By Sarah Green
KHI News Service
TOPEKA, Feb. 5
There”s no gold standard for state health care reform initiatives; no single model that points the way for states seeking to expand health coverage to the uninsured.
Still, there are states that appear further down the path than others and no shortage of
proposed reforms that share common elements.
“There”s no question that this is an issue that has leapt to the top of the visible heap in terms of health issues in 2007 state legislative sessions,” said Richard Cauchi, health program director for the National Conference of State Legislatures.
It”s not a new issue, Cauchi said. For the last decade, state legislatures have been grappling with the big question of how best to reform the health care system and provide coverage to the millions of their residents who lack it.
But media coverage, and a new level of proposed and approved legislation have expanded the debate over what is needed and what is possible.
Health reform legislation is or has been under consideration in at least 16 states this year, Cauchi said. But even that number is hard to pin down because of the different ways to define what constitutes a health reform initiative. It could be legislation that has been introduced or even the creation of governmental commissions to study the issue and propose policy changes.
“Part of the lesson for states is this is not a topic to be discussed quickly and simply,” Cauchi said. “They (states that have implemented reforms) spent many months with the stakeholders at the table, going through different levels of discussion and debate, then passing something in one chamber, then another, and coming to an agreement later,” he said. “The process is as important as the final product.”
Here”s a survey of a few of the states that have had success, are debating legislation, or are in some other way seeking to address the issue of reforming the health system to expand access to care.
Click on the state for more information or scroll down to see all of the states:
California
Illinois
Maine
Massachusetts
Minnesota
New York
Vermont
The plan:
Expand enrollment in the state”s public insurance programs to all children, regardless of their immigration status, who live in homes where the family income is as much as 300 percent above the federal poverty level, or FPL which, for a family of three, is $51,500 a year.
The plan also allows uninsured, legal resident adults with incomes below 100 percent of FPL for single adults that means earning less than $10,200 a year to enroll in Medi-Cal, one of the state”s public programs.
Legal resident adults with incomes between 100 and 250 percent of FPL for those who are single that is between $10,200 and $25,500
would be eligible for coverage through state programs.
If passed as proposed, state law would require all individuals to have a minimum level of coverage.
Who pays for it:
The proposal, estimated to cost $12 billion, requires small businesses with 10 or more workers that do not offer insurance coverage to pay 4 percent of their payroll to a state fund. That fund would be used to subsidize health insurance for the working uninsured.
Also, doctors and hospitals will pay 2 and 4 percent of their respective revenues to the state”s Medicaid program to help cover higher reimbursements for those who treat Medicaid patients.
Status:
Gov. Arnold Schwarzenegger unveiled the proposal on Jan. 8. It requires approval from the state”s Legislature. Two other major plans to address the issue have been debated
the first in 2004 and the second in 2006
but neither were approved.
The plan:
The Covering All Kids Health Insurance Act makes insurance coverage available to all uninsured children by making insurance more accessible to low-income families.
The goal is to cover about 50 percent of uninsured children in Illinois whose families have incomes above 200 percent of the Federal Poverty Level, the eligibility ceiling for Illinois” State Children”s Health Insurance Program. Two-hundred percent of the FPL is equivalent to an annual income of about $34,300 for a family of three.
The All Kids program is also linked with other public insurance programs and relies on outreach efforts to educate parents about their options.
Of the 250,000 eligible uninsured children in Illinois, the state predicts that 50,000 will be enrolled in the first year of the program.
Who pays for it: The program, estimated to cost $45 million to cover the 50,000 children targeted by the state, will be funded mostly
about 75 percent
through premiums and co-pays from the families enrolled in the program. The state also expects to save more than $50 million in the first year by moving most of the state”s Medicaid enrollees into a primary-care case management program designed to improve quality of care and reduce costs.
Status:
The program began covering children on July 1, 2006; as of January 2007, the All Kids program will be available to any child who has been uninsured for 12 months or more. The cost to the family will be determined on a sliding-scale basis.
For more information:
http://www.allkidscovered.com/
The plan:
Expand coverage, control costs and improve quality of health insurance programs through the state”s Dirigo Health Reform Act to insure all uninsured Maine residents by 2009.
Who pays for it:
Funding for DirigoChoice coverage and the cost and quality initiatives comes from employer and individual contributions, state general funds and federal Medicaid matching funds for those individuals who are eligible.
DirigoChoice, a program that offers discounts on monthly premiums and reductions in deductibles, is available to small businesses, the self-employed and eligible individuals who do not have access to employer-sponsored insurance. Low-income enrollees have incomes below 300 percent of the Federal Poverty Level, which is equivalent to about $51,500 per year for a family of three.
Status:
The health reform act was enacted in 2003. About 12,000 Maine residents enrolled in the DirigoChoice program in its first year, drawing criticism from some because the number was much lower than the state had anticipated. Most of those enrollees were low-income individuals who benefited from the subsidies.
