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Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
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OCR for page 15
Uninsured
Karen Davis
When we began our discussions and were considering whether to
include demonstrations to expand health insurance coverage, we really
felt that it would be impossible to achieve our vision of transforming the
health care system to achieve high quality for all if we didn't address the
fundamental problem of the uninsured.
There were many reasons for doing that. I think the most basic one is
that it is consistent with our fundamental values as a society that is com-
mitted to social justice and equality of opportunity. But we also turned to
the Institute of Medicine's committee on the consequences of uninsurance
and took note of the fact that there are serious health and economic conse-
quences of having 41 million uninsured.
There is also evidence that there is poor-quality care in the health care
system and particularly problems that the uninsured present in acute care
services without health insurance coverage. There is waste to the system
from turnover in insurance coverage whereby people change sources of
insurance coverage and receive fragmented care as a result.
There are financial strains on health care providers who are trying to
serve the needs of the poor and the uninsured. The basic proposal is to
support three to five state demonstrations, presumably run by the Cen-
ters for Medicare and Medicaid Services that would issue a Request for
Proposals (REP) to states to come forward with proposals to achieve health
insurance coverage for all residents in a state.
That, too, is not a particularly new idea. In looking back I found an
op-ed by Howard Hyatt in 1993 in The New York Times, where he noted
that in clinical medicine, we would never think about making a bold
15
OCR for page 16
16
FOSTERING RAPID ADVANCES IN HEALTH CARE
change without doing it on a trial basis. So, I think we are following his
advice perhaps 10 years later.
But it is also consistent with the award of planning grants by the
Health Resources and Services Administration over the last few years to
20 states to mount planning efforts on how they might go about expand-
ing health insurance coverage. This particular set of demonstrations is not
budget-neutral. We had a lot of discussion about that but concluded that
it really would not be possible to do it without additional funding. In fact,
some of the limits on demonstrations requiring them to be budget neutral
are one of the major barriers to really moving forward in this area. There
needs to be at least a 10-year commitment if states would be willing to
mount the effort to put these systems in place.
The basic goals of the demonstration would be to provide coverage
for all residents of a state. Coverage would be affordable, stable, would
provide a choice of plans and would be family centered; it would empha-
size providing the right care at the right time; there would be a shared
responsibility for health care between patients and their clinicians; it
would improve primary preventive care and management of chronic con-
ditions; it would be satisfactory to patients and would promote continuity
of care and ease of access of care.
In addition, goals of the demonstration would include reducing
waste particularly by promoting continuity of care for patient and clini-
cian and improved coordination of care. There would be reduced ad-
ministrative cost but major emphasis upon electronic administration and
there would also be an emphasis on a public-private partnership in this
demonstration as well.
The two major components of the demonstration would be, first, an
expansion in the public and private insurance coverage and provision of
new options of affordable coverage for the population and, secondly, es-
tablishment of a statewide electronic enrollment and insurance clearing-
house.
The states would be encouraged to come forward with proposals for
achieving coverage for all residents in a state. We put forward two basic
models: the first would use tax credits, administered through the state's
income system. Obviously, not all states have an income tax system. So,
those states would probably turn to the second alternative, which would
be building on current Medicaid and children's health insurance programs
to expand coverage. States would have the option of either a tax credit
approach or expansion of what we call family-centered care or a combina-
tion of these.
But the basic goal was that there would be one plan per family; that
there would be an evidence-based package of services that would include
effective, preventive mental health and developmental screening and
OCR for page 17
UNINSURED
17
treatment services; that everyone insured would designate a personal cli-
nician. It is hoped that such practice would ensure that patients have the
information they need, including reminders, for example for preventive
services, and that it would be the primary source of primary care and
patients, as part of this would be to agree to access care through primary
care settings, rather than through emergency rooms.
There would also be fair payment that would reward higher-quality
care. The demonstration would also include the establishment of an elec-
tronic enrollment clearinghouse, and this is part of the information and
communications technology initiative that cuts across all of the demon-
strations. This would serve a number of functions, with the first being
eligibility verification for insurance coverage.
That is not covered under this demonstration but is under Medicare
and under private insurance, including employer plans. So when a pa-
tient shows up at a health care setting, that setting can access this data-
base, find out if the person is insured, where they are insured and, in
particular, if they are not insured, then begin working with that person to
be enrolled in an appropriate type of plan.
It would also be used for enrollment purposes, so there would be
modern electronic enrollment mechanisms that would reduce the current
barriers that befall many people who are eligible for public programs but
fail to enroll. It could be used for other purposes over time, such as facili-
tating billing and payment, as well as eventually as a mechanism for im-
proving quality of care and providing information to patients and others.
Representative terms from entire chapter:
health insurance
