State Health Policy Analysis

qa_state_health_policy_analysis

Final Project

The major written assignment, a Health Policy Analysis, is due in Week Six. Completion of this paper will involve research utilizing selected websites and the Ashford Online Library.

You are employed as an analyst in a state governor’s office and have been asked to write a 15 to 20 page health policy analysis. Your analysis will include the following;

1. Problem Statement: A one to three sentence question in which you succinctly identify a health-related problem. Do not include any recommendations in your problem statement, but rather phrase your problem statement so that it lends itself to an analysis that considers several options.
2. Background: Explain why the problem has been selected for analysis. Provide statistics and background data to document the scope and nature of the problem.
3. Landscape Identification: Identify the key stakeholders and the factors that must be considered e.g. political, social, economic, practical, and legal factors when analyzing the problem. For each factor, your analysis should discuss relevant views of the identified stakeholders. You may organize this section by stakeholder or by factor. Some stakeholders may not have relevant views for all of the factors, but each stakeholder must be addressed as often as necessary to convey their policy position. The tone of the landscape section should be neutral and objective.
4. Alternatives Section: Provide three to five options to consider. This section is not just a statement of choices, but an analysis of each alternative by stating the positive/negative and pro/con aspects of pursuing each option. Analyze all your options equally, and avoid providing more detail for the option you plan to recommend. This section should be completely objective. In completing your alternatives section, you may wish to utilize any of the following criteria in your analysis: cost, cost-benefit, political feasibility, legality, administrative ease, fairness, timeliness, targeted impact. Identify and evaluate the impacts of these processes e.g. persons served, lives saved, hospital days avoided, people screened.
5. Side-by-side Tables of the Alternatives: Create descriptive or analytic tables of your alternatives in which you summarize key information. A descriptive table would provide a description of each option but not provide any analysis. An analytic table would assess the option based on the criteria chosen. Make sure to clearly label your tables.
6. Recommendations: Select one of your alternatives, and clearly differentiate it as the best option, making sure to provide a detailed explanation as to why it is preferred over the other options. Weigh the data/evidence and analyze it in terms of technical feasibility, political feasibility, or economic and financial viability. In addition, also identify what, if any, actions may be taken to mitigate or overcome the negative aspects of your selected recommendation. (You presented these in your Alternatives Section) Do not make a hybrid recommendation of multiple options, as you must select only one option. Therefore, your explanation/justification of your selected option needs to be fairly detailed and include data to support it.)
7. Implementation Strategy: Identify steps to manage the policy process to gain public, professional, and/or consumer support for change and backing of the most appropriate alternative. How will you assure that key implementers and/or consumers buy into the process? How will conflicting interests be mediated?
8. Implementation Planning: Identify, analyze, evaluate, and justify steps to assure successful implementation of your recommended alternative. How will you determine if the recommended alternative was an improvement?
9. Reference page: Utilize a minimum of 10 to 15 scholarly and/or peer-reviewed sources that were published within the last five years. All sources must be documented in APA style, as outlined in the Ashford Writing Center.

Final Project

The major written assignment, a Health Policy Analysis, is due in Week Six. Completion of this paper will involve research utilizing selected websites and the Ashford Online Library.

You are employed as an analyst in a state governor’s office and have been asked to write a 15 to 20 page health policy analysis. Your analysis will include the following;

1. Problem Statement: A one to three sentence question in which you succinctly identify a health-related problem. Do not include any recommendations in your problem statement, but rather phrase your problem statement so that it lends itself to an analysis that considers several options.

2. Background: Explain why the problem has been selected for analysis. Provide statistics and background data to document the scope and nature of the problem.

3. Landscape Identification: Identify the key stakeholders and the factors that must be considered e.g. political, social, economic, practical, and legal factors when analyzing the problem. For each factor, your analysis should discuss relevant views of the identified stakeholders. You may organize this section by stakeholder or by factor. Some stakeholders may not have relevant views for all of the factors, but each stakeholder must be addressed as often as necessary to convey their policy position. The tone of the landscape section should be neutral and objective.

4. Alternatives Section: Provide three to five options to consider. This section is not just a statement of choices, but an analysis of each alternative by stating the positive/negative and pro/con aspects of pursuing each option. Analyze all your options equally, and avoid providing more detail for the option you plan to recommend. This section should be completely objective. In completing your alternatives section, you may wish to utilize any of the following criteria in your analysis: cost, cost-benefit, political feasibility, legality, administrative ease, fairness, timeliness, targeted impact. Identify and evaluate the impacts of these processes e.g. persons served, lives saved, hospital days avoided, people screened.

5. Side-by-side Tables of the Alternatives: Create descriptive or analytic tables of your alternatives in which you summarize key information. A descriptive table would provide a description of each option but not provide any analysis. An analytic table would assess the option based on the criteria chosen. Make sure to clearly label your tables.

6. Recommendations: Select one of your alternatives, and clearly differentiate it as the best option, making sure to provide a detailed explanation as to why it is preferred over the other options. Weigh the data/evidence and analyze it in terms of technical feasibility, political feasibility, or economic and financial viability. In addition, also identify what, if any, actions may be taken to mitigate or overcome the negative aspects of your selected recommendation. (You presented these in your Alternatives Section) Do not make a hybrid recommendation of multiple options, as you must select only one option. Therefore, your explanation/justification of your selected option needs to be fairly detailed and include data to support it.)

7. Implementation Strategy: Identify steps to manage the policy process to gain public, professional, and/or consumer support for change and backing of the most appropriate alternative. How will you assure that key implementers and/or consumers buy into the process? How will conflicting interests be mediated?

8. Implementation Planning: Identify, analyze, evaluate, and justify steps to assure successful implementation of your recommended alternative. How will you determine if the recommended alternative was an improvement?

