Leading the Way? Maines 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 Enrique Martinez-Vidal Vice President, AcademyHealth Director, State Coverage Initiatives

Overview of Presentation Lessons from Maine Lessons from State Reform Efforts Key Policy and Design Issues State Reform Evaluations Concluding Thoughts 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 Benefit design/Affordability Tradeoffs between coverage and costs -Premiums/Out-of-Pocket -Preventive benefits – PCP; HRA -Choice? (e.g., MA) State Coverage Initiatives

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 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

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 simultaneouslyconcern 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. State Coverage Initiatives

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 State Coverage Initiatives

Health Reform Evaluations Acknowledgment: –State Health Access Data Assistance Center –State Health Access Reform Evaluation 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? Source: CMS Evaluating Demonstrations: A technical assistance guide for states.

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 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 –Its more difficult to go back and evaluate a program without good baseline data and information State Coverage Initiatives

State Health Care Reform If States are the Laboratories….. Where are the lab reports? State Coverage Initiatives

Concluding Thoughts State health care reform is not going away –Uninsurance climbing, ESI eroding, costs increasing –No federal solution in the near-term 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 State cannot achieve universal coverage without a federal framework and funding: acknowledge significant variation across statesincluding 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