    • Massachusetts, Vermont, and Maine

  • Incremental

    • Covering children

    • Making new insurance options more affordable for low-income working uninsured

    • Improve access through safety net


  • Reactions to recent state reforms

    Reactions to Recent State Reforms

    • New approach presents excitement about what is possible– states want to “avoid being left behind”

    • This works for that State, but we are different

    • New idea sparks new creative approaches

    • Fear of over-reaching – sustainability of initiatives

    • Importance of on-going coalition of support


    Improving coverage and access an overview of state activities donald cohn associate

    Comprehensive Efforts

    Massachusetts

    Vermont

    Maine


    Improving coverage and access an overview of state activities donald cohn associate

    Maine’s Dirigo and MaineCare Eligibility

    Dirigo Health: Affordable Premiums for Workers in Small Firms

    Dirigo Health: Reduced Employee Contributions for Workers in Small Firms

    MaineCare Expansion

    MaineCare


    Access dirigochoice

    Access: DirigoChoice

    Individual

    Premiums

    General Funds

    Year 1

    • New Insurance product offered by Anthem

    DirigoChoice

    Small Employers,

    Individuals,

    Self-employed

    Employer

    Premiums

    Medicaid

    Savings Offset

    Payment in Year 2

    Premium

    Subsidy

    < 300% FPL


    Maine potential lessons

    Maine - potential lessons

    • Voluntary programs not likely to achieve universal coverage

    • Financing – difficult to transfer uncompensated care dollars to premium subsidies

    • Challenge of building and maintaining a consensus


    Employer and individual coverage mandates

    Employer and Individual Coverage Mandates

    • Hawaii Prepaid Health Act (1970s)

      • 86% employers offer insurance versus 56% nationally

      • 12% uninsured vs. 18% nationally

    • Maryland Fair Share Act

      • Court rejected

    • Massachusetts

      • Employer Assessment & Free Rider Surcharge

      • Individual mandate (affordability is key question)

    • Vermont

      • Employer Assessment

      • Will consider individual mandate in 2010 if 96% coverage not achieved


    Improving coverage and access an overview of state activities donald cohn associate

    Incremental Approaches

    Children

    Purchasing Pools

    Limited Benefits

    Reinsurance

    Creative Uses of Medicaid

    Safety Net


    Children and allkids illinois

    Children and AllKids: Illinois

    • IL – AllKids expansion (July 2006)

      • All uninsured children eligible, sliding scale premium

      • $45 million estimated cost - financed through savings from shift to primary care case management (PCCM)

    • Builds on success and bi-partisan support for SCHIP

    • Cost effective to cover children

    • Improves outreach to eligible, but unenrolled

    • Other states consider

    • SCHIP Reauthorization due in 2007


    Purchasing pools california pacadvantage

    Purchasing Pools: California PacAdvantage

    • Longest running and largest health insurance purchasing alliance formed in 1993

      • Over 100,000 covered lives

    • Small firms (2-50) able to enroll and offer a choice of private health plans

    • Evaluations demonstrated that PacAdvantage improved choice of health plans, but was never demonstrated to have expanded coverage

    • August 2006 - PacAdvantage announced closing due to withdrawal of participating plans


    Purchasing pools insure montana

    Purchasing Pools: Insure Montana

    • $10 million coverage initiative funded through tobacco tax

      • Tax Credits

        • 40% of overall funding is for tax credits for small business that provide health insurance (tax credit provided on a “first come first serve basis”)

      • Purchasing Pool –

        • 60% of overall funding is for subsidies for small businesses that were previously unable to offer coverage on a “first come first serve basis” to assist both employer and employee pay portion of health insurance premium.

    • Enrollment (Fall 2006) = 360 firms, 2200 lives


    Lessons learned purchasing pools

    Lessons Learned: Purchasing Pools

    • Strategy has generally not expanded coverage to the uninsured

    • Has improved plan choice for small firms

    • Has not generated significant administrative savings or price discounts

    • Unless designed carefully, pools can create adverse risk selection

    • To be effective, need to combine pool with other strategies such as subsidy or individual mandate


    Limited benefit plans have had marginal impact

    Limited Benefit Plans have had Marginal Impact

    • At Least 13 states have passed limited benefit legislation, 2 states have passed new legislation in 2005

    • Barebones and other limited benefit plans have had low take-up rates

    • May lead to currently insured to scale back benefits

    • May contribute to increased uncompensated care


    What are consumer directed health plans

    What are Consumer-Directed Health Plans?

