Health Policy Commons^™

Insurance Discrimination On The Basis Of Health Status: An Overview Of Discrimination Practices, Federal Law, And Federal Reform Options, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

Actuarial underwriting, or discrimination based on an individual's health status, is a business feature of the voluntary private insurance market. The term "discrimination" in this paper is not intended to convey the concept of unfair treatment, but rather how the insurance industry differentiates among individuals in designing and administering health insurance and employee health benefit products. Discrimination can occur at the point of enrollment, coverage design, or decisions regarding scope of coverage. Several major federal laws aimed at regulating insurance discrimination based on health status focus at the point of enrollment. However, because of multiple exceptions and loopholes, these laws …

Boosting Health Information Technology In Medicaid: The Potential Effect Of The American Recovery And Reinvestment Act, Brad Finnegan, Leighton C. Ku, Peter Shin, Sara J. Rosenbaum

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

The American Recovery and Reinvestment Act of 2009 (ARRA) will invest approximately $49 billion to expedite health information technology (HIT) adoption through Medicare and Medicaid. Our analysis of 2006 NAMCS data found that approximately 15 percent of the practicing office-based physicians in the country would qualify for up to $63,750 over six years in Medicaid financial incentives for HIT adoption. Included within the 45,000 eligible physicians are about 99 percent of all community health center physicians. If all qualifying physicians apply for the Medicaid incentives and receive the maximum level of payments, the federal government would invest more than $2.8 …

Medicaid's Medical Transportation Assurance: Origins, Evolution, Current Trends, And Implications For Health Reform, Sara J. Rosenbaum, Nancy Lopez, Melanie J. Morris, Marsha Simon

Health Policy and Management Issue Briefs

This 24-page policy brief examines Medicaid's assurance of medical transportation in the context of medically necessary but non-emergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid's unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low income persons since Medicaid covers non-emergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to assist …

Improving Medicaid's Continuity Of Coverage And Quality Of Care, Leighton C. Ku, Patricia Mactaggart, Fouad Pervez, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

Medicaid provides health insurance coverage to tens of millions of low-income children, parents, seniors and people with disabilities. Unfortunately, Medicaid enrollment is like a leaky sieve; every year millions of people enroll, only to subsequently lose their coverage, despite still being eligible, because of inefficient and cumbersome paperwork requirements. The interruptions in coverage affect the continuity and effectiveness of health care received. Interruptions also impair quality monitoring and improvement activities because many Medicaid enrollees were not enrolled long enough to assess the quality of their care. The presumption is that people who have been enrolled for less than a year …

Paying Medicare Private Plans By Competitive Bidding: Not The Same As Costs In Regular Medicare, Brian Biles, Jonah Pozen

Health Policy and Management Faculty Publications

Medicare Advantage plans are now paid $11 billion a year, and $150 billion over 10 years, more than costs in regular fee-for-service (FFS) Medicare. In the past two years there have been discussions about reducing MA payments to the level of 100 percent of average costs in FFS and using the savings to offset the costs of new Federal health initiatives such as health care reform. Earlier this year, OMB proposed "reducing Medicare overpayments to private insurers through competitive payments." Under this proposal, MA plan "payments would be based on an average of plans' bids submitted to Medicare." This issue …

Tri-Committee Draft Proposal For Health Care Reform, Fitzhugh Mullan

Health Policy and Management Congressional Testimonies

The Tri-Committee draft legislation takes a significant step towards establishing a health care workforce which will sustain a high-quality, cost-effective, fully accessible health care system. Moves to establish an Advisory Committee on Health Workforce Evaluation and Assessment, re-invest in the National Health Service Corps and Title VII of the Public Health Service Act, redistribute unused Medicare GME positions to primary care programs and establish teaching health centers, and address payment and practice challenges to primary care through the medical home and accountable care organization pilot programs are all positive moves towards a sustainable health care workforce. However, to fully achieve …

