What Works: Public and Private Initiatives to Improve Access to Health Services

In this chapter, we examine structural responses to gaps in health care for the uninsured and underinsured and discuss some of the successful programs that have emerged in other states and localities. Broadly speaking, there are two types of initiatives to extend health care access to low-income Americans: subsidies for health services (either financial, in public sector programs, or in-kind, through voluntary and charitable efforts) and expansions of health insurance coverage. The following discussion focuses primarily on the health insurance strategy, but this focus is not intended to understate the importance of direct services, particularly for the most vulnerable Americans. We do not anticipate further coverage expansion initiatives from the federal government in the immediate future, and thus focus on alternative responses at the state level.

Which Kentuckians lack access to necessary health services? A recent study by the UK Center for Health Services Management and Research reinforced the well-documented link between health insurance and access to services, particularly for adults, and found that the uninsured are more likely to be poor, poorly educated, and rural Kentuckians than their insured counterparts.(1) Some uninsured Kentuckians are actually eligible for coverage: 1997 survey analysis by the Kentucky Legislative Research Commission found that some 123,000 Kentucky children who were uninsured would qualify for enrollment in either Medicaid or the new Kentucky Children’s Health Insurance Program.(2) Extensive studies have demonstrated that Americans without health insurance are far less likely than their insured neighbors to receive preventive care, early intervention for chronic conditions, and even lifesaving treatment.(3)

Insurance Regulation and Government Sponsorship

Legislation that mandates broader health insurance availability has been enacted in most states during the 1990s. Statutes typically have the effect of requiring commercial insurance purchasers to cross-subsidize those who were previously excluded from coverage because of health or employment status.(4) While premiums for these health plans may be slightly lower for those who were charged more because of their poor health, it is clear that the price reduction this strategy yields does not suffice to extend coverage to the large majority of those who are currently uninsured.(5) Insurance market reform alone cannot succeed in extending coverage to low-income Americans.

Affordability is a critical issue for families with limited resources who face premium costs that often exceed $5,000 per year for even a modest policy. For those with income levels above Medicaid eligibility but below 200 percent of the federal poverty level (FPL; see Table 1), coverage is likely to be affordable only with a subsidy. This premise is illustrated by the federal standards for the Children’s Health Insurance Program, which allow states to offer free or heavily subsidized coverage to families up to 200 percent of the FPL. The question then becomes how, and to whom, this health insurance subsidy will be provided.

Table 1: Federal Poverty Levels, by Family Size

Several options are available to add to the pool of funding for low-income uninsured Kentuckians. Some of these have been tested in various forms. For example:

• managed care

  : the use of cost-containment mechanisms to generate savings for coverage expansion,

• time-limited General Assistance

  : state- or locally-funded support for targeted residents,

• local tax-supported initiatives

  : other community-based programs, generally supported by property taxation,

• limited-benefit policies

  : insurance policies with statutory exemption from benefit mandates in exchange for tight restrictions on marketing,

• vouchers:

  certificates that can be exchanged for specific subsidized services,

• donated services

  , in the honored tradition of the health professions, and

• Medicaid expansions

  , discussed at greater length in this chapter.

Other proposals currently being considered nationally or regionally, such as tax credits or deductions, have yet to be implemented and can be evaluated only hypothetically.

Even programs that are available without the payment of premiums do not reach all eligible persons: Medicaid only attracts about 80 percent of eligible persons, and this figure has remained quite stable for years.(6) The whole concept of insurance requires a degree of social integration and stability that some Americans have difficulty maintaining or consciously reject, and even universal access to coverage will never translate into universal coverage in the absence of stringent (and unpalatable) mandates.

Assessing the Options

The effectiveness of initiatives designed to expand access to health care is often difficult to determine. Consequently, in our evaluation of initiatives from other states, we used a number of criteria that we believe are important considerations in determining whether an initiative is indeed exemplary. Many programs that are too new for definitive evaluation may yield transferable ideas and innovations in the years to come. The criteria we considered were:

• the policy objective

  : was the program enacted to expand Medicaid eligibility generally, to reach targeted populations, to maximize use of federal matching funds, or to support vulnerable providers?

• the demographics

  : is the level of enrollment attributable to the composition of the local population, the proportion of working-age or senior citizens, or alternative subsidized program availability?

• the eligibility criteria of the program

  : for example, some are limited to children, families, the recently unemployed, or small business employees;

• the longevity of the program

  : a recent study suggests that a plan must be in place for at least three years before its effects can be assessed meaningfully;(7)

• the effect of the program on the cost of health care

  , both as an element of the state budget and across the range of policies and programs.

Empirical data on program innovations can be elusive. As a distinguished investigator has remarked, such programs "are extremely complex, and experience often is not reported in the literature, especially on a timely basis and with sufficient operational detail to explain how state programs, in fact, work."(8)

In the following sections, we survey state strategies using Medicaid, state funding, combinations of Medicaid and state-only revenues, local tax initiatives, innovative types of insurance, and several federal tax options, in addition to creative combinations of public and private support for comprehensive health programs. Economist Sherry Glied notes that different strategies benefit different groups of uninsured persons, and a combination of approaches is probably necessary to achieve equitable access to appropriate health care while keeping costs at a sustainable level.(9)

Medicaid

Medicaid covers 13.6 percent of Kentuckians,(10) above the national average of about 10 percent in 1998. Because states have broad discretion to set Medicaid eligibility criteria and because of rapid change in Medicaid delivery systems, it is very difficult to make meaningful interstate comparisons of the success of Medicaid strategies. Seventy percent of Medicaid expenditures nationally are attributable to services for aged, blind, and disabled persons, although adults and children in low-income families account for nearly three fourths of Medicaid beneficiaries.(11) Medicaid’s complex eligibility policy, which "both states and the federal government have relied on ... as a tool for limiting their financial exposure for the cost of covered benefits," makes the program difficult for its beneficiaries to understand and for the states to administer.(12)

An unexpected side effect of the massive (42 percent since 1994) decline in welfare caseloads has been a significant downturn in the number of people seeking Medicaid coverage nationally. Program administrators attribute this decline to the requirement that eligible persons apply separately for Medicaid, rather than being enrolled automatically as part of a broader eligibility determination process, because of the new time-limited cash assistance rules.(13) However, most employed former welfare recipients do not receive health care coverage through their employers and are unlikely to be able to afford it without subsidy.(14)

The removal of burdensome Medicaid waiver requirements under the Balanced Budget Act of 1997 accelerated the pace of managed Medicaid development. Over half of Medicaid enrollees are now in some form of managed care plan.(15) Many states look to managed care to help contain Medicaid costs and provide funds for coverage expansions to previously ineligible residents. A less "managed" form of managed care, the Primary Care Case Management (PCCM) model(16) familiar to Kentuckians as KenPAC, is used exclusively in Arkansas and appears in other states, as in Kentucky, where managed Medicaid has not yet been implemented. The proportion of Medicaid eligibles in managed care varies from 13.6 percent in Illinois to 100 percent in Tennessee, depending on legislative mandates and the state’s experience with managed care. Sudden moves to universal managed care in states such as Tennessee and New York have been far more disruptive than in Oregon and Minnesota, with their long histories and broad enrollment in commercial managed care plans.

