Massachusetts passed landmark legislation this year aimed at ensuring nearly universal health insurance for its residents. Other states have made similar attempts, some with limited success. Many states continue to search for points of agreement between disparate factions concerned with meeting the health care needs of the uninsured, working within the dismal context of tax cuts and budget deficits. And with approximately 47 million Americans currently lacking health insurance across the country, the stakes are high.
On Friday, October 20, policymakers and researchers convened in Snyder Auditorium to share their experiences at Public-Private Partnerships: Strategies for Reaching the Uninsured, a half-day symposium co-sponsored by the Division of Public Health Practice, the Department of Health Policy and Management, and MassCONECT (Massachusetts Community Networks to Eliminate Cancer Disparities through Education, Research and Training).
MASSACHUSETTS
Salvatore DiMasi, Speaker of the Massachusetts House of Representatives
Although the new law presents implementation challenges, the basic plan is a "great blueprint to follow," DiMasi said. "A lot of people in this country are calling to find out how Massachusetts has done this, and they will watch to see if we are successful."
The Massachusetts plan requires all adults in the state to be insured by next July, through private, public, employer-sponsored, or combination programs. Employers will be asked to pay a "fair share" assessment if they do not make a "fair and reasonable" contribution to coverage, and individuals will be penalized if they do not seek coverage, but only when there is coverage that is affordable for them.
A new state agency, the Commonwealth Health Insurance Connector Authority, will coordinate and oversee the availability of affordable, quality insurance products for people in certain income brackets, young adults, and others who need assistance paying for the required coverage. Sliding-scale subsidies will help low-income individuals purchase insurance.
The plan also includes guarantees and incentives to providers. Enrollment caps on existing Medicaid programs will be lifted, and money from the Free Care Pool will combine with other funds to guarantee a safety net for even the most indigent individuals.
MAINE
In 2003, Maine enacted Dirigo Health Reform to reduce costs, improve quality, and assure all Mainers access to health care. It included the creation of a comprehensive health plan for small businesses, self-employed workers, and individuals that subsidizes premium and deductible costs on a sliding scale for members at a certain point below the federal poverty level. The plan reins in health care costs by imposing cost-growth limits on insurers and providers; strengthening the review of proposals for costly investments in health care facilities, technologies, and new services; and launching a major initiative-the Maine Quality Forum-to improve quality and lower costs.
When Dirigo was proposed in 2003, Maine had the highest uninsured rate in New England, and the state now has the lowest, said Trish Riley, director of the Governor's Office of Health Policy and Finance. The plan helped the state save money, including dollars that otherwise would have been spent on charity care and bad debts incurred by uninsured patients, she said. The savings justified the imposition of an assessment on insurers and those who administer self-insured plans to fund the program, she said. The financing strategy remains controversial, and a Blue Ribbon Commission has been convened to develop alternative proposals.
VIRGINIA
"If you have your health, you have everything. But, what if you don't [have your health]?" asked Deborah Oswalt, executive director of the Virginia Health Care Foundation (VHCF).
One of the ways her state has addressed its uninsured problem is by creating a not-for-profit foundation to help build a safety net for the state's one million uninsured. The VHCF has supported a large number of community health clinics spread throughout the state, expanding patient capacity and increasing the availability of medical, dental, and mental health services. It has also dramatically increased access to free medications with The Pharmacy Connection, a special foundation initiative that assisted 53,000 uninsured patients last year.
In addition, she explained, VHCF has worked hand-in-hand with state agencies to maximize the number of children enrolled in the state's Medicaid and SCHIP programs via initiatives to simplify applications, streamline eligibility regulations, and promote program benefits.
Until insurance is available to everyone, said Oswalt, it is imperative to have a strong health care safety net. A public-private partnership blends the best of both worlds, she asserted. She cited the flexibility and entrepreneurial spirit in the private sector as invaluable characteristics, and good stewardship as an important public sector quality.
While this approach has been effective in Virginia, it has limitations, Oswalt observed. Safety net services and capacity vary dramatically by locality. There's no endowment to help weather a poor economy. And, at its best, it delivers only primary health care.
CALIFORNIA
Physician Amerish Bera shared his experience with Sac-Advantage, a community-based program in Sacramento, California. Using a combination of funds from multiple sources including state and federal monies, this community-run program offers coverage to the most medically indigent uninsured and underinsured through an employer-based model. It began with support from many stakeholders-hospitals, health plans, providers, advocates-and has grown and expanded over the past five years.
