The Users' Guide to the Health Reform Galaxy

Health Reformer's Lexicon: High-Risk Pools

The Health Reformer's Lexicon is a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: High-risk pools

High-risk pools are private, self-funded health insurance plans that serve high-risk individuals with costly pre-existing medical conditions such as cancer or HIV/AIDS.

Why It Matters: As the National Association of Health Underwriters explains, most Americans get their health insurance in group-purchasing arrangements—typically through their employers or the employers of family members—but some people do not have access to this type of coverage and need to buy their own insurance independently.

Unlike in the group health insurance market, however, insurers in most states traditionally have been allowed to deny coverage to individuals with serious pre-existing conditions. That’s because when you buy insurance individually, you’re essentially a “group of one.” The health insurance company has to determine how likely it is to take in more premium dollars from you than it pays back in benefits—and if it appears that the odds are you will get sick, then it is in the insurance company’s financial interest to avoid taking on the risk you represent.

(There have also been widely commented-upon incidents in which insurance companies have found reasons to rescind people’s coverage after they get sick.)

For this reason, many states offer some form of risk pool that individuals can buy into.

Roots: High-risk pools were first implemented in Minnesota and Connecticut in 1976, according to the Kaiser Foundation, and now operate in 34 states, providing insurance to nearly 200,000 people.

Where the Term Appears: The recently passed health reform law established a national high-risk pool program to insure individuals with pre-existing conditions from now until 2014, when the law’s broader provisions for expanding access to coverage begin to kick in. Getting this temporary program up and running is one of the first things that HHS Secretary Kathleen Sebelius has been tackling. She recently sent a letter to governors and state insurance commissioners asking whether they are interested in creating high-risk pools. Some states have responded that they need more time to decide.
 
Previous Lexicon entries include:
- Individual Mandate
- Uncompensated Care
- Value-Based Purchasing

Moving the Needle on Kids' Enrollment in Public Insurance Programs

Today’s post comes to us from Catherine Hess, Senior Program Director at the National Academy for State Health Policy (NASHP) and Program Director, Maximizing Enrollment for Kids.

Too often, when trying to address problems in our society, we look for a silver bullet – one solution. To the casual observer, last year’s passage of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) might seem like a silver bullet for the problem of uninsured children. Unfortunately, while public insurance programs like the Children’s Health Insurance Program (CHIP) and Medicaid theoretically extend coverage to a wide swath of the uninsured, many who are eligible are not enrolled in these programs.

But we know from research and over a decade of experience with CHIP that there is no silver bullet. There are multiple key strategies, and to be effective, they need to be tailored to different state and local circumstances.

To that end, the National Academy for State Health Policy (NASHP) collaborated with the Robert Wood Johnson Foundation (RWJF) to launch Maximizing Enrollment for Kids, a four-year, $15 million national program that helps states tailor and adopt key strategies to improve enrollment. Our ultimate goal is to “move the needle” to cover many more uninsured children, and we are documenting and sharing what works as we go along. 

We received applications from over half the states for this program, a positive sign of their interest. Eight states demonstrating commitment and vision to maximizing enrollment of eligible, uninsured children were selected: Alabama, Illinois, Louisiana, Massachusetts, New York, Utah, Virginia and Wisconsin.

If this program is successful – and so far, so good – these states will increase the efficiency of their systems. But another simple but particularly remarkable point is that as they improve systems, these states will spend more on covering additional children. Think about that. Even in a nasty budget climate, states want these programs to function at their top potential. This is highly encouraging.

Health Reformer’s Lexicon: Individual Mandate

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Individual mandate

Similar to the way that auto insurance is required for all drivers, the individual mandate is a provision that requires all Americans to carry health insurance.

Why It Matters: Supporters of the concept believe that the mandate will lead more people to obtain health insurance and push the U.S. closer to universal coverage.

As Laura Meckler of The Wall Street Journal explains,

The thrust is to get everyone into the health-insurance pool so that healthy people, who are cheap to cover, help balance out the sick, who are expensive.

Opponents believe the mandate is unconstitutional and claim that it encroaches on individuals’ personal rights. Others fear that individuals may not be able to afford it.

Roots: The concept originally surfaced in the early 1990s. It was included in the Health Equity and Access Reform Today Act of 1993.

In 2006, Massachusetts introduced an individual mandate that penalizes people who do not have coverage. As a result, the state now has the lowest rate of uninsured residents in the nation – at 2.7 percent, and an increase in the number of people covered under employee-sponsored insurance, but is currently struggling to rein in the overall cost of health care.

Where the Term Appears: The individual mandate appears in the health care bill, which was signed by President Obama earlier this week. According to the language in the bill, the mandate will:

Require U.S. citizens and legal residents to have qualifying health coverage.

Individuals without coverage will be subject to pay a tax penalty that will be phased-in over four years starting in 2014. Certain qualifying individuals will be considered exempt from having to pay these fees.

Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, if the lowest cost plan option exceeds 8% of an individual’s income, and if the individual has income below 100% of the poverty level.

Although similar, the reconciliation act presents a slightly different tax penalty structure.

Previous Lexicon entries include:
- Accountable Care Organization
- Meaningful Use
- Patient Centered Medical Home

The economic squeeze on the American middle class

Brian C. Quinn a senior program officer at the Robert Wood Johnson Foundation and Lynn A. Blewett, Director of the State Health Access Data Assistance Center (SHADAC) write about Cover the Uninsured Week.

The inner researcher(s) in us don’t generally get excited about spending days working on national awareness campaigns. But for the last eight years, Cover the Uninsured Week has provided an exciting opportunity for RWJF and SHADAC to explore interesting trends in health insurance coverage. This year, with families across the country struggling through the second recession in the last decade, it seemed natural for us to look into how those economic downturns have affected health insurance coverage.

The resulting report – Barely Hanging On: Middle-Class and Uninsured –released today, chronicles coverage trends in all 50 states from 2000 to 2008.  The findings? The first decade of this century has been marked by declines in employer-sponsored insurance coverage, greater costs to employers and employees for individual and family health insurance policies and significant erosion in private coverage.   Coupled with this we find significant declines in median incomes across the US.  This raises increasing concerns for the affordability of coverage for the middle class and a continued increase in the numbers of uninsured in nearly every state.

One finding that hits home for millions of people: America’s middle-class is bearing the brunt of these trends. Middle-income earners – families making roughly $45,000 to $85,000 a year – became uninsured at a pace faster than those who made more money, as well as those with lower incomes. In total, 13 million middle-income earners were uninsured in 2008 – about 2.4 million more than in 2000.

As the cost of health insurance premiums rose by 56 percent for family coverage (adjusted for inflation), many employers stopped offering health insurance coverage, shifted the increase in costs to employees in terms of higher premiums or changed the criteria for employees’ eligibility. By 2008, more than one in five people who work in firms that offer health insurance weren’t eligible for the benefit. For those employers who still paid the bulk of their employees’ insurance premiums, rising costs have been passed on to workers, likely causing some workers to drop their work sponsored coverage. In all, 21 percent of employees who worked for firms that offered employer-sponsored insurance (ESI) in 2008 did not accept or “take up” the offer.  Among the middle class, just 66 percent now receive insurance through their employer, a drop of seven percentage points since 2000.  

ESI has long been the mainstay of health coverage for middle-class families, who typically do not qualify for government insurance programs. Among middle-income Americans, only about half of the decline in employer-sponsored coverage from 2000 to 2008 was offset by increased enrollment in government insurance programs. For people who earned less money, declines in ESI were even steeper, but those numbers were almost completely offset by increases in coverage through government insurance programs like Medicaid and SCHIP. The result is that it’s the middle class that is going without.

America’s middle class is being squeezed to the point that they are barely hanging on. Overall, the average cost an employee paid for a family insurance policy rose significantly by 81 percent from 2000 to 2008, while median household income fell significantly by 2.5 percent (adjusted for inflation). Clearly, hard-working families are at the brink.

We are concerned about the erosion of ESI and the continued growth in health care coverage costs.  In this economic crisis, we know that business owners can’t afford to shoulder more of the burden of health care costs.  Yet, at the same time, state are facing unprecedented budget shortfalls and are not able to meet the need of  laid-off workers and the members of the once-middle class who are now uninsured.   If nothing is done to stave off these trends, it could spell doom for our nation’s middle class, our health care system, and ultimately the future of our economic recovery.

During this 8th Cover the Uninsured Week, people across the nation will hold events and have discussions about what to do about this national crisis. We’ve certainly done our part to build awareness. Now it’s up to the people to take action.

America's uninsured: still matters.

I know this is going to make me sound old (truth hurts), but I can clearly remember the first Covering the Uninsured Week, eight years ago.  It was one of the very first issues I worked on at RWJF and one that I'd really like to see get solved in our lifetime. And, I think you can choose to either get really depressed about the fact that we haven't solved it yet, or, you can reflect on how long it really takes to change the thinking around a particular problem and to make that problem really matter to a broad swathe of people, but eventually, success starts to seem more possible.  The sun is shining today, so I choose the latter.

There's lots of chatter going on in the blogosphere about this year's CTUW, so I'll just point you to a few of those, beginning with one of the very first posts on this blog, from David Morse about last year's CTUW.  And then you can check out the Wall Street Journal blog and the New Health Dialogue about this year's CTUW, and our prospects for making the goal of covering all Americans a reality. 

Road Closed, Danger Ahead!

RWJF President and CEO Risa Lavizzo-Mourey writes on America's uninsured.  This post first appeared on The Huffington Post today.  

