Health Policy Efforts and the Uninsured in Ohio: An Overview

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Health Policy Efforts and the Uninsured in Ohio
An Overview

• William D. Hayes, Ph.D.
• President
• March 28, 2008
• Center for Community Solutions
• Human Services Institute

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Senator Bill Frists Vision for the 21st-Century
Health Care System

• From the January 20, 2005 New England Journal of
  Medicine

Guiding Principle All Americans deserve the
security of lifelong, affordable access to
high-quality health care.
Current health care sectors cannot meet the
needs of a 21st century America without a true
transformation on the scale of what most
American industries went through in the 1980s
and 1990s
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HPIOs Model for Thinking About Health

• To improve health it is important to focus policy
  attention
• on four different areas. In each area there may
  be
• public or private policy actions that can make a
  positive
• difference. These areas are
• HealthBefore Care (genes, individual behavior
  and social and physical environment)
• Access to Health Care (coverage, income, provider
  hours, transportation)
• Health Care Delivery (quality of care,
  appropriateness of care, safety of care)
• Monitoring Health Trends/Evaluating Policies
• A key assumption is the need to view health as an
  investment and not just as a liability cost to
  government and employers

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Applying the model to helping the uninsured

• What should happen to reduce threats to the
  health of the uninsured before care is needed?
• What should happen to increase the chance that
  the uninsured afford coverage?
• What should happen to increase the ability of the
  uninsured to access care?
• What should happen to make sure that the
  uninsured get safe, appropriate care?
• What can we do to reduce unnecessary health
  spending, freeing up money for expanding coverage?

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PROFILE OF OHIO 2004 (Ohio Family Health
Survey)
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2007 OHIO HEALTH ISSUES POLLUNINSURED AND
ROTATIONAL UNINSURED
Uninsured Growth 2004 to 2007 Comparisons

• The new Ohio Health Issues Poll shows uninsured
  rates rising for those 18-64 years, from 15.04
  in 2004 (2004 OFHS) to 17.7 in 2007. This
  increase results in approximately 209,000 new
  uninsured since 2004.
• 30.3 of 18-64 year olds reported being uninsured
  for some period during the 12 months prior to
  being surveyed this equates to approximately
  2,169,279 Ohioans.

Sources 2004 Ohio Family Health Survey, 2007
Ohio Health Issues Poll. (Note that the Current
Population Surveys 2005-2006 aggregate mean for
Ohio of the total uninsured proportion (all ages
for adults and children) is 10.7. The 2004 Ohio
Family Health Survey total proportion is 10.6,
or 1,211,624 Ohioans.
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Uninsured Rates for Adults Living in Metropolitan
Areas (Ohio Adults Ages 18 to 64) 2004 Ohio
Family Health Survey
Mahoning County had the highest non-elderly adult
uninsured rate at 19.9. Lorain County had the
lowest non-elderly adult uninsured rate at 11.0.
589,000 or 55.8 of Ohios 1,056,000 non-elderly
uninsured live in metropolitan counties.
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Percentage of Uninsured Adults by Race/Ethnicity
for Firm Size (Ohio Adults Ages 18 to 64) 2004
Ohio Family Health Survey
Uninsured rates for minority workers are higher
than rates for White workers particularly for
small firms and independent workers. However,
very large firms uninsured rates are similar
across all races.
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Percentage of Uninsured Adults by Geographical
Residence for Firm Size (Ohio Adults Ages 18 to
64) 2004 Ohio Family Health Survey
Independent workers in all demographic regions of
Ohio experienced higher uninsured rates.
Appalachia workers experienced higher uninsured
rates for all most firm sizes.
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UNINSURED FAMILIES BREAKOUT BY POVERTY OHIO (88
COUNTIES)
87.4 of Ohios uninsured children (136,265) live
below 301 of the Federal Poverty Level. 89 of
uninsured Ohio parents (387,216) report annual
household incomes below 301 of the FPL. 83.9
of all uninsured adults between ages 18 and 64
live below 301 of the FPL.
Source 2004 Ohio Family Health Survey
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Health Coverage Reform Developments in Ohio