    • Common characteristics

      • High deductible insurance plan

      • Personal account to pay for care

      • Gap between the annual amount in account and deductible

      • Internet-based decision support

    • Driven by rising health care costs

    • Past cost containment approaches have not worked

      • Traditional health insurance (until early 80’s)

      • Regulated prices for government programs (until early 90’s)

      • Managed care and purchaser power (until early 00’s)

    • New solution- CDHPs?

      • Shift of power to cost-conscious, educated consumers


    Distribution of health spending adults ages 18 64 2001

    Distribution of Health SpendingAdults Ages 18-64, 2001

    Source: Employee Benefit Research Institute estimates from the 2001 Medical Expenditure Panel Survey.


    Common state reactions to cdhps

    Common State Reactions to CDHPs

    • State as a Payer

      • CDHP option within state employees plan or high-risk pool?

      • Medicaid reform

      • Give additional state tax incentives to encourage CDHPs?

  • State as a Regulator

    • Allow high deductible plans to be sold in market? If so, sold in which market?

    • Market segmentation and risk selection

    • Do consumers really understand new cost sharing?


  • Reinsurance healthy new york

    Reinsurance: Healthy New York

    • 20% of people account for 80% of health spending

    • State subsidizes costs for high cost enrollees with the goal of lowering premiums for all

    • State requires all HMOs to offer product

    • Some benefits excluded (MH/SA)

    • Small firms w/ low-wage workers, low income self-employed, uninsured workers w/o access to employer sponsored insurance may enroll


    Healthy new york reinsurance subsidy

    Healthy New York Reinsurance Subsidy

    • Estimated savings of 50% for individuals

    • Over 125,000 enrolled (8/06)

      • Most enrollment is non-group

    • State Reinsurance Fund spent $13.3 million in 2003, $34.5 million in 2004, $61.7 million in 2006

    State Reinsurance Fund 90%

    Carrier 10%

    Carrier 100%

    Carrier 100%

    $ 0

    $5,000

    $75,000


    Early lessons on reinsurance healthy ny

    Early Lessons on Reinsurance: Healthy NY

    • Requiring HMOs to offer Healthy New York product is

      less expensive than establishing new program

    • Perceived efficiency and value of program

    • Getting participation requires long-term partnership to build trust that coverage will continue to be there

    • While targeting small groups, product has enrolled mainly individuals and self-employed

    • Must have market oversight to assure lower premiums


    Creative uses of medicaid

    Creative Uses of Medicaid

    • Premium Assistance: 15 states

      • Medicaid/SCHIP pays for employee portion of existing private insurance

    • Medicaid Buy-In

      • All-Kids = sliding scale subsidy subsidized by SCHIP

      • New Insurance Product with a subsidy

        • Subsidy for low income individuals, and small firms


    Coverage both a problem of offer and take up

    Coverage: Both a Problem of Offer and Take-up

    4%

    13%

    35%

    8%

    55%

    92%

    14%

    79%

    15%

    52%

    30%

    Note: Data taken from “Changes in Employees’ Health Insurance Coverage, 2001-2005”, Kaiser Commission on Medicaid and the Uninsured, October 2006.


    New medicaid strategies address low offer rates

    New Medicaid Strategies Address Low Offer Rates

    • New insurance products for small firms with low-wage workers

    • Employers, individual and Medicaid pay premium

      • New Mexico – open to uninsured adults <200% FPL, individuals may pay employer contribution

      • Oklahoma covers workers and spouses <185% FPL who work for small firms; program begins with voucher; safety-net option will be provided for workers with employers unwilling to participate

      • Arkansas recently received waiver to offer limited benefit product to small firms, Medicaid funding will be available for low-wage workers (<200% FPL)


    Improving coverage and access an overview of state activities donald cohn associate