Eleven Medicaid demonstration projects expand eligibility in highly variable ways: Vermont has increased eligibility to 150 percent of the FPL, Hawaii’s limit is 300 percent of the FPL, and in Tennessee, all uninsured persons were eligible for Medicaid at varying contribution rates, regardless of income until an enrollment cap was reached.(17) California and New Jersey have implemented Medicaid demonstration projects to supplement revenues for safety net providers such as public hospitals and health department clinics. Florida subsidizes commercial insurance premiums for low-income employed persons with non-Medicaid funds; a similar Oregon plan is discussed at greater length below.

Although the state of Washington’s Medicaid waiver program was only recently approved by the Health Care Financing Administration, the state has been working through a major health care reform effort for the past decade. Washington’s Basic Health Plan (BHP) subsidizes health insurance coverage from participating plans. Sliding scale subsidies are available up to 200 percent of the FPL, and those with higher incomes can join by paying the full premium. Employers can purchase coverage for employees through the BHP, but few have chosen to participate.(18)

When looking to other states’ experiences with Medicaid managed care for guidance in Kentucky, it is important to remember that the Regional Partnership system in this state is unique. A recent summary of extensive research into Medicaid managed care across the nation suggests the following observations about Kentucky’s managed Medicaid:

• Most states limit Medicaid managed care to children and younger adults rather than including elderly and disabled enrollees who participate in Medicare as well. This approach simplifies implementation but limits potential savings. The inherent difficulty in meshing managed Medicaid with nonmanaged Medicare plans for persons enrolled in both Medicare and Medicaid portends serious problems with Kentucky’s integration of these Medicaid beneficiaries into managed care plans.

• Many states, like Kentucky, are finding that managed care savings are modest because traditionally low Medicaid fee-for-service payment rates make it difficult for states to squeeze capitation levels or for HMOs to negotiate further discounts. The dramatic increase in prescription drug utilization has also overtaken projected savings.

• Safety net providers—public hospitals, community health centers, primary care and rural health providers, and clinics operated through local health departments—that need Medicaid revenues to survive have received special allocations from many states. These payments have helped to preserve the fiscal status of these providers, but the additional cost reduces potential Medicaid savings.(19) The effect of managed Medicaid on safety net providers was well documented before Kentucky’s Regional Partnerships were implemented.

• The combination of low capitation rates and protections for safety net providers has limited the willingness of commercial HMOs to enter into Medicaid managed care contracts in some states. There may be a tradeoff between expansion of access to providers in the private sector and maintenance of safety net providers.(20) In light of recent history, Kentucky’s decision to set up separate Medicaid HMOs with regional monopolies may have been prescient because it avoids the volatility of other states’ interactions with commercial HMOs.

• Managed care implementation has been slow and difficult in rural areas because of providers’ resistance, lack of commercial managed care activity, and an inadequate supply of providers. Other states have attempted to cope by modifying contracting strategies, travel time standards, 24-hour coverage requirements, and primary care case management requirements to adapt programs to the realities of rural environments.(21)

Non-Medicaid State-Subsidized Coverage

In 30 states, General Assistance (GA) programs provide cash and in-kind resources to low-income persons for limited periods when they are ineligible for other federally funded assistance. In some areas, part of this funding is allocated for health benefits. These programs are financed and administered entirely by the state, county, or locality in which they operate.(22) Jefferson County is the only jurisdiction in Kentucky that provides any GA, and the Jefferson County program does not include health care benefits. Income eligibility limits vary, but most programs limit assistance to those with income below half the poverty level. Because the income and resource limits are so stringent and because eligibility is typically time-limited, no state’s enrollment in GA programs exceeds 15 percent of enrollment in the state’s regular cash assistance program. A comprehensive survey of GA and related programs by the Urban Institute found that states with broad-based state-sponsored programs had uninsurance rates for low-income persons that were 30 percent lower than those in states with limited programs. However, GA programs do not give childless adults without access to employer-sponsored coverage a stable source of health care coverage.

Combining Medicaid with State-Sponsored Programs

Several states have added their own programs to Medicaid to extend coverage to specific categories of uninsured residents. Generally, these programs have focused on the temporarily unemployed, the elderly (to supplement prescription drug coverage), children (before the implementation of the state-federal CHIP initiative), and those with incomes just above the cutoff for Medicaid eligibility.(23)

Massachusetts funds several programs for low-income residents in addition to its Medicaid waiver for managed care.(24) MassHealth, as the programs are known collectively, is a comprehensive health insurance premium assistance program for parents, children, senior citizens, and persons who are disabled or unemployed. Coverage in MassHealth is provided under contract with eight managed care plans, and, as in many other areas, managed care offerings in rural areas are quite limited.

In addition to the Massachusetts Children’s Health Insurance Program, a pre-CHIP Children’s Medical Security Plan gives children access to health insurance coverage for primary and preventive health care. Another program called the Medical Security Plan provides health insurance for people collecting unemployment benefits. The Insurance Partnership helps qualified small employers and the self-employed pay for health insurance provided to their employees under age 65 whose incomes are low enough to make them eligible for MassHealth. The Insurance Partnership reduces eligible employers’ premiums for qualified employees by up to 30 percent.

Apart from the usual Medicaid funding, MassHealth is funded by a statewide tobacco tax and modest premiums for children in families with income between 150 percent and 200 percent of the FPL. Special financial protections augment the funding stream for safety net providers by bringing their net revenue to a level that approximates the pre-managed care revenue under cost-based reimbursement.

We may well question what Kentucky can learn from Massachusetts because of the profound historical, socioeconomic, and demographic differences between the two states. The relevance of Massachusetts programs is primarily that they have been in place for long enough for meaningful evaluation, and to a lesser extent, that several programs are specifically tailored for subsets of uninsured residents. It is also worth noting that managed care is a relatively recent, and rather controversial, phenomenon in Massachusetts, as in Kentucky.