Bera said it was difficult to get small business employers to offer new health benefits, even at a low cost. Small business owners prefer high-deductible products, but those require a strong safety net for employees who cannot afford the deductibles.
"Universal coverage must be simple, basic and generic," Bera said, "and this will be difficult for a government entity [to offer and administer]."
ILLINOIS
Craig Backs, immediate past president of the Illinois State Medical Society, discussed what it took to pass the Illinois State Health Care Justice Act of 2004, sponsored by then-state senator Barack Obama. The law created a task force, which included the medical society, insurers, hospitals, advocates for patient interest groups, nurses, and business representatives. The task force aimed to develop a statewide plan to maintain and expand existing services.
Illinois has 1.8 million uninsured, almost half under the age of 29. Many are employed. There are great health care need differences between urban and downstate rural populations, explained Backs, and consequently, five plans are being melded into one hybrid that will build on the existing health system and, hopefully, fix what doesn't work.
TENNESSEE
While many of the programs described at the symposium have experienced various measures of success, a program that was initiated in Tennessee offers a cautionary tale. In 1994, the state expanded its Medicaid program and renamed it TennCare. Under a special waiver from the federal Centers for Medicare and Medicaid Services, the state was able to leverage additional federal funding for coverage of the uninsured. That funding, combined with substantial savings realized through risk-contracted managed care, enabled the state to extend coverage to a half million uninsured Tennesseans not eligible for traditional Medicaid.
At its apex, the TennCare program covered 1.4 million individuals, reducing the state's percentage of uninsured to one of the lowest in the nation. TennCare not only reduced the number of uninsured patients, but it saved the state money, and improved the quality and type of available health care, according to state auditors. It demonstrated that, with sufficient political will, it is possible to cover the uninsured with only a comparatively small increment of additional funding.
However, explained Gordon Bonnyman, executive director of the Tennessee Justice Center, a changed political environment brought the program to an abrupt end in 2005. Today, the state has eliminated almost all benefits and eligibility categories not mandated by federal law. Tennessee is left with one of the most limited Medicaid plans in the country, in terms of both scope and eligibility. Within the past year, Tennessee has eliminated coverage for nearly 200,000 of the state's sickest residents, the largest single increase ever in the number of uninsured Americans, said Bonnyman. Medical care for the underserved has been cut by $1.8 billion annually, the largest single disinvestment in funding for a public health program in U.S. history.
IF YOU BUILD IT, WILL THEY COME?
Alan Monheit raised the issue that more emphasis has been placed on addressing deficiencies in the supply side of the health insurance market, rather than on factors that affect the demand for coverage. Monheit is professor of health economics, School of Public Health, and associate director of the Center for Health Economics and Health Policy at the University of Medicine and Dentistry of New Jersey. He presented survey data that revealed that a sizeable proportion of uninsured adults display weak interest in either public or private coverage that is available. Monheit suggested that a lack of interest in private plans may be due to their high cost, and the fact that health insurance has an uncertain yield in terms of its benefits.
Uninsured individuals eligible for public programs may also have weak interest in health insurance. Possible reasons include the difficulty and length of time required to enroll, the stigma associated with being on a state plan, a lack of knowledge about availability and eligibility, the availability of safety net health care, and a belief by some that health insurance isn't necessary.
To overcome these obstacles, Monheit suggests that states mandate health insurance, rather than rely on voluntary efforts. However, mandates should be accompanied by subsidies to low-income households, he said. At the same time, educational efforts are required to explain the purpose, cost, and impact of such health insurance to help promote stronger preferences for coverage.
The panel was moderated by Robert Blendon, director of the Harvard Opinion Research Program and HSPH professor of health policy and management.
The symposium Public-Private Partnerships: Strategies for Reaching the Uninsured was made possible through an unrestricted education grant from Astra Zeneca.
Howard Koh, Associate Dean for Public Health Practice and Harvey V. Fineberg Professor of the Practice of Public Health, introduced the speakers. Koh is also a principal investigator for MassCONECT, a co-sponsor of the event. James Ware, HSPH Dean for Academic Affairs, welcomed guests to the School. David Blumenthal, director of the Harvard Forums on Health and of the Institute for Health Policy, provided an overview of the state of health care insurance in the country.
—PHC
Copyright, 2009, President and Fellows of Harvard College