• Budget expanded coverage for uninsured children
  up to 300 of poverty, with premium support
  requirement for families with incomes between
  200 and 300 of poverty, but Bush Administration
  rejected expansion
• Budget created coverage opportunity for
  uninsurable children within families with incomes
  above 300 of poverty
• Budget planned to increase provider payments and
  recently cut adult Medicaid benefits, but those
  expansions are on hold because of budget issues

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Ohio Government Reform Opportunities.

• Governor Strickland wants to develop a plan to
  reduce number of uninsured by 500,000, working
  with Health Reform Advisory Group. Key ideas
  being discussed include use of a connector and
  reinsurance to shore up individual and small
  group market, with subsidies for low income
  people (for documents and details go to
  http//www.healthcarereform.ohio.gov/reports.aspx)
  
• House created new committee Healthcare Access and
  Affordability (Rep. Raussen R as chairman)
• Representative Raussen introduced health reform
  legislation
• Two universal coverage bills introduced in the
  House Rep. Budish (D) and Rep. Skindell (D)
• Strickland Administration is moving forward other
  health-related agenda items Healthy Ohioans,
  Broadband Ohio, and Health Information Exchange,
  Quality Institute proposal

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Ohio Private Sector Reform Opportunities.

• Ohio Business Roundtable sponsoring reform
  development process goal is transformation
  initiative for 2008
• Consumer advocacy led efforts underway, received
  RWJ funding for statewide group
• COSE has health reform proposal
• OSMA has created the Physicians Framework for
  Healthcare Reform
• Hospitals/OHA are developing health reform
  concept
• Health underwriters and health plans have each
  offered health reform preferences/principles

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Local Health Care Reform Efforts in Ohio

• Organized charity care (Lucas, Summit, Franklin)
• Pharmacy assistance programs (Stark, Franklin)
• Three Share primary care insurance (Butler)
• Increased number of free health clinics and FQHC
  clinics or look alike clinics
• Community health workers and outcome-based
  contracts (Richland, Franklin)
• Affordable and sustainable health system
  initiatives similar to Seattles Puget Sound
  Health Alliance (Franklin, Summit)

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Examples of Health Insurance Coverage
ProposalsIncrease Access to Affordable Insurance
Private Non-Group

• Individual and/or employer mandate
• Income tax credits or deductions (HSAs)
• Sliding-scale premium subsidies
• Insurance exchange or purchasing pool
• High risk pool
• Reinsurance for low-wage employers
• Guaranteed issue for 1-50
• Small group rating rules
• Children on parents plan to age 30

Employer-Sponsored
SOURCE The Ohio Department of Job and Family
Services, Results from the Ohio Family Health
Survey, March 2005 Created by Health Management
Associates
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Examples of Health Insurance Coverage
ProposalsExpand Medicaid Coverage
Private Non-Group

• Increase children from 200 to 300 FPL
• Increase parents from 90 to 100 FPL
• Add uninsured adults up to 100 FPL
• Outreach to enroll uncovered eligibles
• Increase income limits (Buy In)

Employer-Sponsored
SOURCE The Ohio Department of Job and Family
Services, Results from the Ohio Family Health
Survey, March 2005 Created by Health Management
Associates
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Critical Issues for Health Coverage Reform

• How to create a sustainable program?
• How to finance coverage? (who pays what how)
• How to administer coverage?
• What and how much to cover under the plan?
• How to design cost sharing?
• What and how can people obtain additional
  coverage outside of any plan?
• What to pay providers?
• Is there enough workforce capacity to meet demand
  for services?