Nearly one in four Minnesotans is enrolled in Medicare or another publicly sponsored program, a fact that largely accounts for the state’s very low uninsurance rate.(25) MinnesotaCare was created in 1992 as a sliding-scale, subsidized health insurance program for low- and moderate-income people who do not have access to other health insurance coverage. Funding for MinnesotaCare, apart from a modest Medicaid allocation, comes from a provider tax and premiums. Kentucky readers will doubtless be aware that provider taxes have been very unpopular here.

Families with children are eligible for MinnesotaCare at income levels below 275 percent of the FPL. Adults without children are eligible up to 175 percent of the FPL. An applicant must have been uninsured for at least 4 months, and must have had no access to employer-subsidized insurance coverage for at least 18 months, with limited exceptions. About 105,000 people (2.1 percent of the state population) were enrolled in MinnesotaCare at the end of 1998. Parents and children make up 89 percent of enrollees, and three quarters of enrollees have family incomes below 150 percent of the FPL; over 90 percent have family income under 200 percent of the FPL.

Very small and declining numbers of Minnesotans who are ineligible for Medicaid are enrolled in the state-funded General Assistance program (0.7 percent of population) and the state’s high-risk pool (0.6 percent of population). As in Kentucky, funding for the excess of costs over premium revenue for high-risk pool enrollees is through an assessment on state-regulated plans, but the growth of self-insured plans exempt from state regulation had decreased the revenue from this source to such an extent that the 1997 Minnesota legislature appropriated $15 million to the high-risk pool for 1998 and 1999 to assist in covering losses.

An interesting byproduct of Minnesota’s high rate of insurance coverage is the decline in the state’s overall rate of uncompensated care. The state’s hospitals now spend an average of only 2.8 percent of their total expenditures on uncompensated care, compared with a national average of 6.1 percent.(26)

As with Massachusetts, Kentucky can learn from Minnesota despite the obvious differences in demographics and Minnesota’s longstanding tradition of investment in the health of its residents. Diverse funding streams—state and federal tax dollars, provider taxes, health plan assessments, and excise taxes—support both general programs for low-income residents and groups of specific concern, such as families with children and persons with potentially high-cost health conditions. The very low rate of uninsured Minnesotans has clear costs as well as benefits, but these are costs the state’s citizenry appears willing to bear. Unlike Kentucky, Minnesota has a very competitive, well-established managed care market that covers all but the most rural areas, and a population well oriented to managed care may be another factor in the success of Minnesota’s programs.

Oregon’s unique approach to expanding state-subsidized health coverage was enacted in 1989 and implemented in 1994.(27) Citizen groups and experts meet periodically to decide which services should be covered under the plan, raising and lowering the standard to match funding. This explicit rationing of services has resulted in a list of covered benefits that is at least as generous as standard Medicaid packages in other states. Oregon’s reforms have reduced the percentage of uninsured residents from 18 percent in 1990 to 11 percent in 1997. As of early 1999, 684,700 Oregonians participated in the plans.

While cost containment was one goal of the state legislature, reimbursement rates were intended to be adequate to avoid the pervasive practice of cost shifting that led providers to increase charges for non-Medicaid patients to cover inadequacies in Medicaid reimbursement. Research into the financial impact of Oregon’s unique structure suggests that the rationing process accounts for no more than 2 percent of program cost savings over the first five years of the program, while three times as much has been saved through the use of managed care plans. In addition to the usual state-federal Medicaid funding stream, Oregon’s coverage expansions have been funded by part of a state cigarette tax.

Oregon’s health care initiatives, collectively known as the Oregon Health Plan (OHP), include a Medicaid Demonstration; the Oregon Medical Insurance Pool, a high-risk pool; the Insurance Pool Governing Board, an individual and small business purchasing cooperative; Small Employer Health Insurance reforms; the Family Health Insurance Assistance Program, a subsidized program described below; and the Children’s Health Insurance Program.(28) More than 80 percent of all Oregon Health Plan participants are enrolled with a managed care plan, but the number and geographic range of the plans have shrunk significantly, and there is little if any choice of plan in rural Oregon.(29) Nearly all licensed physicians in the state participate in the Medicaid program, along with more than half of the state’s dentists.

The most unusual of the OHP plans is the Family Health Insurance Assistance Program,(30) which subsidizes low-income (under 170 percent FPL) uninsured Oregonians’ purchases of commercial health insurance on an income-related sliding scale.(31) Employees receive direct subsidies for employer-sponsored or state-certified insurers in the form of checks that arrive before the payment is due or the payroll deduction occurs. Despite the hypothetical appeal of such a program, only 3 percent of uninsured Oregonians with incomes below 170 percent of the FPL participated in the program in early 1999, and almost 90 percent of participants had incomes at or below 150 percent of the FPL.

The OHP must fight for adequate funding in each legislature, and there appears to be a general sense that it is too expensive in its current form. The 1999-2001 Oregon budget proposals included $80 million reduction request from the governor and a further $48 million cut recommended by Republican legislators.(32) Oregon’s legislature has made specific appropriations to help public hospitals and other safety net providers continue their service to uninsured and underinsured persons.(33)

Health policy analysts watched the development of the Oregon plan with great interest because of its uniquely public decisionmaking process. An important lesson for Kentucky policymakers is the need for adequate reimbursement to support wide provider participation as the proportion of providers’ revenue that depends on publicly funded plans grows. The perspective of Oregon’s physician-governor is doubtless influential in the maintenance of this provider-friendly program feature. Publicly funded plans in many cases pay less than the actual cost of providing a given service, so providers’ ability to participate in these plans depends on the extent to which revenue shortfalls can be made up from other funding sources. If publicly funded patients represent a large majority of a practice or facility’s revenue stream, the provider will find it difficult to survive financially.

Rhode Island provides expanded health care coverage to low-income children and pregnant women up to 250 percent of the FPL through RIteCare, its Medicaid program.(34) In November 1998, RIteCare expanded parents’ eligibility to 185 percent of the FPL using state funding and eliminated the limits on assets that characterize most Medicaid coverage for adults. As with most publicly funded coverage expansions, persons who already have health insurance are not allowed to drop it voluntarily and enroll in RIteCare.

RIteCare increased enrollment by 12,000 in the first six months of 1999, for a total of 86,000 enrollees.(35) The governor’s ultimate goal is to eliminate uninsurance in Rhode Island; over the balance of 1999, he hopes that RIteCare will add another 13,000 to its rolls.