9. Reference page: Utilize a minimum of 10 to 15 scholarly and/or peer-reviewed sources that were published within the last five years. All sources must be documented in APA style, as outlined in the Ashford Writing Center.

State Health Policy Analysis MHA 620 Health Policy Analysis

State Health Policy Analysis
Abstract: The rises of health cost have put strains on State, Federal and employers budgets and have severely hurt US families’ income in recent years.   An analysis of State health policy by the federal government projects that premiums for insurance for employer based programs will increase from 12,298 in 2008 to 23,842 by 2020.   This would be a 94% increase in insurance cost.   It is projected that health reforms by the federal government will help states reign in health cost and slow the growth by 1% in all states by 2020.   This would save $2571 per year per family under an employer sponsored plans for family coverage.   It is thought that if the states and federal government can control growth by 1.5 percentage points many agree in the insurance industry would save $3759.   This paper will look at and analyze a health policy for the state with the help of the federal government to control administrative cost and provide cost control and quality and access. Various suggestions on what state health policy should look like will be addressed and a concrete suggestion will be made to ensure the values of an excellent state health policy plan. (The commonwealth fund August 2009)
As a result of a declining United States economy many States are being asked to do more with less when it comes to health care.   Some States have come

up with their own Universal Health plans such as Massachusetts and Washington.   Other States are experimenting with federal waivers to expand Medicaid and some States are looking at ways to improve managed care.   Rising health insurance premiums have also put States in a bind and are hurting the middleclass.   Retail clinics have risen as a result of lack of access and affordability.   This paper will look at analyze the stakeholders involved in States push for Universal Health, the expansion of Medicaid as a way to control cost and cover the uninsured, managed care and Retail clinic and how the States look to them to improve access and quality of care. States are concern with controlling cost without giving up quality in health care.   Many States feel if they can accomplish reducing cost and providing greater access to individuals and children they can save money in the long run.   States must consult with all of the stakeholders if they are going to implement a successful health policy.   Monthly meeting must be held with providers, hospitals, homecare agencies, the various foundations of health insurance plans and Centers for Medicaid and Medicare.   Other groups that have a stake in how health policy is formed for the State department of health, mental health and public health advocates.   
The problem is many States have high unemployment rates and loss of income have led many people to turn to Medicaid for their health coverage.   Unfortunately the rate that the States have collected tax revenue has gone down

and enrollments of Medicaid and the uninsured have increased.   Medicaid enrollment grew from December 2007 to December 2009 by 13.6 percent o about 6 million¹.     According to the Kaiser commission if there was not a safety net of Medicaid the uninsured would have grown to 50 million Americans in 2009.²   States are looking for ways to decrease cost but due to the increase in enrollment because of the economic downturn the money the federal government spent on Medicaid went up from $338 billion of the federal budget in 2007 to 359 billion in 2008 and rose to 387 billion in 2009.   The increase in the federal budget went up for Medicaid from 6.4% in 2007 to 7.7% in 2009.   The money Medicaid spent on medical services grew also as a result of high unemployment from $300 billion in 2007 in 2008 Medicaid spent $318 billion and in 2009 the federal government spent $347 billion.   A health policy must be constructed to help reduce cost with providing quality care and reduce fraud and waste.   Medicaid grew faster than the national health expenditure and the gross national product in the last couple of years.   Enrollment growth may be attributed to the recession and the decision to expand Medicaid eligibility in some states because of the American Recovery and Reinvestment Act. (Kaiser Commission February 2011)   Unfortunately the ARRA Medicaid matching funds are due to expire on June 30, 2011 and States are being crippled by immediate budgetary crises and many cuts are expected in the Medicaid programs despite their success

in controlling per capita cost growth.   If the ARRA is allowed to expire despite many states fiscal situation are still bad, it could be castrophic for those on Medicaid because states will be forced to cut services and spending and this could have an adverse effect on access to the poorest and most ill patients because access and health quality will be affected.   If States decide to reduce enrollment it will affect the already growing uninsured population. (Kaiser Foundation February 2011)
State Governors according to the Kaiser Family foundation commission on Medicaid were able to maintain all Medicaid expansions and improvements to their Medicaid programs and State Children Health Insurance plans despite budget constraints.   This allowed States to cover millions of low income families who would be part of the uninsured.   State Medicaid programs could not cover adults without children before the health reform law provided the money and the waiver.   The New Law allows for expansion of Medicaid and made it easier for the excluded adults to receive coverage if they were at or below 133 % of the federal poverty line.   For example a family of three the income requirement would be 24,352 and for an individual 14,404 would qualify for Medicaid coverage in 2010.   States such a Connecticut and Washington D.C.   were the first to start the option of covering adults without children and using federal dollars as opposed to state dollars.   Other states like California applied and received a waiver to expand it Medicaid

program to cover adults without children.   Minnesota plan are pending a waiver and states like Arizona, Connecticut, Delaware, D.C., Hawaii New York and Vermont already provided this coverage for adults without children.   This is a good plan but very expensive but, during the downturn in the economy and sharp increases in unemployment and declining tax revenues threaten to derail State Children Insurance Programs and cut benefits in Medicaid. The Kaiser Commission foundation survey did find that 49 states made improvements in their Medicaid and CHIP rule for eligibility and procedures for enrollments. The governors of 13 states were able to stream line the administrative paper work for CHIP and Medicaid and were able to reduce the burden on families.   Hopefully, by the year of 2014 States will be in position financially to cover their share of the cost of the uninsured but until then many Americans will not be able to receive coverage once the ARRA money expires in July 2010. (ProQuest Jan. 24, 2011)
Medicaid makes up about one sixth of the country spending on health care and Medicaid in the fiscal year of 2009 spent about 18% of all hospital spending and covered about 40% of all Nursing home costs.   The federal and state governments spent about $339 billion on Medicaid spending.   According to the Kaiser commission about three- fifths of the money spent was on medical care such as hospitals physicians, drugs and other ambulatory and acute services.   Long term care and nursing home care cover about one