For decades, our health care system has been barreling down a dangerous road, plowing through stop signs and ignoring obvious warning signs – Higher Health Costs Approaching; 46 Million Uninsured Merging; Employer-Sponsored Coverage Closed Ahead.

Today, as part of the ninth annual Cover the Uninsured Week, the Robert Wood Johnson Foundation released a new report that warns of the dangers still ahead of us – and our health care system – if we don’t change direction. The analysis, conducted by researchers at the Urban Institute, shows that without significant reform to the current health care system the number of uninsured Americans could grow by 10 million people in just five years.  Spending on government health care programs for the poor will balloon, more than doubling by 2020. For employers who continue to offer health insurance benefits, an increasing amount of the costs would come out of workers’ pockets. At the same time, individuals and families would face higher out-of-pocket costs for premiums and health care services.

The report also finds that unless we change our health system so that it expands coverage to those who don’t have it, and makes coverage more affordable for those who do, middle-income families will be hardest hit. The uninsured rate for middle-class families earning roughly $40,000-$75,000 a year – could rise up to 28 percent.  That means one in four middle-income workers could be uninsured in 10 years. Uninsured rates will also rise among adults, age 45-64 and in 10 short years nearly a quarter of these middle aged adults could be uninsured.

This tells me, Warning: Danger Ahead. While we might not have an actual bright yellow sign signaling what comes next, we do have a map.  By examining the best available economic data, we can project what will happen to our health care system on its current trajectory—the number of uninsured Americans will continue to soar, and the increases in public and private spending will be dramatic and unsustainable.

For almost four decades, the Robert Wood Johnson Foundation has been making certain that the forces of health-system change remained fueled and driving forward. But the signs on this road are clear.  Unless action is taken to change the trajectory, our nation is on a collision course.

Creating a Positive Exchange

Enrique Martinez-Vidal, Director of the State Coverage Initiatives program, discusses the role of states in building and implementing health insurance exchanges:

I think we can all agree that watching the federal health reform efforts over the past couple of months has left us feeling like we are on a rollercoaster ride. Given our continued work with state officials, we know that despite the drama here in Washington, DC, the states must continue to focus on health care issues despite the historic recession that has caused dramatic deficits in almost every state. Over the past decade, we’ve documented the efforts of states to expand coverage to the uninsured, to reorganize and improve their insurance markets, and more recently, to undertake efforts to increase value in the health care system by redesigning the delivery system and exploring alternative payment incentives. Even this past year, despite fiscal constraints and uncertainty about potential federal reforms, a number of states made substantial strides in implementing reforms.

States have a wealth of experience with health reform efforts and, among the many lessons we’ve learned along the way, perhaps one of the most important is that the success of any reform is dependent on how well it is actually implemented.  As critical as good policy is to the inherent success of a reform, so too are the operational components. That’s where the reform rubber meets the road.

A perfect example and most relevant to us theses days is the concept of establishing state exchanges. We know that President Obama’s most recent proposal follows the Senate’s framework to have states play an important role in creating and overseeing health insurance exchanges. Moreover, whether or not federal reform occurs, we believe that states will be at the forefront of establishing exchanges. Some states are contemplating creating or already working towards implementing their own exchanges as a way to improve the functionality of the individual and small group markets. Likewise, individuals and employers are yearning for more comparative information about their insurance policy benefits and costs. While we already have the experience of Massachusetts’ and Utah’s initial work to look to, they took very different approaches. With more state experimentation in this arena, there will be various iterations along the policy continuum.

Because there still remain many questions regarding how to build an effective and sustainable exchange, we have begun the process of building an inventory of resources to support state work in this area. In late January, we hosted a meeting for state policymakers in partnership with officials from Massachusetts’ Commonwealth Health Insurance Connector Authority to learn from their experience thus far. Most recently, we released an issue brief Preparing for Health Reform: The Role of the Health Insurance Exchange, that raises many important issues that states must evaluate and consider before establishing an exchange. An exchange can do a lot – organize the insurance market, provide a central source of information, enable comparability of benefit designs, administer public subsidies, facilitate the purchase of insurance through standardized enrollment processes, and improve competition among carriers. And, at its very core, an exchange can seek to alter competition in the health insurance market from one based on avoiding risk to one based on price and quality. That is, if you build it correctly.

States policymakers need to develop a thorough understanding of both their uninsured and insured populations, the existing sources of public and private coverage, and the current structure of the commercial insurance market in their state. The roles and responsibilities of an exchange must be defined to determine the appropriate administrative and governance structure it should have. States may need to determine how premium subsidies (if there are subsidies) will be targeted and processed, how to be strategic with effective outreach and enrollment, as well as how to mitigate the potential for adverse selection where one participating carrier ends up with a disproportionate share of high-cost enrollees. In the final analysis, it is critical for a state to clearly understand the goals it is trying to achieve as it takes on the restructuring of its insurance markets.