Women's Health And Health Care Reform: The Economic Burden Of Disease In Women, Susan F. Wood, Avi Dor, Rebekah E. Gee, Alison Harms, D. Richard Mauery, Sara J. Rosenbaum, Ellen Tan

Health Policy and Management Faculty Publications

This report estimates the direct and indirect costs of care for women for the major chronic diseases and conditions that women face across the lifespan. It also identifies the key primary care and preventive services that can lead to prevention, early detection or early intervention for these conditions. Health care screening, counseling, early diagnosis, and early intervention health care services are important for women at each stage of their lives. But women typically seek care in primary care settings for family planning services and cancer screening prior to becoming pregnant. As a result, high quality care during the reproductive years …

Health Insurance Fraud: An Overview, Sara J. Rosenbaum, Nancy Lopez, Scott Stifler

Health Policy and Management Faculty Publications

In 2007, the U.S. spent nearly $2.3 trillion on health care and public and private insurers processed more than 4 billion health insurance claims. The National Health Care Anti-Fraud Association (NHCAA) has estimated that, conservatively, 3% of all health care spending—or $68 billion—is lost to health care fraud. Other estimates by government and law enforcement agencies place fraud-related losses as high as 10% of annual health care spending; at this rate, the losses in 2007 alone – over $220 billion – would have been enough to cover the uninsured.

This report, funded by the Robert Wood Johnson Foundation, delves into …

Medicaid And Case Management To Promote Healthy Child Development, Sara J. Rosenbaum, Kay Johnson, Emily Jones, Anne R. Markus

Health Policy and Management Faculty Publications

This policy brief presents options for financing and delivering case management services to low-income and special-needs children in Medicaid. The analysis builds on a literature review of case management, a review of the legal underpinnings of Medicaid case management, and consultation with experts in the fields of health care finance and program operations. It aims to inform the policy community about the importance of case management for assuring the health and development of our youngest and most vulnerable children.

The Application Of The Emergency Medical Treatment And Labor Act (Emtala) To Hospital Inpatients, Lara Cartwright-Smith, Sara J. Rosenbaum, Karen Belli, Elaine Purcell, Tasmeen S. Weik

Health Policy and Management Issue Briefs

This issue brief provides a brief overview of the Emergency Medical Treatment and Labor Act (EMTALA) and focuses on its application to hospital inpatients. EMTALA applies differently to patients than non-patients, and also applies differently to patients admitted through the emergency department than patients admitted as regular inpatients. In addition, courts and the Centers for Medicare and Medicaid Services (CMS) have differed in their interpretation of the statute. Depending on the specific facts of any particular case, EMTALA may or may not have implications for specialty-related transfers and discharges.

Financing Community Health Centers As Patient- And Community-Centered Medical Homes: A Primer, Peter Shin, Leighton C. Ku, Emily Jones, Brad Finnegan, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

This policy brief is part of a Commonwealth Fund-supported project that examines community health centers in the context of the patient-centered medical home (PCMH) movement. Community health centers—non-profit primary care facilities that provide care to patients regardless of their ability to pay—are widely lauded as critical components of the health care safety net, providing comprehensive primary care for lowincome, high-risk populations in both urban and rural areas. Since their inception, health centers have directed their activities at improving patient care—through comprehensive primary health care, coordination with specialty care, and the provision of enabling services—as well as improving population-level health status …

Roundtable: Health Care Coverage, Sara J. Rosenbaum

Health Policy and Management Congressional Testimonies

At the Senate Finance Committee Hearing held on May 5, 2009, Sara Rosenbaum, J.D., addressed three issues related to health care coverage: How can coverage be made more affordable and workable for individuals and small businesses? What are the roles and responsibilities of individuals, employers, and government in achieving health coverage for all Americans? What role should public programs play? This transcript of her official statement begins with general observations concerning Health Coverage in America in order to provide a context to address these more specific questions.

