Urban Institute: Health/Healthcare

ACA Implementation-Monitoring and Tracking: Oregon Site Visit Report

paffairs@urban.org ( Teresa A. Coughlin, Sabrina Corlette ) — Wed, 08 Feb 2012 00:00:00 EST

Many of the provisions to expand health coverage in the Affordable Care Act must be implemented by the states. With support from the Robert Wood Johnson Foundation, the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of the ACA in ten of the states: Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island and Virginia. This first report is a case study analysis of Oregons efforts to advance health care reform. Derived from a site visit and extensive interviews with state officials and state stakeholders, it documents Oregon's considerable progress in establishing an exchange, implementing insurance reforms, and preparing for an expansion of Medicaid, all within a challenging fiscal environment.

Policy Options to Improve the Performance of Low Income Subsidy Programs for Medicare Beneficiaries

paffairs@urban.org ( Stephen Zuckerman, Baoping Shang, Timothy Waidmann ) — Thu, 02 Feb 2012 00:00:00 EST

Low-income Medicare beneficiaries are eligible for subsidies to help them pay premiums and cost sharing. However, these subsidies fall short of those contained in the Patient Protection and Affordable Care Act (ACA) that help low-income families afford adequate health coverage. In this report we consider policy options to reform Medicare's low-income subsidies to better align with ACA provisions. We estimate that a significant simplification in low-income protection and cost-sharing rules could greatly reduce burdens on the poorest and sickest beneficiaries. Depending on how they are implemented, these reforms could either reduce or only modestly increase total public spending.

Health Reform's Tax on Investment: Facts and Myths

paffairs@urban.org ( Donald Marron ) — Tue, 31 Jan 2012 00:00:00 EST

To help pay for expanded health insurance coverage, the health reform legislation enacted in 2010 included a new 3.8 percent tax on the net investment income of high-income taxpayers. When it goes into effect in 2013, it will increase the top tax rate on capital gains, dividends, and other investment income, regardless of whether the 2001 and 2003 tax cuts are allowed to expire. Almost all the burden will be borne by taxpayers with extremely high incomes. More than half the burden, for example, falls on taxpayers in the top 0.1 percent of the income distribution.

Health Reform in Massachusetts as of Fall 2010: Getting Ready for the Affordable Care Act & Addressing Affordability

paffairs@urban.org ( Sharon K. Long, Karen Stockley, Heather Dahlen ) — Fri, 27 Jan 2012 00:00:00 EST

Five years after the enactment of Massachusetts health reform initiative, gains in insurance coverage and access to care have been sustained. This report provides an update on trends in the Bay State since fall 2006, just prior to the implementation of the state's health reform initiative, along with a more in-depth overview of the circumstances of working-age adults in 2010, as the state begins implementation of the Affordable Care Act.

Improving the Efficiency of Primary Care in Safety Net Clinics: San Mateo County's System Redesign

paffairs@urban.org ( Embry M. Howell, Ashley Palmer ) — Wed, 25 Jan 2012 00:00:00 EST

San Mateo County is one of a small number of innovative local jurisdictions that is expanding coverage for uninsured adults and at the same time undertaking a reform of its safety net primary care system. We evaluated the impact of the systems redesign by comparing outcomes for a group of people served at the largest county safety net clinic prior to systems redesign (2006) to those served at the clinic after systems redesign (2009). Use of any preventive care services in a year climbed from 25.9 percent to 33.3 percent. Continuity of care also rose significantly, and emergency room use declined. The county's experience provides an example for other communities to follow as they improve the efficiency of health care services for the most vulnerable members of society.

State Progress Toward Health Reform Implementation: Slower Moving States Have Much to Gain

paffairs@urban.org ( Fredric Blavin, Matthew Buettgens, Jeremy Roth ) — Mon, 23 Jan 2012 00:00:00 EST

We use the Health Insurance Policy Simulation Model to explore the correlations between a state's progress toward implementing the Affordable Care Act and the anticipated benefits of the reform for state residents, as measured by the expected state gains in insurance coverage and federal subsidies. We group states in three categories based on the status of legislative action and the receipt of level 1 federal establishment grants. We find that states that have made the least progress in establishing health insurance exchanges are in general those that have the largest potential gains in coverage and federal subsidy dollars per capita.