RIteCare is administered through contracts with managed care organizations that also serve commercial members. Reimbursements to health care providers—a common source of trouble in such plans—are being supplemented through a $1.2 million increase in health plan funding over 18 months. RIteCare has increased enrollee access by requiring health care providers to take RIteCare enrollees if they want to care for commercial members of a participating HMO. Private and public agencies perform outreach and enrollment functions and receive a small fee for enrolled applicants.

Rhode Island’s population is only one fourth of Kentucky’s, so a much smaller improvement in its insured population translates to a higher percentage change. The significant lesson from Rhode Island’s recent success in expanding public coverage is the pivotal role of the governor. By making health care coverage for low-income residents a primary goal of his administration, he appears to have found the funding and political will to overcome the usual budgetary and political obstacles.

Our neighbors in Tennessee have both positive and negative lessons for us. They have suffered provider rebellion, consumer confusion, enrollment caps, and management turmoil since their TennCare program was implemented in January 1994. Despite its rocky start, the program has succeeded in lowering Tennessee’s uninsurance rate significantly.(36) Its long-term viability, however, is a frequent concern; in September 1999, yet another TennCare director resigned. Tennessee’s experience must be accounted for in any analysis of public health care funding, but whether its expansion of coverage will ultimately be found to justify its human and financial toll remains to be seen.

TennCare enrollment at the end of June 1999 was approximately 1,312,969, of which 814,181 were in Medicaid programs and 498,788 were either previously uninsured or had been rejected by insurance carriers. Enrollment has been closed and reopened to various groups over the past four years, but the program has been open continuously for low-income children, dislocated workers, and those who have been denied commercial coverage because of their health. TennCare eliminated deductibles and limited copayments for these newly eligible populations and all uninsured children who had previously enrolled in TennCare.

Enrollment is financed by pooling current federal, state and local expenditures for indigent health care, including Medicaid and hospitals’ identified pre-TennCare indigent care load. Of the program’s total 1999 budget of $3.779 billion, $1.418 billion funds long-term care programs, Home and Community-Based Services Waiver programs, Medicare crossovers through the Medicaid system, Medicare premiums, and administration for the total program.

The state’s cost-containment goal is a TennCare budget that grows at a predictable rate no greater than the overall rate of growth in state spending.(37) However, this goal does not appear to be achievable in the current TennCare environment. One of the most serious concerns about TennCare is the solvency of its participating managed care organizations, several of which have either gone into receivership or been the subject of solvency alerts.(38) In early 1999, the legislature pumped an additional $190 million in state dollars, to be matched with $380 million in federal dollars, into the 1999-2000 TennCare budget, increasing it to nearly $4.3 billion next year.(39)

An insurance system whose survival is constantly threatened heightens the anxiety that leads Americans to seek insurance in the first place. While TennCare has succeeded in the short term by reducing the number of uninsured Tennesseans, newspaper accounts frequently report its impending collapse. Tension between budgetary demands and escalating health care costs are amplified when such a large proportion (nearly one in four) of the population is covered through a public program.

Wisconsin is often held up as a model of health care access, boasting an uninsurance rate that is about half the national average.(40) State initiatives are only part of the picture: a strong economy, a healthy population, and a very high rate of employer-sponsored coverage are important factors. The program highlighted here is only a small part of the state’s public health insurance initiatives, but its innovative design will bear watching in the future.

Wisconsin implemented BadgerCare in July 1999 to provide health care coverage to families (both parents and children) with incomes under 185 percent of the FPL. Enrolled families can keep their coverage up to 200 percent of the FPL. The state uses Medicaid funds to cover parents in BadgerCare families and Children’s Health Insurance Program (CHIP) funding for newly eligible children.

Wisconsin initially sought to use CHIP dollars for parental coverage, but the stringent federal limits on CHIP for adults resulted in repeated HCFA rejection of state proposals. The state then opted to use the Medicaid waiver process for parental coverage funding. The flexibility of the waiver system allowed Wisconsin to charge premiums for families with incomes above 150 percent of the FPL and exclude individuals with access to affordable employer-based coverage.

The waiver also addresses concerns that using Medicaid as the vehicle for financing the program could create a fiscal burden on the state. If spending exceeds budgeted targets, eligibility will be restricted, although current enrollees will be allowed to remain in BadgerCare even if they exceed the lowered income guidelines.

Wisconsin’s broad, stable base of insured residents probably facilitates the precise, targeted policymaking of which BadgerCare is an example. As in the case of its innovative welfare-to-work policy, we may question whether what works in Wisconsin will work in Kentucky or elsewhere in the absence of a similar breadth and stability of employer-sponsored coverage.

Creative combinations of Medicaid expansions and state-supported programs obviously require legislative endorsement of supplemental funding (in addition to normal Medicaid budgeting) and careful balancing of expanded entitlements with fiscal constraints. Despite their diversity, these state approaches have some common features:

• Now that the CHIP programs expand children’s eligibility, state programs focus on other members of low-income families, low-income workers, and those whose health status is an impediment to coverage;

• Budgetary flexibility is built in through provisions that lower income-based eligibility levels when necessary to avoid funding shortfalls (Oregon is unique in adjusting benefits);

• Managed care systems are used in most areas, although many rural areas are administered through more traditional financing systems;

• Staged implementation is more palatable than TennCare-style instant changeovers, but either requires careful planning to avoid incentives for providers to cost-shift and consumers to drop commercial insurance coverage (a phenomenon known as "crowd-out");

• State funding beyond Medicaid requirements is perpetually subject to renegotiation at each new legislative session.

Local Initiatives

Community-level initiatives exemplify the "bottom-up strategies" that are advocated by several health care leaders we interviewed. On a smaller scale than the statewide initiatives just described, local programs make important strides in closing gaps in access to health care. The first two initiatives described in the following section are Ford Foundation/Kennedy School of Government Award winners and have been cited as models for the Bureau of Primary Health Care’s new campaign to promote access and eliminate socioeconomic disparities in health.

Public and private sector representatives in the greater Tampa area have created a nationally celebrated model by pooling assets from the community’s share of state appropriations, community provider resources, and local tax revenue to subsidize health services for low-income residents without health insurance.(41) In 1991, after the Hillsborough County Commission petitioned the Florida legislature for local taxing authority, the county was authorized to impose a 0.5 percent sales tax (later reduced to 0.25 percent) to fund uncompensated health care. A recent report by the Deputy County Commissioner indicated that 70 percent of the target population (up to 100 percent of the federal poverty level) had been enrolled at some point during the seven years of the program.(42) The plan also offers coverage to persons rejected from commercial insurance plans due to health status, and a supplementary benefit for low-income enrollees in Medicare or a military-related health plan. The mean monthly cost per enrollee has been reduced from $233 to approximately $200. It is important to note that maternity benefits are not included because pregnant women at the target income eligibility level are eligible for Florida’s Medicaid program.

