KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
These are the complete toplines for a survey that builds on the Foundation’s previous survey work in measuring Americans’ attitudes toward U.S. global health investments and priorities. The survey tracks some questions that were asked earlier in 2009, and delves into some new questions about specific areas of global health spending and how aid should be distributed. Following President Obama’s announcement of the Global Health Initiative, the survey also measures public perception of the current Administration and Congress with regards to global health efforts.
The survey was designed and analyzed by public opinion researchers at the Kaiser Family Foundation. It was conducted October 21 through October 28 among a nationally representative random sample of 1,205 adults ages 18 and older. The margin of sampling error for the overall survey is plus or minus 3 percentage points.
This Medicare Part D data spotlight examines the stand-alone Medicare drug plan options that will be available to beneficiaries in 2010, including the number of available plans, premiums for those plans, and benefit designs. About two-thirds of the nearly 27 million Medicare beneficiaries who are enrolled in Part D plans get their coverage through stand-alone plans.
The analysis is based on the 2010 Medicare drug plan information released by the Centers for Medicare & Medicaid Services on Oct. 1, 2009. The analysis was conducted jointly by Jack Hoadley and Laura Summer of Georgetown University, Juliette Cubanski and Tricia Neuman of the Kaiser Family Foundation, and Elizabeth Hargrave of NORC at the University of Chicago.
This data spotlight examines changes in the availability and premiums of private Medicare Advantage options for Medicare beneficiaries in 2010 as the annual open enrollment period begins.
While the number of plans available in 2010 declined somewhat from 2009, the analysis finds that Medicare beneficiaries on average have 33 Medicare Advantage plans to choose from. For Medicare Advantage enrollees who stay in the same plan in 2010, monthly premiums will increase by 32 percent on average, with a steeper 78 percent average increase for enrollees in private fee-for-service plans who do not switch plans.
This data spotlight is one in a series looking at the 2010 Medicare Advantage plan options and trends around the Medicare Advantage plan. These spotlights were prepared by a team of researchers at Mathematica Policy Research Inc. and the Kaiser Family Foundation.
This data spotlight examines the coverage gap, or “doughnut hole,” in Medicare stand-alone drug plans available in 2010. While in the gap in coverage, Part D enrollees (other than those receiving low-income subsidies) are required to pay 100 percent of total drug costs until they reach the catastrophic coverage level.
In 2010, nearly all the private stand-alone drug plans have a coverage gap, though a small share do provide some help to beneficiaries in the coverage gap, usually covering only generics or a small number of brand-name drugs. One third of those plans with gap coverage charge more for generic drugs in the gap than they do for the same drugs in the initial coverage period.
The spotlight is one in a series analyzing key aspects of the Medicare Part D drug plans that will be available to beneficiaries in 2010. These spotlights were prepared by a team of researchers at Georgetown University, NORC and the Kaiser Family Foundation.
For as long as I have been in the field, there have been two dominant schools of thought about how to control health care costs. One school, The Regulators, believed that the best way to slow increasing costs was to control the total resources going into the health care system: putting limits on the supply of medical professionals, technology and facilities; setting payment rates; or putting enough purchasing power in the hands of government to drive the right bargain with the health care industry. The other school, The Marketeers, believed that competing health plans and information-empowered, prudently-purchasing consumers would drive down costs, especially if insurance were restructured to give people the right incentives. Although their philosophies were mirror opposites, both the Marketeers and the Regulators sought to control costs by applying external forces of different kinds to the health care system. Neither school had much interest or faith in getting inside the black box of health care delivery or medical practice as a way to control costs; doctors, hospitals and insurers—whether regulated or competing in a marketplace—would have to work that out on their own.
We may now be witnessing the ascendancy of a third school, the Systems Reformers. The Systems Reformers believe that the best way to bend the cost curve is not through external market incentives or regulatory controls, but from the inside out, by creating a smarter health care system with the information base, new delivery models and payment incentives that will improve quality and lower costs. In truth, the Systems Reformers have lived among us all along, but until recently their research and ideas were more focused on improving quality than controlling costs and were featured mainly in respected journals and conferences. They seldom made it into the lexicon or armamentarium of policymakers or the spotlight of journalists.