So, if states build exchanges, will the people come?  While this question may only be answered over time, we believe that, for states, much will depend on assuring they are well-prepared by having laid the necessary groundwork for the development and implementation of these mechanisms that hold the promise of improving insurance markets.

Robert Otto Valdez makes Christmas appeal to the U.S. Senate

Robert Otto Valdez, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico, channels FDR and Jimmy Stewart to make the case for expanding Medicare to achieve universal health coverage.

I was reminded the other day watching “Mr. Smith Goes To Washington” that
sometimes you just need to say what needs to be said until the Senate hears what is
right. This is right: We all have a right to life and liberty. These are founding principles
of our nation; they define our social contract to one another. And one cannot have life
and liberty without good health. ALL those living and working in the USA must have
access to quality health care and healthy communities, lest we break the social
contract itself. The Senate’s debates on health insurance reform must restore our
nation’s social contract in accord with these principles.

President Franklin Delano Roosevelt commented that “the test of our progress is not
whether we add more to the abundance of those who have much; it is whether we
provide enough for those who have too little.” The Senate would be wise to heed
these words as they debate health insurance options for our nation. History shows
that private enterprise and the profit motive do not ensure the well-being of every
individual - public commitment is essential to achieve our ideals as a society.

We would do well to recognize our own history with the Social Security program,
the cornerstone of our nation’s economic security. At first, coverage was
limited to only a few. Only gradually, over several decades, was the program
expanded to its present nearly universal form. Today, it is recognized as our nation’s
most important anti-poverty program, the major or only source of income for many
seniors.

I'm dreaming of a white paper ...

David C. Colby, vice president of research and evaluation at the Robert Wood Johnson Foundation, shares his favorite health reform policy papers in the spirit of regifting.

While many of you might already have visions of sugar plums dancing through your heads, I (not surprisingly) have health reform on my mind.  That doesn’t mean I am not in the holiday spirit. In fact, I propose a “white elephant” holiday gift exchange here at the foundation. ‘Tis the season of regifting.  The best part of the gift exchange is how it highlights that value is truly in the eye of the beholder.  Many recycled gifts are still perfect gifts.

In that spirit, I want to regift to you some of this year’s health reform policy papers that are as good as stocking stuffers today as when they were released last February, April, June or October. I started with 12 gifts of policy analysis, but with Hanukkah wrapping up tomorrow, feel free to pick your favorite eight…

America’s Uninsured Crisis
Released in February by the Institute of Medicine (IOM), this report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

Crossing Our Lines: Working Together to Reform the U.S. Health System
In June, three wise men, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole completed The Leaders’ Project on the State of American Health Care, a two-year consensus-building process resulting in a plan for reforming America’s health care system.  This report outlines their key recommendations.

How Do We Pay For Health Reform?
Conducted by Urban Institute researchers and released in July, this analysis reports that savings from many popular health reform ideas would finance the lion’s share of the cost of comprehensive health care reform. The authors also conclude that a combination of revenue options would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

How Does the Quality of U.S. Health Care Compare Internationally?
This analysis from the Urban Institute, which we released in August, looks at the evidence on how quality of care in the United States compares to that in other countries and highlights the implications for health reform.

How Will the Uninsured Be Affected by Health Reform?
In this four-part series, released in August by RWJF and the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute’s Lisa Dubay and Allison Cook calculate how many uninsured people could gain coverage through a health reform scenario that draws on proposals being discussed on Capitol Hill.

Bending the Curve
Released in September, this report is not about making candy canes. Compiled by the Engelberg Center for Health Care Reform at the Brookings Institution, the paper proposes that health care reform should include comprehensive efforts to achieve higher-value care. The report was co-signed by a distinguished group of scholars and policymakers: Joseph Antos, Ph.D., (American Enterprise Institute for Public Policy Research); John Bertko (Brookings Institution); Michael Chernew, Ph.D., (Harvard Medical School); David Cutler, Ph.D., (Harvard University); Dana Goldman, Ph.D., (RAND Corporation); Mark McClellan, M.D., Ph.D., (The Brookings Institution); Elizabeth McGlynn, Ph.D., (RAND Corporation); Mark Pauly, Ph.D., ( University of Pennsylvania); Leonard Schaeffer (University of Southern California); and Stephen Shortell, Ph.D., (University of California, Berkeley).

Is Massachusetts Reform Working for Doctors?
This study, published in the Oct. 21 issue of the New England Journal of Medicine, finds that 70% of practicing physicians in Massachusetts support health reform three years after its passage in 2006. We partnered with Blue Cross Blue Shield of Massachusetts Foundation to fund the research, which was designed and conducted by researchers at the Harvard School of Public Health.

Trust for America’s Health Prevention Poll
The poll, conducted for RWJF and Trust for America’s Health by Greenberg Quinlan Rosner Research and Public Opinion Strategies, indicates the majority of Americans support disease prevention investments as a part of national health reform. Poll findings were released in November.

