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                    [post_content] => The Center for Medicare & Medicaid Services (CMS) and 26 states are moving to launch a large scale managed care demonstration project potentially involving millions of the poorest, sickest, most expensive Medicare and Medicaid beneficiaries, the so-called dual eligibles. The experiment is getting more and more attention from policy experts, but with controversial issues like the survival of the Affordable Care Act and converting Medicare to a premium support program grabbing the limelight, it has otherwise flown under the radar screen.

The 9.1 million dual eligible beneficiaries represent just a small share of the 97 million beneficiaries served by either Medicare or Medicaid but account for about 35 percent of all dollars spent by the two big programs. As a group they are sicker than other Medicare beneficiaries -- half have three or more chronic conditions and six in ten have cognitive limitations, leading to increased use of health and long-term care services. While most are over age 65, four in ten are younger with permanent disabilities. Two of three are women. A striking 56 percent have incomes of less than $10,000 per year. (Kaiser.EDU, Medicare/Medicaid Dual Eligibles.)

Of the 26 proposed state demonstrations, most are planning capitated managed care models, but some propose using a managed fee-for-service approach. For the capitated model, states and the federal government will enter a three-way contract with private managed care companies to manage the care of the enrolled population. Medicare, which mainly pays for acute care, and Medicaid, which mainly pays for long-term care, will blend payments into one rate, with savings taken off the top for both Medicare and Medicaid. The demonstration is moving quickly; half of the 26 states are looking to implement either the capitation or fee-for-service model in 2013 and others in 2014. Both the challenges and the potential of this health reform experiment are enormous. (Dx For A Careful Approach To Moving Dual Eligible Beneficiaries Into Managed Care Plans, Health Affairs, June 2012.)

Analysis by researchers on our staff and at the Urban Institute shows that while the duals as a group are higher utilizers than other Medicare beneficiaries, a smaller subset of duals are very high utilizers: 2 million of 9 million duals in 2007 (the last year for which merged Medicare and Medicaid data were available) were responsible for 60 percent of Medicare and Medicaid spending; the remaining 7 million duals accounted for 40 percent of spending (The Diversity of Dual Eligible Beneficiaries).

Some states will pursue broad demonstrations while others may pursue more targeted approaches, focusing on groups with recurring high expenses, such as nursing home residents. If states and health plans could target their efforts and more effectively coordinate the care of the very high utilizers, the benefits to both beneficiaries and the programs could be quite large.

In the capitated model, managed care companies will strike deals providing front-end savings to Medicare and Medicaid to manage the care of this population. The real challenge will be to assemble the delivery networks at the local level to effectively manage the broad range of services duals use, including behavioral health, pharmacy, community-based and institutional long-term care services, and a full range of acute care services. Managing care for a population that includes some who are very reliant on long term care, in particular, will require developing new networks of services for many managed care companies. So will managing care for a population with a high incidence of cognitive and mental health problems. Very few health plans now have the necessary experience to manage the care of this complex population and it will take time to develop new arrangements for appropriate services.

Medicaid is a federal-state program administered by the states and Medicare is a federal program, both with different populations and benefits (Medicare’s Role for Dual Eligible Beneficiaries; Medicaid’s Role for Dual Eligible Beneficiaries). It is predictable that there will be federal-state control issues to work through as a demonstration program involving a merger of both programs with private plans evolves. None of these challenges are reasons not to undertake the demonstration, only to recognize that implementation will take careful planning and time because the details of delivering care and services will matter.

I learned first-hand about the challenges of developing new service networks in the early days of Medicaid managed care in the 1980's, as Human Services Commissioner in New Jersey. We established the first state-run, federally-qualified HMO for Medicaid. It achieved front-end savings and some ability to reallocate more of the Medicaid dollar to primary care. But we never were able to build the network of providers to more effectively manage care to improve outcomes or lower costs, for a population far less complex than the dual eligibles are.

Across the country Medicaid managed care slowly replaced fee for service for children and their parents but it never became the huge cost saver it was originally expected to be. Thirty years after it began to gain momentum Medicaid managed care is now moving to higher cost populations where the potential for savings are thought to be larger but the risks to sick patients are also greater.