third of Medicaid spending.   Most of the money Medicaid spends is on the elderly and disabled population.   Adults with children account for 75% of Medicaid enrollees but account for only a third of the spending.   The State has a great interest in controlling Medicaid cost because most states are responsible for 43% of its costs.   States over the past ten years have tried to implement an assortment of cost containments measures as well as new delivery models which entails manage care and medical home models.   These innovations were used to control costs and are still being used today. Today overall Medicaid spends less on health care than employer based plans.   Medicaid spent about an average of 4.6 per year per capita growth while employer based insurance was 7.7% per year.   The national average for health care spending expenditures was about 5.9 per year according to the Kaiser Commission.   (Kaiser Commission January 2011) 
States should look at managed care as a way to solve their cost problem for their Medicaid Programs.   Managed care makes sense because it saved the state money and cuts down on overuse of the emergency room.   Managed care is designed to coordinate care and to make sure there is controlled usage of services.   Managed care companies are supposed to improve service and control cost and that’s why they are so attractive to Congress and the government.   Health expenditures are not regulated and that is contributing to the increase in cost in the managed care and private insurance industry.  

The Government and Congress and the States are finding ways to cut cost in Medicare and Medicaid and these reductions are being shifted to managed care companies and private insurer by hospitals and physicians who are not capitated.   The government is paying particular attention to the rising cost of their Medicaid and Medicare members.   The American families are hurt as a result of cuts in Medicaid and Medicare by Congress and the states.   Many states in the 1990’s sponsored demonstration projects which forces certain cities to enroll their Medicaid and Medicare population in to managed care programs.   These programs proved to be somewhat successful for the States because they were paying only one monthly fee for every family enrolled in managed care.   The problem with enrolling their beneficiaries is many of them were overweight and had chronic illness for example asthmas, diabetes and obesity.   These patients required special attention and cost are driven up as a result.   Many states have imposed high patient co pays and reduced their Medicaid roles by increasing requirements. ¹   The administrators of Medicaid and Medicare are looking for was to have all of their chronically ill disabled and elderly beneficiaries enroll in some sort of managed care program.   The government is spending about 96% on this group where their medical cost exceed about 25,000 per year for their illnesses.²   Shifting these patients to Managed care   in the hopes of controlling cost for disease management is favored by the government

and the states.   However, patients may not receive the care needed under managed care because utilization of the system is closely scrutinized and may put these patients at a higher risk for poor management of their conditions because of cost and raise premiums the government pays the managed care companies which are passed to the private and commercial subscribers. ³   Managed care is suppose to reduce the cost by identifying patient with chronic illness and reduce the trips to the hospital emergency rooms for episodic visits. (ProQuest Nov/Dec 2007)
Managed care is costing some insurer with their bottom line with reduced Medicare and Medicaid payments and rising cost.   United Health had a decline of 40 % in growth in the last quarter of 2009 due to managed care, rising cost and lower commercial enrollment as a result of unemployment. The rising cost for United Health will result in higher premiums for the government and private enrollees.   “The economy remains the challenge and we have limited visibility today into January group terminations and employee participation level.   That said, we do have local markets where we are seeing growth for the first time in two years or more, “Chief Executive Stephen Hemsley said.   (ProQuest 1/23/2009)
The aging population is making it difficult for managed care companies to control cost and usage.   The Department of Health and Human Services conducted a study and found that spending in health care rose about 8.7% in 2001 and health care spending made up for a record

of 14.1 percent of the US economy.   This rate of spending was higher than any other nation in the industrialized world.   The US economy is in a continued recession and healthcare cost continues to rise and affect the American family. The study found that most of the cost was contributed to the increased use of health services and products associated with health not premium increases.   Funds paid to the hospitals increased as a result of increased admissions and usage per patient.   (ProQuest 2/2003)   
The American families are being affected because employers are cutting cost and forcing their employees to go in to more restricted managed care programs.   The rising costs are forcing employers to not hire full time employees because of health cost are affecting their balance sheets.   If these families are not covered by employers they are forced to go uninsured or if their incomes allow enroll in Medicaid which increases the cost.   If they are uninsured they are forced to use the emergency room for preventative care and episodic visits.   The cost of using the emergence rooms of hospitals for the uninsured is passed on to managed care companies and private insurers.   ProQuest 8/20/2004 
Managed care companies enjoyed some success in controlling cost in the 1990’s but after years of stability they are being affect by rising cost.   The cost of the latest and expensive medical test and treatment are moving up prices.   The laws are now mandating how utilization for hospitals stays for patient dictated could

be a contributing factor to cost.   For example in the 1990’s a normal vaginal delivery of a child would require a one day stay for most managed care companies but after consumer complaints an extra days was mandated.     Consumers put pressures on legislators to make managed care companies provide more choices and cost increased for American families as a result. 
A study was conducted to find out what the major concerns of managed care companies were and what contributes to the rising cost are as follows:
1.) The recession is making the economy weak and long term unemployment is driving larger numbers of uninsured higher.   The idea of increasing premiums can have a negative on corporate earnings.
2.) In the 1990’s utilization management dominated decision making in managed care and the ability to control cost but now they are shifting to more preventative care for the chronically ill which contributes to the disproportionate increase in cost.
3.) As a way for cost control measures more managed care companies support health reform for example Universal Health Care.
4.) Working together with provider with the implementation of electronic claims submissions and electronic medical record will help improve error rates and eliminate the cost of paper and files. (ProQuest 4/2003) States can work together with Managed Care Companies to foster better utilization and control of escalating cost.   If Medicaid recipients are enrolled into managed care mandatorily states should provide a choice of different health plans

