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This is the Health Chairs e-Bulletin for July 2005.From our State Health Notes:Medicaid Reform Shifts to The Front BurnerIn mid-June, as members of the U.S. Congress began wrangling over ways to peel $10 billion from the federal Medicaid budget over five years, state lawmakers met just a mile away to discuss a similar agenda: how to contain Medicaid costs while protecting enrollees. The lawmakers were all chairs of state health committees, and they met under the auspices of NCSL’s Health Chairs Project, funded by the Henry J. Kaiser Family Foundation. They heard some of the top Medicaid experts in the nation explain the extraordinarily complex nature of the program and traded tips on what’s working in their own states. The focus on Medicaid was timely. With 58.5 million enrollees and $316 billion in state and federal expenditures in 2005 (according to the Congressional Budget Office, March 2005), Medicaid has surpassed Medicare to become the largest public insurance program in the country. Medicaid now accounts for about 22 percent of the average state budget (if federal funding is included), more than states spend on average on all elementary and secondary education. If the federal share is not included, Medicaid consumes 13 percent of the average state budget. Read the story at http://www.statehealthnotes.org/issues/26_447/cover/140486-1.html. If you need your SHN password, contact Faith Chang (faith.chang@ncsl.org). This year’s Chairs Meeting was webcast! You can share sessions with your colleagues by having them log in to Opportunities and Challenges to Meaningful Medicaid Reform or Restructuring within the States. National Conference of State Legislatures http://www.kaisernetwork.org/healthcast/ncsl/16june05. The sessions are also written up in the most recent issue of NCSL’s State Health Notes. Additional readings, overheads and links based off the agenda will be posted soon. Look for a link on the Chair’s page, http://www.ncsl.org/programs/health/forum/chairs . Looking AheadWe also look forward to seeing you in the other Washington in August, at the Annual Meeting in Seattle. We are holding a Health Chairs session featuring Washington’s innovative approaches to long term care, from 3 to 5 on Tuesday, August 16 in Seattle in room 611 of the Convention Center. To see all NCSL Annual Meeting sessions dealing with health go to http://www.ncsl.org/annualmeeting/agenda/showmain3.cfm?topicsel=xhlt. Access and Public ProgramsThe Urban Institute has released a report detailing changes in the SCHIP program between 2002 and 2003. Ebbing and Flowing: Some Gains, Some Losses as SCHIP Responds to Third Year of Budget Pressure by Ian Hill, Brigette Courtot, and Jennifer Sullivan. In a scant 12 pages, the report packs in detailed analyses of policy alternatives and decisions around the program in Urban’s13 “New Federalism” study states. http://www.urban.org/UploadedPDF/311166_A-68.pdf. More on coverage options for children: The Maternal and Child Health Policy Research Center recently published a review of States’ Use of Medicaid Options for Expanding Children’s Eligibility. According to their press release, “All states use at least one of 13 major options for extending Medicaid eligibility to children who do not meet the criteria for mandatory coverage, and most use at least 7, with the most common being coverage of children in state-subsidized adoptions and children in home- and community-based waiver programs.” Read more about each option, and see which states use each, at http://www.mchpolicy.org/documents/MedicaidEligibilityOptionsFactSheet.pdf. The Center also has other policy documents that may be of interest. Check out their main page, http://www.mchpolicy.org/.