With the spotlight on the ACA and Medicare and Medicaid budget challenges, this experiment involving millions of some of the highest cost, sickest people served by public programs has so far been under-reported. Eventually, covering this story will require getting inside delivery systems and interviewing policymakers, providers, and especially patients and their families, just the kind of journalism news organizations are hard pressed to do with their frayed budgets. This is not a breaking story a reporter can cover in one day. It will never have the drama of the highly politicized ACA and Medicare wars. But it deserves attention beyond our world of health policy.

Success in the dual eligibles demonstration could help reduce federal and state health spending in both big health care entitlement programs and improve the health of a very needy population. But the pressure to save money always cautions prudence, patience, and in this case careful targeting and customization of services, when large numbers of low-income people with disabilities and serious illnesses are involved.
                    [post_title] => Pulling it Together: Duals: The National Health Reform Experiment We Should Be talking More About
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                    [post_content] => Former Senate Majority Leader Bill Frist, who is a member of our Board, recently published a column making the case very effectively for continued investments in global health.  Today we released our latest national survey on attitudes towards global health, which uncovered important nuances about the argument for foreign aid and global health.

When it comes to helping other countries with health, younger people are much more likely to be supportive than older people.  Perhaps that is not surprising but it says something about how globalization has touched younger people, as well as who the most receptive audience is for the global health message.  We can see this in the intense interest in global health in schools of public health and in the interest in global health of the many students I hear from at the Foundation.

One of the strongest predictors of support for global health spending was the belief that aid would make a difference.  This means that documenting the impact of assistance and then communicating that to opinion leaders and the public is absolutely critical for advocates of foreign aid and global health.  We found that the public believes that almost half of every dollar we spend to help other countries is lost through corruption, so this is a formidable challenge.  Based on the evidence I have seen, the public’s perception is a gross over estimate, but perhaps surprisingly, this is not a subject that has been extensively and rigorously studied, especially with regard to U.S. aid.

Another really strong predictor of support for global health spending was knowledge (or misperception).  People who understood that foreign aid represented just a small share of the federal budget — it does actually represent just one percent of the budget — were more likely to support more spending on global health.  The misperception has been documented in our survey and others many times.  What’s more important is the finding that, controlling for other variables, knowledge seems to influence, or at least be closely associated with attitudes.  That is sometimes but not always the case on policy issues.

Those who had travelled to a developing country were also somewhat more likely to support increased U.S. spending, though the effect was smaller.  Combined with the stronger support from young people, this finding suggests that the many college semester and year abroad programs in developing countries could have an impact on attitudes towards global health and foreign aid beyond the personal impact we have all seen them have on young people’s lives.

We also found in the survey, as we have in previous ones, that specifying that the purpose of foreign aid is for health matters.  Fifty four percent of the American people say we are spending "too much" on "foreign aid" whereas only 21% say we are spending too much "to improve health for people in developing countries" (32% said not enough).


Educating people about the extent of U.S. foreign aid currently, in addition to its purpose, also has the potential to change opinions.  After we asked people's initial opinion on the amount of foreign aid spending, we told them that foreign aid represents about one percent of the budget, and found that the share saying we spend too much was cut in half (from 54% to 24%).  The share saying we spend too little more than doubled (from 17% to 36%).The message here is threefold.  First, global health aid has the potential to be relatively popular even if foreign aid is not.  It may not move votes in an election as issues like jobs and the economy can, but it could be a plus instead of a minus for elected officials.  Second, information and public education — to counter misperception — can matter to the level of public support.  But third, whether for foreign aid generally or global health more specifically, the ultimate obstacle to greater public support is the need to make the case effectively that aid is not ripped off and makes a difference.


                    [post_title] => Pulling it Together: What We Know about Making the Case to the Public for Global Health
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                    [post_content] => A new Kaiser analysis sheds light on how the country might react to the Affordable Care Act (ACA) when it is implemented.  It looks at how the benefits of the ACA's coverage expansions will vary around the country by census areas (technically, Public Use Microdata Areas, or PUMAs).  PUMAs are artificial areas of about 100,000 people each created by the Census Bureau to provide more detailed demographic, social and economic information at the local level.  They are generally bigger than zip codes and often overlap with counties, but all fall within state lines.  While people today don’t really know about their PUMAs, next year local agencies will be naming each PUMA. Get ready for the excitement — there will be a PUMA coming to your area soon.

