Health Policy Commons^™

Medicare Advantage: Déjà Vu All Over Again?, Brian Biles, Geraldine Dallek, Lauren Hersch Nicholas

Health Policy and Management Faculty Publications

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expands the role of private health plans in Medicare through prescription drug plans and a revised Medicare+Choice (M+C), renamed Medicare Advantage, program. This paper discusses the factors responsible for the failure of M+C to develop as intended in 1997 and analyzes the challenges for MMA implementation in light of these factors. They include making a complex program understandable to beneficiaries; addressing plans? efforts to avoid enrolling high-cost beneficiaries; ensuring stability of benefits, providers, and plans; dealing with beneficiaries enrolled in unsuitable plans; providing equity of health benefits throughout the …

Economic Stress And The Safety Net: A Health Center Update, Sara J. Rosenbaum, Peter Shin, Julie S. Darnell

Health Policy and Management Faculty Publications

Federally funded health centers provided care to 11.3 million patients in 2002, the vast majority of whom were either uninsured (39%) or covered by Medicaid (34%). This paper provides new information on the demographic profile of health center patients and the revenue sources available for financing their care, including recent increases in federal discretionary funding. It examines the impact of the recent economic downturn on health centers in selected communities, exploring the effect of elevated unemployment levels among lower wage workers, declining private health insurance coverage, and widespread state cutbacks in Medicaid – the single most important source of health …

Walking A Tightrope: The State Of The Safety Net In Ten U.S. Communities, Marsha Regenstein, Lea Nolan, Marcia J. Wilson, Holly Mead, Bruce Siegel

Health Policy and Management Faculty Publications

This report presents the findings from the Urgent Matters safety net assessments and identifies common characteristics, opportunities and challenges for communities that wish to better serve the health care needs of uninsured and underserved individuals. It also illustrates differences across many of the communities, especially in terms of the structure and financing of their safety nets. It is a companion report to the individual safety net assessments and provides an overarching perspective of problems that affect safety nets across the country.

Olmstead V. L.C. And The Americans With Disabilities Act: Implications For Public Health Policy And Practice, Joel B. Teitelbaum, Taylor Burke, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

This installment of Law and the Public’s Health examines the meaning of Olmstead v. L.C. for public health agencies administering personal health care programs. Handed down by the U.S. Supreme Court in 1999, Olmstead was a landmark decision that interpreted the Americans with Disabilities Act (ADA or the Act) as it applies to public programs and thus is of great relevance to many public health agencies. Following an overview of the decision and its interpretation by lower federal courts, this column concludes with a discussion of the implications of Olmstead and its progeny for public health policy and practice.

Monitoring The Health Care Safety Net: Developing Data-Driven Capabilities To Support Policymaking, Robin M. Weinick, Peter Shin

Health Policy and Management Faculty Publications

Health care organizations are now emphasizing evidence-based medicine, which involves using research findings on the effectiveness of various practices to help make treatment decisions for patients. A parallel practice that is receiving increased attention is using data and the findings from data analysis to inform the policymaking process. The data-driven policy framework presented here involves an explicit statement of priorities and policy questions to be answered by new and existing data and provides general guidance for using data to support the process of developing policy options for the health care safety net.

An Assessment Of The Safety Net In Memphis, Tennessee, Lea Nolan, Jennel Harvey, Karen C. Jones, Marsha Regenstein

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in Memphis. It provides background on the Memphis health care safety net and describes key characteristics of the population served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Detroit, Michigan, Marsha Regenstein, Khoa Nguyen, Karen C. Jones, Kyle Kenney

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in Detroit. It provides background on the Detroit health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Lincoln, Nebraska, Lea Nolan, Lissette Vaquerano, Karen C. Jones, Marsha Regenstein

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and under-served residents in Lincoln. It provides background on the Lincoln health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