Gov. John Baldacci established a Blue Ribbon Commission in 2006 to make recommendations for long-term funding and cost-containment. Changes were implemented recently aimed at streamlining the administration of the program and making it easier for individuals to participate. Outreach and marketing strategies have also been increased to help boost enrollment.
For more information:
http://www.dirigohealth.maine.gov/
The plan:
Cover 95 percent of the state”s uninsured residents in three years.
Massachusetts residents are required to carry insurance coverage. Those who do not, and do not obtain a waiver for religious reasons, will be assessed a penalty on their income tax returns.
Employers too are expected to chip in.
Those who do not provide insurance to their employees are required to contribute financially to help cover the cost of health care for their employees.
Who pays for it:
Individuals, employers and the government. The state requires employers with more than 10 employees to provide health insurance coverage. Individuals who can afford health insurance are required to purchase a coverage plan; government subsidies are available to families who make at or below 300 percent of the federal poverty level which is equivalent to about $51,500 per year for a family of three who may purchase insurance on a sliding scale using pre-tax dollars. The state”s Medicaid program was expanded to give free coverage to children in those families.
A “connector” (the Commonwealth Health Insurance Connector) will help individuals and businesses find affordable health coverage. The connector also allows individuals to keep their policies and health care providers if they switch employers.
Young adults may remain on their parents” plan up to two years after they are no longer considered dependents for tax purposes or until age 25. Low-cost health insurance options are being created for young adults ages 19 to 26.
About $385 million in federal matching funds previously used to fund safety-net and uncompensated care will be redirected to help subsidize the reform. The state will also invest $308 million in general fund revenues over three years.
The status:
Former Gov. Mitt Romney approved the insurance coverage law in April 2006. Massachusetts residents have until July 1 of this year to purchase an insurance plan.
For more information:
Commonwealth Health Insurance Connector
The plan:
Require all Minnesota residents to carry health insurance. Those who do not comply would be subject to a penalty based on income and what they would pay for coverage; anyone who does not comply may be subject to pre-existing condition limitations when they do apply for coverage.
Who pays for it:
Individuals and the government. Residents who make up to 300 percent of the Federal Poverty Level, or the equivalent to about $51,500 per year for a family of three, could be eligible for a sliding-scale subsidy to help pay their premiums for private insurance. Employers are not required to participate, but incentives and barriers that prevent employers from dropping insurance coverage could influence employers” decisions.
All insurers that provide policies to businesses or groups are required to participate in the individual market, and must offer at least three insurance plans. Unmarried children would be allowed to stay on their parents” policies up to age 25, regardless of student status.
The plan is estimated to cost $900 million.
Status:
The state is now discussing a plan to focus primarily on covering children and allowing individuals without insurance from their employer to pay for their own private insurance premiums with pre-tax dollars. Gov. Tim Pawlenty released the new proposal in mid-January after his State of the State speech. Legislation that would create one proposal, the Children”s Security Program, is now in committee in the state”s legislature.
The plan:
Make health insurance available to all children and enroll all eligible adults in Medicaid.
Who pays for it:
No specifics on a New York plan yet; however, the United Hospital Fund, a not-for-profit health services research group in New York, estimated in a 2006 report that 2.4 million uninsured New York citizens could be covered for $4.1 billion a year using approaches that combine individual mandates; a modest employer assessment; and an expansion of public programs
much like the Massachusetts model.
The status:
Gov. Eliot Spitzer asked the New York Legislature in early January to work on a budget that “in the very first year, guarantees access to health insurance for all of New York”s 500,000 uninsured children.”
The plan:
Insure 96 percent of Vermont residents by 2010. Participation in the plan is voluntary unless the goal is not met by 2010; the state will then consider an individual mandate.
Who pays for it:
Individuals, employers and the government. Funding will come from federal matching funds, premiums, employer assessments and an increased tobacco tax.
The health reform plan, called Catamount Health, is available for residents who have been uninsured for 12 months. Coverage is based on plans available to those who do not have insurance through their employers, but with less of a contribution from the individual or family.
Families with an annual income up to 300 percent of
FPL are also eligible for the state”s Catamount Health program. Three-hundred percent of FPL is about $51,500 for a family of three. The state also provides premium assistance to low-income individuals with access to employer-sponsored insurance that previously have been unable to afford insurance.
Employers must pay an annual assessment if they don”t offer plans that pay some part of the employee”s insurance. Those employers who do offer such a plan must still pay the annual fee for ineligible workers and for those who refuse to participate and do not have insurance from another source.
Status:
The coverage expansion has been paired with an additional health reform effort: the Vermont Blueprint for Health. The Blueprint focuses on chronic care management and provides incentives for residents who monitor their health.
Private insurers will begin selling Catamount policies beginning Oct. 1, 2007; the state plans to expand the Blueprint program across the state by 2009.
Sources:
“State of the States” report from AcademyHealth, a non-partisan organization that includes health services and policy researchers and practitioners; the National Business Group on Health, a non-profit organization that researches health care for large companies; the National Conference of State Legislatures; The New York Times.
Federal Poverty Level estimates are calculated using 2007 guidelines.