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Health Affairs Blog: States That Have Aimed To Close The Coverage Gap—What Can We Learn?

Published On February 6, 2018

Despite progress in reducing the numbers of uninsured, many people are left behind—approximately 27.6 million nonelderly individuals lack health insurance coverage; even those with coverage may face deductibles and out-of-pocket costs that threaten access to care when they are sick. The United States health care system badly lags behind other high-income countries on most indicators of performance, including access to care, health outcomes, and efficiency.

We can do better. We can have a country where people no longer go bankrupt from medical bills and where everyone has access to a regular source of care.

The good news is that there is enough money spent in the health system in the United States (more than $10,000 per person) to provide everyone with access to the care they need. If we could contain costs. If we could reduce waste and ineffective care. If we could pay for the treatments and therapies we need in a smarter way, thereby aligning incentives with quality. If everyone had affordable health insurance coverage for cost-effective, timely care. If what we know works could be implemented at scale. Together these ‘ifs’ can feel like an insurmountable barrier to progress.

Addressing these ‘ifs’ is the genesis of a new non-partisan organization, United States of Care, and its research partnership with the University of Pennsylvania’s Leonard Davis Institute of Health Economics (Penn LDI). United States of Care is launching a movement to ensure access to quality, affordable health care for every single American regardless of health status, social need, or income. Core to Penn LDI’s mission is to promote multidisciplinary, policy-relevant research, and to bring research findings to bear in policy debates. Together we will provide resources and actionable approaches to state and federal policymakers, based on analysis of research evidence, stakeholder engagement, and best practices.

Lessons Learned From States Attempts To Close Coverage Gap

In our first publication, we review prominent state efforts that have, or had, as their primary goal to close the coverage gap, including the most ambitious proposals in Massachusetts, Vermont, Colorado, California, and Nevada.

The report identifies common challenges encountered by states in attempts to close the coverage gap, summarizes important lessons learned from the experience in each state, and highlights the themes that emerge across states. It serves as a case study in how different states build, or fail to build, the popular and political will towards health care coverage for all residents, and these areas in particular stand out:

Stakeholder Involvement
Building a broad stakeholder coalition in support of proposals is an important element of success in swaying public opinion and political support. Influential stakeholders who feel left out, or who feel their interests may be threatened, are likely to galvanize opposition to efforts to expand coverage. Colorado’s ballot initiative was defeated in the absence of broad stakeholder involvement early on. Our current health care system includes many players—all of whom are essential to providing care and need to be part of the conversation. But all participants need to offer solutions, not just highlight problems.

Building Public Support
Educating the public about present health care costs and existing financing mechanisms—including trade-offs—is key. Many people understandably worry about losing the care they depend on, the choice of providers that care for them, or an increase in taxes. Public support for California’s ambitious single payer proposal is 65 percent, yet drops to 42 percent if such a plan requires an increase in taxes. Fully engaging the public, and listening to their hopes and needs, is essential to understanding the “problem”—where the health system is underperforming—and understanding the trade-offs of any proposal.

Coverage Is Also About Costs—And A Financing Strategy Is Critical
Proposals had varying levels of information as to the financing for the reforms. Some efforts floundered by either not offering information about how their policy would be fiscally sustainable, or by proposing drastic tax increases that faced backlash from the public and business community. Financing through taxes leaves taxpayers (and the proposals) vulnerable to health care costs that grow at greater rates than revenue sources. Massachusetts found success by demonstrating that its subsidized insurance program could be paid for by reallocating existing funding sources and would require minimal new state funds, in the “shared responsibility” model. Vermont’s proposed single-payer reforms were derailed by a delayed financing plan that exceeded earlier estimates and surprised even its supporters. California’s single-payer plan remains stymied by a lack of a clear financing plan at all.

Building Political Coalitions
Coverage expansion is more often perceived as a priority for Democrats and cost management more often considered a priority for Republicans, but the example of Massachusetts shows that health coverage expansion can be driven by either party. Conversely, the example of Colorado shows that health reform can cause intraparty division and bipartisan opposition, especially if it conflicts with other party priorities. This can’t be a strictly partisan conversation.

Getting To The Details
In some cases, proposals have garnered support by remaining general and nonspecific at first, but this is not sustainable when trying to pass major legislation. Nevada didn’t provide much detail on premiums, costs, and cost-sharing in its Medicaid buy-in plan, which may have contributed to its veto by a governor who called it an “undeveloped remedy to an undefined problem.” On the other hand, providing details in the absence of a process for building public and political support is likely to fail, as was a problem in Colorado.

Going Forward With United States Of Care

Ensuring that everyone has health coverage is a popular idea with the public, but there is little consensus around policies to get us there, and the politics are as divisive as ever. Yet there are details inherent to any policy proposal that need to be understood, new ideas to be explored, and knowledge gaps to be filled to empower policymakers and stakeholders in their decision-making.

The immediate work at United States of Care is to listen to the personal stories and experiences of local stakeholders and experts, and harness public opinion so that our policies can connect again to the hopes and concerns of Americans, rather than being driven by the polarizing politics. Penn LDI will bring its expertise to bear on important questions of affordability, value, quality, and health care markets, and identify and address emerging knowledge gaps regarding the implications of health care coverage policies. Together we hope to inform the conversation with lessons learned across states, and with evidence generated through rigorous research. The best ideas can shift the nature of the conversation and drive real change.

In the coming years, many states will consider a variety of approaches specific to each state’s economic and political characteristics. We’ll be watching and updating our analysis to build on the foundation of both the successes and the failures, and pushing to find new ideas. This review is only the first step in our partnership, and the first in a series of reports. We plan to work together to create resources for state and federal policymakers as they consider ways to close the coverage gap, and will remain responsive as the landscape of the national health debate evolves.