to which recipients can choose.
In order for States to establish a successful health policy regardless of budget constraints they must establish a health relationship with the stakeholders which are the federal and state legislators and agencies, the providers, hospitals   and medical companies, the health organizations and the people of the state.   A healthy start must be established and accomplish the following:
  * The effort must cover a broad range of stakeholders with a multidisciplinary approach
  * There must be a certain number of different stakeholders from various groups on an advisory committee
  * The group must assess any health policy issues annually
  * The state must establish amongst its stakeholders small groups to provide leadership on a day to day basis to look at how any new policies are working
  * Subcommittees must be established to look at policy evaluate provider training to managing utilization and cost and the people must be educated on how the new health policy plan works as far as choosing a health plan or exchange and how referral and resources work
There are several reasons why stakeholders must be engaged and they are:
  * It provides valuable resources and manpower and will assist with how programs will be developed and will help promote the state’s health policy
  * Relationships with stakeholders will help foster stronger health policy and provide credibility and strength to the programs and provide a different viewpoint from the Governor and legislators

and there will be a diverse amount of experience to develop a comprehensive   policy 
  * Stakeholders can help find various resources for funding and infrastructure
  * Developing and engaging relationships will help prevent lobbyist and other groups from putting up roadblocks because their view and need will be look at when developing health policy (Engaging June 18,2007)
Stakeholders of all State Medicaid programs must identify and prioritize their goals which may be linked to the expansion of Medicaid.   The priority of stakeholders within the state government including the state senate and assembly must look at controlling growth and health cost.   
In Rhode Island the stakeholders looked at individual mandates but, due to a bad economy and low tax revenue the idea was tempered by the budget realities.   In Rhode Island the stakeholders agreed that there must be an affordability aspect to their Health Hub and mandate individuals to purchase insurance through and employer group or buy it individually.   The Stakeholder in Rhode Island agreed that like Massachusetts tiers of coverage would help individuals compare insurance exchanges and provide competition. The pros and cons for goals of the stakeholder in Rhode Island to establish exchanges and to 1) have better organization in their health insurance exchanges; 2) make sure that insurance would be affordable for all of their state residents; 3) to control cost and affordability. (Considering a Health 2008) The cons about the Rhode Island plan was that

the stakeholder goals were very general and broad and needed more detail and the stakeholders need to clarify how to organize health insurance plans and whether a health exchanges were necessary to accomplish these goals.   
Rhode Island stakeholders wanted to establish how their exchanges would work and came up with five concepts because unlike the large ambitious plan of Massachusetts their funding was limited.
1) Rhode Island wanted to establish a standardized market and provide transparency;
2) The stakeholders wanted to make it easier for individuals to purchase insurance and provide choice and portability;
3) Rhode Island wanted to established greater access and provide excellent benefits while providing incentivizes to control cost and quality and establish individual mandates;
4) Provide subsidies through the state’s Medicaid program for the working poor;
5) Rhode Island stakeholder wanted to establish cost containment procedures that would help control cost.
Ultimately, Rhode Island stakeholders could not agree on a set plan and are looking for ways to combine all of the above in to an interoperateble health exchange. (Considering a Health 2008)
The Federal and State governments are trying to design a system for individual to contain cost. These governments are looking to design a subsidy system for low and moderate income that provides access and quality and will offer the individuals a choice.   The Center for Medicare and Medicaid Services wanted to have exchanges provide affordable plans and

provide specific information so that individuals can make a specific choice with competing health plans.   The exchange that CMS and the States are looking at benefit design and minimum standards to ensure the price is right for individuals and that there rights are protected.   Exchanges must offer the same standards that provides for comprehensive coverage with complete benefits such as doctor visits, impatient care at a hospital and comprehensive drug coverage. (Judith Solomon May 21, 2009)
The States must prevent insurers by limiting their degree of variations to benefit design and make sure that the exchanges provide protection against insurers seeking to find the healthiest people to insure.   For example, Massachusetts health reform provides this protection and provides choice and offer comparable health exchanges. States must limit the number of plans to choose from so that the consumers can make an informed choice. States must require that exchanges have different benefits designs and that their premiums are based on a single pool of people for the area being insured.   In Massachusetts the Commonwealth choice plan is set up so that premiums are adjusted to be higher if additional coverage is provided.   Massachusetts choice plans are not allowed to have the chronically ill individuals pay more than healthier individuals simply because the plan has a disproportionately amount of sick people.   (Judith Soloman May 21, 2009)
The passage of the health reform law will provide coverage to many people regardless

of their socioeconomic background and will promote social and health equality amongst community’s diverse backgrounds and color.   Blacks will hopefully gain the most form health reform because the law should eliminate health disparities.   Expanding Medicaid will help to cover many African Americans and their children who are uninsured now.   African Americans accounted for about 19% of the nation’s uninsured which was high when compared to Hispanic at 15% and other nonwhites at 11%.   Funding will be increased for the States and US Territories to help provide medical coverage.   The new law provides legislation to fund about 6.3 billion to the US Territories for Medicaid.   African American children will be helped the most through more money being poured into State Children Health Insurance plans and Medicaid.   Data configured by the Kaiser commission show the percentages of uninsured children by race. See below (CHIPRA June 2009)
(CHIP 2009)
The report from the census bureau shows that in 1998 there were more uninsured children than there were in 2007.   The Children’s Health Insurance Program Reauthorization Act addressed many of the racial and ethnic disparities from 1998 to 2007 and has been strengthened by the new health law passed in 2010.   Congress relented in 2009 after President Obama fought hard to ensure CHIP was renewed until the end of 2013 to continue to cover the 7 million children.   Despite the upgrade in coverage children of color are still at a disadvantage when it comes to being insured.