The safety net assessment team's analysis of the Lincoln safety net …

An Assessment Of The Safety Net In Fairfax County, Virginia, Lea Nolan, Lissette Vaquerano, Karen C. Jones, Marsha Regenstein

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in Fairfax County. It provides background on the health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Boston, Massachusetts, Holly Mead, Peter Shin, Marsha Regenstein, Kyle Kenney, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in Boston. It provides background on the Boston health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Atlanta, Georgia, Jennel Harvey, Marsha Regenstein, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines issues that shape the health care network available to uninsured and underserved residents in Atlanta. It provides background on the Atlanta health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In San Diego, California, Khoa Nguyen, Peter Shin, Marsha Regenstein, Marcia J. Wilson, Kyle Kenney, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in San Diego. It provides background on the San Diego health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In San Antonio, Texas, Marcia Wilson, Peter Shin, Marsha Regenstein, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in San Antonio. It provides background on the San Antonio health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Phoenix, Arizona, Lea Nolan, Lissette Vaquerano, Marsha Regenstein, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines key issues that shape the health care network available to uninsured and underserved residents in Phoenix. It provides background on the Phoenix health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

An Assessment Of The Safety Net In Queens, New York, Holly Mead, Marsha Regenstein, Karen C. Jones

Health Policy and Management Faculty Publications

This report examines key issues that shape the healthcare network available to uninsured and underserved residents in Queens. It provides background on the Queens health care safety net and describes key characteristics of the populations served by the safety net. It then outlines the structure of the safety net and funding mechanisms that support health care safety net services. The report also includes an analysis of key challenges facing providers of primary and specialty care services and specific barriers that some populations face in trying to access them.

Public Health Insurance Design For Children: The Evolution From Medicaid To Schip, Sara J. Rosenbaum, Anne R. Markus, Colleen Sonosky

Health Policy and Management Faculty Publications

In 2005 Medicaid will turn 40, a momentous event in the life of the largest and most complex of all means-tested public entitlement programs. Since 1997, Medicaid has co-existed with the State Children’s Health Insurance Program (SCHIP), a small program which covers a fraction of the number of Medicaid enrolled children but whose legislative structure looms large against its much beleaguered companion. To the unpracticed eye, SCHIP and Medicaid appear to be quite similar in design; in reality however, their differences could not be more profound, and it is in these differences that clear directions for Medicaid’s possible future become …

Emtala: Dedicating An Emergency Department Near You, Brian Kamoie

Health Policy and Management Faculty Publications

This article offers a brief history of healthcare civil rights, describes a range of healthcare issues that have a civil rights component, and discusses the need for an expanded civil rights framework to guide the provision of health care. Unequal health care based on race and ethnicity has received renewed attention over the past several years, but healthcare discrimination based on socioeconomic status, disability, age, and gender also deserve careful attention.

Covering The Uninsured: What Is It Worth?, Wilhelmine Miller, Elizabeth Richardson Vigdor, Willard G. Manning

Health Policy and Management Faculty Publications

One out of six Americans under age sixty-five lacks health insurance, a situation that imposes sizable hidden costs upon society. The poorer health and shorter lives of those without coverage account for most of these costs. Other impacts are manifested by Medicare and disability support payments, demands on the public health infrastructure, and losses of local health service capacity. We conclude that the estimated value of health forgone each year because of uninsurance ($65?$130 billion) constitutes a lower-bound estimate of economic losses resulting from the present level of uninsurance nationally.

Schip-Enrolled Children With Special Health Care Needs: An Assessment Of Coordination Efforts Between State Schip And Title V Programs, Anne R. Markus, Sara J. Rosenbaum, Soeurette Cyprien

Health Policy and Management Faculty Publications

This study explores how the State Children's Health Insurance Program serves children with special needs and assesses the role of the Title V Maternal and Child Health Services Block Grant program in filling in gaps in coverage. It also discusses the implications of state choices on publicly-funded health coverage for pediatric health care.

