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This is the Health Chairs e-Bulletin for May 2005.

Access

Cover the Uninsured Week is the first week of May. The site for this annual event, sponsored by the Robert Wood Johnson Foundation, deserves some exploring if this issue is of interest to you at http://covertheuninsuredweek.org/.  Near the bottom of this page is a drop-down menu that lets you access state-specific information on how to get coverage.  You can find out about planned events near you—there are events in every state-- at http://covertheuninsuredweek.org/events/. 

A new report issued in conjunction with the week gives state-level information about numbers and characteristics of the uninsured.  The report has more information about what that means for access than is usually seen in counts of the uninsured because it is based on a different survey--the Behavioral Risk Factor Surveillance System Survey (BRFSS) The analysis was done by Minnesota’s State Health Access Data Assistance Center (SHADAC).   According to the press release, “Working But Uninsured: Millions of Employed Americans Uninsured and Unable to Get Medical Care:  State-by-state analysis shows 41% of uninsured adults unable to see a doctor when needed due to cost.” http://covertheuninsuredweek.org/media/research/SHADAC2005.pdf

State Planning Grants

Some of the most interesting policy developments now surfacing in the states got their first rigorous airing as a result of the federal Health  Resources and Services Administration (HRSA) State Planning Grants.  A new report summarizes states’ experience to date with the program, which funded states to gather and analyze information on who lacked coverage and convene state decisionmakers to strategize about policy options.  Eight states have moved on to the pilot program stage.  This valuable documentation is a little like a high school yearbook, full of promising new beginnings.  Time will tell which go on to make a permanent mark.  http://www.cmwf.org/tools/tools_show.htm?doc_id=273662

Table 1. State Planning Grant Program Grantees

FY 2004 (9)	FY 2003 (10)	FY 2002 (12)	FY 2001 (9)	FY 2000 (11)
American Samoa	District of Columbia	Alabama	Arizona	Arkansas
Guam	Florida	Georgia	California	Delaware
Kentucky	Mississippi	Hawaii	Colorado	Illinois
Louisiana	Missouri	Indiana	Connecticut	Iowa
Michigan	Nebraska	Maine	Idaho	Kansas
North Carolina	New Mexico	Maryland	South Dakota	Massachusetts
Pennsylvania	North Dakota	Montana	Texas	Minnesota
Puerto Rico	Oklahoma	New Jersey	Utah	New Hampshire
Tennessee	Rhode Island	South Carolina	Washington	Oregon
	Virginia	Virgin Islands		Vermont
		West Virginia		Wisconsin
		Wyoming

Note: States and territories that have not received a State Planning Grant are Alaska, Nevada, New York, Ohio, and Northern Mariana Islands.
Source:  Health Resources and Services Administration.

Medicaid

The Kaiser Commission on Medicaid and the Uninsured recently sponsored two sessions on Medicaid that offer a lot of information at different levels.  Both the webcasts allow you to hear the speakers, see their transcripts and view related documents.

An introductory briefing on Medicaid, given to Congressional staff, can provide a refresher for you or an introduction to this complex program for new members and staff. It features presentations by KCMU president Diane Rowland, Rodney Whitlock of the Republican staff of the Senate Finance Committee, and the Executive Director of the National Academy for State Health Policy, Alan Weil. The session, with related documents, is available on line, for http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1373

For another level of discussion, a recent session on possible policy changes in Medicaid from Kaiser is a “meet the experts” with Jim Frogue, state project director, Center for Health Transformation; Alan Weil, executive director, National Academy for State Health Policy ; and Jeanne Lambrew, Ph.D. http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1406

Medicaid waivers are where states—and the federal government--do most of their experimenting with the program.  Samantha Artiga and Cindy Mann are the authors of a new analysis of recent waivers and their policy implication.  New Directions for Medicaid Section 1115 Waivers: Policy Implications of Recent Waiver Activity examines the 17 waivers that have been approved since January 2001. The brief and a companion fact sheet may be reached from http://www.kff.org/medicaid/7286.cfm  

