solutions for the uninsured
DESCRIPTION
Solutions for the Uninsured. Karen Davis President, The Commonwealth Fund Second National Medicaid Congress 2007 Washington, DC June 15, 2007 [email protected] www.commonwealthfund.org. What Are the Problems?. Uninsured Rates. Costs of Care. Administrative Complexity. - PowerPoint PPT PresentationTRANSCRIPT
Solutions for the Uninsured
Karen DavisPresident, The Commonwealth Fund
Second National Medicaid Congress 2007Washington, DC June 15, [email protected]
www.commonwealthfund.org
2
What Are the Problems?What Are the Problems?
Uninsured Rates
Quality of Care Chasm
Costs of Care
Administrative Complexity
3
Uninsured Non-Elderly Adult RateUninsured Non-Elderly Adult RateIncreased from 17.8% to 20.5% in Last Five Years;Increased from 17.8% to 20.5% in Last Five Years;
Varies from 11% to 30% Across StatesVaries from 11% to 30% Across States
Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
19%–22.9%
Less than 14%
14%–18.9%
23% or more
1999–2000 2004–2005
MA
RI
CT
VTNH
MD
NH
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
4
Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
Percent of Uninsured Children Declined Since Percent of Uninsured Children Declined Since Implementation of SCHIPImplementation of SCHIP
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
10%–15.9%
Less than 7%
7%–9.9%
16% or more
1999–2000
DE
MARI
WA
ORID
MT ND
WY
NVUT
KS
NE
MN
MO
WI
TX
IA
ILIN
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DC
HI
CO
GAMS
NJ
SD
2004–2005
CT
VTNH
MD
AR
CA
AZ NMOK
5
21.0 21.4 21.6 21.9 22.6 25.5 26.3 27.8
3.3 4.65.3 6.0
6.2
1.90.9
0
20
40
1997 1998 1999 2000 2001 2002 2003 2004
SCHIP
Medicaid
Source: The Commonwealth Fund; Data from Georgetown Center for Children and Families and CRS. Based on children ever-enrolled over the course of a year.
Children’s Enrollment in Medicaid and SCHIP, Children’s Enrollment in Medicaid and SCHIP, 1997–20041997–2004
Of 6.2 million in SCHIP in 2004:
1.8 million were in Medicaid 4.4 million were in separate programs
22.3 23.525.2
21.0
27.230.8 32.3
34.0
Millions of children (under age 19)
6
THE COMMONWEALTH
FUND
Financial Burden for Low- and Financial Burden for Low- and Middle-Income Families Is IncreasingMiddle-Income Families Is Increasing
26 24
16
7
33
24 23
10
0
25
50
<100% FPL 100% to <200%
FPL
200% to <400%
FPL
400%+ FPL
1996 2003
Percent of non-elderly adults spending 10% or more of disposable income on family out-of-pocket medical costs and premiums
Note: Financial burden includes out-of-pocket expenditures on premiums for private insurance and other health care services.
Source: J.S. Banthin and D.M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger than 65 Years,” JAMA 296, no. 22 (Dec. 13, 2006): 2712-19.
7
THE COMMONWEALTH
FUND
The Solution is in SightThe Solution is in Sight
1. Extend health insurance to all
2. Promote effective cost control strategies
3. Organize the care system
4. Pursue and raise benchmark levels of high quality, safe, effective, efficient care and enhance system capacity to innovate and improve
5. Shape a coherent set of health care policies through national leadership and public-private collaboration
8
THE COMMONWEALTH
FUND
Building Blocks for Building Blocks for Extending Health Insurance to AllExtending Health Insurance to All
• Individual mandate• Shared responsibility
– Employer financing coverage for workers or contributing to pool; covering young adults under parents’ plans
– State and federal financing• Federal/state subsidies to make coverage affordable for low-
income individuals and families– Expansion of Medicaid/SCHIP with federal matching– Sliding scale premium subsidies
• Pooling insurance risks– State Connector/Health Insurance Exchange– Federal Employees Health Benefit Plan (Congressional
Health Plan)– Medicare for All
• Quality and Efficiency Provisions
9
THE COMMONWEALTH
FUND
New Coverage for Currently Uninsured
Purchasing Pool Congressional
Health Plan FEHBPConnector
TOTAL = 24 m
MedicareTOTAL = 38 m
11m 13m
CHIP/FHIPTOTAL = 43 m
Employer Group Coverage
TOTAL = 165 m
14m 1m
Improved Coverage for Underinsured
3m 1m3m 11m
Source: K. Davis and C. Schoen, “Creating Consensus on Coverage Choices,” Health Affairs (Web Exclusive April 23, 2003).
Creating Consensus on Automatic and Creating Consensus on Automatic and Affordable Health Insurance For AllAffordable Health Insurance For All
10
THE COMMONWEALTH
FUND
Massachusetts Health Plan:Massachusetts Health Plan:Major InnovationsMajor Innovations
Individual mandate Shared Responsibility
Employers cover workers or pay $295/employee
Subsidies for affordable coverageAvailable to those between 100 and 300% of
povertyMassHealth expansions for children below
300% poverty and adults below 100% poverty Pooling insurance risks
Commonwealth Care Connector to organize affordable insurance offerings
Source: John Holahan, “The Basics of Massachusetts Health Reform,” Presentation to United Hospital Fund, April 2006.