  Many minorities are eligible for CHIP and Medicaid but because many minorities do not know they are eligible.   According to a study conducted by the Kaiser foundation found that more that 80% of black children and 70 % of Hispanic children were uninsured but eligible for public health assistance.   More money must be invested by the federal and state governments to cover minorities and their children and much more could be done to address the disparities and make the CHIP program stronger and must contain more provisions to 1) provide more grants and monies to outreach minorities to increase the enrollments for CHIP and Medicaid; 2) Congress and the Federal government must work together to amend the law for a five year waiting period for legal immigrants children and pregnant women; 3) the State and Federal government must provide matching funds for interpreters and provide translation services; 4) Health outcomes must be analyzed and tracked to understand the quality of care minorities and their children are receiving. (CHIPPA June 2009)
States must come up with a campaign to be a part of the National Outreach program sponsored by the federal government to enroll uninsured children.   The National campaign will spend 100 million dollars to outreach parents of uninsured children.   States should establish phone banks and hotline to provide information to uninsured families.   These campaigns are an inexpensive way to insure more children.   Participating states should have to provide information on their outreach

activities and measure the effectiveness of the outreach program grants. The information collected by the states on enrollments will be reported to Congress annually by the Secretary of Health and Human Services. (CHIPPA June 2009)
The Implementations of health policy I would make for the States child health insurance programs would be to have a state wide outreach program to increase enrollment for children who are uninsured.   Use the states part of the 80 million dollars to fund outreach programs and provide information collected to the States department of health for it to be forwarded to the Department of Health and Human Services.   Lobbyist groups should be sent to Congress and DHHS to lobby for increased access for legal immigrant children and pregnant women.   The five year rule is a bad one and it cost States more money to cover the legal immigrants in the emergency rooms.   According to the census data the numbers of uninsured legal immigrants have increased since the 5 year law passed in 1996.   Currently about 19 states offer some sort of State sponsored programs for legal immigrants but if theses States economy continues to be influx these programs will be the first cut.   Other implantations would be to develop health exchanges and set rules for community rating to prevent discrimination against sicker people. (CHIPPA June 2009)
Expanding Medicaid under the new law will provide more coverage for people with incomes up to 133 percent of the federal poverty level. The state and stakeholders should

establish commission to look at universal state health care or a single payer system.   The commission must explore the following ideas and see what will work:
  * The system must address all patient needs and must be as simplistic as possible and provide coverage to the entire population.
  * Health care should be provided to individuals based on a person’s need and not what their financial ability to pay.   
  * The committee should find out how foreign countries with universal health care run their systems and try to implement some of their good ideas.
  * The committee will need to explore what the best option for health care in America.       Should health care be publically and privately funded or publically funded by the government and what role would the individual states play in financing.
The commission could suggest that new technology be developed to implement electronic medical card which will have the patient’s medical history on it from birth if born in America.   This would help cut down on medical mistakes and create less paper work and would help reduce cost.
The commission should look at providing prevention programs for disease and this should be done immediately so that studies could be done to see if prevention reduces cost. The role of regular physical exams should be required.   ( Solving 2010)
Congress must take steps to either legislate or regulate the above ideas and push for universal health care.   If Americans are required to be covered by a universal health plan entitlement

program like Medicare, Medicaid and Managed Care programs could be eliminated.   If these forms of health care are eliminated it would reduce cost because everyone would belongs to one system.   The government could still subsidize health care for the poor and the elderly and those who meet low income requirements.   Universal health care would reduce the role of private insurers and aid in limiting high deductibles and the private insurer should be mandated to accept all people that apply for their insurance.   Congress must pass laws to restrict frivolous lawsuits by individual taking advantage of the system.   Congress should also put limits on prescriptions pricing and advertisements on television which are aggressively done by pharmaceutical companies. (Solving 2010)
The idea of providing a Health Benefit Exchange where individuals can purchase health insurance is a good one.   Under this exchange the working poor and the uninsured can receive cost sharing credits if the fall within the federal poverty guidelines of 133-400%.   Small business will be required to provide insurance for their employee if they have 50 and over employees. Under 50 with one fulltime employee they will be given vouchers to purchase or assist with purchasing insurance.   The mandate requires all legal residents in the United States to have health insurance by 2014 with a few exemptions for financial hardships, religious objections American Indians illegal immigrants, people in prison or jail.   Health reform also expands Medicaid

to all individuals who are under 65 to 133% of the federal poverty line which is based on income.   Funding for State Medicaid programs in 2014 with is at 100 percent through the federal government.   The new law requires that the States maintain current level for Children’s Health Insurance Programs and the government will provide 100% funding for this program.   Cost sharing subsidies would be provided by the federal government to individual who are at federal income guidelines levels of 100-150 FLP: 94%, 150-200FLP: 87%, 200-250 FLP: 73% and 250-400 FLP: 70% for those people who need help.     Unfortunately, Abortion is carved out of this program as a compromise to pass the law.   (Focus 3/26/10)   In the State health exchange abortion could be added back into the plan since they will end up paying for this care indirectly in the emergency room.   The idea of health exchanges in every state means that individuals and small business will be able to shop around and compare coverage’s, prices and benefits in the private market.   Financial assistance will be provided by the federal and state governments to ensure coverage is affordable for every family and individual.   (Health care Reform March 2010)
I agree with the push for mandated insurance sponsored both publically and privately which means everyone will have coverage.   This system will cut cost and provide quality and have better utilization manage and plenty of oversight by the state, federal governments and the private exchanges providing coverage.   Rhode