Controlling the Deficit: The Debate Continues

paffairs@urban.org ( John L. Palmer, Rudolph G. Penner ) — Fri, 20 Jan 2012 00:00:00 EST

The report discusses the important budget events of 2011. It begins with the House Republican budget and the president's response. The very different approaches to health and discretionary spending and tax policy are analyzed in detail. The policy debate continued into the confused debt limit negotiations of July. The Budget Control Act finally emerged. It capped discretionary spending and created a "super committee" that was to propose additional deficit reductions. The committee failed miserably. An automatic across-the-board spending cut is supposed to result from that failure. The report describes its effects on defense and nondefense spending.

Eliminating the Individual Mandate: Effects on Premiums, Coverage, and Uncompensated Care

paffairs@urban.org ( Matthew Buettgens, Caitlin Carroll ) — Thu, 12 Jan 2012 00:00:00 EST

The federal requirement for most Americans to have health insurance-the individual mandate-is an important part of how the ACA would reduce the number of uninsured. We use the Health Insurance Policy Simulation Model to estimate the effects of health reform with and without the mandate. With the mandate, the number of uninsured would decrease from 50 million to 26 million. Without a mandate, about 40 million would remain uninsured. Depending on the effectiveness of the health benefit exchanges in enrolling those eligible for subsidized coverage, exchange premiums would be 10 to 25 percent higher without a mandate.

The Case Against Premium Support

paffairs@urban.org ( Judy Feder, Paul Van de Water, Henry J. Aaron ) — Thu, 22 Dec 2011 00:00:00 EST

Proposals to replace traditional Medicare with "premium support"-or vouchers for the purchase of private insurance or, in some cases, Medicare-have once again emerged on the political agenda. This critical commentary on the Rivlin/Domenici proposal (markedly similar to the Ryan/Wyden proposal) finds much wanting in premium supportin particular, that Medicare already provides benefits more equitably and at lower cost than private insurance; that without "regulatory teeth", premium support would actually create coverage inequities and increase costs; and that implementation of the Affordable Care Act's payment and other Medicare reforms, not Medicare replacement, ought to be the nation's top priority in controlling overall health costs. These remarks were presented at a Brookings Institution forum on December 16, 2011.

Health Insurance Policy Simulation Model (HIPSM) Methodology Documentation

paffairs@urban.org ( Matthew Buettgens ) — Wed, 21 Dec 2011 00:00:00 EST

Describes in detail the Urban Institute's Health Insurance Policy Simulation Model (HIPSM) and the methodology behind it.

Recent Trends in Childhood Asthma-Related Outcomes and Parental Asthma Management Training

paffairs@urban.org ( Genevieve M. Kenney, Adela Luque, Christine Coyer ) — Mon, 19 Dec 2011 00:00:00 EST

Asthma is one of the most common chronic conditions among children in the United States, affecting nearly 10 percent of children in 2008. Medicaid and CHIP are covering a growing number of asthmatic children; by 2008, two-thirds of low-income asthmatic children were covered by Medicaid/CHIP. Our findings suggest that over the last decade, there has been a trend towards improvement in asthma-related outcomes and receipt of parental asthma management training for asthmatic children with Medicaid/CHIP coverage. Further expansions in health insurance coverage could lead to reductions in negative asthma outcomes and their associated costs, but other changes to the service delivery system would be needed as well.

Containing the Growth of Spending in the U.S. Health System: Methods Appendix

Mon, 19 Dec 2011 00:00:00 EST

The growth in U.S. health care spending has become a focal point in debates over federal and state health care reform. While the problem is easy to quantify, strategies for slowing rising expenditures are controversial, and evidence of their effectiveness is often elusive. Our full report provides background that describes the problem and reviews the cost containment provisions of the Affordable Care Act (ACA). It also presents estimates of cost savings from several policies that go beyond those included in the ACA. In this appendix, we provide more detail on the methods used to generate these cost savings estimates.

The Potential Savings from Enhanced Chronic Care Management Policies

paffairs@urban.org ( John Holahan, Cathy Schoen, Stacey McMorrow ) — Thu, 01 Dec 2011 00:00:00 EST

The United States spent an estimated $635 billion on the chronically ill and disabled in 2010; about half of this was spent on those dually eligible for Medicare and Medicaid. Recently, there has been a series of innovative chronic care management programs that have shown considerable promise in reducing hospital admissions, readmissions, specialty care and prescription drug use. Considerable savings could be achieved if these programs could be expanded broadly. In this paper, we argue that this should primarily be a Medicare initiative because most of the current expenditures and savings from these programs would accrue to Medicare. We estimate potential savings of close to 1% of national health expenditures.