The Systems Reformers’ paradigm is reflected in the “bending the curve” elements of the health reform legislation currently in Congress, which mostly come in the form of pilot projects and experiments. These include tests of ideas like Accountable Care Organizations, “pay for performance” and “bundled payments,” as well as efforts to create a smarter, evidence-based health delivery system through comparative effectiveness research. But not all Systems Reformers’ ideas are embodied in the health reform bills in Congress. Numerous experiments are underway across the health care delivery system and in both the private and public sectors and touted by a broad range of health care leaders.
The Systems Reformers’ paradigm did not emerge because of some recent discovery. Jack Wennberg published his first major study of small area variations in costs and practice patterns in Science in 1973, and continued to publish similar research regularly after that. And the cost effectiveness of the Mayo Clinic was as regularly reported then as it is now. These ideas have been in the mix for a long time, but they have never before joined with regulatory and market strategies with the primary goal of controlling costs rather than improving quality or received the kind of high level endorsements they are getting today.
Partly what has happened is the health policy equivalent of being in the right place at the right time. In the current health reform debate, policymakers needed approaches to cost containment that offered the promise of long-term results and the potential to bring conservatives, liberals and large stakeholders together. Systems Reformers offered the promise of future savings without the old ideological fights and interest group opposition. Articulate experts and prominent leaders in both the public and private sectors were also willing and able to make the case for Systems Reformers’ ideas, not least OMB Director Peter Orszag. The President also gave Systems Reformers a huge boost by embracing these themes until switching the emphasis more recently to “health insurance reform” when it became clear that Systems Reformers resonated better with insiders and policy wonks than with the public.
In a feat never before seen in our field, Atul Gawande’s wonderful New Yorker piece traveled through the White House and across Capitol Hill in about two days, not so much because the research he was describing was new (Wennberg had reported similar findings many times for thirty years) or because his analysis was so brilliantly written (which it was). The timing was right for a new strategy to bend the curve through delivery, information and payment changes that did not divide policymakers and stakeholders along the familiar ideological lines. The article also rippled through the medical profession with similar speed. For many practitioners this was health reform they could relate to; getting under the hood of medical practice and health care institutions and changing practice as well as pursuing quality improvement and cost containment in tandem. News media attention to the New Yorker piece and policymaker interest in it brought attention to Systems Reformers’ ideas to new levels.
No doubt some veteran health policy people see Systems Reformers’ ideas as a way to avoid bigger regulatory or market changes that they believe need to be made. But many in the loose Systems Reformers’ movement seek far-reaching changes in the practice of medicine and in how health professionals and health care institutions are paid that would reshuffle financial interests in fundamental ways. The driving force for the Systems Reformers agenda comes from health care leadership groups themselves, but its broader vision it is not a defensive, narrow or timid one.
As a strategy for controlling costs, the Systems Reformers’ approach trades the political downsides of the old approaches for much less certainty about scalability and results. As Brookings’ Henry Aaron commented when speaking to Lisa Wangsness of the Boston Globe: “The truthful answer is, we’re trying things out. When exactly the [cost] curve gets bent and how far it bends eventually is something no responsible person can give a hard answer to today.”
There are still many very serious question marks here. Can we figure out how to bundle payments? Will Accountable Care Organizations take off or remain limited to the relatively small number of integrated health systems that already exist today? Is this just the new buzz word in health care like so many before it? How long will it take for comparative effectiveness research to begin to pay off, and will we be able to figure out a system for incorporating it into coverage and payment decisions without raising the spectre of “rationing”? Can all of the promising delivery reform efforts now underway across the country to make the health care system more cost effective “scale up” in a way that is measurable, not just at Mayo or for one company here or there but to really bend the curve?
It is a note of caution that when it came to producing hard cash to pay for health reform legislation, the Congress—driven in large part by the Congressional Budget Office’s estimates—did not put many of its eggs in the payment and delivery reform basket. To produce a scoreable, deficit-neutral bill, they resorted to a mix of tried and true reductions in Medicare payments and new revenue raisers, plus added a Medicare Commission modeled loosely on the military base closure commission.
