States Move Ahead on Health Care Reform as Federal Government Lags Behind

As Congress continues to debate federal health care reform legislation, several states have pushed ahead with their own health care reform initiatives. By enacting measures that have expanded access, improved quality and contained costs, they are providing a road map for national health care reform efforts. That's according to state senators and other state officials who spoke during the AAFP's 2009 State Legislative Conference here Nov. 20-21.

States can no longer wait for the enactment of national health care reform, said Iowa state Sen. Jack Hatch, D-Des Moines. As a result, several states, including Iowa, Massachusetts, Maine, Minnesota, Vermont and North Carolina, have passed their own health care reform measures during the past few years.

"We have to understand that every state has something they can offer," said Hatch, who is chair of the White House Working Group of State Legislators for Health Reform and assistant majority leader of the Iowa Senate. He spoke about states' reform efforts during a panel on comprehensive system reform, saying, "We are more innovative. As you probably know, there are things going on in your state that the federal government needs to listen to."

For its part, Iowa passed a comprehensive health care reform bill in 2008 that ensures coverage for all children in the state. The state committed to providing health coverage for all children under the age of 19 by the end of 2010. And it already has achieved 99.9 percent coverage for that age group, which is the highest level in the country, according to Hatch.

"Everything we have done in Iowa was either tried somewhere else or initiated somewhere else," he said. "We are good thieves of public policy."

Hatch described family physicians as the key to the success of Iowa's reform efforts. "We have to focus on keeping people healthy," he said. "There is only one group who is responsible for that, and that is you family doctors.

"The AAFP must now speak louder than it has ever spoken before. Of all the physician groups, your practice of medicine has the most important responsibility. You are trusted by your patients. Your future role will increase more than any other practice, and your historic position in protecting your patients by helping to prevent further illnesses cannot be understated."

Lisa Marraché, M.D., D-Waterville, a family physician and assistant majority leader in the Maine Senate, is convinced that states can serve as laboratories for health care reform by developing and refining new ideas and approaches. In 2003, Maine applied a three-pronged approach to health care reform that required improved health care quality, lowered cost growth and investments in greater access to health care.

"What we were finding is that people were not getting the right care at the right place at the right time," said Marraché, who spoke during a panel about health care reform efforts in Maine and Massachusetts. "We had more people who went to the emergency room than were going to primary care offices because they didn't have their own doctors."

The state subsequently launched the Dirigo Health Reform act, an initiative that expanded the state's Medicaid program and created a subsidized insurance program for small businesses, the self-employed and individuals. The public/private partnership known as Dirigo Choice eliminated the waiting period for pre-existing conditions and provides mental health parity and preventive coverage.

During the past six years, the state has enrolled about 24,000 people and more than 725 small businesses in Dirigo Choice. It also has expanded MaineCare Medicaid coverage to 5,500 additional patients, said Marraché.

Before the advent of Dirigo, Maine had the highest uninsured rate in New England, at 12 percent. That rate is now 9.7 percent and is the second lowest in the region. In addition, before Dirigo, Maine employers experienced the highest average annual growth in premiums in New England, according to Marraché. Now, after enactment of the law, they have the lowest rate of employer premium growth, she said.

Marraché is hopeful that any federal health care reform plan will incorporate some of the more effective components of the Dirigo Health Reform Plan.

Massachusetts state Sen. Richard Moore, D-Uxbridge, also expressed hope that federal health care reform would "supplement and support the foundation of what states have established."

Moore, who is chair of the Massachusetts Legislature's Committee on Health Care Financing and president-elect of the National Conference of State Legislatures, spoke about the Massachusetts law that requires nearly all state residents to carry health insurance. The Massachusetts Health Care Reform Plan reduced the number of uninsured residents in the state to about 3 percent and brought more than 300,000 previously uninsured people into the health care system.

In addition, the state created a loan forgiveness program for physicians and nurses who agree to practice primary care in medically underserved areas. It established an affordable housing pilot for health care professionals who practice in underserved areas, and it created greater tuition incentives for University of Massachusetts medical students who agree to practice primary care in the state for four years.

Not surprisingly, Massachusetts and other states are pursuing payment reform as a part of larger health care reform efforts. State officials equate payment reform with care coordination and greater health care quality, making it a fundamental component of health care reform.

For example, according to Carol Backstrom, assistant to the commissioner for health reform for the Minnesota Department of Health, Minnesota passed a comprehensive health care reform measure in 2008 that relies on four core strategies: public health investment, market transparency, consumer engagement, and care redesign and payment reform. As part of these strategies, the state is taking steps to turn its primary care practices into patient-centered medical homes, she said during a panel discussion on Minnesota's reform efforts. State officials plan to start certifying primary care practices as medical homes in January, and, in July, they will start paying practices for serving as medical homes.

The state also has established so-called baskets of care by allocating set fees or bundled payments to physicians and other caregivers for the care and management of patients with designated conditions, such as asthma and diabetes.

"Medical homes and baskets of care offer a way for providers to think about how they can deliver care differently and really focus on the health outcomes that we are striving for," said Backstrom.