The Continuing Cost Of Privatization: Extra Payments To Medicare Advantage Plans Jump To $11.4 Billion In 2009, Brian Biles, Jonah Pozen, Stuart Guterman

Health Policy and Management Faculty Publications

The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, MA plans have, for the past six years, been paid more for their enrollees than they would be expected to cost in traditional fee-for-service Medicare. Payments to MA plans in 2009 are projected to be 13 percent greater than the corresponding costs in traditional Medicare—an average of $1,138 per MA plan enrollee, for a total of $11.4 billion. Although the extra payments are used to provide enrollees additional benefits, those benefits are not available to all beneficiaries—but they are financed by …

The H1n1 Influenza A Virus: A Test Case For A Global Response, Rebecca L. Katz, Karyn Feiden

Health Policy and Management Faculty Publications

The threat of widespread infection from the new H1N1 influenza A virus (also known as a swine flu virus) provides the first real-time test of the global and domestic preparedness activities that have moved forward over the past few years. The World Health Organization has declared the event a "public health emergency of international concern," the first time that designation has been used under the revised International Health Regulations. A public health emergency has also been declared in the United States.

Those steps have pushed influenza plans at the local, state, national, and global levels into motion. This paper reviews …

Primary Health Care Access Reform: Community Health Centers And The National Health Service Corps, Fitzhugh Mullan

Health Policy and Management Congressional Testimonies

This testimony by Fitzhugh Mullan, M.D., addresses the following issues:

• Improving access to health care in the United States will require modifications in the U.S. health care workforce, the foremost of which will be the construction of a strong primary care base.
• Two-thirds of the U.S. physician workforce practice as specialists and the number of young physicians entering primary care is declining.
• The distribution of health care providers in the U.S. heavily favors urban areas. Metropolitan areas have 2-5 times as many physicians as non-metropolitan areas and economically disadvantaged areas have significant health care access problems.
• Today's physician-to-population ratio is …

Examining The Experiences Of Puerto Rico's Community Health Centers Under The Government Health Insurance Plan, A. Seiji Hayashi, Brad Finnegan, Peter Shin, Emily Jones, Sara J. Rosenbaum

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

This research brief examines the experiences of Puerto Rico's community health centers under the Commonwealth’s 1994 Government Health Insurance Plan (GHIP) – the Commonwealth's Medicaid program – also known as the Reforma. Of particular interest are the effects of Medicaid under-financing coupled with health centers' continuing obligations to furnish subsidized care for uninsured patients. To finance GHIP, the Commonwealth substantially curtailed its involvement with the direct provision of health care in both community and inpatient settings, transforming the former system of direct care provision into health insurance premium subsidies.

In 2007, the 47 operating sites of Puerto Rico's 19 federally …

Children’S Health Care: Health Information Technology And Electronic Health Records, David M. Stevens

Health Policy and Management Faculty Publications

The panel addressed: Why pediatric electronic health records are different from adult EHRs; How HIT/EHRs can be helpful in the area of prevention with pediatric populations; How using HIT/EHRs can help improve quality and outcome measures for children and underserved communities; Barriers to getting HIT/EHRs into underserved communities and ways to overcome these challenges; Opportunities for stimulus funds to support HIT access for underserved pediatric populations; and Privacy and confidetiality concerns regarding pediatric EHRs.

Health Care Workforce Issues And Access To Care: Assessing The Present And Preparing For The Future, Fitzhugh Mullan

Health Policy and Management Congressional Testimonies

Summary of Testimony Fitzhugh Mullan, M.D. Before the House Energy and Commerce Subcommittee on Health, March 24, 2009

• Improving access to health care in the United States will require modifications in the structure of the U.S. physician workforce, the foremost of which will be the construction of a strong primary care delivery base.
• There are over 800,000 practicing physicians today or 280 physicians per 100,000 people. This represents a greater physician density than Canada (210) and the United Kingdom (250) but a density less than France (340) and Germany (350).
• The distribution of physicians in the U.S. heavily favors urban …