The State of Quality Improvement Science in Health: What Do We Know About How to Provide Better Care?

paffairs@urban.org ( Kelly J. Devers ) — Thu, 01 Dec 2011 00:00:00 EST

This policy paper by Kelly Devers analyzes the trend toward quality improvement (QI) efforts in health care, concluding that while QI alone is no magic bullet, it generally has modest, positive effects. The paper, funded by the Robert Wood Johnson Foundation, reviews the evolution of QI initiatives, the current evidence about whether QI interventions work, QIs promise for the future, and how to help it find success in health care. The paper offers recommendations for enhancing QI, including by providing incentives for providers to prioritize quality; improving education, training, and technical assistance; investing in health IT; and promoting greater collaboration across organizations.

Evaluation of the San Mateo County Adult Coverage and Systems Redesign Initiative

Wed, 23 Nov 2011 00:00:00 EST

In 2008 San Mateo County, California launched its Adult Coverage Expansion and Systems Redesign Initiative. The initiative expanded coverage for all uninsured adults below 200 percent of the poverty level and redesigned care in county safety net clinics. The program substantially improved access to care for uninsured adults, as well as improved continuity and quality of care for those served by county safety net clinics. However, access remains a problem for new enrollees, due to restrained provider supply and the economic recession. The report provides lessons for other counties as they expand coverage under national health reform.

How Human Services Programs and Their Clients Can Benefit from National Health Reform Legislation

paffairs@urban.org ( Stan Dorn ) — Thu, 10 Nov 2011 00:00:00 EST

Human services programs-the Supplemental Nutrition Assistance Program, Temporary Assistance to Needy Families, subsidized child care, etc.-and their clients can benefit from national health reform. Millions of low-income health coverage applicants can be connected with human services programs, as the latter programs: (a) help health programs efficiently reach eligible consumers; (b) access unprecedented, time-limited federal funding for modernizing eligibility computer systems while limiting risks to current funding; (c) keep social services offices available as an avenue for seeking health coverage; and (d) use a forthcoming Medicaid expansion to accomplish core human services goals related to employment and child development.

What Directions for Public Health under the Affordable Care Act?

paffairs@urban.org ( Randall R. Bovbjerg, Barbara A. Ormond, Timothy Waidmann ) — Tue, 08 Nov 2011 00:00:00 EST

The Affordable Care Act (ACA) presents opportunities to support what has often been called the new public health. This analysis of the ACA provisions suggests five interrelated issues of importance for the future of public health-defining a new paradigm, identifying reliable funding streams, developing the evidence base, establishing effective relationships with other actors, and communicating the value proposition of public health. The brief concludes by noting that much work must still be done to assure that the ACA becomes a wellspring of appreciation for public healths value, rather than the high water mark for public health advocacy.

Accountable Care Organizations in Medicare and the Private Sector: A Status Update

paffairs@urban.org ( Robert A. Berenson, Rachel A. Burton ) — Thu, 03 Nov 2011 00:00:00 EST

This issue paper examines the latest developments in accountable care organizations (ACOs), including a look at the final regulations on ACOs issued in October 2011 by the Centers for Medicare & Medicaid Services (CMS). Written by the Urban Institutes Bob Berenson and Rachel Burton, this paper provides an overview of ACOs, the key complaints about CMS' proposed regulations and their resolution in the final regulations, and the status of adoption of this new model for delivering health care by both Medicare and private health insurance plans. This paper is supported by the Robert Wood Johnson Foundation.

Implementing Best Start LA: Momentum Grows in Metro LA

paffairs@urban.org ( Ian Hill, Sarah Benatar ) — Tue, 01 Nov 2011 00:00:00 EST

This second case study of the implementation of Best Start LA finds that the place-based investmentdesigned to improve the well-being, development and care experienced by children ages five and underhas made good progress during its second year, gaining momentum as it has become more firmly established in the downtown Metro LA pilot community. Welcome Baby! home visiting appears to be a high-quality service that could serve as a model throughout Los Angeles County. Community strategies have been funded through a series of "first step" contracts with various local agencies. And systems-level efforts appear to be laying the groundwork for important changes that could make Los Angeles communities more family-friendly for parents with young children.