To learn more about a specific state’s waivers, including older ones and more targeted waivers as well, visit the Department of Health and Human Serices’ clickable map at http://www.cms.hhs.gov/medicaid/waivers/waivermap.asp

Insurance and Market Innovations

The National Health Policy Forum has released three new reports that provide in-depth looks at some issues related to innovations in the private insurance market.  The reports, about 30 pages long, give the historical and legislative background of these programs, details on how they operate, and an exploration of various policy proposals currently being considered. Health Savings Accounts: The Fundamentals, by Beth Fuchs and Julia A. James and Fundamentals of Underwriting in the Nongroup Health Insurance Market: Access to Coverage and Options for Reform by Mark Merlis and  Health Insurance Coverage for Small Employers by Dawn M. Gencarelli can all be found at http://www.nhpf.org/.

To see what individual insurance market policies prevail in one state, see the California Health Care Foundation’s updated issue brief on rules affecting California’s individual market.  The page also links to briefs about California’s small group and managed care regulations.  http://www.chcf.org/topics/healthinsurance/index.cfm?itemID=20739&subTopic=CL500&subsection=reports

The Commonwealth Fund has released two reports that take a skeptical look at the market for health savings accounts (HSAs) among the uninsured.  “The Effect of Health Savings Accounts on Health Insurance Coverage,” by Sherry A. Glied and Dahlia K. Remler can be downloaded at http://www.cmwf.org/publications/publications_show.htm?doc_id=274002 and “How High Is Too High? Implications of High-Deductible Health Plans,” by Karen Davis, Michelle M. Doty and Alice Ho, which concludes that even these plans are likely to be unaffordable for most of the uninsured. http://www.cmwf.org/publications/publications_show.htm?doc_id=274007

Life and Death

The Schiavo tragedy caught the nation’s attention.  Some groups have been working for years to help individuals and providers communicate clearly about their final wishes and think through these hard decisions so that choices can remain private.

Caring Connections has information about end-of-life care including sections on care giving, pain management, grief, hospice, and advanced directives including links to state documents for advanced directives. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1 .

From Aging with Dignity, a comprehensive alternative to other living wills is the “Five Wishes” document.  Five Wishes helps its users to be clear about their preferences in regards to “medical, personal, emotional and spiritual” aspects of end-of-life care.  The site also includes discussion of how to talk about these choices with family and caregivers. Over two-thirds of states accept this document as an alternative to a living will. http://www.agingwithdignity.org/states.html  

The National Right to Life Project presents the same information framed in terms of a “will to live,” explaining how to give precise and clear advanced directives that take into account a variety of possible circumstances. http://www.nrlc.org/euthanasia/willtolive/index.html

The National Association of Attorneys General (NAAG) has been conducting an end-of-life-care project for several years. In addition to issues related to advanced directives, they have been a voice for states in regards to pain management for terminally ill patients. A report on activities in a dozen states, links to state sites, and reports including a collection of thumbnails on 30 state coalitions can be found at http://www.naag.org/issues/issue-endoflife.php

Simple illustrated advanced directives forms may be found in English and Spanish at the Institute for Healthcare Advancement’s (IHA) site.  The forms help people with limited literacy create a California advanced directive.  They would need to be adapted for use in other states. According to IHA, “Results from the 1992 National Adult Literacy Survey showed that nearly 90 million American adults, or nearly one of every two adults, could not function above the lowest 2 levels of literacy.”  Check out the good information and materials on the rest of the site.  Low literacy can be an obstacle to good health, especially for many people on public programs. http://www.iha4health.org/index.cfm?menuitemid=112&menusubid=41

Quality

Finally, to see how this reporting is done by a medical center that has been a national leader in quality measurement, here is how New Hampshire’s Dartmouth-Hitchcock Medical Center provides information to its community. http://www.dhmc.org/qualitymeasures/default.cfm

Wellness