Health Coverage in the States — Maine's Plan for Universal Access
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《新英格兰医药杂志》
For at least 25 years, states have served as laboratories for health care reform initiatives, advancing strategies that have later been enacted by the federal government. In the 1970s, Hawaii led the way when it required most employers to provide health care coverage for workers or to pay a tax so that the government could do so. Hawaii received an exemption from Congress when the Employee Retirement Income Security Act (ERISA) was enacted, allowing it to continue its pay-or-play experiment, which substantially reduced the number of uninsured in that state. In the 1980s and 1990s, states advanced Medicaid reforms and the federal government responded, making it easier to secure Medicaid waivers in order to expand coverage of the uninsured. Forty-six states had enacted insurance reforms before Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which protects consumers from insurance practices that left them vulnerable to the loss of coverage when they needed it most. A quarter of the states had established children's health insurance programs before Congress enacted the State Children's Health Insurance Program (SCHIP), aimed at reducing the number of uninsured children in the country. States also enacted patients' bills of rights before the Congress took up that debate.
States have a long tradition of laying the groundwork for incremental federal reforms but have had less success in winning federal support for comprehensive approaches that achieve universal access. Now the wave of state reforms seems to be building again. California recently enacted a pay-or-play law like that in Hawaii. And in Maine, the new Dirigo Health Reform Act promises reforms in terms of cost, quality, and access that are intended to make universal access possible there within five years. Such initiatives at the state level require federal attention and action if they are to realize their promise fully, just as federal action on SCHIP has allowed all states to provide health coverage for children. Although more than 40 million Americans remain uninsured, that number would surely be even larger were it not for these state reforms.
Maine has long been a hotbed of debate about health care reform, which has been stimulated in recent years by double-digit increases in premiums, poor health status among many citizens, and growing numbers of uninsured persons. Maine has little competition in its insurance and provider systems and has more hospital beds per capita, higher utilization rates, and higher rates of chronic illness than any other state in New England. Over the past decade, Maine has led the nation in growth in per capita personal spending on health care. Its hospital cost per discharge (adjusted for the case mix) is higher than the U.S. average. One of every eight citizens is without coverage, which results in $275 million each year in bad debt and charity care.
It is no surprise, then, that during the most recent gubernatorial campaign, health care reform was a major issue. On his election in January 2003, Governor John Baldacci appointed a "health action team," including more than 60 representatives of business and government, consumers, providers, and purchasers. Working on a volunteer basis in open meetings, the team reviewed plan designs and developed recommendations, many of which were incorporated into the governor's final proposal. Ultimately, Dirigo Health, named in reference to the state's motto, meaning "I lead," was created as a new independent state agency to provide a health care program targeted initially to small businesses, self-employed persons, and other individual consumers. Subsidies will be provided to families and individuals with incomes of up to 300 percent of the federal poverty level.
The new agency will determine eligibility and conduct enrollment, arrange health coverage through either a private plan or Medicaid, pay subsidies, monitor and provide information on quality, conduct disease management and health promotion programs, and serve as a model "health and wellness" plan. Dirigo will contract with private insurers, maintain authority over the design of health care benefits, and define allowable administrative costs.
All of this work will be funded through a combination of employer and employee payments, Medicaid dollars for those who are eligible, and an assessment on the gross revenues of health insurers. Employers who choose to participate will be required to contribute a portion of the costs in an amount to be determined by the agency (but not more than 60 percent). Medicaid will be expanded to include parents with incomes of up to 200 percent of the federal poverty level and single adults with incomes of up to 125 percent of this level, many of whom are employed by small businesses. The assessment on gross revenues of insurers, including reinsurers and third-party administrators, is designed to recapture savings from reductions in bad debt and charity care, as well as other cost reductions.
Maine will limit health care costs through close state oversight. The new law includes voluntary budget limits and margins for insurers, hospitals, and providers and creates a state health plan with limits on global expenditures and a process for addressing key public health problems. A one-year moratorium, with an emergency exception, has been placed on certificate-of-need (CON) review. Future projects requiring review can be approved only up to the limits of a capital investment fund that has been established to budget for and solicit capital projects. The CON program is also being extended to cover some nonhospital services, such as ambulatory surgical units, with the goal of controlling the growth of outpatient costs. For the first time, insurance regulation in the small-group market and the disclosure of prices by providers are required. The law also establishes the Maine Quality Forum, funded in part by the assessment on insurance companies. It will serve as a watchdog, stimulate the diffusion of evidence-based medicine, provide consumer education about wellness and health promotion, and conduct assessments of technology.
The Dirigo law was enacted after an outpouring of public concern — the hearing on the bill lasted nine hours — and long hours of "shuttle diplomacy" between the governor's staff members and key stakeholders. Initial support came from the Maine State Chamber of Commerce, the Alliance for Small Businesses, numerous individual consumers and consumer advocacy groups, unions, and the Maine State Nurses Association. Hospitals, physicians' organizations, and insurers all registered substantial concerns about specific features of the proposed bill, but after extensive negotiations, the primary objections of each constituency were addressed.