The Role of Prevention in Bending the Cost Curve

paffairs@urban.org ( Timothy Waidmann, Barbara A. Ormond, Randall R. Bovbjerg ) — Thu, 27 Oct 2011 00:00:00 EST

Among the health promotion and cost-control strategies included in the Affordable Care Act (ACA) is a focus on disease prevention. In addition to bolstering coverage of clinical preventive services the ACA includes new funding for evidence-based lifestyle interventions targeting chronic diseases like diabetes, hypertension, heart disease, stroke and renal disease, all of which are growing in prevalence in the U.S. This brief examines the budgetary implications of unchecked prevalence growth, describes promising approaches to reducing that growth, and estimates the potential return on investment in these approaches as envisioned in the ACA, finding ample justification for these efforts in a larger cost-control strategy.

Why Employers Will Continue to Provide Health Insurance: The Impact of the Affordable Care Act

Wed, 26 Oct 2011 00:00:00 EST

The Congressional Budget Office, the Rand Corporation, and the Urban Institute have estimated that the Affordable Care Act (ACA) will leave employer-sponsored coverage largely intact; in contrast, some economists and benefit consultants argue that the ACA encourages employers to drop coverage thereby making both their workers and their firms better off (a winwin" situation). This brief's analysis shows that no such "winwin" situation exists and that employer-sponsored insurance will remain most workers' primary source of coverage. Analysis of three issues-the terms of the ACA, worker characteristics, and the fundamental economics of competitive markets-supports this conclusion.

How Can We Move Clinical Genomics Beyond the Hype?

paffairs@urban.org ( Michael L. Millenson ) — Fri, 21 Oct 2011 00:00:00 EST

More than a decade after the successful mapping of the human genome, clinical genomics is starting to permeate important parts of patient care. Although the field has fallen far short of the transformational therapeutic impact once widely predicted, the use of genomic interventions is rising rapidly, if not always appropriately. Avoidable patient harm and excess costs mix with significant clinical and economic benefits. A health policy community long fluent in the argot of DRGs and billing codes needs to acquire similar proficiency in the language of DNA and genetic codes. This paper, by Michael Millenson, a senior policy consultant to the Urban Institute, examines what's hype, what's hopeful and what's starting to make a genuine difference in clinical genomics.

A Comprehensive Review of Immigrant Access to Health and Human Services

paffairs@urban.org ( Karina Fortuny, Ajay Chaudry ) — Wed, 12 Oct 2011 00:00:00 EST

The Immigrant Access to Health and Human Services study maps and describes the policy context that can affect immigrant access to health and human services and the well-being of immigrants and their children. This paper summarizes federal provisions and key aspects of state-level variation related to immigrants' eligibility for TANF, SNAP, Medicaid, and CHIP based on a review of literature and the latest information. It provides a building block for the fieldwork and in-depth assessment of the policy context around immigrant access to health and human services.

Profile of Virginia's Uninsured 2010

Tue, 11 Oct 2011 00:00:00 EST

This report provides detailed demographic information on Virginia's uninsured population in 2009, including data on their income, employment status, race, ethnicity, age and citizenship, and region of residence. Between 2008 and 2009, 47,000 nonelderly adults in Virginia became newly uninsured, though there was no significant change in the number of uninsured children, due in part to increased coverage through Medicaid and CHIP. Overall, 13.2 percent of Virginians (889,000 total) under the age of 65 lacked health insurance in 2009. The majority of Virginia's uninsured are US citizens and live in working families, but most are in low-income families.

A Good Start for Best Start in Metro LA: Focus Group Insights from Parents, Home Visitors, and Community Stakeholders

paffairs@urban.org ( Ian Hill, Fiona Adams ) — Tue, 11 Oct 2011 00:00:00 EST

Best Start LA is a place-based community investment in Los Angeles County designed to improve the well-being, development, and care experienced in children ages five and under. Focus groups with parents, home visitors, and community members -reveal that the investment is off to a good start. Mothers receiving "Welcome Baby!" home visiting were very satisfied with the education and support the service provides. Home visitors described the close bonds they form with their clients, but also feel that the program's model doesn't always meet families' extensive needs. Stakeholders involved in community mobilization efforts were excited about their early progress and shared vision for parents as the leaders.

