Moving Toward Universal Health Care: What States Are Doing

1
Moving TowardUniversal Health CareWhat States
Are Doing

• February 26, 2007, New York City
• Physicians for a National Health Program
• Mark Hannay
• Director, Metro New York
• Health Care for All Campaign

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The Logic Rationale

• States CAN do significant things to increase
  coverage, improve access to services, and assure
  quality (but not so much for cost control)
• States as drivers of federal reform, especially
  in more conservative eras or during legislative
  gridlock (post failure of Clinton reform efforts)
• States as laboratories for policy innovation
• States can only go so far (ERISA, funding
  waivers) push the edge of the envelope
• State campaigns as organizing vehicles

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State-based Approachesto Health Care Reforms

• Principles and Standards
• Studies
• Legislative political processes
• Policy-specific legislation

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Principles and Standards

• Basic concept A broad foundation or set of
  rules to establish a basic right, which is then
  used to force legislative policy initiatives
• Similar to Health Care Access Resolution (H.Con.
  Res. 99) in 108th Congress
• IL Bernadine Amendment in late 90s
• MA Constitutional amendment in 2004-06
• NY? Article XVII (public relief and care,
  public health, mental health care)

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Studies

• Basic concept assess a specific policy or range
  of policy options along a range of parameters
  (coverage, access, cost, implementation)
• Various New England states in late 90s and early
  2000s
• Public, single-payer programs capable (or
  superior) in achieving universal coverage for
  less and control costs

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Legislative/Political Processes

• Basic concept Do not pursue specific policy
  proposal(s) at outset, but put all options on the
  table within the context of a public political
  process
• Via a special commission or legislative hearings
  (or both)
• Can include consultation, education, assessment,
  debate, recommendations

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Examples of Process Approaches

• ME lead up to adoption of Dirigo plan also
  built off Maine Rx campaign
• CA Health Options Project
• IL Health Care Justice Campaign
• NJ, NM, VT currently in process
• NY A.6575 (Gottfried) passed Assembly in 2006
  revisions and reintroduction soon

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Policy-Specific Approaches

• Basic concept Lay the foundation for, move
  toward, or implement a universal plan
• Insurance market regulation
• Building on existing public programs
• State flexibility re public programs
• Fair Share mandates
• Hybrid programs
• Single-payer programs
• Deregulate the market, or create new markets

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Building on Public Programs

• Basic concept Expand Medicaid and/or SCHIP by
  income level and/or category
• Various states in mid-late 90s, mainly via
  regulated Medicaid waivers
• Favored targets children, parents, pregnant
  women, newborns mothers
• NY Child Health Plus expansion (1997) Family
  Health Plus (2000-1) legal immigrants (2002)
  hospital financial aid (2006)

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State flexibilityre Public Programs

• Basic concept Mandatory managed care programs,
  limited/basic benefits (thinning the soup),
  new cost-sharing requirements (premium share,
  deductibles, co-pays), and use the savings to
  expand coverage to more lower-income people
• Spurred via Bush administration HIFA waivers
  (early 2000s) and super-waivers (mid-2000s)
• Governors given blank check
• New wrinkles vouchers for private insurance and
  HSAs for Medicaid recipients
• OR, WA, UT, FL, SC, WV, FSHRP in NY

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Fair Share bills

• AKA employer mandate or pay-or-play bills
• Basic concept Require employers of a certain
  size to either provide private coverage or pay
  into a public fund to reimburse for services
  provided
• CA multi-year phase-in stepping down to smaller
  employers (50) passed and signed into law
  (2003) repealed by referendum in 2004
• MD (2005-6) employers of 10,000 (Wal-Mart)
• NYC Suffolk Co. (2005)
• NY Working Families Party priority (2005)

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Hybrid/Mixed proposals

• Basic concept combine various policy options
  spanning the political spectrum
• Expand public programs for lower-income provide
  premium subsidies and/or tax credits/deductions
  to purchase private coverage for moderate income
  regulate individual and small group markets
  create a public entity to broker coverage
  options reallocate charity care funds require
  employer participation require individuals to
  buy coverage
• Cost control is often a secondary concern (if at
  all)

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Examples of hybrids Maine

• ME Dirigo expansion of public programs,
  reform of individual and small group market,
  captured charity care savings employer and
  insurer surcharges to subsidize sliding-scale
  premiums
• whole program under attack by Heritage Foundation

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Examples of HybridsMassachusetts Vermont

• MA (2006) expands Medicaid subsidizes premiums
  for moderate income market reforms modest
  employer surcharge individual mandate (if
  affordable) impetus Medicaid waiver renewal
• VT (2006) similar to MA with addition of new
  disease management program for those with
  multiple chronic illnesses (to control costs)
• CA, MN (2007, proposed) similar to MA

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Single-Payer Reforms

• NY (1992) NY Health passed Assembly (A.6576,
  Gottfried in 2005-6), to be reintroduced in 2007
• MA (2004) Referendum fails by 2
• CA (1995-2006) Bill passes both houses of
  legislature (w/out financing mechanism), but
  vetoed by Governor
• Bills introd in many states

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Lessons Learned Essentials

• Political leadership (ideally from Governor)
• An active, organized, well-resourced advocacy
  effort over time before, during, and after
  legislation is adopted
• Moral aspect breaks through entrenched opposition
  at key moments
• Stakeholders put larger public interest above
  their own, narrow, short-term economic interest

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Lessons Essentials (contd)

• Comprehensive proposals that phase-in over time
  easier to pass, but risk of unraveling
• Easier to expand coverage than restrain costs,
  but both must be addressed ultimately
• Federal incentives (even modest) can be a
  critical stimulus for political consensus

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Whats Up Here in NY for 2007?

• Expand CHP from 250-400 of FPL (dependent on
  SCHIP reauthorization)
• Streamline renewal process for public insurance
  programs
• Expand home and community-based long-term care
• Expand Medicaid managed care to SSI and
  seriously/persistently mentally-ill
• Require all EPIC enrollees to use Medicare Part D
  plans as primary payer

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NY in 2007 (contd)

• Freeze Medicaid rates for hospitals, nursing
  homes, managed care plans
• Shift funds to hospitals that treat Medicaid
  patients (vs. more broadly)
• Direct GME funds only to those hospitals that
  have training programs
• Continue HCRA pool allocations until 2008

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NY Over the Longer-Term?

• Shift funds from institutions to community-based,
  primary care (patients first)
• Medicaid funding follows Medicaid patients
• Combat Medicaid fraud
• Streamline enrollment for public insurance
  programs ? 1/3-1/2 cut in uninsured s
• Rx drug bulk purchasing program
• Disease management for complex chronically ill
  to include mental health and substance abuse

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Whither Universal Care in NY?

• Reintroduction of Gottfried NY Health and
  Legislative Commission bills include funding
  for latter in budget?
• Cover New York (GNYHA 1199 SEIU) hybrid
  proposal like Massachusetts
• Blueprint for New York (UHF and Commonwealth)
  components of a possible UHC approach over time
  includes buy-ins to and subsidies for public
  insurance programs

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Federal-State Partnership

• Basic concept Federal legislation is needed to
  facilitate/enable full state-based reform and
  experimentation
• Pioneered by Sen. Paul Wellstone (2000-2)
• Promoted by think tanks from Heritage Foundation
  to Brookings Institution
• S. 325 (Bingaman-Voinovich) and H.R. 506
  (Baldwin-Price) introd in 110th Congress