Being underinsured can mean almost as much trouble as being uninsured. In a Health Affairs Web Exclusive, “Insured but Not Protected: How Many Adults Are Underinsured?" the authors estimate that 16 million Americans are underinsured. Like the uninsured, they are likely to go without needed care and suffer medical debt. The authors warn that new trends in insurance products may exacerbate the problem. According to the Commonwealth Fund site, the authors defined underinsured as having “insurance all year but inadequate financial protection, as indicated by one of three conditions:
One size doesn’t fit all—and we can prove it! This Health Affairs report by Gleid and Gould, “Variations in the Impact of Health Coverage Expansion Proposals across States” models the potential impact of various approaches to expanding coverage, taking into account current differences in state policies and markets. The conclusion: policies affect different states in different ways. The paper summarizes a great deal of information about things that contribute to the impact of various policies in a compact space. It includes state-by-state data on variables such as nongroup premiums, low income uninsured, and uninsured workers in small firms, and ranks states into five categories of expected effect of various strategies. http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.259v1. Medicaid and BudgetsTestimony on Medicaid reform from the National Governors Association has opened a very important debate about which Medicaid budget numbers states should be using—total budgets or general fund accounts—when describing Medicaid’s importance in state budgets. http://www.ncsl.org/statefed/health/NGAresp.htm Be sure to read the Congressional Research Service’s analysis, including trends in state general fund spending. http://www.familiesusa.org/site/DocServer/CRS_Memo_Medicaid_Share_State_Budgets.pdf?docID=9381&autologin=true I asked NCSL’s Medicaid expert, Donna Folkemer (donna.folkemer@ncsl.org) why certain states did show much higher levels and jumps in state general fund dollars between 1990 and 1995 as compared to other states wondering if these represented states that had been aggressive with DSH and IGT strategies. While this explains some of the variation, other states may look very different depending on unrelated factors such as k-12 education spending is a state or a local budget item. So, interpret the numbers with caution! OPINION ALERT (we report but do not necessarily endorse this): FFIS’ Vic Miller says the most important number isn’t in either analysis. It is the rate at which Medicaid is growing, regardless of how it is being funded, and what proportion of new state spending goes into Medicaid budgets, potentially supplanting other policy choices. (At least 40 states subscribe to FFIS’ budget analyses, available at http://www.ffis.org/.)
If you want to make this comparison, you might take a look at the 2002–2003 State Health Expenditure Report is now available from the National Association of State Budget officers (NASBO), Milbank and the Reforming States Group at http://www.milbank.org/reports/05NASBO/NASBO2005.pdf (this is the complete version including state profiles). This report shows all state spending for health, including state employees, corrections and public health, and puts them in the context of other state spending. Another Congressional Research Service report on How Medicaid Works: Program Basics updated March 16, 2005 is now available. This 62-page report includes all sorts of background including state-level breakdowns of Medicaid by eligibility category and current and projected federal matching rates through 2006. The table below shows that the greatest rate of growth in recipients has been among the blind and disabled, while the number of aged recipients has changed little. The report is archived at the University of Maryland, which archives many CRS documents http://www.law.umaryland.edu/marshall/crsreports/index.asp
By the way, CRS reports will now be easier to find, thanks to a project that has linked a number of different archives. Operated by the Center for Democracy and Technology, a Washington-based civil liberties group, http://www.opencrs.com/ links and centrally indexes thousands of these reports.
The National Health Law Program (NHeLP) has posted a June update on state Medicaid eligibility cuts, prepared by the Title II Community AIDS National Network: 2005 State Medicaid Eligibility Cutbacks & Exclusions: Proposed & Recently-Enacted. NHeLP is a health rights advocacy organization, as reflected in the comments in this roundup. The document also includes some links on Medicaid for advocates. http://www.healthlaw.org/library.cfm?fa=detailItem&fromFa=detail&id=70858&folderID=43248&appView=folder&r=id%7E%7E43248,appview%7E%7Efolder,fa%7E%7Edetail,rootfolder%7E%7E23177.
Medicaid Managed Care has been an essential part of the program’s cost and care management in virtually every state. The National Academy for State Health Policy has just released an extremely detailed report on the topic, using results of surveys conducted from 1990 to 2002. Although the most recent years are not included, the 1990s were a time of rapid growth and change in managed care, and the report explores the many variations of managed care and programmatic authority. Download Trends in Medicaid managed care: 1990-2002 at http://www.nashp.org/Files/mmc_guide_final_draft_6-16.pdf. Source: NASHP 2005 The Government Accountability Office (GAO) has released a report, “States’ Use of Contingency-Fee Consultants to Maximize Federal Reimbursements Highlights Need for Improved Federal Oversight”. It was written for a Congress that seems to have Medicaid in its sights, but the report may also be interesting to states who want more clarity on what activities are currently deemed acceptable and which are in dispute. http://www.gao.gov/new.items/d05748.pdf