Containing the Growth of Spending in the U.S. Health System

Wed, 05 Oct 2011 00:00:00 EST

In this paper we review data on health care spending growth and the reasons for the persistent high rates of growth. We discuss the cost containment provisions that are incorporated into the Affordable Care Act.A number of options that are not included in the ACA are then analyzed.We use a consistent analytic framework for making estimates relying on an extensive body of research evidence.We make estimates of the savings from eliminating tax exclusion, malpractice reform, chronic care management, prevention and various approaches to setting rates for providers.We conclude that no one option could provide substantial savings by themselves and that a combination of several policies is necessary to reduce the rate of growth.

Health Cost Containment: No Silver Bullets, Needs Multipronged Approach

paffairs@urban.org ( Urban Institute ) — Wed, 05 Oct 2011 00:00:00 EST

With annual health care spending growing 60 percent faster than the gross domestic product, an array of cost controls analyzed by Urban Institute researchers could produce substantial savings over a decade, a new report concludes.

Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead

Tue, 04 Oct 2011 00:00:00 EST

At 40 percent of Medicare's and of Medicaid's costs, the 9 million dual eligibles who receive benefits from both programs, are a focus of efforts to slow growth in entitlement spending. But, given the two programs' responsibilities, policy-makers are relying far too heavily on states to find the solution. Dollars spent on dual eligibles are overwhelmingly federal; potential savings come from better management of Medicare-financed acute care services; and enhanced state, rather than federal, responsibility for overall spending increases the risk of cost-shifting to Medicare and may undermine quality of care for vulnerable beneficiaries.

Innovative Medicaid Initiatives to Improve Service Delivery and Quality of Care: A Look at Five State Initiatives

Mon, 26 Sep 2011 00:00:00 EST

A number of states have used the flexibility of the Medicaid program to develop innovative payment and delivery systems designed to coordinate and improve quality of care. This brief, based on site visits from Nov. 2009 through March 2010, highlights care coordination and related efforts in five states: Alabama, Oklahoma, Oregon, Pennsylvania and Washington State. Such efforts by states to realign the provider payment and delivery systems are key to improving Medicaid and to successfully implementing coverage expansions under the health reform law.

Using the Basic Health Program to Make Coverage More Affordable to Low-Income Households: A Promising Approach for Many States

paffairs@urban.org ( Stan Dorn, Matthew Buettgens, Caitlin Carroll ) — Mon, 26 Sep 2011 00:00:00 EST

We estimate national and state effects of implementing the Basic Health Program option in national health reform to provide near-poor adults with coverage like Medicaid and the Children's Health Insurance Program.Implemented nationally, such a policy would reduce these adults' annual premium and out-of-pocket costs from $1,652 to $196; lower the number of uninsured by 600,000; provide federal dollars that exceed baseline Medicaid/CHIP costs by 23 percent; reduce exchange enrollment from 9.8 to 8.2 percent of non-elderly residents; save states $1.3 billion annually in Medicaid costs; and raise risk levels in individual markets. State policy choices could change these results.

Implementing Best Start LA in Metro LA - Slow but Steady Progress for the Place-Based Community Initiative

paffairs@urban.org ( Ian Hill, Sarah Benatar, Fiona Adams, Heather Sandstrom ) — Wed, 21 Sep 2011 00:00:00 EST

A case study of the initial implementation of Best Start LA-a place-based community investment in Los Angeles County designed to improve the well-being, development, and care experienced by children ages five and under-finds mostly positive results, thus far.At the family level, home visiting for pregnant and parenting mothers is off to a strong start, rendering services to nearly 750 families by the end of 2010.Community-level efforts to mobilize community members and develop family-support strategies have been slower to develop.Systems-level investments to develop family-friendly policies and services across the county are proceeding on schedule.

Preserving Medicare: A Practical Approach to Controlling Spending

paffairs@urban.org ( Robert A. Berenson, John Holahan ) — Mon, 19 Sep 2011 00:00:00 EST

Some of projected Medicare spending growth over the next decade (6.5 percent per year) can be explained by the retirement of the baby boomers; moreover, provisions in the Affordable Care Act will reduce spending per enrollee to about 3.5 percent. We agree with the analysis of the Congressional Budget Office that concluded that privatization initiatives would actually increase health care spending and shift costs to beneficiaries themselves. We argue that it is possible to reduce Medicare spending growth further by selected policies such as increasing home health co-insurance, reforming cost sharing provisions, increasing premiums for beneficiaries earning more than 300 percent of the federal poverty line, increasing the age of eligibility, reducing fraud, and better management of Medicare's dual eligibles.