A State Policymaker's Guide to Federal Health Reform
These three documents released by the National Academy for State Health Policy (NASHP) last month identify the most challenging health policy issues that states are addressing; describe the tools they have at their disposal and how federal health reform may affect those tools. It also describes the support they would need to implement federal health reform legislation.

County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations
This report, released earlier this month by Health Management Associates, analyzes the effects that substantial funding cutbacks from local, state, and federal sources have had on already-strapped local health departments.

Leveling the Field - Ensuring Equity Through National Health Care Reform
Bruce Siegel, M.D., and Lea Nolan, M.A., from the Center for Health Care Quality, The George Washington University School of Public Health and Health Services, published this piece in the Dec 3 edition of the New England Journal of Medicine. The paper discusses how health reform legislation would reduce racial and ethnic disparities by extending coverage to disadvantaged groups.

The Cost of Failure to Enact Health Reform: Implications for States
Released at the end of September, researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change in every state between now and 2019 if the health system is not reformed.

Wishing you a happy and healthy holiday season. May all your policy papers be white!

Finding the sweet spot between affordability and access in health reform

Bowen Garrett, a senior research associate at the Urban Institute, writes about finding the sweet spot between making health care more affordable for low- and middle-income families while limiting overall costs.

As legislators continue to hammer out details on key provisions of health reform legislation, they face a difficult balancing act. To craft a successful health reform bill, they must limit the overall cost of the reform package, while at the same time, making health insurance affordable for low- and middle-income families. That’s no small feat for even the most nimble-footed of policymakers. 

A key component in finding the right balance is where to set levels of premium and cost-sharing subsidies.  These subsidy levels will go a long way toward determining how affordable insurance coverage and access to medical care would be for families under reform.  If the levels are wrong, the cost burden will be too high for low- to moderate-income families driving down compliance with an individual mandate. The resulting lack of widespread compliance would ultimately make it very difficult to maintain insurance reforms on the table because at their core, they depend on broad risk pools.

Health reform could hurt minority groups if not done right

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

Regulators need to step up enforcement to protect consumers

Peter Harbage, of the DC-based health policy firm that bears his name, writes that federal and state regulators must do more to enforce the law, if proposed new consumer protections are to be effective. We published another post on this topic, by Hilary Haycock of Harbage Consulting, which can be found here.

In the current health reform debate, President Barack Obama as well as many Senators and Members of Congress have repeatedly promised to end rescissions, the practice of insurance companies cancelling coverage for policyholders who get sick.  While this is a line guaranteed to generate applause from audiences fired up about insurance company bad acts, little attention has been paid to the federal law that should have been protecting consumers from such practices since 1996.  A recent report we released with the support of the Robert Wood Johnson Foundation aims to understand why that law has failed to change the individual insurance market, and what lawmakers can do to ensure that any new regulations created by health reform are more effective.

Rescissions occur because private health insurers have a strong financial incentive to sell their product to a healthy population.  The better the risk pool, the better the profit.  This leads insurers to underwrite their products—that is to evaluate the risk of the person or family purchasing insurance and issue or price the product accordingly.  In the case of a high risk applicant, the insurer will likely refuse sale of the product.  Once covered, if an individual subsequently becomes sick, the insurer may re-review the original application to find any preexisting conditions that may have been missed during underwriting.  If this process of post-claims underwriting finds new information, the insurer can rescind—or take back—coverage leaving the individual uninsured.  While it is believed that rescission happens on a limited basis, it can be financially and physically devastating to those who lose their coverage.   

How important are individual mandates in achieving health reform?

Debra Lipson, a senior researcher at Mathematica, writes about individual mandates and health reform through the lens of reform efforts in Massachusetts and Maine.

Nearly every health reform proposal now under consideration in Congress has a provision that would require individuals to purchase health insurance coverage. For years, the notion of government requiring individuals to have health insurance was anathema. To those on the right, it smacked of government intrusion into personal affairs. The far-left opposed mandatory purchase of private insurance because they argued that it would perpetuate an overpriced, unfair system stacked against consumers.
 
Thanks to Massachusetts’ health reforms passed in 2006, we have experience with individual mandates and lessons about what it takes to make them work:  Adequate subsidies to make premiums affordable to those with low or moderate income. Penalties for non-compliance high enough to induce participation. Exemptions for those who demonstrate that premiums for available policies remain unaffordable, even with subsidies. Regulations that require insurers to issue plans to all applicants regardless of health status, and that limit the extent to which rates can vary based on age, gender, and other personal characteristics. 

Even with such provisions, not everyone gets covered. That’s because Massachusetts is unable to raise sufficient revenues to provide adequate subsidies to everyone who needs help paying premiums. This could well be the case with federal health reform. There is little appetite on Capitol Hill (at least in the Senate) for raising enough funds to subsidize families earning more than 300 percent of the federal poverty level. In addition, Massachusetts didn’t get around to serious health care cost control until this year, so premium rates remain high.