Accountability In Medicaid Managed Care: Implications For Pediatric Health Care Quality, Sara J. Rosenbaum, Anne R. Markus, Colleen Sonosky, Lee Repasch, D. Richard Mauery, Andy Schneider

Health Policy and Management Faculty Publications

This study examines the structure and operation of Medicaid and State Children's Health Insurance Program (SCHIP) health care access and quality monitoring systems for children enrolled in comprehensive managed care arrangements. As the single largest purchasers of pediatric health care in the U.S., Medicaid and SCHIP agencies play a potentially powerful role in pediatric health policy. How these agencies approach, design, and carry out health quality monitoring activities has the potential to have a major impact not only for poor and low-income children, but for the entire pediatric health system. Even when these systems are developed exclusively for publicly insured …

Medicare+Choice In Palm Beach: Watching And Waiting?, Lauren Hersch Nicholas, Geraldine Dallek, Brian Biles

Health Policy and Management Faculty Publications

Under the Medicare+Choice program, firms have been able to offer products on a county by county basis, making participation decisions based on factors such as county payment rate, strength of local provider networks, and beneficiary's affinity for managed care. In 2003, Medicare+Choice payment rates paid to plans range from $495 in rural floor counties to a high of $872 in Staten Island, NY. Consequently, there is large national variation in benefits, premiums, and plan participation. A recent site visit to Palm Beach county and neighboring Miami-Dade highlighted many of the differences between counties which may pose challenges to firms trying …

Medical Necessity In Private Health Plans: Implications For Behavioral Health Care, Sara J. Rosenbaum, Brian Kamoie, D. Richard Mauery, Brian Walitt

Health Policy and Management Faculty Publications

This report addresses how the term "medical necessity" is defined in private health insurance coverage decisions. It summarizes a review of the literature, an extensive review of legal cases that challenge insurer decisions, materials prepared by the insurance industry, consultation with experts in the field, a review of investigations conducted by State departments of insurance and attorneys general, and interviews with health care executives regarding the decision-making process itself. The report does not explore factors that can affect access to care that might be considered clinically necessary by treating professionals or the effects of medical necessity decisions on therapeutic outcomes.

The Epidemiology Of U.S. Immunization Law: A National Study For The National Immunizations Program, Centers For Disease Control And Prevention: Medicaid Coverage Of Immunizations For Non-Institutionalized Adults, Sara J. Rosenbaum, Alexandra M. Stewart, Marisa A. Cox, Alexis Lee

Health Policy and Management Faculty Publications

As a health policy matter, coverage of immunizations and their administration for all ages at levels recommended by the Advisory Committee on Immunization Practices (ACIP) has grown in importance for several reasons: 1) the growing attention to both manmade and naturally occurring public health threats; 2) recognition of the value of immunization to society; and 3) the relatively high cost of at least certain immunization services in relation to personal income. No population stands to benefit more from immunization coverage than low income persons.

Studies suggest that adult immunization status is particularly low, and that financial barriers play a role, …

Analysis Of Carefirst's Performance As A Charitable Not-For-Profit Health Insurance Company In The National Capital Area, Sara J. Rosenbaum, Brian Kamoie, Charlotte Collins, Ann Zuvekas, Judy Feder, Gary Claxton

Health Policy and Management Faculty Publications

The George Washington University School of Public Health and Health Services ("GWU") and the Georgetown University Institute for Health Care Research and Policy ("GU")conducted this analysis on behalf of the DC Appleseed Center for Law and Justice in order to examine whether, in its operations and business practices, CareFirst BlueCross BlueShield ("CareFirst") appears to be fulfilling its chartered mission for the National Capital Area. The study began as an analysis of the coverage and access implications for the region of a proposal made by CareFirst and WellPoint Health Networks, Inc. ("WellPoint") to convert CareFirst to for-profit status and permit its …

Public Health Communicable Disease Reporting Laws: Managed Care Organizations' Laboratory Contracting Practices And Their Implications For State Surveillance And Reporting Statutes, D. Richard Mauery, Brian Kamoie, Sarah C. Blake, Jeffrey Levi

Health Policy and Management Faculty Publications

This report, prepared for the U.S. Centers for Disease Control and Prevention by the GWU Center for Health Services Research & Policy (CHSRP), presents findings from analyses of contractual specifications related to public sector managed care contractors' duties and activities related to public health surveillance and education activities for communicable disease control, specifically HIV/AIDS, sexually transmitted diseases, and tuberculosis.