The Hillsborough County plan is particularly noteworthy for its ability to mobilize and coordinate community resources in the ongoing development and monitoring of its programs. With a local population rapidly approaching one million and a large tourist industry that employs many low-income workers, the county appears to have had both an acute enough problem to motivate action and a resource base adequate to meet the need.

Buncombe County, where Asheville, North Carolina, is located, has used its indigent care funds to coordinate public and private groups in order to provide comprehensive health services to 13,000 of the county’s estimated 15,000 uninsured persons.(43) The Buncombe County Medical Society Project Access links the local health department, Medicaid agency, and medical society, along with hospitals, indigent care clinics, and pharmacies. Some 500 physicians and dentists participate and are recognized by having their names published regularly in the local newspaper.

The local medical society is under contract with the county to provide program oversight, volunteer recruitment, coordination and tracking of referrals and services, and management of pharmacy assistance. Physicians donate their services; hospitals donate laboratory, radiology, and nursing services; pharmacists donate their dispensing fees; and the county funds the cost of bulk medications. Uninsured low-income patients reach these services through a primary care provider at private physician offices, health departments, or other community-based medical clinics. North Carolina’s governor has promoted the replication of the Project Access structure in eight other counties. (44)

Other Exemplars

The following programs are also winners or runners-up in the Bureau of Primary Health Care’s "Models That Work" Program. They were selected because they represent comprehensive approaches to health services for their target populations and, like the Tampa and Asheville models, involve both public and private partners.

Importantly, the Tampa and Asheville models have several features in common with these award-winning initiatives that suggest approaches for Kentucky communities:

• consensus identification of underserved target population and health care needs;

• broad-based community support, particularly among physicians and other health care providers;

• cooperation among public agencies, physicians, civic organizations, hospitals, businesses, and other stakeholders in the health of the community;

• combination of public and private funding in addition to donated services;

• identification of roles and contributions for each partner;

• public acknowledgment of participants’ contributions; and

• inclusion of consumers in planning and evaluation processes.

In the Commonwealth, Health Kentucky and Kentucky Physicians Care exemplify the types of provider organizations that have made many programs across the country into sustainable vehicles for comprehensive service to low-income members of their communities. These Kentucky organizations served as the model for an entire foundation-funded program earlier in the decade because their appeal and effectiveness are so compelling. If communities are to take charge of their uncompensated care problems, however, it is unrealistic to expect private health care providers to bear the entire burden. The missing pieces here have been: cooperation and coordination with local health departments, primary care centers, hospitals, other health care providers (e.g., imaging centers, clinical laboratories, prescription drug vendors), businesses and civic organizations. The challenge is to mobilize the wealth of available resources towards common goals, creating a synergy that is greater than the sum of its parts.

Tax-Based Approaches

Several proposals to expand health insurance access use the federal income tax structure to create incentives, for example, by

• increasing the deductibility of health insurance premiums for individual purchasers;

• providing tax credits for low-income health insurance purchasers; or

• building on the Earned Income Credit process.(45)

The likely success of these proposals in bringing down the rate of uninsurance will depend on factors such as:

• the adequacy of the tax credit offered;

• the ability of low-income workers to leverage the credit into premium payments at the time they are due; and

• the type of commercial insurance policy available for purchase with the tax credit-generated funds.

Workers who currently have income tax withheld from their paychecks may be able to adjust their withholding and eliminate end-of-the-year reconciliation, but managing these adjustments is an added complication for families and may reduce willingness to participate. For many low-income employees, wages vary significantly from season to season or week to week, making the use of tax incentives even more problematic. Many others have no tax obligation at all, so even a fully refundable credit does not give them cash for premiums in the months before the refund check arrives.

Another structural issue for strategies to provide low-income uninsured persons with funds to purchase policies on their own is the high cost and instability of the individual market, particularly in Kentucky.(46) The theoretical appeal of individual choice encounters grim reality in many smaller insurance markets like Kentucky’s where only one or two carriers offer individual policies. This phenomenon is acknowledged in a recent proposal by Senator Pete Stark (D-CA) that would establish a separate insurance pool for these purchases and require insurer participation as a condition of offering coverage to federal employees.

High-Risk Pools

Over half the states, including Kentucky, have high-risk health insurance pools.(47) These arrangements are intended to allow people to buy commercial health insurance despite health conditions that would lead insurers to reject their applications (in the absence of mandatory guaranteed issue). Premiums are partially subsidized but are typically 25 percent to 50 percent higher than the average for persons of the same age and place of residence. It is important to note that without a high-risk pool, some of these individuals would be impoverished by uninsured health care costs to such an extent that they would qualify for Medicaid. Risk pools normally cover a very small fraction of any state’s insured population for two reasons: enrollment is often capped, and premiums are high enough to be prohibitive for lower income uninsured persons.

A high-risk pool obviously does not solve the problem of the uninsured: high-risk enrollees were recently found to range between 0.3 percent and 8.23 percent of the total number of uninsured persons, depending on the state in question.(48) A recent study suggests that the presence of a high-risk pool that does not have an enrollment cap adds about one percent to the rolls of the privately insured and over time, decreases Medicaid enrollment by 1.3 percent.(49)

Because of the small number of enrollees in any state, global surveys are unlikely to unearth information about high-risk pool enrollees. However, research suggests that having this kind of mechanism to take potentially high-cost persons out of the regular insurance market "may enable insurers to worry less about adverse selection and thereby price lower in the individual market, which could increase private coverage."(50) Another investigator who interviewed officials in Wisconsin and Indiana found that risk pools helped small businesses contain insurance costs by avoiding a significant global premium increase when one employee was diagnosed with a high cost condition.(51) While this effect may be helpful for small businesses with a small number of high-risk employees, premiums for other employers and employees are slightly higher when insurers pass on the cost of the assessments that subsidize high-risk enrollee premiums. Conversely, to the extent that high-risk pools cover high cost cases that would otherwise be uncompensated, having a pool may lower costs for insured persons by eliminating some of the cost shifting that providers would otherwise have to use to support uncompensated care.