Our analysis illustrates the percentage of the non-elderly population in each PUMA who could benefit personally from the Medicaid expansion or tax credits available through the new state-based insurance exchanges.  We also created a web tool that allows people to put in their zip code and see what percentage of the non-elderly population will benefit in their area (i.e.,PUMA).  A full description of the results and the methodology, including caveats, is available online.

The study of “small area variations” in health care costs and delivery was pioneered years ago by Dr. Jack Wennberg, with whom I worked early in my career.  But there has been less focus on variations in health coverage below the state level.

In fact, there is wide variation in how many people will benefit from the ACA’s coverage expansions… really wide!  It ranges from 2-4% of the non-elderly population who could benefit from coverage expansions in parts of states with broad coverage, such as Massachusetts and New York, to as much as36-40% in parts of Florida, New Mexico, Texas, Louisiana, and California.  PUMAs in the country benefiting the most are parts of the Miami area, areas northwest of Albuquerque, and Fort Worth.  And the PUMAs benefiting the least are all in the Massachusetts suburbs.  Of course,Massachusetts already has its own nearly universal coverage plan.  On average across the country, 17% of the non-elderly population could benefit from the coverage expansions.

Over time, more people will benefit because insurance coverage isdynamic.  People’s employment and economic circumstances change and theywill cycle in and out of eligibility for Medicaid or tax credits.  Andthey will all have family members and friends who will see them receive thesebenefits and presumably value the fact that their relatives and friends havecoverage.

Of course, we have always known that states with the largest uninsured populations will benefit the most from the ACA’s coverage expansions.  The new analysis, however, shows that there will be real variations even within these states.  For example, in the state of California where KFF is headquartered, the share of the non-elderly population who could benefit ranges from 5-36%, mirroring the variation for the country as a whole.  The ranges are large in smaller states, too — from 13-29% in Utah, 5-19% in Wisconsin, and 7-23% in Virginia.

But, there is a flip side to this picture.  The more uninsured people there are in a PUMA, the greater their number that will be subject to the insurance mandate, which is the least popular provision of the ACA and the subject of the Supreme Court case to be heard this spring.

There is also an interesting pattern if you overlay PUMAs with a high percentage of people benefiting from coverage expansions with congressional districts.  Republicans oppose the ACA but there are slightly more high benefit Republican districts than Democratic ones, a subject my colleagues and I address in a separate op-chart published in Politico.

I doubt there will be a direct relationship between high and low benefit PUMAS and how people perceive and respond to the law.  For one thing, the law benefits people in many ways beyond its coverage expansions.  For example,there are its many consumer protections (including provisions guaranteeing coverage regardless of pre-existing conditions), its coverage of preventive services without cost sharing, its coverage of drug costs for seniors who fall in the donut hole, and much more.  On the other side of the coin there are  many provisions of the law that offend its critics that have nothing to do with expanding coverage, most famously the individual mandate.

It may be that there will be no clear public judgment of a law that affects the public so variably and in so many different ways. Many Americans will have a hard time knowing whether a change in their insurance or health care arrangements was made by their provider, their insurer, their state government, or as a result of the ACA.  Our media and horse race driven society tends to expect a thumbs up,thumbs down verdict on everything.  But the ACA may come to be viewed by the public as a collection of parts and pieces; some more successful and popular than others and some less; some easy for people to connect to the ACA and some not; with a varying pattern of impact across the country not only from state to state, but from community to community.
                    [post_title] => Small Area Variations and the ACA’s Coverage Expansions
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                    [post_content] => What is remarkable about 2012 (and the current era in health policy) is how many big health policy issues and marketplace changes will be in play at the same time:


	
HEALTH REFORM: There is the implementation of a historic but fragile health reform law, with a Supreme Court decision pending and so much hanging in the balance.




