State Insurance Plus Initiatives

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State Insurance Plus Initiatives

• Cathy Schoen
• Senior Vice President, The Commonwealth Fund
• Alaska Work Shop Panel National Overview and
  State Strategies
• Anchorage, Alaska
• December 7, 2006

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Moving Forward Recent State Strategies to
Expand Insurance
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Massachusetts Health Plan

• MassHealth expansion for children up to 300 FPL
  adults up
  to 100 poverty
• Individual mandate, with affordability provision
  premium
  subsidies between 100 and 300 of poverty
• Employer mandatory offer, employee mandatory
  take-up
• Employer assessment (295 if employer doesnt
  provide health insurance)
• Connector to organize affordable insurance
  offerings through a group pool

Source John Holahan, The Basics of
Massachusetts Health Reform, Presentation to
United Hospital Fund, April 2006.
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Massachusetts Strategies for Coverage Building
Blocks for Reform
Government
Health Care System

• Builds on past low income expansion
• Subsidized insurance
• Uncompensated Care pool reform
• The Connector

• Meet quality and performance standards
• New levels of transparency
• Adjust to payment changes

Expanded Coverage
Employers
Individuals

• Fair Share Assessment
• Free Rider provisions
• Mandatory cafeteria plans

• Individual Mandate

Source A. Lischko, Massachusetts Health
Reform. NASHP 19th Annual State Health Policy
Conference, Pittsburgh, PA (October 16, 2006) and
Alliance for Health Reform Briefing, November
2006.
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Maines Dirigo Health Knitting Together Public,
Private and Employer Insurance
Annual expenditures on deductible and premium
2,738

• New insurance product sliding scale deductibles
  and premiums below 300 poverty
• Employers pay fee covering 60 of worker premium
• Began Jan 2005 Enrollment 14,700 as of 4/30/06
• Combined with expanded public

2,188
1,638
1,100
550
0
After discount and employer payment (for
illustrative purposes only).
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Building Quality Into RIte CareHigher Quality
and Improved Cost Trends

• Low income insurance expansion
• Quality targets and incentives
• Improved access, medical home
• One third reduction in hospital and ER
• Tripled primary care doctors
• Doubled clinic visits
• Significant improvements in prenatal care, birth
  spacing, lead paint, infant mortality, preventive
  care

Cumulative Health Insurance Cost Trend Comparison
Percent
RI Commercial Trend
RIte Care Trend
Source Silow-Carroll, Building Quality into
RIte Care, Commonwealth Fund, 2003. Tricia Leddy,
Outcome Update, Presentation at Princeton
Conference, May 20, 2005.
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Rhode IslandFive-Point Strategy

• Creating affordable plans for small businesses
  individuals
• Increasing wellness programs
• Investing in health care technology
• Developing centers of excellence
• Leveraging the states purchasing power
• RI Quality Institute
• Non-profit coalition -- hospitals, providers,
  insurers, consumers, business, academia
  government
• Partnered with SureScripts to implement
  state-wide electronic connectivity between all
  retail pharmacies and prescribers in the state
• Health Information Exchange Initiative
• Statewide public/private effort
• AHRQ contract 5 yr/ 5M
• Connecting information from physicians,
  hospitals, labs, imaging other community
  providers

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Illinois All-Kids

• Effective July 1, 2006
• Available to any child uninsured for 6 months or
  more
• Cost to family determined on a sliding scale
• Linked to other public programs - FamilyCare
  KidCare
• Federal and state funds
• Children lt200 of FPL covered by federal funds
• Children 200 of FPL funded by state savings
  from Medicaid Primary Care Case Management
  Program
• All-Kids Training Tour
• Public outreach program to highlight new and
  expanded healthcare programs

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New Jersey Raises Age of Dependent Status for
Health Insurance

• Rapid increase in uninsured young adults since
  2000
• Several states have expanded age of dependents
• As of 5/2006, NJ requires all state insurers to
  raise dependent age limit to 30
• Highest age limit in country
• Covers uninsured, unmarried adults with no
  dependents, NJ residents or FT students
• Premium capped at 102 of amount paid for
  dependents coverage prior to aging out
• 200,000 young adults expected to receive coverage
  