Island and Massachusetts has the right idea to provide health exchanges for their people and if merged into a federal single payer system they already have the ground work setup.   The American Reinvestment and Recovery Act received input of several stakeholders across the country.   My plan would be similar to the Patients Protection and Affordable Act to control cost and health expenditures.   The state should look at collection of all Medicaid overpayments the states paid to hospitals and providers and cut fraud and waste. The establishment of more state fraud investigator would save the state money in the long run these investigators should conduct annual audits to detect waste and fraud. Use managed care for better utilization of care until the Federal mandates and exchanges kick in.   A tax on those high income individuals could be implemented to help support the state exchanges or for example the Cadillac (tax an assessment on the highest cost insurance plans) could be voted on by the state assembly to help support the state health exchange.   Medicaid administrative costs are already low and the health exchange should be design with low administrative cost.   If these changes are followed it will provide increased revenue for the State. Also the subsidized provided to employer should help reduce the state expenditure on health care.   (ProQuest June 3, 2010)
Under a new state health policy I agree with McLaughlin and McLaughlin in that cost controls seem to work overtime and any new plan should look at

the following before implantations can take place:
1) Control overutilization by removing the incentives for doctors
2) Competitions to reduce margins and incomes of doctors and the suppliers such as pharmacies
3) Controlling the cost of malpractice and frivolous lawsuits and the doctors need to perform defensive medicine
4) Congress should look at medical outsourcing and regulate and allow more international competition to keep down prices
5) The single payer system should control treatment choices and look for the most effective treatments
6) Give providers more control over utilization and self referral
7) Implement community ratings system and mandatory information technology
These are the seven implantation I agree with McLaughlin and McLaughlin but I don’t agree with allowing longer waiting periods for elective procedures and no fault insurance for high risk behavior because individuals behaviors in their private lives is private. (McLaughlin and McLaughlin 2008 pg 378)
I would also propose within the States Health policy reform the use of Retail Clinics to compete with the traditional health care system. More than 1,000 retail clinics have open within 37 states and can no longer be look at as a passing fad.   Retail clinics provide reasonable access to care usually in urban and suburban settings sometimes the clinic can be found within drug stores, supermarkets or large retail stores like Wal-Mart and Target.   Most of these clinics have convenient hours such as weekends without long waiting periods

for appointments.   The cost or retail clinics cost less money because they are staffed by low cost providers such as physician assistants and nurse practitioners. The cost of care is substantially less than hospital emergency rooms and urgent care centers.   The clinics services provide a various range of services and follow the established clinical practice guidelines. The Cons against retail clinics is that their care man be fragmented and they primary physician may not be aware of services provided and may duplicate care if the clinic does not have electronic record capabilities.   Immunizations could be duplicated or treatment of a reoccurring problem may not be discovered by the primary care physician.   The state must also figure out a plan to regulate retail clinics and how to administer practice issues, corporate practice medicine issues and states will have to adjust the expansion of Medicaid to reimburse the clinics.   Physicians of traditional care also fear that the retail clinics reliance on computerized treatment protocols could lead to improper diagnosis and treatment.   On the community health centers side they fear that they may lose their patients to the retail clinics and they do not want to compete.   (Mary Takach and Kathy Witgert February 2009)
The cost of care if regulated properly by the states would make the retail clinic attractive to both the consumer and the insurer who pays the claims.   Most retails clinics usually charge between $40 to $80 dollars for services.   Retail clinics also

provide price transparency when the patient comes through their doors so that their patients can make the correct decision. States must not let price transparency become an issue for example Illinois and Massachusetts wanted to restrict retail clinic advertising and tried to legislate the scope of retail clinic advertising but the federal trade commission rule against the proposed regulation. The following chart may be used by the States as a guide of how six other states are regulating oversight of nurse practitioners: (Mary Takach and Kathy Witgert February 2009)
Table 1 Physician Oversight of Nurse Practitioner in Six States ²⁸ |
Other regulations imposed by the States | Ratio of MD to NP | |
California | 4:1 | Retail Nurse Practitioner must collaborate with a doctor to set written protocol   and the doctor must supervise written prescriptions |
Florida | 4:1 | Doctor Supervision is required to run the clinic and the Doctor may not supervise more than four clinic other than their primary office |
Illinois | None Reported | Retail Nurse Practitioner must collaborate with a doctor to set written protocol and a doctor must supervise written prescription.   The Doctor must be at the clinic at least once a month |
Massachusetts | None Reported | Retail Clinics must be supervised by a doctor and must have a written protocol.   A chart review must be conducted by the doctor at least once every third month |
New Jersey | None Reported | Doctors must be there for written prescription and must review

Charts an unspecified amount of times of the year. |
Texas | 3:1 | Retail clinic must be supervised by a doctor with written protocol Doctor delegation   required for prescriptions and doctors must be there 20% of the time and doctors less in the underserved areas and must review charts 10% of the time less in the underserved areas |
Retail clinics use to only accept cash a payment and would not accept any public or private insurance as payment but since 2000 many retail clinics are accepting private insurance, Medicare and negotiating with Medicaid in the States because Medicaid is being expanded. The out of pocket expenditures to individual went from 100% in 2000 to 15.7% in 2007⁶   The expansion of Medicaid has forced states to take a hard look at retail clinics because they could provide acute but non emergent care to individuals and keep them out of hospital emergency rooms.⁷   A study by Health Affairs found that found that retail clinics for a episodic visits was $51 dollars less than a urgent care visit at a health center, $55 dollars less than the doctor’s office and $279 dollars less than the hospital emergency room. ⁸The study by health affairs warned that eventually cost might increase because retail clinics will see the demand of individuals who self medicate and treat increase and the delay of care for those with chronic or preventative illness that would have been provided by a doctor’s office visit delayed and have higher cost on the back end.⁸ (Mary Takach and Kathy Witgert February 2009)

