Coverage

When it comes to health reform at a state level, the state that gets the most attention is usually Massachusetts. But other states, such as Vermont, Hawaii, and recently, Wisconsin, are starting to get recognition for their innovations. Different states have different priorities and strategies to accomplish the goals of reform. While Massachusetts, for example, focused on expanding coverage with an individual mandate to purchase health insurance, Wisconsin started simplifying and building on existing public health programs to expand coverage, says a new report.

In the world of state health reform, Vermont often plays the Jan to Massachusetts' Marcia. However, preliminary evaluations suggest that other states and policymakers would do well not to ignore New England's favorite middle child. My colleague previously wrote about Vermont's most recent legislative action on health reform passed in May of 2006. Now, a study published by the Robert Wood Johnson Foundation this week updates us on Vermont's achievements. Here are some of the successes from the Year 1 Interim Report:

Every Christmas, our Uncle Billy makes Italian sausage. In addition to various ground meats, he uses a rotating cast of cheeses and spices, along with the some well-guarded Testa family secrets (our guess: orange zest added to the fennel seeds). It's a big undertaking, full of cranks and casings. But it's nothing compared to the sausage making ahead for Congress on health reform.

The New York Times sets the stage in the House and Senate, laying out the challenges faced by Speaker Nancy Pelosi and Senate Majority Leader Harry Reid as they try to craft legislation that can pass their respective chambers of Congress and be merged into a final bill that President Obama can sign into law.

The challenge for Ms. Pelosi is to write a measure with sufficient coverage and benefits to appease the left wing of her caucus without alienating too many of the moderate and conservative Democrats whose votes she needs. [...]

Mr. Reid may have the more difficult job since Ms. Pelosi, of California, has a larger majority as well as stricter House rules that limit opportunities for Republicans to slow the process.

Hawaii is a popular destination for anyone seeking sun, sand, surf, or even volcanoes. It's also a top spot for affordable health care coverage.

As The New York Times reported this weekend, Hawaii has the lowest Medicare costs per beneficiary and is tied with North Dakota for the nation's lowest health care premiums. People in Hawaii also tend to live longer than those elsewhere in the United States. As we've mentioned before, Hawaii ranks as one of the top states when looking at health indicators that represent health care access, quality, costs, prevention and treatment, equity and health outcomes.

There are many different theories as to what causes relative health and longevity in Hawaii's population. April Donahue, executive director of the Hawaii Medical Association, told American Medical News Hawaii's population typically has a healthy diet. The Times interviewed a number of doctors and hospitals, and found answers ranging from an active population to a significant military presence to dominance by just a few non-profit insurers in the market.

"I am a Republican who did not vote for President Obama," writes John Hewko, public policy scholar at the Woodrow Wilson International Center, however, "I support his health-care initiative because I have just experienced first-hand our system's dysfunctional wrath -- and it isn't pretty."

As we've written before, our health care system fails the people that need it the most when they need it the most. But it also fails -- as Hewko argues -- the "lucky ones" who are healthy and financially secure. And that tells us that the system is indeed in big trouble.

Overall, it's been a pretty good week for health reform.

We know there is a ton of work to do, both for the politics (60 votes) and the policy (we need to merge the bills correctly and not just to get the votes but to make health reform work for the people who need it -- which is all of us.)

None of the five bills passed by the House or Senate committees on their own is perfect. No final bill will be "perfect" either, of course. But we're still hoping for really really good.

When we write about how far we've come, rather than how far we need still to go, it's not an effort to minimize any of the flaws or challenges that we still need to address. Trust us, we live and breathe flaws and challenges. But we do think it's important to keep in mind that this legislation will be the single biggest  advance in U.S. social policy since the passage of Medicare and Medicaid in 1965. And when you think about it in those sweeping historical terms, it's pretty exciting.