	
MEDICARE AND MEDICAID: There are continuing debates about potentially big changes in Medicare and Medicaid, driven by the desire to reduce the deficit.  With the collapse of the Super Committee triggering big cuts in defense and with the Bush tax cuts set to expire, there will be pressure to make a new deal to meet budget targets that protect defense spending and preserve at least some of the tax cuts.  Complicating matters is the pressure to avoid major cuts in Medicare payment rates for physicians when the short-term “doc fix” expires.  All this could cause policymakers to look again at savings and changes in Medicare and Medicaid, as well as the Affordable Care Act (ACA).  While health reform attracts the most attention, these two public programs cover more than one hundred million low-income, disabled and elderly Americans.  And, Medicare is unique as a health issue because, despite the clamor about health reform, it is the one health issue proven to move votes.




	
OUTSIDE THE BELTWAY: Then there are the changes occurring outside the beltway.  Faced with lingering budget pressures and the expiration of enhanced federal matching payments, states continue to cut back their Medicaid programs (mostly through provider payment reductions, since maintenance of effort rules prevent cuts in eligibility). States are also cutting other programs and services for low-income people.  The health care delivery system continues to morph and change rapidly with mergers, consolidations, Accountable Care Organization (ACO) mania, and more.  The insurance system continues to change as well. Insurers are experimenting with new payment arrangements while insurance itself is becoming less comprehensive with the growth of high-deductible plans. People continue to be hard-pressed by their out-of-pocket health care costs.  Strikingly, the Census recently reported that the biggest factor driving people into poverty was their out-of-pocket health costs.




	
THE ELECTION: Last, and potentially most significant of all, there will be an election in 2012.  Elections matter hugely for policy directions, if not always substantive legislative changes, and quite obviously, if President Obama is unseated by any of the Republican candidates (and especially if the Senate changes hands at the same time), the direction of health policy could fundamentally change.

This graphic summarizes how much could be in play in 2012:

There is a tendency to think of this period in health policy as the early ACA years. To be sure, the ACA has and will make fundamental changes in the health care system.  No doubt it is the new big thing and the big story.  But it alone is not what is most remarkable about this year or the current era in health policy.  What is unusual about 2012 is how many programs, issues, and changes are in play all at once. It is entirely possible that the court will uphold the law; nothing much will be done to “reform” (some would say harm) Medicare and Medicaid, despite budget and political pressures; and the President will be re-elected and policy directions will continue largely unchanged. Or, it may be that some of these tipping points will tip and others will not. Big changes or small, policy is generally better when it is informed by facts and analysis and made more accountable by good journalism.  And no matter what happens in Washington many of the changes in payment and delivery unfolding in the marketplace will continue, and they warrant real assessment to determine if they are merely the latest fads, or if they represent real progress.For journalists it will be a target-rich environment. But with such a broad health policy beat, journalists will need to make choices about which stories to cover, and they will be hard pressed to get beyond the beltway where many of the most important stories will be found.  It will be a challenging year for analysts too. There is a need for data and analysis on such a wide range of issues, and it will need to be generated in real time to be relevant and useful.  Assessing the changes occurring in the marketplace is always a special challenge, because up-to-date data on the private market are difficult and sometimes impossible to find.

At Kaiser we will do our best to provide explanation, data and analysis, polling, and in-depth journalism, on as many of these issues as possible. And we will keep our eye on our special focus: the impact policy debates and marketplace changes have on people.
                    [post_title] => Pulling it Together: 2012: The ACA, and More
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                    [post_content] => Beginning this Spring, between expected approval of an economic stimulus package and the start of campaigning for the midterm election, there will be a rare window of opportunity for passage of major health reform legislation. History suggests that momentum can be lost if policymakers do not move quickly to seize these rare openings when they occur. There is an opportunity now because the nation has a popular new president with political capital to burn who is making health reform a priority. Democratic leaders in control in the Congress want to deliver on health care. And a historic recession has transformed health care into a bread and butter economic issue of real salience to working people and the middle class, who are worried about paying their health care bills and about losing their jobs and their families’ health coverage. Many years ago a great political scientist named Aaron Wildavsky wrote an article called "The Two Presidencies" in which he contrasted the relative power of the presidency in foreign policy with its comparative impotence in domestic affairs. But Wildavsky argued that times of crisis such as the economic meltdown the country faces today present exceptions to the rule. There remain serious obstacles to passing major health legislation, not least the challenges of reaching across the aisle and forging consensus on key elements of reform and the very real problem of finding a way to pay for expanding coverage in the current budgetary environment. However, the kind of opportunity the president and Congress have now in health does not come along often.