Reforming health care in rural America

Keith J. Mueller, PhD, director of the Nebraska Center for Rural Health Research and the Rural Policy Research Institute (RUPRI)’s Center for Rural Health Policy Analysis, writes about a new report prepared by the RUPRI Health Panel, Assuring Health Coverage for Rural People through Health Reform.

The benefits of living in rural America may be many, but enjoying stable, comprehensive health insurance is not necessarily among them. The 50 million Americans who live outside metropolitan areas are more likely to be uninsured or underinsured than their urban counterparts. In order to improve the health care of all Americans, regardless of geography, policy makers need to pay attention to these differences.

The challenges rural Americans face in obtaining health insurance are partly due to the structure of the rural economy. Simply put, jobs in rural communities are less likely to come with health benefits than those in urban America. Rural workers also pay more for health insurance plans than workers at urban businesses.

The secrets of Massachusetts' success (including bigger carrots and smaller sticks)

Robert Restuccia, Executive Director of Community Catalyst, writes about the less-talked-about lessons from Massachusetts-style health reform.

Massachusetts as model – it’s a common claim in health policy circles. With the lowest rate of uninsured residents in the nation – just 2.7 percent – it’s clear to those watching that Massachusetts’s mix of Medicaid expansions, sliding scale subsidies, private insurance reforms and individual mandate are working to expand coverage and have served as the template for national reform. 

But there are other, less obvious lessons from the Massachusetts experience that have not really filtered into the political and policy discourse in Washington.  Here are a few of the most important.

There are good policy and political reasons for putting coverage expansions ahead of cost containment

Massachusetts made the strategic decision to tackle health coverage before cost containment – making it easier to keep all players at the table.  Despite bold words to the contrary at the start of the process, the Congressional leadership and the Obama Administration too are finding it hard to arrive at a consensus on significant cost containment while still keeping the industry backers of coverage expansion at the table.  But Massachusetts is using the pressure from the cost of its coverage expansion to jump-start a more serious debate about cost containment than ever before.

Faster is better

The current health reform is not the first time Massachusetts attempted to enact a near-universal coverage program.  In the late 1980s under Governor and soon-to-be Presidential candidate Michael Dukakis, Massachusetts enacted a major health reform proposal with an employer “pay or play” as its central element along with a number of other smaller programs.  Today those smaller programs, implemented almost immediately after reform passed, are still going strong, while the employer pay or play, which was not scheduled to go into effect for several years after passage, was first delayed and then repealed as the political and economic environment shifted.

What Massachusetts docs think about health reform

Gillian K. SteelFisher, a research scientist at the Harvard School of Public Health, writes about a recent poll she and her colleagues conducted with physicians on health reform in Massachusetts, highlighted today in the New England Journal of Medicine.

With the passage of the 2006 health insurance law, Massachusetts has made significant changes in health insurance coverage and now can claim the lowest uninsured rate in the country.  As the debate on health reform in Washington, D.C. unfolds, policymakers at the national level have turned their attention to the state’s health reform; in fact many of the Congressional proposals currently on the table include elements from the Massachusetts plan.  In this process, there have been some criticisms of the reform, with suggestions, for example, that the reform has made it more difficult for people to access care.

We already know from past research that the reforms hold majority support among the public, but what about physicians who are on the front lines of care and directly see the potential impacts of that reform?
To address that question, my colleagues and I polled more than 2,000 Massachusetts physicians.  Our goal was to assess their perceptions in three areas: their overall support for the legislation, their views of its impact on their own practice, and their views of its impact on health care across the state.

Bills would boost quality by shining a light inside the health-care system

Debra Ness, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and president of the National Partnership for Women & Families, writes about provisions to improve health care quality in pending legislation.

And now there are five. With its vote this week, the Senate Finance Committee reported out the final of five reform bills that hold the potential to transform our broken health care system.

It has been a long road getting here. The National Partnership, for one, has worked for 15 years with a wide range of consumer and patient groups to shine a light on the need for improving the quality of health care, getting costs under control and expanding affordable coverage.

I’m encouraged because the Finance Committee bill builds on the momentum we’ve seen over the past several months to make some sorely needed improvements to our health care system – things that will help Jane Citizen and her family get the care they need. Chief among them are key insurance market reforms that take great strides towards protecting Americans’ health coverage — making it illegal for insurance companies to raise rates based on a pre-existing condition or gender, denying coverage based on health status, and dropping people who get sick.

Let's learn some health reform lessons at home

Lynn Blewett, director of the State Health Access Data Assistance Center (SHADAC), shares more lessons from the Massachusetts experience with health care reform. 