U.S. District Court Directs Fda To Reevaluate Previous Plan B Decision, Susan F. Wood, D. Richard Mauery

Health Policy and Management Faculty Publications

Judge Edward R. Korman of the U.S. District Court, Eastern District of New York, issued a decision today (Mar. 23, 2009) in the case of Annie Tummino et al v. Frank M. Torti, Acting Commissioner of the Food and Drug Administration. The case involved plaintiffs' claims that the FDA, in deciding that Plan B, known as emergency contraception or the morning-after pill, be made available over-the-counter (OTC) only with age restrictions, was unduly and inappropriately influenced by pressures from the White House among other factors.

An Overview Of Major Health Information Technology, Public Health, Medicaid, And Cobra Provisions Of The American Recovery And Reinvestment Act Of 2009, Sara J. Rosenbaum, Melissa M. Goldstein, Taylor Burke, Phyllis Borzi, Lara Cartwright-Smith

Health Policy and Management Faculty Publications

A detailed side-by-side analysis of the individual components of the American Recovery and Reinvestment Act of 2009 (ARRA), signed into law on February 17, 2009. One of the most sweeping pieces of economic legislation ever enacted, ARRA not only provides hundreds of billions of dollars in new health and health care spending but also makes comprehensive reforms in health law and policy, particularly in the area of health information law, including health information technology (HIT) adoption and health information privacy.

Workforce Issues In Health Care Reform: Assessing The Present And Preparing For The Future, Fitzhugh Mullan

Health Policy and Management Congressional Testimonies

Summary of Testimony Fitzhugh Mullan, M.D. Before the Senate Finance Committee March 12, 2009

• Health Care Reform will require modifications in the structure of the U.S. physician workforce the foremost of which is the construction of a strong primary care delivery base.
• There are over 800,000 practicing physicians today or 280 physicians per 100,000 people. This represents a greater physician density than Canada (210) and the United Kingdom (250) but a density less than France (340) and Germany (350).
• The distribution of physicians in the U.S. heavily favors urban areas. Metropolitan areas have 2-5 times as many physicians as non-metropolitan …

Community Health Centers In An Era Of Health System Reform And Economic Downturn: Prospects And Challenges, Sara J. Rosenbaum, Brad Finnegan, Peter Shin

Health Policy and Management Faculty Publications

This Policy Brief examines the role of health centers in the U.S. health care system, assessing their current and future roles in an era of both great promise and challenge. On one hand, government is poised perhaps more sharply than any time in nearly a generation to undertake a comprehensive effort at national health reform, addressing not only coverage but also access, quality, prevention, and the reinvigoration of primary health care, particularly for populations who face the highest health risks. On the other hand, the nation is facing the most severe economic recession in years, with lower income families and …

Vaccines And Autism: The Evidence And The Law, Alexandra M. Stewart

Health Policy and Management Faculty Publications

A potential link between the measles-mumps-rubella vaccine and autism was dismissed by a federal vaccine court in February 2009. The U.S. Department of Health and Human Services said the findings demonstrate a lack of medical evidence for any association, while Autism Speaks, a patient advocacy group, said questions remain about potential risks for certain subgroups.

Other legal actions are pending as the scientific and patient advocacy communities debate the need to conduct further research on the vaccine-autism link. Meanwhile, public health advocates worry that continuing concerns about the safety of vaccines may depress the population immunization rate. A small rise …

How Is The Primary Care Safety Net Faring In Massachusetts? Community Health Centers In The Midst Of Health Reform, Leighton C. Ku, Emily Jones, Brad Finnegan, Peter Shin, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

Massachusetts' landmark 2006 health reform legislation sets an important precedent for national reform. Initial evaluations have demonstrated the law's success in dramatically expanding health insurance coverage and health care access, but less is known about its effects on community health centers, which serve one of every 13 residents and one in four low-income residents. This analysis evaluates the experiences of health centers with the Massachusetts reforms, using administrative data to examine finances and patient enrollment in addition to the qualitative results of in-depth interviews conducted during site visits in August 2008 and the results of a short survey of health …