Kentucky’s high-risk pool, known as the Guaranteed Acceptance Plan (GAP), is too new to have been included in any of these studies. The success of the GAP in shoring up Kentucky’s fragile individual insurance market will be followed with interest by many observers. As is so often the case, there is a critical need for data and informed analysis in this area, both within the Commonwealth and across the country.

Medical Savings Accounts and Other High-Deductible/Limited-Benefit Plans

Medical savings accounts (MSAs) were a popular approach to expanding health insurance coverage in the mid-1990s, although the very low sales of these policies since their authorization by the 1996 Congress suggests that both supporters’ enthusiasm and opponents’ fears may have been misplaced.(52) MSA legislation allows self-employed and small group purchasers of high-deductible policies to tax shelter out-of-pocket costs (with limited employer contributions). Several states have mirrored federal tax exemptions for MSAs.

The underlying philosophy of MSAs is that comprehensive insurance leads to overutilization because coverage makes the insured person insensitive to the costs incurred for unnecessary care. Because the MSA enrollee would have to pay routine health costs out of pocket, he or she has a clear incentive to be a more prudent purchaser of essential services.

A number of arguments have been raised regarding the propensity of MSAs to attract the relatively healthy and wealthy, leaving others to make the non-MSA insurance market less favorable and thus more expensive. Most workers are healthy and thus would gain financially by switching to MSAs from traditional insurance. This adverse selection would raise costs, and therefore premiums, for those who chose to remain with non-MSA plans.

To date, the number of enrollees in MSAs has been so small that their market impact is likely negligible. Congressional MSA advocates have proposed changes that would make them more appealing, such as opening enrollment to larger employee groups, lowering the minimum family deductible from $3,000 to $2,000, and allowing employees to tax shelter the full deductible amount, rather than the current 65 percent or 75 percent.(53)

Low-cost, "bare bones" health insurance plans have been authorized in some 31 states. Generally, the statutes establish closely regulated sales options in exchange for exemption from certain state-mandated benefits.(54) Their effect on increasing the number of insured persons nationally has been insignificant, despite the well-documented tendency of mandated benefits to increase the rate of uninsurance.

State Prescription Drug Plans for Medicare Enrollees

The cost of prescription drugs for Medicare enrollees has been a growing national concern because of the relatively high premiums and limited drug benefits of Medicare supplement ("Medigap") policies. Medicaid covers drug costs for the very poorest Medicare enrollees, but Medicaid income and asset tests are so stringent for senior citizens that only the truly indigent qualify. Proposals to address this problem at the federal level appear to have died for the current congressional term, but will doubtless re-emerge in 2000. In much of the country, Medicare HMOs offer some drug coverage, but Kentucky has thus far seen very limited Medicare HMO activity. The escalating cost of prescription drugs has led many Medicare HMOs in other parts of the country to restrict or drop generous drug coverage.

At least 14 states provide prescription drug assistance to low-income residents on Medicare; about 700,000 people received benefits under these plans in 1997.(55) Most have very low (under $12,000 per year) income eligibility levels, although New York and New Jersey set eligibility at over $18,000. All require a modicum of enrollee cost sharing, either in the form of copayments, enrollment fees, or deductibles. While the primary target population is low-income seniors, several states have parallel plans for persons enrolled in Medicare because of disability. Some limit coverage to specific drugs or therapeutic categories, and Maine requires the drug manufacturer to agree to a rebate arrangement in order to have a specific drug covered. Several states have annual coverage limits; Massachusetts, for example, only covers up to $750, but the computation is based on the state’s heavily discounted purchase price. State prescription drug assistance plans are funded by general revenue, lottery proceeds, and casino gambling revenues (New Jersey).

Maintaining the Safety Net

Regardless of the changes Kentucky makes in insurance funding for low-income Kentuckians, some will still need services outside a public or private insurance system. Even universal health insurance coverage will not eliminate the need for safety net providers: community health departments and other clinical centers, hospital-based services that are open when most other health care sources are closed, and public hospitals themselves.

Subsidized or charitable health services are extended to uninsured Americans in myriad programs spanning the public and private sectors. Examples of government subsidies for health services (as opposed to health insurance) include block grants for services to pregnant women, children, and persons with specific diseases or conditions, the Disproportionate Share Hospital payments to facilities that serve Medicaid enrollees, programs for migrant workers, homeless persons, and the developmentally disabled. The charitable provision of health services takes place informally throughout the health care sector, but its more visible and organized manifestations include free clinics, free or reduced-price drugs, medical society voluntary programs such as Kentucky Physicians Care, and targeted outreach programs at schools, health fairs, and other public gathering places.

The need to maintain adequate publicly funded services is particularly obvious for children because they often cannot reach necessary health services without an adult’s assistance. An evaluation of three pre-CHIP Medicaid expansions for children showed that while extending health insurance to low-income children affected their access positively, insurance alone did not result in more appropriate use of preventive services and emergency departments. Important variables in access to care included the availability of a convenient "medical home" with after-hours services, continuity of enrollment, and support services.(56) Thus, even with health insurance, these children needed the safety net for adequate care.

Medicaid managed care has predictable and well-documented effects on safety net providers such as community health centers, health department clinical services, and hospitals with large low-income service populations. Some states that have implemented Medicaid managed care appear to have reduced provider reimbursement to an extent that limits resources available to cross-subsidize care for the medically indigent.(57) A recent multistate study (not including Kentucky) concluded that access to care for low-income uninsured persons is lower in states where a higher proportion of Medicaid enrollees were in managed care plans. This finding should not surprise anyone familiar with the budgetary goal of Medicaid managed care. When less money is allocated for services to low-income people, either directly through Medicaid or in a combination of Medicaid and subsidies to safety net providers, fewer services can be provided.(58)

A policy question that can be addressed constructively is the extent to which safety net providers should be asked to compete with their counterparts in the private sector for state-funded enrollees and state funds in general. If Kentucky values the services that safety net providers offer to uninsured and underinsured Kentuckians, the cost of these services can be identified and accounted for. Declining to provide adequate funding sends a clear message that the fiscal viability of safety net providers is not a priority for the state. The recent shortfalls for health department-based primary care services in Kentucky graphically illustrate the extent to which these clinics depend on reimbursement beyond normal managed care payment rates to finance indigent care.

Getting Back to Cost

Many of the health sector leaders interviewed for this report put the cost of health care or health insurance at the top of their list of concerns. Their view is shared by the majority of Americans: the 1999 Health Confidence Survey conducted by the nonpartisan Employee Benefit Research Institute found that 89 percent of those surveyed thought that making health care more affordable should be a major goal of U.S. health care reform.(59) The survey also found that the cost of health insurance is the major reason why most people lack health care coverage: 77 percent of the uninsured cited cost as the major reason for not having health insurance.

