What is next for states moving toward near-universal coverage?
What is next for states moving toward near-universal coverage?
Vermont, Maine, and Massachusetts are all front runners in the effort to achieve near-universal coverage. And many state Medicaid directors are planning to follow in their footsteps: As of November 2008, 14 additional states were moving toward comprehensive reform, according to the Kaiser Commission on Medicaid and the Uninsured.
But how will the economic downturn affect these plans? "States like Massachusetts are not interested in going backwards. So they will be trying to hold on to what they have," says Robin Rudowitz, a principal policy analyst for the Kaiser Commission on Medicaid and the Uninsured, and former Medicaid director in the Office of Legislation at the Centers for Medicaid & Medicare Services.
Regarding the 14 states that have announced plans to move toward comprehensive reform, Ms. Rudowitz says these are a "mixed bag. Some states are really committed to moving forward with their health coverage expansion, such as Iowa, which just did a big health expansion for kids. A number of states that did advance that are trying to hold on and not move backward," she says.
Whether the states can maintain or even expand coverage depends largely on two pieces of federal legislation, says Ms. Rudowitz: What happens with reauthorization of SCHIP, and the economic stimulus bill that is expected to include Medicaid fiscal relief.
In the previous downturn, Medicaid federal fiscal relief was successful in helping states to address shortfalls, avoid deeper program cuts, and maintain eligibility levelsa condition of the relief. The relief, however, was criticized for coming too late to help some states, which had already made significant budget cuts.
"States are certainly anxious for fiscal relief now," says Ms. Rudowitz, "especially as governors are developing and releasing their proposed budgets. So, timing is also going to be a factor." She notes that coverage expansion is difficult to do without providers, as states face a shortage of primary care physicians and physicians failing to re-contract despite rate increases.
Program affects nation
According to Tom Dehner, Massachusetts' Medicaid director, the state's health care reform law was designed to achieve near-universal access to health insurance. "Our progress, so far, is very encouraging," he reports. "By every available estimate, our rate of uninsurance has fallen dramatically in a very short period of time."
More than 439,000 people in Massachusetts are newly enrolled in health insurance plans since the health reform was passed into law in June 2006. "Almost half of those are insured in the private market. This is particularly encouraging and will help to ensure the long-term sustainability of our program," says Mr. Dehner.
According to an August 2008 report from the U.S. Census Bureau, Massachusetts now has the lowest percentage of uninsured of all states, with a two-year average of 7.8% in 2006-2007. This represents a decrease of 2.4% from the 2005-2006 period.
The number of newly insured includes 72,000 individuals whose primary coverage is through MassHealth, which covers 1.1 million people overall, and 176,000 individuals who now are insured through Commonwealth Care.
Mr. Dehner says the state's health care reform efforts are even having a significant impact on the national level.
The August 2008 report indicates the national rate of uninsured has decreased by 1.34 million people from 2006-2007. "In our state, the number of uninsured dropped by 317,000. This indicates that Massachusetts is responsible for 24% of the overall national decline, while we account for only 2.1% of the population," he reports. "This speaks to the impact that individual state actions can have on the national level."
Obstacles were overcome
Initially, the greatest challenge was creating and starting enrollment in the new health coverage programs in a very short time frame. Mr. Dehner says Massachusetts was "enormously successful" in meeting those initial operational objectives, primarily through collaboration between MassHealth, the state Medicaid program, and the newly-created Commonwealth Health Connector.
"We have been fortunate throughout to have had the strong support of U.S. Secretary of Health and Human Services Michael Leavitt, and through our Medicaid 1115 waiver, we have secured ongoing federal support for our health reform programs," says Mr. Dehner.
The $21.2 billion agreement, a $4.3 billion increase over the current waiver, fully preserves existing eligibility and benefit levels as well as federal matching funds for all programs, including Commonwealth Care at 300% of the federal poverty level. The agreement protects federal matching funds for MassHealth waiver programs for the long-term unemployed, the disabled, and people living with HIV. It also allows the state to meet all of its health care obligations for the current fiscal year.
The state will be able to meet all of its health care obligations for FY 2009, when the state will be able to claim $150 million for programs for which it was unable to claim matching funds in FY 2008.
The agreement also expands the Patrick administration's authority to bill for programs in the Safety Net Care Pool, which represents authority for federal reimbursement for Commonwealth Care payments, Health Safety Net spending, and hospital supplemental payments by $1 billion over the current waiver period.
The federal government has proposed a three-year cumulative cap on Safety Net Care Pool expenditures, instead of the current annual cap. This flexibility allows the state to meet all of its commitments for FY 2009 and to plan ahead to meet all FY 2010 and FY 2011 commitments.
Looking ahead, however, Mr. Dehner says controlling health care costs is critical to ensure that the gains made in access to care are sustainable. "We also need to focus on health care quality, so that the care people get is appropriate to their needs," he says.
In December 2008, the HealthyMass initiative was launched. Nine agencies from across state government came together in their roles as employers, purchasers, providers, regulators, insurers, administrators, stewards of public health, and sources of health care financing. The goals are to ensure access to care, contain health care costs, advance health care quality, promote individual wellness, and develop healthy communities by aligning policies across state agencies.
"These state agencies are collaborating to decrease administrative burdens on providers, decrease the impact of chronic disease, and align payments to support primary care and community hospitals," says Mr. Dehner.
Model for other states
"We are keenly aware that other states and federal policy-makers are watching our demonstration closely, as well as our success in dramatically reducing the number of uninsured in such a short period of time," says Mr. Dehner. "It is important to note that Massachusetts had some critical building blocks in place before 2006."
These included a relatively generous Medicaid program, strong consumer protections in private insurance, and a pool of money to cover some expenses for uninsured individuals.
Ultimately, however, Mr. Dehner says Massachusetts has been successful because of a solid policy design, strong federal support, an efficient operational infrastructure for implementation, and broad support for reform from the public, the advocacy community, and the health care industry.
"Those are components that any fundamental reform effort will need to contain to succeed," says Mr. Dehner. "Policy-makers in other states will need to clearly assess their own system's starting points for expanding health care access."
Like many states, Massachusetts recently has had to make some difficult but necessary budget decisions. "As part of $1.4 billion in budget cuts across state government, we trimmed $293 million from our Medicaid program," says Mr. Dehner. "In making these cuts, we fully preserved coverage levels and eligibility for our members, which were our top priority."
Contact Mr. Dehner at (617) 573-1770.Vermont, Maine, and Massachusetts are all front runners in the effort to achieve near-universal coverage. And many state Medicaid directors are planning to follow in their footsteps: As of November 2008, 14 additional states were moving toward comprehensive reform, according to the Kaiser Commission on Medicaid and the Uninsured.
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