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Leveraging Federal Grant Funds to Expand Coverage:  Experiences from the HRSA SHAP Grantee States

Leveraging Federal Grant Funds to Expand Coverage: Experiences from the HRSA SHAP Grantee States



Presentation by Elizabeth Lukanen at the AcademyHealth Annual Research Meeting (ARM), in Boston, MA, June 27 2010.

Presentation by Elizabeth Lukanen at the AcademyHealth Annual Research Meeting (ARM), in Boston, MA, June 27 2010.



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  • Specifically, the states need to propose a coverage initiative for a specific group not already eligible for existing programs25-30 states appliedFunding amounts in year 1 range between 1 and $10 millionGiven the grant amounts these fairly small, targeted projects (first year enrollment projections range from the hundreds to just over 10,000)TA contracts with NASHP and SHADAC
  • The 13 SHAP Grantee states : Colorado, Kansas, Maine, Minnesota, North Carolina, Nevada, New York, Oregon, Texas, Virginia, Washington, Wisconsin, and West Virginia.Graphically diverseVarying level of uninsurance, distributions of coverageDemographically diversePolitically diverseAll of these things shaped their response to the HRSA RFP
  • Focused on coverage expansion Relatively speaking, these grants are small, so there was focusStates took a varied approach - Some focused all the money on one specific coverage initiative and others funded a hand full of programs7 multi-share models (community-based organization that provides affordable health coverage to small businesses or individual, thought partnerships with local providers, cost is typically share between individual, government, employer – sometimes not)Many premium assistance4 exchangelow income part time or seasonal workers (ME)Parents with kids enrolled in CHIP (NC)Children with access to ESI (CO) Many states used the money to fund issues related to coverageTargeted benefit design: (small employers, young adults, limited benefits) Enrollment and retention activitiesStreamlined eligibility, renewal and verificationOnline applicationTargeted outreachDelivery system reformPayment reformMedical home and care management
  • SHAP states in unique position, in that they have funding, but still face challengesTalk about these challenges, how states addressed them
  • Needed governor’s letter to applyIn many states there was little appetite to expand “government plans” despite a 80% to 20% federal match. Employer based: Maine is using it to creat an Insurance Exchange to connect part-time/seasonal employees withtheir employers’ health benefit plans Washington, using it to do HIP, a small business exchange including premium assistance for low-income employees and their families (up to 200 percent), TX is creating Healthy Texas a reinsurance program, with goal to support ESIPublic private: MN and NC are leveraging funds to strengthen existing partnerships between communities and providers to create access to care plans that offer low cost coordinated care to people regardless of employment statusIndividual: In almost all cases the coverage expansion includes individual contribution in the form of a fee or premium and some cost sharing. In addition, some require wellness activities.
  • Requirement of the program to think about sustainability and plan for sustainably options after federal fundingSHAP states are all facing deficits, public program cuts, etc. Can’t rely on state picking up the tabWA Policy Maker “we used to talk about doing more with less, but you can only take that so far.” “The reality is, that now we are talking about doing less with less.”Sentiment shared by statesMost of these programs are small and would not happen with HRSA fundingAll have enrollment capsSeveral states proposed to get Medicaid waivers to cover the cost of the expansion population (NC – low income parents, CO –adults with disabilities, ME- program) Some states have free care pools from which they could draw eligible people (know they will have health needs), or they are targeting parents with kids enrolled in CHIP, again, they are not targeting this group to avoid huge waiting listsWI- take advantage enrollment push to get people’s information and put them on a waiting list (WI, MN)Many state have begun work on a “no wrong door” approach, so that people applying for the SHAP programs are first carefully screened to make sure they don’t qualify for other public programsOther activities around cost and quality that work Reauthorization is possible, but unlikely: Representative David R. Obey (D - WI)
  • Definition of benchmark plans in MedicaidCreditable coverage definition in the exchangeModified Adjusted Gross Income, which impacts many things including one line enrollment systems and streamlining eligibility and enrollment systemsThe role of the saftenet and other access plans that are not insuranceAll but one state is expanding access to low income adultsMost have limited experience reaching out to this population and no actuarial history to help anticipate program cost State responses:Very conservative enrollment caps in first yearEvaluate the characteristics and service use of this population in year 1 to inform subsequent yearsEvaluate service use of similar population to project service use and costsContract with consulting firms to model costs