11
THE COMMONWEALTH
FUND
Update: Massachusetts Update: Massachusetts Health Care ReformHealth Care Reform
– The state has already signed up more than half of the poorest people who are eligible (122,000 new residents covered during the first year of health care reform)
– New plans called Commonwealth Choice went on sale May 1 and go into effect July 1, 2007
– Three tier benefits: basic, value, premium -- deductibles range from $0 to $2,000
12
THE COMMONWEALTH
FUND
California Governor’s Proposal:California Governor’s Proposal:Major InnovationsMajor Innovations
Individual mandate Shared Responsibility
Employers cover workers or pay 4% of wages as fee Subsidies for affordable coverage
Available to those below 250% of poverty Medi-Cal expansion to all children below 300% poverty
and adults below 100% poverty Pooling insurance risks
Insurance exchange Guaranteed issue; community rating with age bands 85% minimum medical loss ratio
Other provisions Provider fee assessment (2% of physician revenue to 4%
of hospital revenues)
13
THE COMMONWEALTH
FUND
Maine’s Dirigo Health: Past, Present and Maine’s Dirigo Health: Past, Present and FutureFuture
No individual mandate Governor recently proposed
No requirements on employers Governor recently proposed pay or play
State subsidies for affordable coverageNew insurance product, $1250 deductible;
sliding scale deductibles and premiums below 300% poverty
Medicaid expansions Pooling insurance risks
Dirigo Health Plan: only one insurer participating Governor recently proposed minimum medical loss
ratio
14
THE COMMONWEALTH
FUND
Vermont Health Care Affordability Act Vermont Health Care Affordability Act Enacted May 2006Enacted May 2006
No Individual Mandate Shared Responsibility
Employer assessment State subsidies for affordable coverage
Premium subsidies based on sliding scale up to 300% FPL
Pooling insurance risks Catamount Health Plan targets individuals w/o access
to work-based coverage Quality and efficiency provisions
Comprehensive benefit package including primary care, chronic care, acute care & other services
No patient cost sharing for preventive or chronic care services
Build upon Wagner’s Chronic Care Model
15
THE COMMONWEALTH
FUND
Prescription for PennsylvaniaPrescription for Pennsylvania
Individual mandate for families > 300% FPL; can buy in for the entire premium (expected to be $280 per month)
Shared Responsibility Employer mandate: 3 percent payroll
tax on employers with 50 or more employees that do not provide insurance
Subsidies for affordable coverage Available to all parents below 300%
poverty; sliding scale, low monthly premium ($10-$70)
Employer contribution for employees earning less than the average state wage = $130 per month; employee sliding scale
No pooling of insurance risks
16
THE COMMONWEALTH
FUND
Strategies for Strategies for Extending Health InsuranceExtending Health Insurance
• Tax incentives for individual insurance (President Bush)
• Federal support for state initiatives (Senators Bingaman/ Voinovich; Representatives Baldwin/Price)
• Federal financing with regional insurance exchange (Senator Wyden)
• Hybrid – regional purchasing pools with Medicare-like option (Senator Edwards)
• Hybrid – national purchasing pool based on Federal Employees Health Benefits Program (Senator Obama)
• Medicare for All (Representative Stark; Representative Dingell/Senator Kennedy)
17
THE COMMONWEALTH
FUND
H.R. 5684: Health Partnership Through H.R. 5684: Health Partnership Through
Creative Federalism ActCreative Federalism Act
Rep. Tammy Baldwin (D-WI)Rep. Tammy Baldwin (D-WI)
• Real cooperation from across the aisle – proposed by Baldwin and Price with the support of both the Heritage Foundation and the Brookings Institute; National Governor’s Association also had role in drafting the bill
• Requests that states submit proposals for state health care coverage expansion and improvements in quality, efficiency, cost-effectiveness, and the appropriate use of health information technology
• State proposals defined as statewide, multi-state or limited to certain regions
• Establishes a Commission to:– Request and review proposals and submit a list it
recommends for approval to Congress– Report to the public concerning progress made by
states– Make recommendations for minimizing negative effects
of state programs on national employer, provider organizations, insurer
Rep. Tom Price (R-GA)Rep. Tom Price (R-GA)
Rep. John Tierney (D-MA)Rep. John Tierney (D-MA)
18
THE COMMONWEALTH
FUND
S. 2772: Health S. 2772: Health
Partnership ActPartnership Act
Senator George Voinovich (R-OH)Senator George Voinovich (R-OH)
• Provides states with grants to carry out innovative state health programs, with priority given to programs most likely to expand coverage and improve access
• Establishes a Commission to:– provide states with reform options for state health care
expansion and improvement programs– establish minimum performance measures and goals with
respect to coverage, quality, and cost of state programs– review state applications and determine whether to submit a
state proposal to Congress
Senator Jeff Bingaman (D-NM)Senator Jeff Bingaman (D-NM)
19
THE COMMONWEALTH
FUND
President Bush
State Reforms(15 States)
AmeriCare(Rep. Stark)
Sen. Edwards
Sen. Obama
Total Uninsured Covered, Millions
9.0 20.3 47.8 45?? 40-45??