Nevertheless, the Systems Reformers’ agenda has now become part of the cost containment discussion in a new more official way, and it has a firm foothold in the health reform legislation now moving through Capitol Hill and new energy in the private sector. Time will tell whether Systems Reformers’ school has staying power along with market and regulatory approaches, but for now it is worth noting its emergence as a third leg of the stool of cost containment strategies at the highest level of health policy.
When I was a graduate student at MIT my adviser Jeffrey Pressman was a great political scientist who had just written the seminal book on program implementation. It was called, simply enough, Implementation, with a subhead that read: “how great expectations in Washington are dashed” (OK, we political scientists study politics too much and are a little cynical at times). The book literally created a new subfield in political science focusing on program implementation. This was one of its major conclusions:
“The great problem is to make the difficulties of implementation a part of the initial formulation of policy. Implementation must not be conceived as a process that takes place after, and independent of, the design of policy.”
Jeff Pressman’s life ended at too early an age and he was not able to continue this work, but the message is as relevant now as it was when he wrote it in 1973. So how does health reform stack up?
In one sense, not ideally so far. There are huge administrative challenges ahead in implementing health reform that have barely been discussed in the public debate, and have not been explicitly addressed in the legislation, at least not yet. Congress still has time to address these implementation issues and to provide funding through the health reform legislation itself or the appropriations process.
Many of these challenges would fall on the Department of Health and Human Services (HHS), its Centers for Medicare and Medicaid Services (CMS), and on state governments. For example, HHS and CMS would likely have responsibility for designing, testing and evaluating a broad range of new payment methods, and for developing regulations to implement virtually every aspect of the legislation (some elements of the legislation would also be handled by the Department of Treasury, and in the House bill, much of the implementation related to coverage and insurance would fall to an entirely new federal agency, the Health Choices Administration).
States may be asked to shoulder substantial new administrative responsibilities critical to achieving the goals of the law. In the Senate Finance Committee bill, for example, these include establishing and governing the new health insurance exchanges and overseeing insurance market reforms, both central features of the law. There is debate about how much of the cost of the Medicaid expansion states should bear under the law, but to date there has not been much discussion of the administrative role of states, who have been laying off staff and cutting back on their administrative capabilities during tough fiscal times. I spoke not too long ago to state health reform leaders at a Robert Wood Johnson Foundation sponsored meeting in Albuquerque and I can attest that shouldering these new responsibilities is very much on the minds of state officials.
Government will also have to forge new working relationships with the private sector to implement health reform. Health care’s major interest groups have by and large been inside the tent in formulating the legislation, but this will require establishing new regulatory and working relationships with the health care industry.
The lack of attention so far to implementation issues stands in sharp contrast to the approach ultimately taken when the Medicare Modernization Act (MMA) was passed. The MMA included provisions to help HHS gear up quickly: a big boost in funding for administrative expenses and new authority to hire needed senior level staff. The MMA appropriated $1 billion for the Centers for Medicare and Medicaid Services for administrative expenses associated with implementation and $500 million for the Social Security Administration, which administers the low-income subsidy benefit under the prescription drug law. In addition, the law authorized the Secretary of HHS to hire management staff with expertise in health benefits, actuarial sciences and other content areas that would be needed “as the Secretary determines to be necessary” to “ensure the success of the new Medicare plans.” The new hires could be paid up to the highest rate of basic pay for Senior Executive Level staff. Another important element, obviously not in the legislation but key for successful implementation nonetheless, is leadership. CMS had a strong administrator who focused on MMA implementation. But as of now, the CMS post remains vacant. In the case of the MMA, attention to implementation issues was framed as critical to the success of the law and to helping seniors wade through its complexity, and not as more money for government agencies or bigger government. This will be important in the case of health reform where the task is even more complex, involving implementation challenges for both Federal agencies and the states.
In another sense, however, the health reform legislation is well-designed for implementation success. That is because the law (as currently envisioned) would be phased in over a long period of time, providing time to prepare for implementation and react to naturally occurring opportunities for reassessment and modification in light of changing circumstances.