  • Low income, working adultsEligibility: working adults eligible for health care coverage through a participating employer, who are uninsured, and receive annual wages at or below 300 percent of the Federal Poverty Level (FPL). “Virtual” account will be used, at the employee’s choice at the time of election: premium or point of service (cost-sharing, including deductibles, coinsurance)Choice of three plans: Healthy Texas program (statewide reinsurance-type approach); a large urban safety net hospital-sponsored HMO’s commercial small employer product; and local multi-share programs. Funds are paid to the contracted health plans or to Healthy Texas. Neither employees nor employers own or access the funds. The hope is that people learn to value the service, see the benefit and keep paying “creating a culture of insurance”Addressing : sustainability,the resistance to funding fully public programChallenges: CSA’s can be used to buy a commercial HMO or a multi-share that by definition is not insurance. The state is working to potentially modify the program over time, so that it complies with reform. In addition, the subsidy levels taper quite dramatically, and it is unclear whether individuals will be able to sustain the increased cost.
  • Challenge given the large reduction in subsidies over timeTackle the political perception that this is a gov. only program, deal with sustainabilityHealth reform remains a problem as one of the delivery systems is a multi-share
  • In 2007 WA State Legislature established the Health Insurance Partnership (HIP), an insurance exchange to help small employers offer coverage to their employees/families. Implementation began after passage and continued until late 2008, when a 2009 budget deficit projection caused funding for the program to be cut and the program to be suspected.WA is using SHAP funds to restart the implementation of HIP (still on the books, just unfunded)Employer eligibility: Small employers (with 2-50 employees) can enroll in the HIP if they do not currently offer health insurance coverage to their employees, and if at least 50% of their employees are low-wageBusiness must not offer insurance, but there are no crowd out provisions (this was debated – for reasons of equity)Employee eligibility: Any employee of eligible employerAn employer must contribute at least 40 percent of the premium for a single employee, and at least 75 percent of eligible employees must participate in the plan, the same as the private small group market. Employers don’t have to put money toward a spouse/dependentEmployers must establish 125 plansThe shared responsibility of employer and employee contributions, combined with HIP subsidies, pays the premium for small groups of subsidized and nonsubsidized enrollees. Health insurance carriers rate HIP enrollees in the same community-rated risk pool as the carrier’s other small group enrollees. (focus on FT employees)
  • A seven-member Board of health benefits experts sets policy for the HIP and provides guidance. Forexample, the Board designates the small group health plans offered through the exchange and determinesthe minimum employer premium contribution.HIP was also directed by the Legislature to develop and implement individual employee choice of plan within two years of initial implementationThe HIP does not negotiate rates or design and offer its own health plans, rather it collaborates with health insurance carriers to designate up to five private plans, ranging from catastrophic to comprehensive coverage, and selected from plans already being offered in Washington’s small group market.Challenges: SHAP is primary funding sourceOvercome: public/private, well aligned with health reform, trying to deal with sustainability
  • Many are familiar with Muskegon style multi-share that includes funding from the individual, an employer and come other source of funding, typically government. Portico started in 1995Not eligible for Minnesota health care programsRx: $2,000 annual per person limitFace-to-face family interviewCare management: Social workers and nurses – Navigation, health-related goal setting, assistance understanding medical bills, advocacy, referrals to specialty care, interpreter, referral to community services, transition to ongoing coverageMulti-share (community-based organization that provides affordable health coverage to small businesses or individual, thought partnerships with local providers, cost is typically share between individual, government, employer – sometimes not)
  • Hospitals: Sustain through ROI, which is part of grantChallenge: limited funding source, not credible coveragePublic, private, sustainable, Not tied to employer (health reform)Urban, working, poor and young, (38% are 0 to 19)80% people of color, 66% Latino78% work full or part-time70% are at or below 175 percent FPG
  • State budgets-potential loss of enhanced FMAP ratesHealth care cost-not addressed in reformPolitical turn over might reduce support or momentum (governor’s and Medicaid directors-knowledge and experience )Health reform: in many cases this is the same peopleExperience enrolling and covering low income adults and employees in small businessesStrategies for addressing continuum of coverage – ESI to public programs to the safety netNew models for the safety netDevelopmental work on insurance exchanges, streamlined eligibility and online enrollment systems

Leveraging Federal Grant Funds to Expand Coverage:  Experiences from the HRSA SHAP Grantee States Leveraging Federal Grant Funds to Expand Coverage: Experiences from the HRSA SHAP Grantee States Presentation Transcript

