1. Overview of State Efforts Toward Health Reform
Molly Voris
Senior Policy Analyst
Center for Best Practices
National Governors Association
for the
National Congress on the Un and Under Insured
September 23, 2008

2. The Picture for Health Reform
45.7 million uninsured in 2007
$56 billion in uncompensated care in 2008
Federal and state dollars cover at least 75% of uncompensated care
State and local governments fund $17.2 billion in uncompensated care
U.S. spends the most per individual on health care ($6,714 in 2006) but lags behind in quality of care provided
Sources: U.S. Census Bureau, 2008; “Covering the Uninsured in 2008, Hadley J et al., for the Kaiser Commission on Medicaid and the Uninsured, August 2008; OECD Health Data 2008 – Frequently Requested Data.

3. The Picture for State Health Reform
Fiscal environment for states
Increasing cost of health care unsustainable
States are exploring many options
Medicaid redesign
Coverage expansion mechanisms
Health care system improvements and better population health

4. State Private Insurance Market Reforms
Connector Model: Pools individuals to offer several affordable, private insurance options
States may offer subsidies for low-income individuals to purchase health insurance to ensure affordability
Examples of states: Florida, Massachusetts, Washington
Section 125 Plans: Requiring or incentivizing employers to set them up for their employees
Examples of states: Indiana, Massachusetts,
Minnesota

5. State Private Insurance Market Reforms (continued)
Employer/Individual Mandates: Part of a universal coverage effort to ensure greater participation
Fines and taxes assist with financing of universal plan
Example of states: Massachusetts, Maine (proposed), New Jersey (for children in 2009)
Benefit Package Design: State defines benefit package and solicits bids from private insurers
Success often depends on state insurance market
Example of states: Connecticut, Maine, Tennessee, Vermont
Dependent Coverage: Require insurers to increase age for covering children of employees
Not a great cost to the state
Targets one of larger uninsured groups in states

6. Public Program Reforms
Medicaid/SCHIP redesign
Private insurance model
Medical home model/coordinated care for chronic conditions
Use of incentives (debit cards, rewards)
Beneficiary involvement and responsibility
Coverage expansions
SCHIP outreach
Expansions of program
Buy-in programs
Limited funds for expansions and difficult choices during budget crises

7. Broader State Health Systems Reform
Increased interest in quality and transparency measurement—process, outcomes, and consumer satisfaction
Drive systemic quality improvement and comparative effectiveness
Insurance regulation, purchaser (state employees/retirees), public health system
Increased emphasis on coordinated care/disease management for chronic diseases

8. Broader State Health Systems Reform (continued)
Greater emphasis on e-health initiatives
E-prescribing
E-health records
Increased concentration on inpatient quality initiatives
Non-payment for “never” events
Hospital-acquired infections reporting to the state and some to the public
Greater concentration on prevention and wellness
Medical homes

9. State Coverage Reform Example: Insure Oklahoma
Available to small businesses with 50 or fewer FTEs with incomes <200% FPL
State set requirements to be a “qualified plan,” includes hospital care, pharmacy benefits, and OOP limits
Insure OK pays 60%, employer pays 25%, employee pays 15% of premium
Market determines other benefits and premiums/cost-sharing within state parameters
Competitive market – 19 carriers, 252 qualified health plans
Over 8,000 people enrolled (as of March 2008)

10. State Quality Reform Example: Minnesota QCare
Initiative to improve quality and cost through better performance and outcomes
Coalition of public and private sector partners
State-purchased health care must comply with QCare standards and align payments and incentives
Standards set in four key areas
Diabetes
Hospital stays
Preventive care for adults and children
Cardiac care
Smart Buy Alliance – public/private partnership of purchasers that base purchases on results of uniform quality measurements (QCare standards)

11. State Systems Reform Example: Vermont
Catamount Health Plan
Non-Group market product offered to the uninsured
Comprehensive benefit package
Employer contribution ($365/year per uninsured FTE)
Premium assistance
Blueprint for Health
Statewide partnership to help those with chronic conditions manage their illness and provide preventive services
Gives providers tools to help patients manage illnesses
Chronic Care Management Programs
Medicaid, Dr. Dynasaur (SCHIP) and VHAP
Carriers offering Catamount Health Plans
State employee health care plan
Vermont Information Technology Leaders (VITL)
Public/private partnership
Charged with creating an integrated, electronic health information infrastructure for the sharing of information among health care facilities, health care professionals, public and private payers, and patients

12. Future State Considerations
States not sure they can afford to wait for (and rely on) potential federal reforms
Continue to see incremental reform initiatives as long as health care costs continue to rise, coverage levels drop, and economy is uncertain
Those interested in reform can learn from pioneer states on successes and challenges
Continued focus on maximizing value of health care dollars