Net Health System Cost in 2007 (in
billions)($11.7) $22.7 ($60.7) N/A N/A
Federal Government Costs (in billions)
$70.4 $22.0 $154.5 $90–120?? $50-60??
Change in Insurance
Administration (in billions)
$5.5 $2.0 ($73.9) N/A N/A
1Out of an estimated total uninsured in 2007 of 47.8 million.2 Estimated to cover 86% of the 23.6 million people projected to be uninsured in the 15 states in 2007. Source: S. R. Collins, K. Davis, and J. L. Kriss, An Analysis of Leading Congressional Health Care Bills, 2005-2007: Part I Insurance Coverage, The Commonwealth Fund, March 2007
Features of Current Approaches to Quality Features of Current Approaches to Quality Affordable Health Coverage for AllAffordable Health Coverage for All
20
THE COMMONWEALTH
FUND
Strategies for Achieving a High Performance Health System
• Align financial incentives– Payment incentives to promote efficient and effective care– Effective cost control strategies
• Organize the health care system to ensure accessible and coordinated care
– Patient-centered medical home
– Integrated delivery systems and multi-specialty group practices• Pursue excellence in safe, effective, efficient care and enhance
capacity to innovate and improve
– Investing in health information technology and information exchange systems
– Better information on provider quality and total costs for episode of care
– Spreading best practices and use of benchmark data
– Center on Comparative Effectiveness and Evidence-based Decision Making
• National leadership and public-private collaboration to achieve coordinated policies, simplification, and enhanced value
21
THE COMMONWEALTH
FUND
SCHIP ReauthorizationSCHIP Reauthorization• Senator Kennedy/ Senator Hatch
– Increased funds for outreach and simplified enrollment procedures to reach eligible, but uninsured children
– SCHIP funds to help cover the cost of health insurance premiums for children in lower-income families with access to employer-sponsored coverage and increased flexibility for states to determine income eligibility levels for their programs
• Senator Clinton/ Representative Dingell – Expand SCHIP to children in families with incomes up to 400% of FPL – Employers and parents can purchase health insurance through SCHIP
• Senator Rockefeller/ Senator Snowe– Double state allotments to cover children while streamlining the eligibility
process – State option to cover pregnant women and children who are legal immigrants – Ease requirements to document citizenship and improve benefits – Strengthen standards to ensure mental health coverage and make dental
coverage a guaranteed benefit• Representative Emanuel
– Funding for all currently eligible children; tax credits for middle income families to buy coverage
• Representative Barton/ Representative Deal– Limit SCHIP funds to coverage of low-income children and pregnant women
who live below 200 percent of the poverty level
22
THE COMMONWEALTH
FUND
5945
32 38 3422
3
3244
49 42 39
29
110
20
40
60
80
100
Legal
immigrant
children if
income-
eligible
Children up
to 300% FPL
Buy-in
option for
families
above
income
threshold
All parents
of children
covered by
SCHIP
Childless
adults under
100% FPL
All children
regardless
of income
Children
under 200%
only
FavorStrongly favor
Strong Support for Eligibility Expansions Strong Support for Eligibility Expansions under SCHIPunder SCHIP
8882 80
73
51
Percent
91
14
Note: Segments may not sum to totals because of rounding.Source: The Commonwealth Fund Health Care Opinion Leaders Survey, April 2007.
23
THE COMMONWEALTH
FUND
ConclusionConclusion• SCHIP is a test of Congressional and Administration support for
state initiatives in extending health insurance coverage• Health reform will be a major issue in the 2008 presidential
election• Business/labor/consumer/senior coalitions beginning to lead
the drive for universal coverage• State reforms are pointing the way• Building blocks for universal coverage
– Individual mandate– Shared financial responsibility– Expansion of existing programs:
• Medicaid/SCHIP• Medicare• Employer coverage (e.g. young adults)
– Creation of state or federal purchasing pool• Connector/Health Insurance Exchange• Medicare for All or FEHBP
• Will need to address quality and efficiency; achieve savings as well as expand coverage
24
THE COMMONWEALTH
FUND
Thank You!Thank You!Sign up for e-alerts at www.commonwealthfund.orgSign up for e-alerts at www.commonwealthfund.org
Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commonwealth Fund Commission on a High Performance Health [email protected]
Cathy Schoen, Senior Vice President, Research & Evaluation, Commonwealth Fund [email protected]
Sara Collins, Assistant Vice President, The Commonwealth Fund [email protected]
Anne Gauthier,Senior Policy DirectorCommission on a High Performance Health [email protected]
Katherine Shea, Research Associate, Commonwealth Fund
Rachel Nuzum,Program OfficerState [email protected]