As the federal reform moves forward, we’ve heard many different ideas about how to improve access to health insurance coverage, bend the curve of growing health care costs, and improve the efficiency and quality of health care services.  Washington policy-makers are grappling with uncertainty about how these reform strategies will work and what the unintended consequences might be.  Wrestling with this type of ambiguity is inherent in most policy-making, but it’s particularly challenging when the stakes are as high as they are for health reform.  After all, Congress doesn’t often attempt to reform one-sixth of our economy in one legislative session.

One way to resolve the uncertainty about reform strategies is for policy-makers to look and see how other countries have designed their health care systems.  However, the US is so different from other countries culturally and historically, it’s often impossible to simply transplant reform ideas from outside the US and have the same impact.   We aren’t entirely out of luck, though.  We do have home-grown evidence based on what works.  This evidence is provided by the states, who have been implementing many innovative reforms with some very promising results.  States are demonstrating that reforms can lead to effective, efficient American health care with increased access to coverage. 

How do we spur competition in the health-care marketplace?

Elliot Wicks, a senior economist with Health Management Associates, writes about how to achieve competition in the health care marketplace through health insurance exchanges.  A perspective on the public insurance option, by Karen Pollitz of the Health Policy Institute at Georgetown University, immediately follows.

If we can take the liberal Democrats at their word – that their reason for insisting on a public plan is not to achieve single-payer by stealth but rather to ensure that health insurers have to truly compete on the basis of price—at some point they should probably stop insisting. The key to achieving real competition is structuring the health insurance exchanges properly.

A public option is not a magic bullet to bring down premiums. In the first place, the public option would be available only to people who buy through the insurance exchange – that is, people who buy coverage with the help of federal subsidies, some other individuals buying on their own rather than through their employers, and some small employers. All the people who are covered by self-insured employer plans would be excluded from the competition provided by a public plan. They constitute nearly 60 percent of people with employer coverage. But these large employers can pretty much take care of themselves. All they are buying from insurers are administrative services; the employer assumes the risk associated with the medical expenses their employees incur. They wouldn’t be eligible for the public plan, and they don’t need it because they already have market clout with insurers.

Lessons from Massachusetts about the impact of health reform

Sharon Long of the Urban Institute writes about how health reform might change--or not change--the health insurance many people have.

I suppose I was naïve, but I really thought we’d be making progress on health reform this fall. Instead, we’re still mired in contentious debate based as much on fear as facts. One concern is the possibility that health reform could undermine employer-sponsored health insurance coverage—the backbone of the US health care system. Massachusetts, which has mounted an ambitious initiative with many of the same features currently under consideration at the national level, offers a real-world case study of what health reform can mean for employer-sponsored insurance (ESI) coverage.

The bottom line? ESI was not weakened once health care reform took hold in Massachusetts, which now enjoys the country’s lowest rate of uninsurance. Indeed, ample evidence suggests that the 2006 health care reform law significantly boosted ESI coverage, countering the trend toward lower ESI coverage in the rest of country.

America's uninsured: How bad do the numbers have to get?

Lynn Blewett, Director of the State Health Access Data Assistance Center (SHADAC), writes about the latest numbers on Americans who lack health insurance.  The Alliance for Health Reform sponsored a lunchtime briefing on the new figures today.

Every year, the US Census Bureau releases estimates of how many Americans lack health insurance, and this number then becomes embedded in numerous media reports and speeches that focus on health reform.  The most recent estimates from the US Census Bureau show that the number of uninsured Americans continues to grow, increasing by 600,000 individuals between 2007 and 2008.  There are now 46.3 million individuals in the US without any health insurance coverage.   The estimates also show the continued deterioration in employer-based coverage.  The number of individuals receiving health insurance coverage through their employer dropped from 177.4 million to 176.3 million individuals. 

Physicians support the public option

Salomeh Keyhani and Alex Federman from the Mount Sinai School of Medicine write about recent findings from a survey of physicians on health reform.

The health reform debate has aired out a number of issues about how we can do better at health care, as a country, and one issue that consistently gets zeroed in on—even though it’s by no means the only issue—is whether health reform legislation includes a public insurance option, or not.  Over the last year, polling data has consistently shown majority support for the inclusion of a public option in the final health care reform legislation.  We knew what many of our physician colleagues felt about the public option--they all supported it. They thought of the public option as a moderate solution to unite everyone in covering the uninsured, a policy proposal that tried to sidestep the failures of the past—you could keep your private insurance if you liked it, you could buy private insurance subsidized by the government, or you could buy a public plan similar in design to Medicare.

However, on the national stage, many members of Congress were denouncing the public option as government-run health care, and declaring it would never pass the Senate.  In addition, the AMA initially appeared to be supportive of private-only health care coverage expansions.  We wondered whether the voices of all physicians were being heard.  Were our colleagues who supported the public option among the minority or majority of physicians in the field? 

Take Five for health reform

David Colby wraps up his summer reading recommendations for health reform.