Medicare Prescription Drug Legislation: What It Means For Rural Beneficiaries, Jeanne Lambrew, Becky Briesacher

Health Policy and Management Faculty Publications

Congress is currently debating legislation that would not only add a prescription drug benefit to Medicare but create an unprecedented role for private health insurers in delivering all Medicare services. Such changes would have profound effects on the 41 million people covered by Medicare -- particularly the one in four who lives in rural America. Previous studies have shown that rural beneficiaries have different health care needs and delivery systems than their urban counterparts. Indeed, the bills that passed the House and Senate address payments to rural hospitals and other providers. However, less attention has been paid to the rural …

Reducing Racial And Ethnic Health Disparities: Estimating The Impact Of High Health Center Penetration In Low-Income Communities, Peter Shin, Karen Jones, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

The health disparities literature suggests that although the lack of health insurance is the most basic barrier to health care, improved access to clinically appropriate care is key, particularly in the case of minority and low-income populations where the health risks are greatest. This study examines the relationship between health center penetration into medically underserved communities and the reduction of state-level health disparities. Health centers were developed with the express aim of serving medically underserved persons. Their doubling represents a significant health priority of the Bush Administration and one that enjoys bipartisan Congressional support.

The Epidemiology Of U.S. Immunization Law: Mandated Coverage Of Immunizations Under State Health Insurance Laws, Sara J. Rosenbaum, Alexandra M. Stewart, Marisa A. Cox, Shawnte Mitchell

Health Policy and Management Faculty Publications

Immunizations represent both basic clinical care as well as an essential public health activity with population-wide health implications, and for a number of reasons, the focus on national immunization policy has intensified in recent years. Insurers and employee health plans may cover immunization services as a matter of benefit design choice. Federal and state insurance laws also may mandate coverage of one or more classes of immunization services. For approximately 100 million persons who are members of state-regulated health insurance plans, state law plays a primary role in determining coverage. Thus the extent of state immunization health insurance mandates is …

Lessons From Medicare+Choice For Medicare Reform, Geraldine Dallek, Brian Biles, Lauren Hersch Nicholas

Health Policy and Management Faculty Publications

Medicare has a long history with private health plans, most importantly the 1997 creation of the Medicare+Choice (M+C) program. The objectives of M+C included expanding the types of plans available to Medicare beneficiaries, increasing payments to plans in low-cost areas, and fostering competition among private plans. HMOs have left the M+C program in large numbers. Although many private M+C plans perform well compared with fee-for-service Medicare on selected preventive health measures, on other measures—including access to care, stability of providers, simplicity of benefit structure, and costs to the Medicare program—the history of M+C is less positive.

Contracting For Coordination Of Behavioral Health Services In Privatized Child Welfare And Medicaid Managed Care, D. Richard Mauery, Julie Collins, Jan Mccarthy, Charlotte Mccullough, Sheila Pires

Health Policy and Management Faculty Publications

This study examined coordination between privatized child welfare initiatives and Medicaid managed care systems for the delivery of behavioral health care services for children and families in the child welfare system. Specific objectives: 1) to assess how states expectations as embodied in their contract documents are actually happening during program implementation; and 2) to identify promising approaches for delivery of coordinated behavioral health care services and contracting that can be shared with other stakeholders. The goal was to highlight the real world experiences and lessons learned that others may draw upon when designing and implementing similar contracts for systems of …