In other studies conducted it was found that the requirement for physician supervision was unnecessary and had not impacted quality and access to the clinic.   Retail clinic compared favorable to other health centers and doctors’ offices and the nurse practitioner were great at following the written protocol and updating the electronic medical record that each clinic has implemented.   The following quality controls are done by nurse practitioners at retail clinics and it is important for the States to look at while expanding Medicaid and incorporating retail clinics into the fold:   
The retail clinics reported great internal quality control which included the doctors reviewing of medical records.
Retail clinics   such as Take Care Health Clinics use HEDIS to track and trend their scores against the national average for infections such as upper respiratory, streptococcal and bronchitis infections
The Joint Commission also accredited the Minute Clinics for meeting the ambulatory standards of care provided in a retail setting.
In the end Retail clinics will play a valuable part in triaging patients and saving the state money in the long run and this would be a part of my plan and suggestion to the Governor to regulate and legislate more of these clinics.   (Mary Takach and Kathy Witgert February 2009)
The following chart represents the proposal I would recommend to the Governor regarding health policy:
Expansion of Medicaid to 400% of the federal poverty line with matching funds from the federal government

to cover the uninsured and put limits on co-pays and to address the effects of cost sharing on utilization. | Expansion of the Children Health Insurance program and provide outreach to reach legal immigrants and minorities of underserved communities. | Negotiate lower prices with hospitals and insurance companies | Implement health exchanges with monies provided by the federal government to help small businesses insure their employees and also provide subsidies to the uninsured |
Establish more Peer reviews organizations to provide oversight of the quality of care.   The state a strategy to pay providers for performance.   This would enable states to collect data on access of care by race, education, income and primary language. | Tax people in the higher ended health plans and provide tax incentives for small businesses. | Regulate and legislate more Retail Clinics to reach out to the community to reach out to the community to save money and to provide low cost medical treatment. | Set-up a commission to investigate Medicaid fraud and abuse and collect overpayments. |
Lobby congress to remove the 5 year waiting period for legal immigrants and pregnant women to receive public health coverage because this will save the state money in the long run. | Incorporate more demonstration projects with managed care or use their guidelines to manage utilization of the Health Exchanges.   Use the Federal waiver process to bring more health plans on board. | Establish a fund with State lotteries to cover health cost.

States must invest in infrastructures for minorities in urban communities and this would strengthen patient education and health literacy | CON Certificate Of Need could be to strengthen to build more hospital and medical centers in reducing racial disparities in medical centers.   Make the rich pay more Taxes with anyone making 250,000 or more to help supplement the health costs. |
If these implementation are followed the Federal governments states that by 2020 health care will see a dramatic reduction in cost and health expenditures and administrative cost should be reduced.   By using the above analysis the State can look al 1) look to reduce the cost of coverage and expand access to health insurance; 2) the state should improve outreach and evaluate and improve enrollment efforts for the uninsured and minorities; 3) the States should collect data looking at and improving the Medicaid collection of date for health access and quality by location; 4) the state must provide support for a safety net for the uninsured 5) the State must provide cultural competence improve health care provider and their diversity. (The Commonwealth Fund April 23, 2008)
As a result of a declining United States economy many States are being asked to do more with less when it comes to health care.   Some States have come up with their own Universal Health plans such as Massachusetts and Washington.   Other States are experimenting with federal waivers to expand Medicaid and some States are looking at ways to improve managed care.

  Rising health insurance premiums have also put States in a bind and are hurting the middleclass.   It is imperative that major changes be done to State Health policy to cover the million of minorities, uninsured, legal immigrants and children.   These groups must be provided with better access, quality and cost controls.   Eventually The federal and state governments need to come together to form a single payer system which will cover all Americans for medical services while reigning in the money wasted on paperwork which is more than 400 billion dollars in administrative cost.   Doctors can be paid fee for service according to a formulary similar to what HMO negotiates or if doctors can receive a set salary for the hospital that they are affiliated.   Hospitals will receive a global budget for their expenses to operate.   Health planning board would oversee the management of expensive equipment and should be managed by region.   Finally, a single payer system would cut waste and with slight increase in taxes will replace individual out of pockets premiums paid by employers and individuals.   Cost will be controlled by negotiated fees, bulk processing and global budgeting. (Single Payer September 1, 2009)   As a State health policy maker, the State must move rapidly to install the new federal requirements of the health law.   Most States now realize that they are partners with the federal government to set up quality healthcare and will be provided adequate funding for health exchanges and money to handle high risk pools

and provide rate reviews for premium costs to insure quality health reform.
References
Schoen, Cathy, Nicholson, L. Jennifer and Rustgi, D. Sheila The Commonwealth Fund Data Brief Paying the Price:   How Health Insurance Premiums Are Eating Up Middle Class Incomes State Health I nsurance Premiums Trends and the Potential for National Reform August 2009
Holahan, John, Cope-Clemans, Lisa Lawton, Emily and Rousseau, David Kaiser Commission Medicaid and the Uninsured Medicaid Spending Growth over the Last Decade and the Great Recession, 2000- 2009   February 2009 www.kff.org
¹Kaiser Commission Smith et al.2010
²Kaiser Commission: Holahan etal.2010
Holahan, John, Cope-Clemans, Lisa Lawton, Emily and Rousseau, David Kaiser Commission Medicaid and the Uninsured Medicaid Spending Growth over the Last Decade and the Great Recession, 2000- 2009   February 2009 www.kff.org
ProQuest Health Insurance; With Federal Support, States Hold Steady in Medicaid and CHIP Coverage Policies for Low Income Children and Families Despite Recession Manage Care Weekly Digest Altanta Jan. 24, 2011 pg 86
Kaiser Commission on Key Facts Medicaid and the Uninsured January 2011 www.kff.org
ProQuest Improving The Management of Care For High-Cost Medicaid Patients John Billings,Tod Mijanovich HealthAffairs. Chevey Chase Nov/Dec 2007.   Vol 26, Issue 6 pg 1643, 13 pgs
¹see V.Smidi et al., “Low Medicaid Spending Growth amid Rebounding State Revenue” (Menlo Park, Calif.: Henry J Kaiser Family Foundation, October 2006).
References
²A