I’m going to wind down my summer reading series on health reform because, well, summer’s almost over and Congress is getting back to work.  Although I’ve been somewhat lighthearted in making my reading recommendations, I do hope you know that I know that reading health policy research may not go down as easily as the latest John Grisham or Jennifer Weiner novel (at least, for some of us).  These recommendations were made with two goals in mind—to remind people who care about health reform that facts and sound analysis can and should trump sensationalistic fiction, and to point you to the best examples of what we’ve got by way of facts and sound analysis. 

Before summer officially ends, though, I’m going to take some time to sit on my deck and listen to Dave Brubeck’s Take Five, which is celebrating its fiftieth anniversary this year.  And in that spirit, I’ll encourage you to also ‘take five,” by recommending five topics to learn more about. These are the topics that have dominated health reform discussions in 2009, and they also happen to be five topics on which we can offer you good reading material.  And once again, I’ve tried to make it easier for you readers out there by giving you the gist of what these topics are really about, using literary references that some of you may enjoy. 

Learning from Massachusetts

Sharon Long, a senior fellow in the Urban Institute’s Health Policy Center and economist by training, writes about the Massachusetts health reform initiative. 

What the health reform debate needs is more discussion firmly grounded in facts and data. And that’s what took place at an Alliance for Health Reform briefing held on Monday (where I had the opportunity to speak). Event materials are available here, but in this post, I thought I’d try to parse out the lessons learned in the three years since Massachusetts began implementing health reform—and sum up how those lessons might address some of the concerns about national health reform that were asked of Monday’s panel.

The facts: Our research at the Urban Institute shows that health reform in Massachusetts has accomplished much of what it set out to do. Nearly everyone in the state has health insurance; more people have access to care; and care has become more affordable. Expanded insurance hasn’t crowded out employer-sponsored insurance coverage—instead, the individual mandate has increased enrollment in employer-sponsored insurance plans.

Our surveys found that, over the last three years, health insurance coverage among working-age adults in Massachusetts increased to 96% (well above the 80% on average in other states), with 90% reporting having health insurance coverage for at least a full year. We found that increases in health insurance were most pronounced among adults earning less than 300 percent of the federal poverty level. Among that group, there was a 17 percentage point increase in people having health insurance for a full year so that now 92 percent of lower-income adults report having health insurance.

The future of CHIP: What if it goes away?

Jocelyn Guyer is the co-director for the Center for Children and Families at Georgetown, writes today about children's health insurance provisions in draft health reform legislation and blogs regularly at Say Ahh! A Children's Health Policy Blog.

It is becoming increasingly clear that Congress may well dismantle the popular Children’s Health Insurance Program (CHIP) as part of broader health reform. Children and their families have much to gain in health reform, as my colleagues and I have written about elsewhere, but this is a change worthy of its own discussion. It is a big deal. CHIP is widely viewed, and rightfully so, as one of the most resoundingly successful health coverage programs adopted in recent years. Along with its larger companion program, Medicaid, CHIP has helped to drive down the uninsured rate among low-income children by a third over the past decade.  Right now, 14.1 million children are expected to be on the program in 2013, the year when key elements of health reform would go into effect.

With all of the other debates going on in health reform, the question of the future of CHIP is only now garnering some attention.  Senator Rockefeller expressed displeasure over the prospect that the program might disappear in a New York Times article a few weeks ago, and, just last week turned the heat up even further on the issue, calling it a “crime” according to Roll Call’s CongressNow.

The devil's in the details, but the direction's in the data

David Colby writes about using evidence to take action.  This post originally went out as an RWJF content alert yesterday to subscribers on the Coverage and Health Reform lists.
 
This is a watershed moment in America’s long struggle for far-reaching health system reform. Pressure is building in Washington for profound improvements in how we finance and deliver health care.

What’s the big difference with this round of reform efforts? This time lawmakers and policy experts are guided by a tremendous body of evidence and data-driven knowledge that takes the guesswork out of what’s wrong with health care and how to fix it.

Much of the evidence comes from the Foundation’s partners in the health policy research community. If politics is the art of the possible, then research is the art of the solvable.

Fear of financing: How can we pay for health reform?

Linda Blumberg, PhD, is a senior fellow at The Urban Institute and writes today about paying for health reform.

As we move into the dog days of summer – and the eighth month of congressional discussions about health reform – the voices of gloom are starting to get louder:  “There aren’t enough cost savings in health reform,” they say. Or, “There aren’t any viable ways to pay for it.”

I was part of a team that yesterday released a detailed analysis of savings to the government if various reform ideas are implemented. It showed that the savings would be huge – enough to finance the lion’s share of the cost of comprehensive health care reform. It also showed that a combination of revenue options would provide more than enough money to fill the relatively modest gap between the cost of reform and the savings resulting from it.

Yet still, so many are afraid of financing.