One reason why the cost of insurance, rather than the cost of health services, attracts such attention is that few Kentuckians pay the full cost of health services (with the exception of prescription drugs for many Medicare beneficiaries). As Representatives DeWeese and Damron note, there is no prospect for any short-term decrease in the cost of health insurance. National trends suggest that year-to-year increases may approach 10 percent in the next few years.(60) Kentucky’s Commissioner of Insurance and his staff carefully monitor insurer price increases, but most premiums appear to be justified by dramatic increases in pharmacy cost and utilization, expensive new technologies, and consumer demand for expanded choice of health care providers. If the narrow financial edge on which most Kentucky insurers now claim to operate reflects reality, policymakers must turn to the provider sector and consumer demand for answers.

Cost-cutting initiatives run into one indisputable fact: one person’s cost is another person’s revenue or service,(61) and if the person receiving the revenue or service is valued by policymakers, that person’s interests are likely to be protected. Careful planning may help avoid unwanted consequences of cost cutting, such as the bankruptcies of health care groups and termination of home health services that are currently emerging. Yet attempts to curb unmanageable increases in health care costs often seem to be an exercise in balloon squeezing: shrinkage in one area immediately results in expansion elsewhere.(62) Ironically, the congressional debates over HMO regulation and Medicare funding include repeated pleas for higher rather than lower allocations of both public and private funding for health care.

There are many strategies to contain health costs at the provider level, such as

• reducing the unit cost of services (as with Medicare’s fees for some physician specialists);

• reducing the volume of services (such as therapist visits or inpatient hospital days);

• substituting less expensive caregivers or materials;

• limiting services to the most remunerative types of diagnoses or patients;

• increasing staff workloads;

• automating labor-intensive functions; or

• closing services that attract low-income patients.

The past decade has seen widespread health care mergers, acquisitions, and spinoffs. When internal cost-containment strategies reach their limits, health care providers look for more dramatic solutions: closing entire facilities, selling assets, bankruptcy or receivership. Many of these activities are rational responses to the need to contain costs, but it is important to recognize the price each exacts, both in human terms and in their effect on the availability of health services.

The quest for health care cost containment leads policymakers to look to the insurance sector to manage provider costs and its own administrative load as efficiently as possible. In light of recent Kentucky history, the imposition (or reimposition) of more stringent statutory restrictions on health insurance carriers raises obvious concerns. As Representatives Damron and Burch both note, the ability of states to contain costs by regulating insurance is very limited, and comprehensive action can only occur at the federal level.

The August 1999 takeover of an Owensboro-based provider-sponsored HMO by the Kentucky Commissioner of Insurance is a local manifestation of the deep financial problems encountered by many such organizations.(63) On average, Kentucky managed care plans have spent between 85 percent and 90 percent of their revenues on medical benefits in each of the past four years. While this rate of medical spending far exceeds the classic fee-for-service carriers’ historical trends of 70 percent to 75 percent, it is not unlike spending rates for other states. Illinois, for example, recently reported an 89.7 percent medical spending ratio for its managed care plans. Forty-five of the nation’s 55 Blue Cross & Blue Shield plans had costs for member services and administration that exceeded their premium revenues, but most (34) made up for these deficits with income from investments and securities. Likewise, in the health insurance sector as a whole, $835 million in losses was more than made up for with over $2 billion in investment income and gains on the sale of investments.(64) Industry analysts and observers such as Dr. Holsinger question how long insurers can continue to eat into their capital portfolios to make up for operational losses.(65)

The federal government’s attempt to move the risk of insuring Medicare and Medicaid beneficiaries into the private sector by contracting with HMOs has been under way for the past two years with limited success. Kentucky has seen very little Medicare managed care activity, and thus has not experienced the turbulent market shifts occurring in other states. Kentucky’s Medicaid managed care is unique in its system of provider-based Medicaid-only regional plans, but other states that have relied on the commercial insurance market to serve Medicaid clients have seen many carriers leave in the past two years.(66)

Would restrictions on the business organization of health insurers help contain cost? For-profit insurers are vulnerable to charges of excessive executive compensation and attention to profits at the expense of members’ well-being. Tax laws restrain not-for-profit insurers’ activities, and their tax advantages open them to both a higher level of scrutiny and demands that they provide benefits commensurate with the value of their tax exemption. From an economic perspective, it is unlikely that any regulation of health plan compensation structures or community benefit requirements would generate savings sufficient to offset the relentless cost pressure of pharmacy costs, the health care requirements of our aging population, and growing consumer demand for convenient, state-of-the-art care.

Conclusion

The shortest route to reducing the uninsured population of other states has been the creative use of Medicaid and other state and locally funded health benefits. Obviously, these are also the strategies that require the most difficult legislative decisions. Variations in the economic and political climate in states that have chosen this approach have led to frequent changes in eligibility criteria, covered benefits, and implementation schedules. Depending on the analyst’s perspective, the dynamic quality of these plans may reflect either a negative instability or a positive flexibility. In any case, precise targeting of state subsidies requires timely and accurate data about population health, health care costs, and insurance coverage, all of which are seriously lacking in Kentucky.

State and regional variations in health care organization and delivery systems also influence the structure and outcome of health care initiatives. Oregon had a 40-year history of managed care before implementing its unique approach to Medicaid expansion. In contrast, managed care was quite unfamiliar in Tennessee in 1994, when its entire Medicaid delivery system was suddenly transformed to a managed care system, with widely publicized difficulties.

The first issue in any expansion of state funding for low-income citizens is always cost. A global view of the cost of uninsurance in addition to the cost of state subsidies may bring budgetary implications into clearer focus. Uncompensated services are a major burden for hospitals, physicians, primary care clinics, and all other health care providers. Again, large gaps in Kentucky’s health information infrastructure impede accurate analysis.

Apart from their constant exposure to the winds of political change, state-sponsored coverage expansions must be carefully structured to facilitate input from health care providers in both design and implementation. Physicians and dentists who willingly provide uncompensated care to low-income patients often decline to participate in government-sponsored programs for the same people when the programs treat them as adversaries rather than collaborators in caregiving.

The inclusive, collaborative nature of successful community-sponsored health plans is both cause and effect of their popularity. They are essential health resources, but they are also important sources of civic pride. However, it is important to assess these plans in their historical and political contexts. What works in some states and localities may not work in others for a variety of reasons. Some successful initiatives are responses to legal requirements (the analogy in Kentucky would be the Kentucky Education Reform Act that responded to a judicial mandate). Hillsborough County, Florida, like many localities across the country, developed its prizewinning health plan partly to satisfy a state mandate to provide for its medically indigent population. In Kentucky, only Louisville has a similar legal obligation.