The same may be said of this report Medicaid States’ Efforts to Maximize Federal Reimbursements Highlight Need for Improved Federal Oversight http://www.gao.gov/new.items/d05836t.pdf. Prescription DrugsThe National Association of Attorneys General (NAAG) has issued a report that “assembles in one place some background information about the prescription drug industry, the divergent views of leading thinkers on several important issues related to pharmaceutical prices and the varied responses to these issues that different states are presently exploring.” Since the state exploration draws heavily on NCSL’s work, it’s bound to be good. The entire report—or sections of interest to you—can be downloaded at http://www.naag.org/naag/pdf/20050620-PR-AddressingTheCostAndBenefitsOfPrescriptionDrugs.pdf. Public HealthLeading by Example. Workplace health comes front and center in Partnership for Prevention's Leading by Example CEO-to-CEO initiative. The project emphasizes prevention rather than treatment. Aren’t states big corporations (I said to myself)? You bet. Near the top of the list of CEOs is Arkansas Governor Huckabee, closely followed by Governors Taft of Ohio and Virginia’s Warner. There are plenty of solid ideas here, from other CEOs as well as the governors, that you may want to pick up on for your state. You can click on the states in the list of CEOs or the feature sheets, take a self-assessment (think “state” for “company”) or read the whole report at http://www.prevent.org/lbe_home.htm. Medical EthicsThe New England Journal of Medicine has a review of the changing content of “conscience clauses.” The report includes a chart showing the varying approaches states have taken to the competing needs and rights of patients and providers. The author points out that licensing laws create a monopoly on who can provide certain services, and that this may bear with it some public utility obligations to patients in relation to such things as contraception prescriptions and advance directives. The article points to Illinois’ approach as striking an effective balance between individual and collective duties. Read the report at http://content.nejm.org/cgi/content/full/352/24/2471.
Source: Charo R.A. The Celestial Fire of Conscience — Refusing to Deliver Medical Care. N Engl J Med 2005; 352(24):2471-3, Adapted from a map compiled by the National Women's Law Center. DisparitiesIf all racial and ethnic groups fared as well as Whites, there would be great reductions in premature death and avoidable disability: a study this year estimated 83,000 deaths could be avoided. See how your state is doing—and how far you have to go—in achieving equality in birth outcomes, according to the latest state by state data on infant mortality rates, by race and ethnicity from the CDC http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5422a1.htm. A recent conference at the Commonwealth of Virginia pointed out that a multiplicity of economic and educational factors are important in improving health http://www.rwjf.org/portfolios/features/digest.jsp?iaid=133&id=78216. From the StatesRepresentative Gielow had a copy of a proposal for Wisconsin with him at the recent Chairs meeting, but it didn’t make it into our discussions. With his permission, we’re circulating it to you now. Here’s a four-page concept paper of a proposal described as a “work in progress.” http://www.wisconsinhealthproject.org/plan/whpconcept.pdf. You can also find a great deal of interesting and valuable background material developed in the study at the page for the Wisconsin State Assembly’s Committee on Medicaid Reform, which he chairs, http://www.legis.state.wi.us/assembly/asm23/news/index.htm and at a home page for the proposal, known as the Wisconsin Health Plan, at http://www.wisconsinhealthproject.org/plan/index.htm. Massachusetts has been having a vigorous debate about how to expand coverage to all its uninsured. Two reports prepared by the Urban Institute present policy options for the state and give a mixture of detailed data and stories of the uninsured. They propose a mix of tax credits, purchasing pool, reinsurance and public coverage expansions. Link to these Roadmap to Coverage reports at http://www.roadmaptocoverage.org/pubs/main.html. California. The historical role of counties is the subject of Caring for Medically Indigent Adults in California: A History. County programs vary widely and have very different funding and other resources, and the state often lacks information it might need to better plan for public health needs. The relationship of state and county varies a great deal around the country, but it is common for indigent care to be a local government responsibility. Some other large states have similar intergovernmental issues around health, and smaller states may see similarities between counties and their own experiences vis-à-vis the federal government. http://www.chcf.org/documents/policy/RoleCountiesInHealthOfCalifornians.pdf. Here is a link to Texas’ county indigent care program. http://www.tdh.state.tx.us/cihcp/default.htm. Conventional WisdomThis may be one of those important articles that change the way we look at things. Thorpe and colleagues conclude that insurance costs are going up because we are treating more diseases (not because we are spending more for each treated case). This is due to changing health factors and changing treatments. The article is free from Health Affairs at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.317. WebcastHere’s a webcast of a recent conference, 2005 National HIV Prevention Conference. http://www.kaisernetwork.org/hivprevention2005 Among the items through that site is a list by state of numbers of people living with HIV infection or with AIDS, by age category. http://www.cdc.gov/hiv/stats/2003SurveillanceReport/table12.htm
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