In the States

For years, Maine has been unwilling to wait for the federal government to tackle the crisis of health care. And with good reason: though Maine has one of the lowest rates of uninsurance, it has some of the most expensive health care in the country. One-third of the state budget goes to SCHIP/Medicaid (the highest rate in the country, the state has the highest employer contribution to the cost of employer-based insurance, and the third-highest per capita health care costs. Not surprisingly, the cost drivers that make Maine's health care so expensive are the same as those that afflict the national as a whole, according to a new report by a state advisory group.

In 2003, the Maine Legislature passed far-reaching legislation to tackle coverage and costs—including the creation of the Dirigo Health insurance program—that included aggressive collection of data that had not previously been available. Maine's Advisory Council on Health Systems Development outlined problems and proposed solutions that will look familiar to those who've followed the health reform debate at the national level.

In what's been hailed as the most significant health legislation in Colorado in some 40 years, Colorado has a new law that will help cover up to 100,000 uninsured people and reduce some of the uncompensated care and cost-shifting that hurts the state's health care system and raises costs for people who are insured. It's an impressive achievement in a time of great economic pressure—one that we hope the folks here in Washington notice.

As jobs—and employment-linked health insurance—vanish during the recession, no state has been hit harder than North Carolina. The Washington Post takes a look at crowded clinics and worried people coping with a burgeoning medical crisis.

President Obama has made it clear that he supports health reform this year. As we work on achieving that goal, naturally the key issues include containing costs and increasing coverage. If you want to see real world experience in addressing these problems, look no further than Massachusetts.

In 2006, Massachusetts passed its landmark legislation requiring that everyone in the state have health care coverage. How are they doing? Current estimates show that more than 97 percent of Massachusetts residents now have health insurance.

While they have made significant progress on coverage, Massachusetts reformers are now working on a solution to the next problem—controlling costs. Massachusetts officials are considering a few different options. Governor Deval Patrick has stated he will regulate insurance premiums if hospitals and insurers fail to exercise restraint. A review board is considering revising payment incentives to encourage more focus on preventative care. In the summer of 2008, Massachusetts passed legislation to promote cost containment, transparency and efficiency in the delivery of quality health care.

Even in this economic downturn, Massachusetts continues to move forward in its efforts to provide affordable health coverage to all its citizens.

The 10-member board which runs the state's subsidized health insurance program, Commonwealth Care, unanimously approved an update to the program's affordability schedule. That means that people in the lowest-cost plans will not have to pay higher monthly premiums. Individuals that choose a higher cost plan may actually find themselves paying less, Secretary of Administration and Finance Leslie Kirwan told the Boston Globe.

Commonwealth Care provides low-cost or no-cost coverage to roughly 164,000 of the Massachusetts who make too much to qualify for Medicaid, but would be unable to acquire health insurance on their own. Currently, residents making less than 150 percent of the federal poverty level (about $15,606 for an individual living in the Bay State), pay no monthly premium. Those with higher incomes pay on a sliding scale.

You can lead a horse to water...but you can't make sure it has the necessary paperwork to get a drink.

In his speech to Congress, President Obama stated unequivocally: “Let there be no doubt, health care reform cannot wait, it must not wait, and it will not wait another year.” So should states sit on the sidelines and wait for the federal government to act? Absolutely not. Successful health care reform will require acti

Blood, sweat, and billions have gone toward studying whether different care delivery models can improve health outcomes of the chronically ill while holding down costs. A recent set of Medicare disease management pilot programs with these twin goals showed, at best, uneven results. As previously noted in this space, only three, including a promising one in Pennsylvania, have been extended beyond their initial periods. Even these programs did no yet reduce overall costs of care for the chronically ill. The key word in that last sentence is "yet."

We must not be fickle in funding delivery system innovation. Politicians and the general public have microscopic attention spans and wildly unrealistic expectations as to how quickly new health care programs can fulfill their promise. This is particularly problematic for innovations that deal with the management of chronic diseases. The problem is compounded when patients are poor, uninsured or underinsured and suffer from illnesses that were undertreated if they were treated at all. As detailed below, the state of California is discovering this at the outset of a major public investment in pilot programs focused on these populations.

Beyond questions of effective long-term stewardship of scarce public resources, there are real human costs to short-lived serial infatuation with new pilot programs. We nearly all believe that a real and ongoing relationship between patient and provider is paramount to quality medical care, yet we often reshuffle which federal program people qualify for and what care facilities they can access. Ideally patients should have some stability and consistency of access points, particularly within a system that can seem byzantine and impenetrable even to those who study health policy for a living.

Risk-adjusted rates or a case of gender discrimination?

That's exactly what Connecticut lawmakers are trying to figure out, according to the Hartford Courant. This week, lawmakers heard testimony on a proposal to ban the consideration of gender in determining health insurance rates on the individual market.

A report released by the National Women's Law Center in September found that 40-year-old women in Connecticut pay an average of four to 48 percent more for health insurance than 40-year-old males enrolled in the exact same plan. The range of variation in premiums increases for women over 55—they can pay anywhere between 37 percent more or 22 percent less than their male counterparts.

California is among the states currently experiencing mind-bending budgetary shortfalls. Eventually returning to a period of wealth wisely will depend on fixing health care systems that were strained to a breaking point even before the crisis began. Here are some highlights from an event on Monday that The New America Foundation's Next Social Contract Program and its California Program co-hosted at the Commonwealth Club in San Francisco: "California, the Crisis, and the Next Social Contract: Staying Healthy, Wealthy, and Wise in Challenging Times." (We'll link to the webcast when it's available in a few days.)

Reinventing Government guru David Osborne kicked off the event with a presentation that laid out starkly how, unless brought under control, spiraling health spending will keep the states in permanent fiscal crises. Throughout the rest of the morning, the issue of health care costs kept rearing its head in panels on topics from economic development to education. As it turns out, making progress on any policy issue of importance to state governments will first require getting these costs under control.