How Lifetime Benefits and Contributions Point the Way Toward Reforming Our Senior Entitlement Programs

paffairs@urban.org ( C. Eugene Steuerle, Stephanie Rennane ) — Wed, 07 Sep 2011 00:00:00 EST

The Congress, the President, and various commissions have begun discussing real Social Security, Medicare, and Medicaid reform.This paper suggests that as these discussions move forward, it would be helpful to examine lifetime contributions and benefits for Medicare and Social Security to understand the programs internal fiscal situations and their broader role in overall budget policy and, most importantly, as a way toward a more unified and coherent approach to entitlement reform for seniors. This approach also provides a useful window on how equitably lifetime benefits and taxes are distributed and on the fiscal stability of the overall system.

Improving the Quality and Efficiency of the Medicare Program Through Coverage Policy

Wed, 07 Sep 2011 00:00:00 EST

Medicare coverage determinations can influence the appropriate use of medical technology and the creation of better evidence to support clinical and health policy decisions. In this paper, the Urban Institute's Robert Berenson and co-authors Sean Tunis, Steve Phurrough, and Penny Mohr argue that the process for making coverage decisions in the Medicare program falls short of its potential to contribute to improved health outcomes for beneficiaries. The paper, funded by the Robert Wood Johnson Foundation, offers several achievable steps in five topic areas to improve the coverage process.

Consumer Operated and Oriented Plans (CO-OPs) : An Interim Assessment of their Prospects

paffairs@urban.org ( Bradford H. Gray ) — Wed, 31 Aug 2011 00:00:00 EST

The first loans for creation of Consumer Operated and Oriented Plans (CO-OPs) are expected in early 2012. Proposed as an alternative to the public option in the health reform debate, CO-OPs are to be nonprofit, member-governed health plans that create innovative care delivery models to serve the individual and small group markets in various states. The Patient Protection and Affordable Care Act has features that are attracting potential developers of CO-OPs, but it also contains provisions that will make success more difficult. This status report, funded by the Robert Wood Johnson Foundation, covers the provisions of the legislation that will affect who seeks CO-OP funding and whether they are likely to survive and grow. CO-OPs may become important insurance options in some markets, but it is difficult to foresee their having a transformative effect that was expected of the public option.

Gains for Children: Increased Participation in Medicaid and CHIP in 2009

Thu, 18 Aug 2011 00:00:00 EST

The number of children eligible for and enrolled in Medicaid and CHIP increased in recent years. As a consequence, the number of eligible but uninsured kids fell by about 340,000 between 2008 and 2009. Rates of participation in Medicaid/CHIP increased, from 82.1 to 84.8 percent nationally, with sixteen states achieving participation rates of 90 percent or higher in 2009. This report suggests that the high participation rates among children over the past few years are likely due in part to ongoing federal and state policy efforts aimed at improving enrollment and retention among children.

Medicare Premiums and Social Security's Cost-of-Living Adjustments

paffairs@urban.org ( Rudolph G. Penner ) — Tue, 16 Aug 2011 00:00:00 EST

Medicare Part B and Part D premiums will soon increase for most beneficiaries, likely consuming much of the cost-of-living increase in their Social Security benefits. Part B premiums do not vary with affordability except for the relatively few single beneficiaries with annual incomes exceeding $85,000 and the relatively few married beneficiaries with incomes exceeding $170,000. Consequently, premium levels and increases are often burdensome at low income levels. Rising health care costs leave the entire population with less to spend on nonhealth goods and services, and older adults are affected most because so much of their income goes to health care.

Will the Patient-Centered Medical Home Transform the Delivery of Health Care?

paffairs@urban.org ( Robert A. Berenson, Kelly J. Devers, Rachel A. Burton ) — Mon, 15 Aug 2011 00:00:00 EST

This status report on the patient-centered medical home covers such topics as: What is a medical home? Where did the concept come from? How are medical homes assessed and paid? Do medical homes actually work? How does the health reform law encourage medical homes? The paper, funded by the Robert Wood Johnson Foundation, concludes that the medical home model has the potential to transform health care delivery, but organizations promoting the model should tread carefully because enthusiasm for the approach may not be borne out in evidence of success. Pilots should be completed and evaluated, and the model should be recalibrated before it is broadly expanded.