Millions uninsured, adults ages 1929
Source S.R. Collins et al., Rite of Passage?
Why Young Adults Become Uninsured and How New
Policies Can Help, Commonwealth Fund issue
brief, May 2006. (Analysis of the March 20012005
Current Population Surveys)
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West Virginia Small Business PlanLeveraging
Purchasing Power

• Enacted March 2004
• Partnership between WV Public Employees Insurance
  Agency (PEIA) private market insurers
• Small business insurers pay providers at same
  rates negotiated by PEIA

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Minnesota Smart-Buy Alliance

• Initiated in 2004 alliance between state,
  private businesses, and labor groups
• Purchase health insurance for 70 of state
  residents 3.5 million people
• Pool purchasing power to drive value in health
  care delivery system
• Set uniform performance standards, cost/quality
  reporting requirements technology demands
• Four key strategies
• 1. Reward or require best in class
  certification
• 2. Adopt and utilize uniform measures of quality
  and results
• 3. Empower consumers with easy access to
  information
• 4. Require use of information technology

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Wisconsin

• Wisconsin Collaborative for Healthcare Quality
• Voluntary consortium formed in 2003 -- physician
  groups, hospitals, health plans, employers
  labor
• Develops publicly reports comparative
  performance information on physician practices,
  hospitals health plans
• Includes measures assessing ambulatory care, IT
  capacity, patient satisfaction access
• Wisconsin Health Information Organization
• Coalition formed in 2005 to create a centralized
  health data repository based on voluntary sharing
  of private health insurance claims, including
  pharmacy laboratory data
• Wisconsin Dept of Health Family Services and
  Dept of Employee Trust Funds will add data on
  costs of publicly paid health care through
  Medicaid

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Several States Looking to More Comprehensive
Health Reform Statewide

• Maine, Maine, Vermont, Rhode Island have quality
  initiatives built into coverage expansions
• Maine
• Created Maine Quality Forum to advocate for high
  quality health care and help Maine residents make
  informed health care choices.
• Massachusetts
• Cost and Quality Council formed
• Vermont
• Quality improvement initiatives
• Interest in joint purchaser strategies public
  and private payers collaborate to share
  information and leverage

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What Are the Goals of More Universal
Coverage?Insurance as Foundation to Improve
System Performance

• Meaningful, affordable, and equitable access
• Broad risk pooling
• Eliminate insurance market incentives that reward
  avoidance of health risk or cost shifting
• Use insurance as foundation to facilitate
  system-wide -
• Timely, appropriate and effective care
• Enhanced primary, preventive and well-coordinated
  care
• More effective chronic care
• Lower insurance administrative costs by
  simplification and more efficient coverage
• Stable coverage with seamless transitions
• Reduce marketing, underwriting and overhead costs
• Simplification and coordination
• Use insurance expansions as a vehicle and
  foundation to achieve more integrated, high
  quality and efficient care

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State Strategies to Expand Coverageto Provide a
Foundation to Improve Access, Quality and Cost
Performance

• Develop blueprints toward more universal coverage
• Coherent policies that maximize connection and
  minimize complexity
• Expand public programs and connect with private
  
• Provide financial assistance for affordability
  premium assistance buy-in provisions
• Assure benefit designs cover primary, preventive
  and essential care
• Pool risk and purchasing power, with multi-payer
  collaboration
• More efficient insurance arrangements and
  simplification
• Pool purchasing power
• Develop reinsurance or other financing strategies
  to make coverage more affordable, pool risk and
  stabilize group rates
• Shared responsibility mandate that employers
  offer and/or individuals purchase coverage

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Source Professor Uwe Reinhardt, Princeton
University
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Making Coverage More AutomaticEmployer vs.
Public Insurance
Source Based on D. Remler, S. Glied What Can
the Take-Up of Other Programs Teach Us
Increasing Participation in Health Insurance
Programs, Am. J. of Public Health, January 2003.