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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

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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

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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.