The latest study released by the insurance industry, while better than the one that came before it, is riddled with flaws. The recent report produced by Oliver Wyman (an management consulting firm with an actuarial services arm) for the Blue Cross Blue Shield Association (BCBSA) is more reasonable than the PriceWaterhouseCoopers study issued by America's Health Insurance Plans (AHIP), but it, too, is designed to scare Americans into accepting the status quo rather than comprehensive health care reform.

Lets' be clear here: some of the best plans in the country are Blue plans, and we need all of them to get better post-reform. It's worth noting that the two things the Blues have been lobbying about most vigorously are the same positions that Wyman's analysis supports: (1) prevent the melding of the small group and individual markets, and (2) keep the insurance exchange as small as possible. 

The report gets one thing right: reformers must make sure insurance coverage is affordable and that the mandate to buy insurance is enforceable so that most Americans get coverage. Otherwise, requiring insurers to sell to any customer who wants to buy (guaranteed issue) will risk the stability of the risk pool in the exchange. On this much we (and many others) agree.

What I cannot agree with is the attempt to sway the reform debate with data that cannot be checked and assumptions that seem to be designed to produce the results BCBSA wants us to believe. On many points Wyman and BCBSA could be correct. But since their data are not public, it is impossible to check. 

These are the report's weaknesses:

We posted the other day on the Kaiser Family Foundation-commissioned paper on delivery system reform. In short, Mathematica's Randall Brown concluded that the ideas getting the most attention (medical homes, health IT, ACOs, bundling etc) are worthwhile and may save in the long run but aren't likely to save much in the first five to 10 years. In the promised, albeit slightly belated, part 2 of this post, let's look at how he thinks we can get results faster.

Making dramatic changes in the health care delivery system takes time. While that shift is underway, Brown writes, we have "solid evidence" on strategies for managing patients with serious chronic diseases in ways that reduce hospitalization and rehospitalization. It saves money, and keeps patients healthier.

We also have "less rigorous" but still encouraging evidence on how to address geographic disparities in the practice of medicine and use of resources. The goal is to find approaches that help doctors understand -- and  incentives to change -- the way they themselves practice and how they stack up against other doctors and other regions.

These programs and initiatives can be phased in with tweaks to the current fee-for-service system -- although Brown is not arguing that we shouldn't also make longer term initiatives to reform that system, but it's a heavier and longer-term lift. (And since we've written about a lot of these ideas before, we are feeling affirmed.)

Robert Greenstein over at the Center on Budget and Policy Priorities finds plenty to like about the bill the Senate Finance committee has approved -- and much that still needs work. With his usual mix of progressive values and budgetary common sense, here's how he balances it out:

The bill is a "major step toward enactment of legislation to extend health care to tens of millions of people who lack it, strengthen insurance protections for millions more who are underinsured or face exorbitant charges, and begin to address the nation's most serious fiscal threat -- the relentless rise in health care costs." It is fiscally responsible and will modestly reduce the budget deficit.

The hope of bipartisan and comprehensive health care legislation lives on today thanks to the vote in the Finance Committee of Sen. Olympia Snowe (R-ME).  The bill reported out of the Finance Committee is bipartisan.  Not just because it received support from members of both parties, but because you can see both Republican and Democratic values in the solution. 

For Republicans, the bill relies heavily on market forces and incentives, and it slows the rate of health care cost growth to the tune of reduced budget deficits.  For Democrats, the bill finally provides all Americans access to quality health coverage and strengthens the Medicare program for our nation's seniors. 

As Sen. Snowe and others said, this bill is not perfect.  It will likely be improved along the way.  But it does get serious about solving the access, quality, and cost problems in our health system.  While addressing these challenges on a bipartisan basis requires tough choices, it does not require lawmakers to abandon their underlying goals. It is in her willingness to find policy solutions that will actually solve our health care crisis that Sen. Snowe outshines her colleagues on her side of the aisle on the Finance Committee. 

Let the record show that the Senate Finance Committee approved bipartisan health reform legislation today, and that America took a giant step toward becoming a better country.