Specifically, voluntary hospital planning and the global hospital budget that had originally been proposed were eliminated. The hospitals made it clear that, with or without a budget, they were not interested in a hospital-only discussion regarding the realignment of hospital services statewide. Instead, the state health plan, which includes a global budget, and the capital investment fund were retained, and the creation of a commission to study Maine's hospitals was added to the bill.
The proposed assessment on insurers' gross revenues became contingent on a demonstration of savings through the avoidance of bad debt and charity care and reductions in the growth of health care costs. This savings-offset payment should provide the necessary revenues for subsidies for employees and individual insurance purchasers. Unless and until the cost-containment goals are met, funding for the subsidies will not be available — a provision that directly links the goal of health care access to effective cost containment.
Physicians' groups resisted being included in the CON program and objected to requirements for electronic billing and for all providers to post the prices of common services. However, they supported the plan to address payment inequities between the Medicaid reimbursement rates and those negotiated for commercial carriers; Dirigo will pay physicians at the latter rates. In addition, the state has launched a study to determine the costs of incremental Medicaid increases for physicians' services.
Dirigo Health will be phased in over a period of five years to cover all of Maine's uninsured residents, and state funds made available through federal fiscal relief will provide first-year financing, which will allow the early experience to determine the amount of insurers' assessments. This agreement helped to resolve a serious problem: an assessment in the first year, before any savings had been realized, would most likely have been passed on to other payers in the form of increased premiums. Since the assessments will be linked to demonstrated savings, insurers should recover the assessments through their contract negotiations with providers — not payers.
Like any compromise, Dirigo Health does not please all parties. Two key issues continue to surface. First, advocates of single-payer plans, among others, argue that because Dirigo Health is a voluntary system, it cannot achieve its goal of universal coverage in five years. Supporters of the voluntary program stress that there is considerable transparency in the bill that will result in a better-informed buying public, that subsidies will ensure affordability and encourage enrollment, and that unless and until cost growth is tamed and an affordable insurance product is available on the market, it is inappropriate to discuss mandates.
Second, a new conservative think tank has emerged in Maine that is aggressively resisting the law's requirement to build expansions of Medicaid into the program, arguing that Maine's budget cannot afford even limited expansion. Supporters of the plan note that securing federal financing for Medicaid-eligible enrollees is critical to the plan and that Dirigo has the tools to control the growth of health care costs, including those of Medicaid. This debate may be a precursor to a reemerging national interest in reducing the growth of Medicaid by converting the program to a block grant.
Built on earlier work in Maine and many other states, Dirigo Health represents an attempt to link comprehensive health system reform with an effort to achieve universality. The implementation of the program is now under way. Its success will depend on the collaborative efforts of all constituencies.
Source Information
From the Governor's Office of Health Policy and Finance, Augusta, Maine (T.R.); and the Muskie School of Public Service, University of Southern Maine, Portland (E.K.).(Trish Riley, M.S., and El)
States have a long tradition of laying the groundwork for incremental federal reforms but have had less success in winning federal support for comprehensive approaches that achieve universal access. Now the wave of state reforms seems to be building again. California recently enacted a pay-or-play law like that in Hawaii. And in Maine, the new Dirigo Health Reform Act promises reforms in terms of cost, quality, and access that are intended to make universal access possible there within five years. Such initiatives at the state level require federal attention and action if they are to realize their promise fully, just as federal action on SCHIP has allowed all states to provide health coverage for children. Although more than 40 million Americans remain uninsured, that number would surely be even larger were it not for these state reforms.
Maine has long been a hotbed of debate about health care reform, which has been stimulated in recent years by double-digit increases in premiums, poor health status among many citizens, and growing numbers of uninsured persons. Maine has little competition in its insurance and provider systems and has more hospital beds per capita, higher utilization rates, and higher rates of chronic illness than any other state in New England. Over the past decade, Maine has led the nation in growth in per capita personal spending on health care. Its hospital cost per discharge (adjusted for the case mix) is higher than the U.S. average. One of every eight citizens is without coverage, which results in $275 million each year in bad debt and charity care.
It is no surprise, then, that during the most recent gubernatorial campaign, health care reform was a major issue. On his election in January 2003, Governor John Baldacci appointed a "health action team," including more than 60 representatives of business and government, consumers, providers, and purchasers. Working on a volunteer basis in open meetings, the team reviewed plan designs and developed recommendations, many of which were incorporated into the governor's final proposal. Ultimately, Dirigo Health, named in reference to the state's motto, meaning "I lead," was created as a new independent state agency to provide a health care program targeted initially to small businesses, self-employed persons, and other individual consumers. Subsidies will be provided to families and individuals with incomes of up to 300 percent of the federal poverty level.
The new agency will determine eligibility and conduct enrollment, arrange health coverage through either a private plan or Medicaid, pay subsidies, monitor and provide information on quality, conduct disease management and health promotion programs, and serve as a model "health and wellness" plan. Dirigo will contract with private insurers, maintain authority over the design of health care benefits, and define allowable administrative costs.
