states and federal health care reform skidmore college dr. robert turner state and local politics
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States and Federal Health Care Reform
Skidmore College
Dr. Robert TurnerState and Local Politics
Presented by Courtney BurkeSeptember 23, 2010
Overview of States and Health Care
Examples of How Governments Influence Health Policy and Law
Advertising and marketing of health services & products
Expending funds on public programs, including public health insurance
Regulating anti-trust, health care contracting, privacy
Overseeing employment, workforce, patents, taxation, disparities, consumer protection, bioterrorism, etc.
Overseeing health insurance regulation, Rx regulation, human subjects research
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Government’s Balancing Act
Balance between public regulation for public health’s sake and the rights of private individuals
Examples – regulating companies’ advertising of cigarettes; gun manufacturers’ liability for injury; requiring the use of seatbelts; taxing unhealthy foods
What is federal vs. state jurisdiction?
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Law and Policy Powers of Government
Powers of public health agencies that directly protect and promote health
Power to police (states retain this right, too)
The right to tax and spend (this can coerce certain health behaviors)
Provide for the public’s welfare (public health insurance)
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Who Makes Policy? States
Governors and legislatures – pass laws; allocate money; provide oversight
State agencies – license and accredit; ensure public health; oversee health insurance
Courts – decide on scope of law; enforcement; balance between government and individual rights; punitive role
The scope and role is different in every state
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States and Medicaid
States’ Role in Medicaid
Setting eligibility, benefits
Overseeing payments, program integrity
Enrollment and coordination
Financing
Overall administration
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Interesting Things about States, the Federal Government, and Medicaid Federal government sets minimum rules, provides for
at least half of total costs
Medicaid (MA) is the largest grant-in-aid to states (much larger than education, transportation, or other funds)
To alleviate state budget gaps, the federal government has often used Medicaid as a vehicle for helping states balance their budgets
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Interesting Things about States and Medicaid
Very different across states
States have maximized flexibility
Medicaid is the largest funding source for long-term care (e.g., nursing home care, home care, hospice, durable medical equipment, services for persons with disabilities, etc.)
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Medicaid: NY and US Comparison Source: Kaiser Commission on Medicaid and the Uninsured
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States and Medicaid Waivers
Waivers are a statutory means for flexibility
Waivers have allowed cuts in services, but primarily focused on expansion and innovation
Research & demonstration or programmatic
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States and Health Care Reform
State Role in Health Reform: Financing
Three main sources of costs for states: Increased minimum levels for Medicaid eligibility –
state share
“Woodwork” effect for those currently eligible but not enrolled in public insurance
Administrative costs
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Financing (Example of New York) Woodwork – Enhanced state match may not apply to
those already eligible for public insurance but not currently enrolled (close to 1 million people in NY)
Administrative – Enrolling thousands more people, creating new administrative entities, etc.; NY Bridge Plan, exchange
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State Role in Health Reform: Administration
Create and oversee state insurance exchanges
Regulate products and rules within exchanges
Regulate small group & individual markets
Provide wraparound services or additional subsidies
Coordinate exchange with public insurance programs
Enforce individual or employer mandates
Potentially administer public option or develop co-ops
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Administration Examples in New York
Exchange – upstate/downstate, statewide, interstate?
Change rating rules or keep pure community rating?
Who is eligible for exchange?
Wrap services for those above federal eligibility levels or require them to use exchange with subsidies?
Provide additional subsidies to low-income because cost of insurance is higher?
Expand Family Health Plus buy-in or develop co-ops?
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State Role in Health Reform: Implementation
Update legislation, programs, and processes
Request waivers from federal rules if needed
Inform residents about options, provide outreach
Create technology to link old and new programs
Ensure services and programs mesh
Create new forms and eligibility processes
Assist citizens through the process
Expand capacity to deal with new enrollees
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Other Potential Roles for States What about illegal immigrants? Underinsured?
Interim operator of high-risk pools in some states
Creators/operators of co-op or public option
What exactly might the public option be? A Medicaid or Family Health Plus buy-in? A Medicare buy-in? FEHBP buy-in? A new plan? A stop-gap?
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State and Local Governments
All states (except VT) must have balanced budgets (some annual, some semi-annual)
About half of states have tax and expenditure limitations requiring supermajority or voter approval to increase taxes
Supplement federal programs; fill gaps; implement programs
Administer and help fund Medicaid and SCHIP
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Example of State Role in Health Reform
Implement and monitor compliance with new insurance regulations; oversee insurance products, rating rules
Provide outreach and assistance to residents about new laws and regulations
Set up and administer state-based insurance exchanges
Provide subsidies to businesses or individuals
Coordinate new programs with existing programs
Help finance costs of increased enrollment
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Class Role Play: States and Health Reform
Governor
Community health center
State Medicaid director
State Insurance commissioner
Small business
Medicaid enrollee
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Class Role Play: Health Reform
Explain your role in the policy process
What are your priorities/interests?
Where/how will you intervene in the process?
What will you say to your congressperson?
How will your point of view affect the process?
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Favorite State Health Policy Resources Kaiser State Health Facts online
www.statehealthfacts.kff.org
National Academy for State Health Policy www.nashp.org
Commonwealth Fund www.cmwf.org
Robert Wood Johnson Foundation www.rwjf.org
State Coverage Initiatives www.statecoverage.org
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Rockefeller Institute
The Public Policy Institute of theState University of New York
Courtney BurkeDirector, Health Policy Research Center411 State StreetAlbany, NY 12203-1003(518) 443-5522burkec@rockinst.orgwww.rockinst.org
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