Other notable successes are the culmination of decades of work. Asheville, North Carolina built its comprehensive, multifaceted approach to care for uninsured residents on a long-standing tradition of community-based outreach and philanthropic involvement. The more urban areas of Kentucky have some well-established voluntary and charitable clinical service sites, but rural areas often have too few health care providers to eke out any philanthropic surplus.

Kentucky is facing a difficult policy-balancing act, as enunciated by the state’s health policy leaders in their interviews, between competing priorities:

• maintaining a reasonable degree of stability in the commercial insurance market;

• containing cost; and

• reducing the number of uninsured persons and the concomitant burden of uncompensated care.

In order to solve these tough problems, state policymakers can explore approaches to:

• define local and state accountability in a manner that suppresses the endless round of cost-shifting;

• identify and pool existing and potential indigent care resources;

• identify areas of predictable unmet need;

• foster collaborative initiatives that acknowledge providers, consumers, and funders; and

• support these inquiries with a broad-based, timely and responsive health data infrastructure.

  Back to Leadership Perspectives on the Future of Health Care

  Ahead to Prescriptions for Change

Footnotes

1. Scutchfield, Beaulieu, and Lomax. Return to text.

2. Kentucky Legislative Research Commission, Research Memorandum No. 480, Jan. 1998. Return to text.

3. S.H. Zuvekas and R.M. Weinick, "Changes in Access to Care, 1977-1996: The Role of Health Insurance," Health Services Research 34.1 (1999, Part II): 271-80; J.Z. Ayanian, "The Relation Between Health Insurance Coverage and Clinical Outcomes Among Women With Breast Cancer," New England Journal of Medicine 326 (1993): 326-31; P.D. Sorlie, "Mortality in the Uninsured Compared with that in Persons with Public and Private Health Insurance," JAMA 154 (1994): 2409-16. Return to text.

4. Frank Sloan and Christopher Conover, "Effects of State Reform on Health Insurance Coverage of Adults," Inquiry 35 (Fall 1998): 280-93; Zuckerman and Rajan. Return to text.

5. Richard Kronick and Todd Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs 18.1 (1999): 30-47. Return to text.

6. Liska, Brennan and Bruen. Return to text.

7. Hing and Jensen, note 51. Return to text.

8. Marsha Gold, "Making Medicaid Managed Care Research Relevant," Health Services Research 33.6 (1999): 1639-50. Return to text.

9. Sherry Glied, Report: An Assessment of Strategies for Expanding Health Insurance Coverage. Washington, DC: Henry J. Kaiser Family Foundation, Oct. 1999, online at: http://www.kff.org. Return to text.

10. Personal communication, Kentucky Department for Medicaid Services, 14 Oct. 1999. Return to text.

11. John Iglehart, "The American Health Care System: Medicaid," New England Journal of Medicine 340.5 (1999): 403-08.  Return to text.

12. Andy Schneider, Kristen Fennel, and Peter Long, Issue Paper: Medicaid Eligibility for Families and Children, Washington, DC: Henry J. Kaiser Family Foundation, Sept. 1998. Return to text.

13. Smith et al., note 42. Return to text.

14. Smith et al. Return to text.

15. "Medicaid Statistics," Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services, Baltimore, Maryland, online at: http://www.hcfa.gov, Oct. 1999. Return to text.

16. Under the Primary Care Case Management system, Medicaid enrollees other than the aged, blind or disabled are assigned to primary care physicians who are responsible for coordinating their care and approving referrals, emergency department visits, and other special services. Return to text.

17. 1.3 million persons (initially set at 1.4 million), over 400,000 of whom are new Medicaid eligibles. Return to text.

18. Shruti Rajan, "Publicly Subsidized Health Insurance: A Typology of State Approaches," Health Affairs 18.2 (1998): 101-117. Return to text.

19. Robert Cunningham, "CHCs’ Loss of Medicaid Stealth Subsidy Jeopardizes Uninsured," Medicine & Health 29 July 1996. Return to text.

20. John Holahan, Joshua Wiener, and S. Wallin, Health Policy for the Low-income Population: Major Findings from the ‘Assessing the New Federalism’ Case Studies. Occasional paper no. 18. Washington, DC: Urban Institute, 1998. Return to text.

21. R.T. Slifkin, S.D. Hoag, P. Silberman, S. Felt-Lisk, and B. Popkin, "Medicaid Managed Care Programs in Rural Areas: A Fifty-state Overview," Health Affairs 17.6 (1998): 217-27. Return to text.

22. L. Gallagher, C. Uccello and H. McCallum, State General Assistance Programs, 1998. Washington DC: The Urban Institute, 1998. Return to text.

23. For an in-depth survey of these programs, see Laura Summer, State-Subsidized Health Insurance Programs for Low Income Residents: Program Structure, Administration, and Costs, American Academy on Aging/Commonwealth Fund, April 1998, online at: http://www.cmwf.org/programs/insurance. Return to text.

24. See the HCFA website at: http://www.hcfa.gov/medicaid/mafact, or the Commonwealth of Massachusetts website at: http://www.state.ma.us. Return to text.

25. "Health Care Coverage and Financing in Minnesota: Public Sector Programs," Health Economics Program, Minnesota Department of Health website at: http://www.health.state.mn.us, Mar. 1999. Return to text.

26. Id. Return to text.

27. Lawrence Jacobs, Theodore Marmor, and J. Oberlander, "The Oregon Health Plan and the Political Paradox of Rationing: What Advocates and Critics Have Claimed and What Oregon Did," Journal of Health Politics, Policy & Law 24.1 (1999): 147-80; Thomas Bodenheimer, "The Oregon Health Plan—Lessons for the Nation," New England Journal of Medicine 337.9 (1997): 651-55; 337.10 (1997): 720-23. Return to text.

28. The Medicaid Demonstration covered 50.0 percent (including 82,000 newly eligible), SEHI covered 44.8 percent, IPGB covered 2.6 percent, CHIP covered 1.5 percent, OMIP covered 0.8 percent and FHIAP covered 0.3 percent. Assessment of the Oregon Health Plan Medicaid Demonstration, Oregon Department of Administrative Services, online, Office for Oregon Health Plan Policy and Research Web site, online at: www.ohppr.state.or.us.

    Return to text.