    New Mexico State Coverage Insurance: Public/Private Partnership

    $355 estimate per person

    New Mexico Human Services Department


    Medicaid s changing role

    Medicaid’s Changing Role

    • Use in expanding coverage to the uninsured

    • Covering different populations, sometimes higher income groups

    • Increased cost-sharing

    • Changing benefit designs

    • Consumer Responsibility


    Improving coverage and access an overview of state activities donald cohn associate

    Utah’s Primary Care Network

    • Adults to 150% FPL (1115 waiver)

    • Some reductions in benefits Medicaid

    • Primary care benefit package for expanded population:

      • Office visits- DME

      • Immunizations- Basic dental

      • Emergency/Urgent care- Hearing and vision screening (no glasses)

      • Lab/X-ray - Rx (4 per month)

    • Donated care from Hospitals


    Recent dra state plan amendments

    Recent DRA State Plan Amendments

    • West Virginia:

      • “Secretary-approved coverage” for children and parents

      • Member agreement – providers monitor patient’s compliance

    • Kentucky:

      • 4 Benefit plans: global choice (default), Family Choices (most kids); Optimum Choices (MRDD), Comprehensive Choices (Nursing Home Care)

      • New cost sharing and service limits

      • “Get Healthy Benefit Accounts”

    • Idaho:

      • 3 Benefit plans for healthy children and working adults, individuals with disabilities and elderly

    Source: Robin Rudowitz, KCMU, June 2006


    Medicaid looking ahead

    Medicaid – Looking Ahead

    • Growing complexity of Medicaid

    • Enrollment growth offset decline of employer sponsored insurance

    • Medicaid growing for same reasons health care cost growing + enrollment

    • State budget pressures – cost containment options – eligibility, utilization, reimbursement

    • Medicaid important source of federal matching funds for new state initiatives


    Growth in uninsured population served by health centers 1990 2005

    Growth in Uninsured PopulationServed by Health Centers, 1990-2005

    Percent Increase

    Uninsured Served

    by Health Centers

    (6.4 million;

    128% increase

    since 1990)

    All Uninsured

    (47 million;

    34% increase

    Since 1990)

    SOURCE: Data from 1996-2005 UDS; National estimates from Bureau of the Census.

    1990

    1995

    2000

    2005


    Growth of health centers 1970 2005

    Growth of Health Centers: 1970-2005

    952

    Centers

    150

    Centers

    Source National Association of Community Health Centers


    Access versus insurance

    Access versus Insurance

    • Communities with strong insurance coverage and a strong safety net presence demonstrated the highest access to care.

    • Investment in insurance goes further to improve access to care versus investment in the safety-net.

    • Insurance expansions and safety-net expansions should be viewed as complements.

    • Without universal coverage, the safety net is important and some investment in the safety is needed. The question is how much?

    Cunningham and Hadley, “Expanding Care versus Expanding Coverage: How to Improve Access to Care,” Health Affairs: July/August 2004


    Challenges of community based models

    Challenges of Community-Based Models

    • Assuring long-term, sustainable funding

    • Need to address both access and insurance

      • The safety-net is a delivery system while insurance is a financing strategy

    • Difficult to design a program to fill gaps in complex health system


    Improving coverage and access an overview of state activities donald cohn associate

    Terminology Matters

    Conservative-SpeakLiberal-Speak

    Personal ResponsibilityIndividual Mandate

    Insurance exchangePurchasing Pool

    Basic Health InsuranceBarebones Policies

    Reasonable cost-sharingHigh Deductibles

    Costly Mandated BenefitsEssential Benefits

    Employer AssessmentEmployer Fair Share

    Quality Health InsuranceComprehensive Health Insurance

    Source: Lischko, A. Communicating the Policy Choice. Slides presented at SCI’s Policy Analysis Workshop, Virginia, October 2006.


    Concluding thoughts

    Concluding Thoughts

    • States play critical role in moving the conversations about coverage expansions

      • Testing new ideas (politically and practically)

      • Creating momentum for national policy solution

    • Catch 22: Often need ambitious goal to sell new initiatives but need to be realistic about what states can do

      • Given overall fiscal picture, how far can states go?

    • Comprehensive versus Incremental

      • Sequential = incremental plus a vision

    • Few states can even approach universal coverage without a federal framework and funding


  • Login