These two charts, dating from as far back as the Truman era and as recently as the Clinton one, underscore the argument for moving as quickly as possible to take advantage of moments of opportunity before opposition to health reform legislation emerges and public enthusiasm wanes. They show how opposition to the Truman plan rose and support for the Clinton plan fell when debate shifted from consensus about initial goals to disagreement about details. It's inevitable in a drawn out legislative process that media and public attention will shift to the tradeoffs involved in health reform and the difficult business of controlling costs and paying for expanding coverage. A new poll we will release next week will show both the opportunity for action now, but also the potential for a similar unraveling of support in the face of some of the arguments likely to be made by opponents in the face of a protracted debate about the issues and tradeoffs in health reform. Familiar constants in public opinion always lurk just beneath the surface as well. For example, people do not want to pay more out of pocket as a result of any health reform plan -- in fact, they're looking to pay less -- and they don’t want to be forced to change their current health care or health insurance arrangements. As in the past, these and other fears can be exploited by opponents of legislation in an extended debate, whether or not they are actually true. Maintaining support through a lengthy national debate may be even more difficult in the modern era where public opinion can be influenced by interest groups waging ad wars on TV, or now on YouTube, much like in political campaigns. (Click on a chart to enlarge)

    

Right now, we're mostly in the "happy talk" phase of the health reform debate. All of the major interest groups are in favor of reform of some sort, and the public is supportive of major action. But there are many elements of the plans that have been proposed that could spark opposition – for example, requirements on employers and individuals, a new institute or federal agency with a mandate to conduct research on the comparative effectiveness of treatments, new regulations affecting the health insurance industry, and of course how to finance coverage expansions over the long term. In fact, the notion of creating a public plan like Medicare to compete with private insurance plans has become an early target of the insurance industry. CBO scoring will add to the challenge because in general the measures that will be credited with producing the largest short term savings which political leaders will need to pay for their plans will be the most politically controversial.

While efforts are already being made to rally the public as a counterweight to likely opposition to legislation -- something that didn't happen in a coordinated way during the debate over the Clinton plan -- history suggests that delay and a long public debate can be the enemy of health reform legislation. That may be more true than ever now, when our economic circumstances appear to have created a unique willingness to invest in health care in the short term as part of an effort to stimulate the economy and address the public’s economic insecurities, with the promise of savings as a result of reform over the long term.

Quick action may offend those who think that it’s the job of Congress to get things exactly right when legislation is first drafted, or that a long debate and a full vetting is the right way for a democracy to deal with a big issue like health reform. But more than any other single factor it’s the recession that makes the environment for this health reform debate different from the last one, and a reading of history suggests that if action rather than another health reform stalemate is to be the outcome, one strategy may be to move fast and seize legislative opportunities when they present themselves, get at least the basics right, and fix whatever problems emerge later on.
                    [post_title] => Window of Opportunity?
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            [post_content] => The Center for Medicare & Medicaid Services (CMS) and 26 states are moving to launch a large scale managed care demonstration project potentially involving millions of the poorest, sickest, most expensive Medicare and Medicaid beneficiaries, the so-called dual eligibles. The experiment is getting more and more attention from policy experts, but with controversial issues like the survival of the Affordable Care Act and converting Medicare to a premium support program grabbing the limelight, it has otherwise flown under the radar screen.

The 9.1 million dual eligible beneficiaries represent just a small share of the 97 million beneficiaries served by either Medicare or Medicaid but account for about 35 percent of all dollars spent by the two big programs. As a group they are sicker than other Medicare beneficiaries -- half have three or more chronic conditions and six in ten have cognitive limitations, leading to increased use of health and long-term care services. While most are over age 65, four in ten are younger with permanent disabilities. Two of three are women. A striking 56 percent have incomes of less than $10,000 per year. (Kaiser.EDU, Medicare/Medicaid Dual Eligibles.)

