Leading the Way? Maine’s Experience in Expanding Coverage: Lessons for other States
Cyber-Seminar sponsored by The Commonwealth Fund's State Innovations program and the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization and State Coverage Initiatives programs
February 1, 2008
Overview of Presentation
• • • • • Lessons from Maine Lessons from State Reform Efforts Key Policy and Design Issues State Reform Evaluations Concluding Thoughts
Enrique Martinez-Vidal Vice President, AcademyHealth Director, State Coverage Initiatives
State Coverage Initiatives
Lessons from Maine #1
• Need to understand landscape – How does new program fit in?
– – – – – – Percentage of employers that are small High premium costs in private market High deductibles in private market Limited competition Medicaid eligibility was already high New program vs current market – pooling/adverse selection
Lessons from Maine #2
• Funding source – Finding/Sustaining • Small employer enrollment/outreach
– – – – Marketing/public awareness needs multi-faceted approach Application/enrollment process requires support/multiple entry points plan design encourages, but does not assure, enrollment agents and brokers should be involved in the program
• Benefit design/Affordability • Tradeoffs between coverage and costs
- Premiums/Out-of-Pocket - Preventive benefits – PCP; HRA - Choice? (e.g., MA)
• Implementation challenges • Access in context of broader health care reform (cost containment/quality improvement) • Criticism of program size
- voluntary program not going to result in universal coverage
State Coverage Initiatives
State Coverage Initiatives
Lessons learned in state reform efforts #1
• Successful comprehensive reforms are built on previous efforts, financing mechanisms • No free solutions • Successful efforts to enact reforms often need shared financial responsibility • Voluntary strategies will not result in universal coverage - some states are beginning to recognize the need for mandatory participation • Hard to get agreement on what is covered
State Coverage Initiatives
Lessons learned in state reform efforts #2
• Address access, systems improvement, cost containment simultaneously—concern about long-term sustainability of programs and improved population health New state reforms can be fairly judged only after several years, allowing a realistic length of time to work through implementation challenges. Ambitious goals that brought these programs to life may be their biggest challenge creating an expectation that they will meet these lofty goals in the short term.
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State Coverage Initiatives
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Key Policy and Design Issues
• • • • • • • • • Different Populations Require Different Solutions Defining the Goals Subsidies and Financing: Who will pay? Who will benefit? Should Health Insurance Coverage Be Required? What is Affordable Coverage? What is the Most Appropriate Benefit Design? How Can Risk Be Pooled? Do Insurance Markets Need to be Reformed/Reorganized? Best Mechanisms for Cost Containment/Systems Improvement
Health Reform Evaluations
• Acknowledgment:
– State Health Access Data Assistance Center – State Health Access Reform Evaluation
State Coverage Initiatives
State Coverage Initiatives
The Importance of Reform Evaluation
Inform future state policy Justify program budget/financing Satisfy legislative requirements Identify successful initiatives Change course if program not meeting benchmarks • Inform state and national debate on health reform
– What works at the state level?
Performance Assessment
• How do you know if your health reform was successful? • Key Areas to Assess:
– – – – Coverage Cost and Efficiency Fairness and Equity Choice and Autonomy
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• Develop goals that are measurable, assessable and realistic. • Consider short-term and long-term outcomes. • Think now about what you will want to know later
– It’s more difficult to go back and evaluate a program without good baseline data and information
Source: CMS Evaluating Demonstrations: A technical assistance guide for states.
State Coverage Initiatives
State Health Care Reform
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Concluding Thoughts
State health care reform is not going away
– Uninsurance climbing, ESI eroding, costs increasing – No federal solution in the near-term
If States are the Laboratories…..
Where are the lab reports?
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States play critical role in moving the conversations about coverage expansions
Testing new ideas (politically and practically) Creating momentum for national policy solution
Catch 22: Often need ambitious goal to sell new initiatives but need to be realistic about what states can do - given overall fiscal picture, how far can states go? Comprehensive reforms need sequencing
Sequential = incremental with a vision
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State cannot achieve universal coverage without a federal framework and funding: acknowledge significant variation across states—including uninsured rates, available state funds to invest in coverage, insurance market structures, and other important factors States are hopeful - looking toward other states doing substantial or comprehensive reforms
State Coverage Initiatives
State Coverage Initiatives
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