State leaders challenged to take on health reforms

The numbers, everyone knows, do not look good: From 2000 to 2005, the share of Rhode Islanders under 65 who were uninsured grew from 6.9 percent to 13.3 percent. The share of Rhode Islanders with employer-based coverage shrank from 77.7 percent to 67.6 percent.
Health Insurance Commissioner Christopher F. Koller’s staff has analyzed the data, surveyed employers, gone out on the field and talked with business owners, and come up with some ideas to try to at least slow down the trends.
But in the long run, Koller is the first to admit, more will still need to be done. He’s challenging policymakers, business owners and advocates to tackle the big question – how does the state really turn things around?
Lt. Gov. Elizabeth H. Roberts began hosting discussions on these issues last month in an initiative she’s named “Mission: Healthy RI” that aims to lay the groundwork for a substantial health-care-reform effort next year. Sessions are being held every Friday morning at the R.I. Economic Development Corporation.
The first meeting featured a presentation by John McDonough, executive director of Health Care for All in Massachusetts, on recent reforms in that state.
At the Nov. 30 meeting where Koller issued his challenge, he was asked to speak about who Rhode Island’s uninsured are, and how to reach them.
Along with the basics, Koller offered two key insights: The uninsured are “overwhelmingly” low-to-moderate-income people and employed. And while small businesses tend to be the focus of most conversations about the erosion of employer-based coverage, the biggest factor that Koller’s office has seen in the recent decline is that eligibility rules at large businesses have been tightened.
On the latter front, Koller said, it’s possible that much of the tightening is linked to a change in the business mix in Rhode Island, away from manufacturing and toward service industries that rely a lot on part-timers and often don’t offer insurance.
Among small employers, things are getting worse as well, Koller noted: The share offering coverage dropped from 70 percent to 66 percent between 1997 and 2004.
Armed with this knowledge, Koller said, Rhode Island can try to reach the uninsured through several strategies, including expanded outreach to RIte Care-eligible populations, expanded RIte Care eligibility and/or subsidies for beneficiaries who’d have to pay premiums, and for the 22 percent of the uninsured with incomes above 300 percent of poverty, perhaps a coverage mandate along the lines of what Massachusetts requires.
As it stands, Koller noted, the uninsured are disproportionately younger and healthier people. So to the extent that they’re uninsured by choice (and Rhode Island law guarantees that you can get coverage of some sort if you’re willing to pay for it), “they’re making rational priority decisions based on the likelihood of their getting sick.”
Koller then outlined some of the smaller, “incremental” reforms that have already been passed, such as the creation of the lower-cost HealthPact plans for small business. He then challenged the group to think bigger.
Given the state’s budget crisis, Koller acknowledged, expanding RIte Care in the immediate future seems like a long shot – there will be no new public money for coverage expansions, he said, and even if RIte Care eligibility stays unchanged, new federal documentation rules and other factors will keep pushing people off the rolls at least temporarily.
In the long run, Koller said, bigger reforms are needed, and the key is to decide what the “end point” should be: a stronger employer-based system? Individual-based coverage? A “utility”-type model in which the government tightly controls rates and plan designs? Or something like Medicaid or Medicare for all?
Koller pressed the group to look at the consequences of each choice in terms of cost, cost trends, quality, public health, and the impact on the uninsured – as well as at the fundamental question of whether health care is a right (something usually held in the public sector) or a commodity, something you buy.
“If we don’t answer these questions, we’re going to run out of money, because we’re piling more and more things onto a system that doesn’t quite work,” Koller said.
State Sen. Joshua Miller, D-Cranston, a business owner himself, said he believes the “political will” can only be mustered for reforms that strengthen the employer-based system, and that Rhode Island’s business climate has to be considered in any discussions.
(RIEDC Executive Director Saul Kaplan noted, in that context, that reforms don’t have to hurt businesses, and cost isn’t the only factor to consider, but rather the focus should be on the system of care that Rhode Island aspires to have.)
Roberts pointed out that the trend in recent years – as reflected in reforms passed under President Bush – has been to focus on individuals’ roles and create incentives for people to become smarter and more frugal purchasers of health care services.
Mark Reynolds, president and CEO of Neighborhood Health Plan of Rhode Island, noted that statistics show Americans change jobs roughly every four years, and insurers only cover any given person for about two and a half years at a time, so the employer-based system as it stands now doesn’t provide any incentives for employers or insurers to invest in people’s long-term health. •
For more information about “Mission: Healthy RI,” including a schedule of events, go to www.ltgov.ri.gov/healthyri.