Of the 26 proposed state demonstrations, most are planning capitated managed care models, but some propose using a managed fee-for-service approach. For the capitated model, states and the federal government will enter a three-way contract with private managed care companies to manage the care of the enrolled population. Medicare, which mainly pays for acute care, and Medicaid, which mainly pays for long-term care, will blend payments into one rate, with savings taken off the top for both Medicare and Medicaid. The demonstration is moving quickly; half of the 26 states are looking to implement either the capitation or fee-for-service model in 2013 and others in 2014. Both the challenges and the potential of this health reform experiment are enormous. (Dx For A Careful Approach To Moving Dual Eligible Beneficiaries Into Managed Care Plans, Health Affairs, June 2012.)

Analysis by researchers on our staff and at the Urban Institute shows that while the duals as a group are higher utilizers than other Medicare beneficiaries, a smaller subset of duals are very high utilizers: 2 million of 9 million duals in 2007 (the last year for which merged Medicare and Medicaid data were available) were responsible for 60 percent of Medicare and Medicaid spending; the remaining 7 million duals accounted for 40 percent of spending (The Diversity of Dual Eligible Beneficiaries).

Some states will pursue broad demonstrations while others may pursue more targeted approaches, focusing on groups with recurring high expenses, such as nursing home residents. If states and health plans could target their efforts and more effectively coordinate the care of the very high utilizers, the benefits to both beneficiaries and the programs could be quite large.

In the capitated model, managed care companies will strike deals providing front-end savings to Medicare and Medicaid to manage the care of this population. The real challenge will be to assemble the delivery networks at the local level to effectively manage the broad range of services duals use, including behavioral health, pharmacy, community-based and institutional long-term care services, and a full range of acute care services. Managing care for a population that includes some who are very reliant on long term care, in particular, will require developing new networks of services for many managed care companies. So will managing care for a population with a high incidence of cognitive and mental health problems. Very few health plans now have the necessary experience to manage the care of this complex population and it will take time to develop new arrangements for appropriate services.

Medicaid is a federal-state program administered by the states and Medicare is a federal program, both with different populations and benefits (Medicare’s Role for Dual Eligible Beneficiaries; Medicaid’s Role for Dual Eligible Beneficiaries). It is predictable that there will be federal-state control issues to work through as a demonstration program involving a merger of both programs with private plans evolves. None of these challenges are reasons not to undertake the demonstration, only to recognize that implementation will take careful planning and time because the details of delivering care and services will matter.

I learned first-hand about the challenges of developing new service networks in the early days of Medicaid managed care in the 1980's, as Human Services Commissioner in New Jersey. We established the first state-run, federally-qualified HMO for Medicaid. It achieved front-end savings and some ability to reallocate more of the Medicaid dollar to primary care. But we never were able to build the network of providers to more effectively manage care to improve outcomes or lower costs, for a population far less complex than the dual eligibles are.

Across the country Medicaid managed care slowly replaced fee for service for children and their parents but it never became the huge cost saver it was originally expected to be. Thirty years after it began to gain momentum Medicaid managed care is now moving to higher cost populations where the potential for savings are thought to be larger but the risks to sick patients are also greater.

With the spotlight on the ACA and Medicare and Medicaid budget challenges, this experiment involving millions of some of the highest cost, sickest people served by public programs has so far been under-reported. Eventually, covering this story will require getting inside delivery systems and interviewing policymakers, providers, and especially patients and their families, just the kind of journalism news organizations are hard pressed to do with their frayed budgets. This is not a breaking story a reporter can cover in one day. It will never have the drama of the highly politicized ACA and Medicare wars. But it deserves attention beyond our world of health policy.

Success in the dual eligibles demonstration could help reduce federal and state health spending in both big health care entitlement programs and improve the health of a very needy population. But the pressure to save money always cautions prudence, patience, and in this case careful targeting and customization of services, when large numbers of low-income people with disabilities and serious illnesses are involved.
            [post_title] => Pulling it Together: Duals: The National Health Reform Experiment We Should Be talking More About
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