Retiree Health Vebas: A New Twist On An Old Paradigm: Implications For Retirees, Unions And Employers, Phyllis Borzi

Health Policy and Management Faculty Publications

This issue brief provides an overview of stand-alone Voluntary Employees' Beneficiary Association trusts, through which employers have been able to rid themselves of future obligations to pay retiree health benefits in exchange for making a significant payment to designed to approximate the projected cost of these benefits. The paper include three case studies, including the VEBAs at the Big Three automakers.

An Overview Of Major Health Provisions Contained In The American Recovery And Reinvestment Act Of 2009, Sara J. Rosenbaum, Lara Cartwright-Smith, Taylor Burke, Phyllis Borzi, Melissa M. Goldstein

Health Policy and Management Issue Briefs

On February 17, 2009, President Barack Obama signed the American Recovery and Reinvestment Act of 2009 (ARRA) into law. One of the most sweeping pieces of economic legislation ever enacted, ARRA not only provides hundreds of billions of dollars in new health and health care spending but also makes comprehensive reforms in health law and policy, particularly in the area of health information law, including health information technology (HIT) adoption and health information privacy.

Assessing The Need For On-Site Eye Care Professionals In Community Health Centers, Peter Shin, Brad Finnegan

Health Policy and Management Issue Briefs

Poor vision health severely impacts school and work performance, quality of life, and life expectancy, and results in billions of dollars in medical expenditures each year. While eye and vision problems are often associated with age, low income and racial and ethnic minorities also have elevated risk of eye problems. Federally-funded community health centers, which are mandated to provide comprehensive primary care in underserved communities, are often the only option to improve vision health for low-income residents.

With respect to certain chronic conditions, health centers are able to provide high quality care that meets or exceeds national benchmarks despite limited …

Restoring Medicaid And Schip Coverage To Legal Immigrant Children And Pregnant Women: Implications For Community Health And Health Care For Tomorrow's Citizens, Leighton C. Ku

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

In the coming weeks, Congress will consider the reauthorization of the State Children's Health Insurance Program (SCHIP), whose legislative authorization will expire on March 31, 2009. SCHIP's overarching goal, in tandem with Medicaid, is to assure coverage of low-income children, regardless of race or national origin. As the proportion of uninsured immigrant children grows, a crucial question is whether the SCHIP reauthorization will address the need to restore eligibility for legal immigrant children and pregnant women. Although SCHIP and Medicaid have been successful in improving health insurance coverage for most low-income American children since the mid-1990s, the health coverage gaps …

Health Information Technology In The United States: On The Cusp Of Change, 2009, Sara J. Rosenbaum, Melissa M. Goldstein, Lee Repasch, Catherine M. Desroches, Ashish K. Jha

Health Policy and Management Faculty Publications

In this report we use the data collected for ONCHIT to focus on EHR adoption in the inpatient setting. We report on several important policy issues. These include the rate of adoption of EHRs among U.S. hospitals generally and among safety-net hospitals, changes in both state and federal policy, and the potential of EHRs to change the quality measurement enterprise.

Primary And Preventive Healthcare: A Critical Path To Healthcare Reform For Florida: The Role Of Florida's Fqhcs, Sara J. Rosenbaum, Peter Shin, Brad Finnegan, Ramona Whittington

Health Policy and Management Faculty Publications

Florida's health care system faces numerous challenges: a high proportion of residents without health insurance, a declining supply of primary care physicians at the same time that the state faces a growing need for high quality and cost efficient care for uninsured persons, and a growing emphasis on medical homes, especially for culturally diverse patients with complex chronic conditions. Nearly 3.8 million Florida residents lack health insurance, while more than 8 million lack access to a regular source of primary health care.

Assuring access to timely and high quality primary health care is a key dimension of any health reform …