All of this work will be funded through a combination of employer and employee payments, Medicaid dollars for those who are eligible, and an assessment on the gross revenues of health insurers. Employers who choose to participate will be required to contribute a portion of the costs in an amount to be determined by the agency (but not more than 60 percent). Medicaid will be expanded to include parents with incomes of up to 200 percent of the federal poverty level and single adults with incomes of up to 125 percent of this level, many of whom are employed by small businesses. The assessment on gross revenues of insurers, including reinsurers and third-party administrators, is designed to recapture savings from reductions in bad debt and charity care, as well as other cost reductions.
Maine will limit health care costs through close state oversight. The new law includes voluntary budget limits and margins for insurers, hospitals, and providers and creates a state health plan with limits on global expenditures and a process for addressing key public health problems. A one-year moratorium, with an emergency exception, has been placed on certificate-of-need (CON) review. Future projects requiring review can be approved only up to the limits of a capital investment fund that has been established to budget for and solicit capital projects. The CON program is also being extended to cover some nonhospital services, such as ambulatory surgical units, with the goal of controlling the growth of outpatient costs. For the first time, insurance regulation in the small-group market and the disclosure of prices by providers are required. The law also establishes the Maine Quality Forum, funded in part by the assessment on insurance companies. It will serve as a watchdog, stimulate the diffusion of evidence-based medicine, provide consumer education about wellness and health promotion, and conduct assessments of technology.
The Dirigo law was enacted after an outpouring of public concern — the hearing on the bill lasted nine hours — and long hours of "shuttle diplomacy" between the governor's staff members and key stakeholders. Initial support came from the Maine State Chamber of Commerce, the Alliance for Small Businesses, numerous individual consumers and consumer advocacy groups, unions, and the Maine State Nurses Association. Hospitals, physicians' organizations, and insurers all registered substantial concerns about specific features of the proposed bill, but after extensive negotiations, the primary objections of each constituency were addressed.
Specifically, voluntary hospital planning and the global hospital budget that had originally been proposed were eliminated. The hospitals made it clear that, with or without a budget, they were not interested in a hospital-only discussion regarding the realignment of hospital services statewide. Instead, the state health plan, which includes a global budget, and the capital investment fund were retained, and the creation of a commission to study Maine's hospitals was added to the bill.
The proposed assessment on insurers' gross revenues became contingent on a demonstration of savings through the avoidance of bad debt and charity care and reductions in the growth of health care costs. This savings-offset payment should provide the necessary revenues for subsidies for employees and individual insurance purchasers. Unless and until the cost-containment goals are met, funding for the subsidies will not be available — a provision that directly links the goal of health care access to effective cost containment.
Physicians' groups resisted being included in the CON program and objected to requirements for electronic billing and for all providers to post the prices of common services. However, they supported the plan to address payment inequities between the Medicaid reimbursement rates and those negotiated for commercial carriers; Dirigo will pay physicians at the latter rates. In addition, the state has launched a study to determine the costs of incremental Medicaid increases for physicians' services.
Dirigo Health will be phased in over a period of five years to cover all of Maine's uninsured residents, and state funds made available through federal fiscal relief will provide first-year financing, which will allow the early experience to determine the amount of insurers' assessments. This agreement helped to resolve a serious problem: an assessment in the first year, before any savings had been realized, would most likely have been passed on to other payers in the form of increased premiums. Since the assessments will be linked to demonstrated savings, insurers should recover the assessments through their contract negotiations with providers — not payers.
Like any compromise, Dirigo Health does not please all parties. Two key issues continue to surface. First, advocates of single-payer plans, among others, argue that because Dirigo Health is a voluntary system, it cannot achieve its goal of universal coverage in five years. Supporters of the voluntary program stress that there is considerable transparency in the bill that will result in a better-informed buying public, that subsidies will ensure affordability and encourage enrollment, and that unless and until cost growth is tamed and an affordable insurance product is available on the market, it is inappropriate to discuss mandates.
Second, a new conservative think tank has emerged in Maine that is aggressively resisting the law's requirement to build expansions of Medicaid into the program, arguing that Maine's budget cannot afford even limited expansion. Supporters of the plan note that securing federal financing for Medicaid-eligible enrollees is critical to the plan and that Dirigo has the tools to control the growth of health care costs, including those of Medicaid. This debate may be a precursor to a reemerging national interest in reducing the growth of Medicaid by converting the program to a block grant.
Built on earlier work in Maine and many other states, Dirigo Health represents an attempt to link comprehensive health system reform with an effort to achieve universality. The implementation of the program is now under way. Its success will depend on the collaborative efforts of all constituencies.
Source Information
From the Governor's Office of Health Policy and Finance, Augusta, Maine (T.R.); and the Muskie School of Public Service, University of Southern Maine, Portland (E.K.).(Trish Riley, M.S., and El)