ACA and State Governments: Consider Savings as Well as Costs : State Governments Would Spend at Least $90 Billion Less With the ACA than Without It from 2014 to 2019

paffairs@urban.org ( Matthew Buettgens, Stan Dorn, Caitlin Carroll ) — Wed, 13 Jul 2011 00:00:00 EST

This report finds that state governments are likely to spend $92-129 billion less from 2014 to 2019 with implementation of the Affordable Care Act, thanks to provisions reducing the uninsured population and increasing federal support for health care previously financed by states. The authors find that, overall, the federal government would spend $704 to $743 billion more under reform from 2014 to 2019. Even after 2019, when the federal government' share of Medicaid costs declines to its permanent level, states will still come out ahead, realizing net savings in 2020 alone of $12 to $19 billion.

The Effects of Health Reform on Small Businesses and Their Workers

paffairs@urban.org ( Stacey McMorrow, Linda J. Blumberg, Matthew Buettgens ) — Tue, 21 Jun 2011 00:00:00 EST

This brief consolidates the results of several UI studies addressing the effects of the Affordable Care Act (ACA) on small firms.We find generally positive effects of the ACA on small employers and their workers.Employers with fewer than 50 workers will experience substantial savings on health costs; employers with 50 to 100 workers will seea very small cost increase.The smallest firms are expected to have higher offer rates, resulting in a small increase in employer coverage.Small firm workers and their families will reap substantial benefits from the Medicaid expansion and subsidies to low-income families.

Moving Payment from Volume to Value: What Role for Performance Measurement?

paffairs@urban.org ( Robert A. Berenson ) — Thu, 09 Jun 2011 00:00:00 EST

There seems to be broad support for shifting from reliance on volume-based provider payments to value-based payments. The term value-based payment connotes assessment of performance and making payments commensurate with that assessment. However, most of the actual payment models specified in the Affordable Care Act for testing actually are not based on performance assessments but rather primarily alter payment incentives, with the goal of rewarding value whether or not the enhanced value can be directly recognized and rewarded. This paper explores the challenges in trying to move payment from "volume" to "value" and supports the focus on altered incentives, rather than assessments of performance.

Reforming Beneficiary Cost Sharing to Improve Medicare Performance - Appendix 1: Data and Simulation Methods

paffairs@urban.org ( Stephen Zuckerman, Baoping Shang, Timothy Waidmann ) — Tue, 07 Jun 2011 00:00:00 EST

This is a Methodological Appendix to a paper that explores options for reforming Medicare cost sharing. Using data from the Health and Retirement Study and the Medicare Current Beneficiary Survey, we consider how unified deductibles, alternative coinsurance rates, and a limit on out-of-pocket spending would alter program spending, beneficiary cost sharing, and premiums for supplemental coverage. We show that cost sharing reforms could provide better safeguards to beneficiaries with high costs than the current Medicare benefit structure and that policies could be structured in a way that would add little to overall program costs.

Addressing Coverage Challenges for Children Under the Affordable Care Act

paffairs@urban.org ( Stacey McMorrow, Genevieve M. Kenney, Christine Coyer ) — Tue, 31 May 2011 00:00:00 EST

Maximizing insurance coverage for children under the Affordable Care Act will require considering how the new system and its rules will apply to children facing complex coverage scenarios. The purpose of this brief is to explore several scenarios in which children may face particular challenges in accessing health insurance coverage.We find that roughly 20 million children live in situations that create particular challenges in accessing insurance coverage due to within-family variation in eligibility for different types of coverage and that nearly 28 million children live apart from at least one of their parents, creating additional complexities in accessing coverage.

Savings and Hardship Avoidance Among Households Headed by People with Disabilities: Implications for SSI

paffairs@urban.org ( Gregory B. Mills, Sisi Zhang ) — Fri, 20 May 2011 00:00:00 EST

For households headed by persons with disabilities, savings can provide near-term protection against hardship. Analysis of longitudinal data from the 2001 panel of the Survey of Income and Program Participation indicates that households with $2,000 or more in liquid assets (interest-earning assets held at financial institutions) are better able to avoid subsequent hardships such as forgone doctor visits and missed utility payments, compared to those with smaller (or no) asset holdings. This evidence has implications for possible increases in the resource limits for the Supplemental Security Income (SSI) program, now $2,000 for individuals and $3,000 for couples.

Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys' Content and Operational Details

paffairs@urban.org ( Rachel A. Burton, Kelly J. Devers, Robert A. Berenson ) — Fri, 20 May 2011 00:00:00 EST

This report compares ten provider survey tools designed to measure the extent to which a practice is a 'patient-centered medical home' (PCMH). These tools are primarily used for recognition purposes (i.e., to qualify for entry into a payment pilot or demonstration), as opposed to for practice self-improvement, research/evaluation, or quality measurement. Our analysis, Our analysis, conducted for the Centers for Medicare and Medicaid Services, compares these ten tools' operational details (e.g., price, whether a site visit is required) and their content emphases (i.e., the different practice capabilities that the tools emphasize). We conclude by discussing issues for payers to consider when selected a PCMH recognition tool.

Implementing National Health Reform: A Five-Part Strategy for Reaching the Eligible Uninsured

paffairs@urban.org ( Stan Dorn ) — Wed, 18 May 2011 00:00:00 EST

Health programs often fall short of their coverage goals. Even the Children's Health Insurance Program, now quite successful in reaching uninsured children, suffered low enrollment during its early years. By contrast, other programs rapidly achieved high participation by using reliable data to identify eligible consumers and qualify them for assistance. Federal policymakers implementing the Affordable Care Act could thus pursue a strategy with five parts:

A proactive national campaign to identify and enroll the uninsured via the tax system;
Basing eligibility on reliable data;
Providing hands-on application assistance;
Consumer-friendly enrollment systems; and
Effective interagency coordination.

Does Constraining Health Cost Growth Require Choosing between Obama and Ryan?

paffairs@urban.org ( C. Eugene Steuerle ) — Tue, 26 Apr 2011 00:00:00 EST

The political debates have quickly centered over whether Obama is heading toward ever-more cumbersome government regulation and price-setting and whether Ryan is opening up unregulated markets that would deprive many of needed health care.

Multi-state Health Insurance Exchanges

paffairs@urban.org ( Linda J. Blumberg ) — Thu, 07 Apr 2011 00:00:00 EST

The Affordable Care Act allows multiple states to jointly operate exchanges. There are four reasons why states might consider doing so. First, administrative economies of scale could be significant. Second, regional exchanges might make sense in large metropolitan areas crossing states. Third, they could promote broader risk pooling. Fourth, multi-state exchanges could create a critical mass of insured persons to establish stable risk pools for small population states. However, multi-state exchanges are most likely to focus on shared administrative structures as opposed to risk-sharing. Cross-state risk-sharing would lead to one state subsidizing another and create a complex environment for decision-making.

Who Purchases Long-Term Care Insurance?

paffairs@urban.org ( Richard W. Johnson, Janice Park ) — Wed, 06 Apr 2011 00:00:00 EST

Most Americans will eventually need long-term care, which is often expensive and not usually covered by public programs until recipients have nearly exhausted their savings. In 2009, 5.2 million Americans age 65 and older not living in institutions had long-term care needs. Yet, only about 1 in 10 Americans age 55 and older had private long-term care insurance in 2008. Coverage rates were nearly twice as high among those with annual incomes in excess of $100,000. Private insurance covered only 7 percent of the $240 billion in U.S. long-term care costs in 2009. Nearly a fifth were paid out of pocket.

Restructuring Medicaid through a Swap: An Alternative to a Block Grant

paffairs@urban.org ( John Holahan ) — Fri, 01 Apr 2011 00:00:00 EST

The large and growing U.S. deficit has led to calls for entitlement reform. Two prominent deficit commissions have made proposals to curtail Medicaid spending. One proposed a swap to address issues of gaming or creative financing in Medicaid. More recently, Congressman Paul Ryan proposed a block grant for Medicaid with substantially lower levels of federal spending. Both have problems. Swaps would result in a major redistribution of federal funds among states. The Ryan block grant would undoubtedly lead to much lower levels of coverage and access. In this paper we present a proposal for a swap that would largely eliminate incentives for gaming and strengthen incentives for cost containment without the distributional effects of straightforward swap proposals.