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Critical Issues for Health Coverage Reform

• How to make sure that coverage turns into actual
  access to care
• What requirements/expectations to place on
  individuals? on providers? on administrators?
• How to define and achieve affordability?
• How best to promote prevention and chronic care
  management?
• To mandate or not to mandate?
• Create special plan for young adults?
• How to pool risk?
• Individual rating
• Community rating
• High Risk Pool
• Reinsurance

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Cost of Health Coverage Expansion

• HPIO estimates that covering all the uninsured
  will require around 4 billion more in health
  spending within the current system, with not all
  of these funds coming from government
• Actuarial estimates presented to the Health
  Reform Advisory Group suggest a need for between
  1.5 to 2 billion, most of which is for low
  income subsidies, to cover around half of the
  uninsured

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Is spending reform needed for expansion?

• Health costs as number one concern, higher than
  coverage expansion
• Reform strategy must target spending issues to
  create an affordable, sustainable model
• Per a 2000 study by the Midwest Business Group on
  Health, 30 of health spending adds no value or
  negative value (due to overuse of care, underuse
  of care, misuse of care, and administration of
  care)
• Per Dartmouth Atlas, could reduce spending by 30
  on care for Medicare people with severe chronic
  conditions with better outcomes if resources and
  utilization of efficient providers were realized
  by all providers serving these patients

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The U.S. Health Care Delivery System Is Flawed,
cont.

• The Leapfrog Group, made up of many major
  corporations pushing for effective health care
  purchasing, finds that the quality of the U.S.
  health system is at best equal to how well the
  airline industry handles baggage versus the
  safety record for flying planes
• Study by researchers at Rand Corporation found
  that providers follow best practices on average
  55 of the time, lowest for alcohol related
  conditions, highest for mammography screening

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Needed Components forAn Improved Health Care
System

• Better health information for consumers and
  providers
• Putting the consumer at the forefront of
  consideration
• Adoption of electronic health information systems
  in the practice of medicine
• Improved delivery of quality, cost-effective
  health services
• Revised payment system for services towards
  outcome-based payment
• Improved individual health behaviors
• Improved physical, environmental, and social
  health systems
• Universal health coverage

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Partial List of Citations

• McGlynn, Elizabeth, et. al. June 26, 2003. The
  Quality of Health Care Delivered to Adults in the
  United States. The New England Journal of
  Medicine 3482635-2645. http//content.nejm.org/c
  gi/content/abstract/348/26/2635
• Midwest Business Group on Health. 2003. Reducing
  the Costs of Poor-Quality Health Care Through
  Responsible Purchasing Leadership. in
  collaboration with Juran Institute, Inc and The
  Severyn Group, Inc. http//www.mbgh.org/pdf/Cost
  of Poor Quality Report.pdf
• Cannon, Michael. Announcing the Anti-Coverage
  Club. http//www.cato-at-liberty.org/2007/06/27/an
  nouncing-the-anti-universal-coverage-club/
• The Care of Patients with Severe Chronic Illness.
  Executive Summary. http//www.dartmouthatlas.org

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Partial List of Citations

• McKinsey Global Institute. Accounting for the
  Cost of Health Care in the United States. January
  2007. http//www.mckinsey.com
• Commonwealth Fund State Scorecard on Health
  System Performance 2007. http//www.cmwf.org
• Health Policy Institute of Ohio
  http//www.healthpolicyohio.org
• Mapping Health Spending and Insurance Coverage in
  Ohio
• A Review of Health Coverage Expansion Strategies
  and Lessons for Ohio
• Coverage Expansion Reform Options for Ohio
• Employment and Health Care Coverage in Ohio
  Chart Book of Working Ohioans
• Ohios Small Group Health Insurance Market
• Ohio Medicaid Basics
• A Strategic Roadmap and Policy Options for the
  Effective Adoption of Health Information
  Technology and Exchange in Ohio

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Contact Information

• William Hayes, Ph.D.
• President
• Health Policy Institute of Ohio
• 37 West Broad Street, Suite 350
• Columbus, OH 43215
• [phone] x305
• whayes_at_healthpolicyohio.org

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