States' systematic examination of their public insurance programs, such as whether premium rates are affordable and outreach techniques effective, can greatly influence their success in covering uninsured populations. In State-Subsidized Health Insurance Programs for Low Income Residents: Program Structure, Administration, and Costs, Laura Summer of the National Academy on an Aging Society discusses this and other fundamental lessons gleaned from interviews and reviews of 12 states' efforts to expand coverage for low income uninsured families and children.
Summer interviewed officials from 12 statesDelaware, Florida, Hawaii, Massachusetts, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Vermont, and Washingtonto review programs administrative structures, use of cost-sharing, eligibility rules, and enrollment processes.
She found that administrators are confronting a complex array of concerns as they seek to expand coverage incrementally. A primary concern, for example, was the impact of cost-sharing or charging partial premiums on different income groups.
Administrators worried that premiums may discourage people from enrolling or staying in programs, citing ""nonpayment of premiums"" or ""loss of eligibility"" as common reasons for disenrollment. State policymakers were reluctant to discard premiums, however, as they generate revenues and may discourage otherwise insured families from turning to publicly subsidized programs.
States were also seeking the most effective means of matching program enrollment to available program budgets. The most common approach Summer found was to cap enrollment numbers and institute waiting lists. Yet states are finding that waiting lists can undermine future outreach efforts as additional funds become available. Alternative methods such as phasing in income eligibility expansion may prove more effective as means for targeting growth in enrollment.
Lessons Learned
Summer interviewed officials from 12 statesDelaware, Florida, Hawaii, Massachusetts, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Vermont, and Washingtonto review programs administrative structures, use of cost-sharing, eligibility rules, and enrollment processes.
She found that administrators are confronting a complex array of concerns as they seek to expand coverage incrementally. A primary concern, for example, was the impact of cost-sharing or charging partial premiums on different income groups.
Administrators worried that premiums may discourage people from enrolling or staying in programs, citing ""nonpayment of premiums"" or ""loss of eligibility"" as common reasons for disenrollment. State policymakers were reluctant to discard premiums, however, as they generate revenues and may discourage otherwise insured families from turning to publicly subsidized programs.
States were also seeking the most effective means of matching program enrollment to available program budgets. The most common approach Summer found was to cap enrollment numbers and institute waiting lists. Yet states are finding that waiting lists can undermine future outreach efforts as additional funds become available. Alternative methods such as phasing in income eligibility expansion may prove more effective as means for targeting growth in enrollment.
Lessons Learned
- Coordination between the public and private sectors is important. Ideally, state-subsidized insurance programs should be designed in tandem with efforts to increase employer-sponsored health insurance.
- When phasing in a program, a clear commitment by states to full program implementation is an important impetus for HMOs to take steps to qualify for state contracts.
- Knowledge of the insurance industry and a business orientation are crucial to the success of a program, especially in terms of effective negotiations with managed care organizations.
- States should be willing to refine a program on the basis of experience. Changes may be necessary as a result of shifts in the health care market, federal policies, or other external factors.