Sommers and M. Cohen, “Medicaid’s High Cost Enrollees: How Much Do They Drive Program Spending?”
³J.L Gillespie and L.F. Rossiter, “Medicaid Disease Management Programs:
http://proquest.umi.com/pdqweb?index
ProQuest Managed care weekly Medicare Advantage 1/23/2009
http://proquest.umi.com/pdqweb?index
ProQuest Healthcare spending continues to soar Jill Wechsler, Pharmaceutical Executive. Eugene: Feb 2003 vol 23, iss.2 pg 23
http://proquest.umi.com/pqdweb?index=69&did
ProQuest As health care cost rise, the job market falls sick Eduardo Porter. International Herald Tribune Paris Aug 20, 2004
http://proquest.umi.com/pqdweb?index=48&did
ProQuest Cost tops managed care concerns Dennis J Roszak. Hospitals & Health Network. Chicago Apr 2003
http://proquest.umi.com/pqdweb?index=66&did
Allen G. Scott Healthy Beginning Partners illinois Engaging and Working with Stakeholders June 18, 2007
Faulkner, Deb, Lischko, and Chollet   State Coverage Initiatives Considering a Health Insurance Exchange Lessons from Rhode Island Experience   2006
References
Solomon, Judith Center on Budget and Policy Priorities Ensuring Affordable Health Coverage and Health Care Services in an Insurance Exchange May 21, 2009http://www.cbpp.org/cms/index
Solomon, Judith Center on Budget and Policy Priorities Ensuring Affordable Health Coverage and Health Care Services in an Insurance Exchange May 21, 2009 
http://www.cbpp.org/cms/index
Sullivan, Jennifer Families USA The Children’s Health

Insurance Program Reauthorization Act (CHIPRA): Addressing Racial and Ethnic Health Disparities June 2009
Sullivan, Jennifer Families USA The Children’s Health Insurance Program Reauthorization Act (CHIPRA): Addressing Racial and Ethnic Health Disparities June 2009
Sullivan, Jennifer Families USA The Children’s Health Insurance Program Reauthorization Act (CHIPRA): Addressing Racial and Ethnic Health Disparities June 2009
Sullivan, Jennifer Families USA The Children’s Health Insurance Program Reauthorization Act (CHIPRA): Addressing Racial and Ethnic Health Disparities June 2009
Sullivan, Jennifer Families USA The Children’s Health Insurance Program Reauthorization Act (CHIPRA): Addressing Racial and Ethnic Health Disparities June 2009
Solving The American Health Care Crisis copy rights Umang Malhtora 2010
http://www.answerstohealthcare.com/articles/american-healthcare
                  References
Solving The American Health Care Crisis copy rights Umang Malhtora 2010
http://www.answerstohealthcare.com/articles/american-healthcare
The Kaiser Family foundation   Focus on Health Reform Summary of the New Health Reform Law March 26 2010.www.democraticleader.house.gov/ and www.kff.org
Perry, Sherice, Klein, Rachel, Panares , Rae and Sullvan Jennifer Fact Sheet Understanding the New Health Reform Law From Families USA’s Minority Health Initiatives September 2010
Gruber JonathaN ProQuest The New England Journal of Medicine The Cost Implications of Health Care Reform Boston June 3, 2010 Vol.

362 Issue 22 pg 2050 http://proquest.umi.com/pqd
McLaughlin, P, Curtis and McLaughlin, D, Craig Health Policy and Analysis An Interdisciplinary Approach Jones and Bartlett 2008
Witgert, Kathy Takach, Mary National Academy for State Health Policy Analysis of State Regulations and Policies Governing the Operation and Licensure of Retail Clinics February 2009
Witgert, Kathy Takach, Mary National Academy for State Health Policy Analysis of State Regulations and Policies Governing the Operation and Licensure of Retail Clinics February 2009
Witgert, Kathy Takach, Mary National Academy for State Health Policy Analysis of State Regulations and Policies Governing the Operation and Licensure of Retail Clinics February 2009
Witgert, Kathy Takach, Mary National Academy for State Health Policy Analysis of State Regulations and Policies Governing the Operation and Licensure of Retail Clinics February 2009
References
⁶Mehrota, Ateevel al., “Retail Clinics, Primary Care Physicians and Emergency Department:   A Comparsion of Patients Visits “Health Affairs 27 2008: 1276
⁷ Thygeson et al 2008
⁸ Thygeson et al 2008
Smedley, Brian PhD   Alvarez Beatrice, Panares,Rea MHS Fish Parcham Cheryl and Adland,Sara The Commonwealth Fund Identifying Evaluation Equity Provision in State Health Care Reform April 23, 2008 Volume 90http://www.commonwealthfund.org/content/publication/fund/report/2008
Single-Payer National Health Insurance Physicians for A National Health Program September 1, 2009
http://www.pnhp.org/print/facts/single-payer-resources