Although Congress established a long phase in period for key provisions of health reform primarily to stretch out costs so they could more easily be paid for, the fact that many elements of the law will not be in place until at least 2013 should also help smooth the process of implementation. Congress was well aware that many changes contemplated in the law, such as reforming the non-group insurance marketplace or implementing complex changes in how hospitals and doctors are paid, needed to be phased in or tested through pilot projects. There is a flip side of a lengthy phase in however: much can change as regulations are written and as elections occur that could alter the political landscape. The timeline below illustrates how key features of the law would be phased in, using the recent Senate Finance Committee version of health reform as an example. It shows many, but not all of the implementation milestones ahead, and when tangible benefits for people kick in.
Click on the chart to see a larger version.
This long implementation period could also affect public expectations, and that could cut both ways. Most people already have insurance and will not be directly impacted by the legislation, at least immediately. Passage of any version of health reform currently being discussed would likely look to most Americans like historic progress and a big political victory for the President and the Democrats, with no apparent downsides (or upsides) that affect them directly. On the other hand, given the high profile debate about health reform, public expectations are high (especially among people who are currently having problems in the health care system) and they may not see significant tangible benefits for several years. There could be a letdown for those expecting immediate change.
To be sure, advocates of reform have their hands full just getting reform passed and signed into law as bills are poised to go to the floors of the House and Senate. But for reform to ultimately be successful and accomplish the goals set for it, we should all think harder about Jeffrey Pressman’s advice to plan now, not later, for implementation in formulating policy, and in particular about the substantial implementation challenges HHS and the states will face. As policymakers work through the big policy and financing obstacles to a final agreement on health reform over the next three months, there will be an opportunity for Congress to focus on these issues.
Putting Children on the Express Lane to Health Insurance: Streamlining Enrollment and Renewal of Children in Medicaid and CHIP Through Express Lane Eligibility
Express Lane Eligibility (ELE) is a new tool available to states to streamline enrollment and renewal of children in Medicaid and CHIP. It allows state Medicaid and CHIP agencies to utilize data and eligibility findings from other public need-based programs, such as Head Start or Food Stamps, and/or tax return data to identify, enroll and recertify children rather than requiring them to re-analyze and determine eligibility under their own rules.
A primary goal of this and other outreach and simplification initiatives authorized by the Children’s Health Insurance Program Reauthorization Act of 2009 is to reach the 7 in 10 uninsured children who are already eligible for Medicaid and CHIP. The briefs in this series, which are jointly produced by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured and The Children’s Partnership, provide an overview of Express Lane Eligibility and examine key issues related to implementing an ELE initiative.
Express Lane Eligibility (ELE) is a new tool available to states to streamline enrollment and renewal of children in Medicaid and CHIP. It allows state Medicaid and CHIP agencies to utilize data and eligibility findings from other public need-based programs, such as Head Start or Food Stamps, and/or tax return data to identify, enroll and recertify children rather than requiring them to re-analyze and determine eligibility under their own rules.
This issue brief, one in a series, provides an overview of Express Lane Eligibility, presents an example of what ELE can look like in practice and highlights the potential benefits of implementing an ELE initiative.
The October Kaiser Health Tracking Poll finds public support for health reform unchanged since last month, with more in favor than opposed. Fifty-five percent of Americans believe that it is more important than ever to take on health care reform now, while 41 percent say the country cannot afford it right now.
The survey also shows about half of the public believes that if reform passes, help for the uninsured and changes in insurance market rules would arrive within the first year, years ahead of the timetables contemplated in the legislation.
There is initial public support for a public plan option, an individual mandate and taxing insurers, but opinion is highly moveable. A continuing majority support taxing wealthy households (63%) and health insurance companies that offer the most costly policies (55%). The initial support for the insurer tax is quite malleable depending on what specific arguments are offered.
Also, 57 percent of the public say they favor the creation of a “government-administered public health insurance option,” however the poll indicates that this support dips to one-third (32%) when initial supporters are told that such plans “could give the government plan an unfair advantage over private insurance companies.” Alternatively, support for the public plan rises to two-thirds (65%) when initial opponents are told that public plans would be “a fallback that would only kick in if not enough people had affordable health plans available through the private marketplace.”
The October poll, the seventh in a series designed and analyzed by the Foundation’s public opinion survey research team, examines voters’ specific health care issue interests and experiences and perceptions about health care reform.