  • Leveraging Federal Grant Funds to Expand Coverage: Experiences from the HRSA SHAP Grantee States
    Elizabeth Lukanen, MPH
    State Health Access Data Assistance Center
    University of Minnesota, Minneapolis, MN
    June 27, 2010
    AcademyHealth Annual Research Meeting
  • 2
    State Health Access Program (SHAP)
    Grant program supported by by the Health Resources and Services Administration (HRSA) at Health and Human Services (HHS) 
    Targeted at states
    Focused on expanding access to health care coverage
    13 states were awarded grants totaling almost $71 million for year 1
    Authorized to run 5 years, funding appropriated annually
    Matching funds and project sustainability beyond the 5-year period were required
    Technical assistance available to grantees
  • 3
    13 SHAP Grantee States
  • 4
    Overview of SHAP Activities
    Coverage Expansion Populations
    Low income workers
    Low income parents
    Low income adults without kids
    Coverage Initiatives
    Premium assistance
    Targeted benefit design
    Other Activities
    Enrollment and retention activities
    Delivery system reform
  • 5
    Some Challenges Faced by SHAP Grantee States
    Resistance to expanding entitlement programs
    Uncertainty related to health reform
  • Resistance to Expanded Entitlement Programs
    • Political pressure against expansion of government funded programs
    Some state responses:
    Develop employer-based options
    Support public-private partnerships
    Require individual contributions
  • 7
    • SHAP funded for a maximum of 5 years
    • State budget deficits
    Some state responses:
    Medicaid waivers
    “Soft launch” programs
    Limited outreach
    Don’t target groups of likely eligible
    Create registration or waiting lists
    Graduated subsidies that reduce over time
    Refer eligible people to better funded programs
  • Uncertainty Regarding Health Reform
    • Uncertainly in the rules, regulations and impact of health reform
    Some state responses:
    Fund programs that are likely to align with reform (e.g. insurance exchange, build off ESI)
    Use program evaluation to document experience with new enrollee populations (low income adults, small businesses)
    Focus on programs that will remain relevant as part of the safety net
  • Texas: Graduated Subsidies Cost Sharing Account - Glide Path
    Health Care Cost Sharing Accounts (CSAs)
    Targeted at low-income working adults
    CSAs can be used to pay for monthly premiums or point-of service cost-sharing
    Available to enrollees within 3 delivery systems
  • Texas: Graduated Subsidies Cost Sharing Account - Glide Path (2)
    CSA accounts are funded using a five-year “glide path” of $1200, $900, $750, $500 and $500
    The intent is to create a clear up front incentive to participate
    The goal is to develop a “culture of insurance”
    Experience the benefit of participating in a shared risk pool
    Continue to participate despite the gradually higher individual contribution
  • Washington: Insurance ExchangeHealth Insurance Partnership (HIP)
    Small business exchange, focused on businesses with low wage workers
    Any employee of an eligible firm can purchase through HIP
    Subsidy for employees at/below 200% FPL
    Health plans propose plans ranging from catastrophic to comprehensive (same plans outside the exchange)
  • Washington: Insurance ExchangeHealth Insurance Partnership (HIP)
    Board sets HIP policy including, plan approval
    Currently, employer chooses plan, but state is developing an individual choice model
    HIP may apply a surcharge to health plans to pay administrative and operational expenses
  • Minnesota: Innovative Multi-Share Portico Healthnet
    Access to care plan for low income, uninsured
    “No wrong door” – screens for Minnesota health care program eligibility
    Prevention-based services with care management
    Covered: primary/specialty clinic visits, RX, lab tests, outpatient mental health, outpatient hospital procedures
    Not covered: ER, inpatient hosp, dental, chem dep.
    Under SHAP, income eligibility expanded from 275% to 350% FPL
  • Minnesota: Innovative Multi-Share Portico Healthnet(2)
    Funded predominately through financial partnership with14 local hospitals
    Enrollee monthly fee of $25‐$55 (sliding scale)
    Grant funds
  • Persistent Challenges Faced by States
    State budget outlooks still bleak
    Health care cost will continue to rise
    Political turnover likely
    State responsibility for implementation of health reform
  • 16
    Contact Information
    Elizabeth Lukanen, MPH
    Deputy Director, SHARE
    SHADAC (State Health Access Data Assistance Center)
    University of Minnesota, Minneapolis, MN
    elukanen@umn.edu, 612-626-1537
    For more information on SHAP: http://www.shadac.org/shap
    ©2002-2009 Regents of the University of Minnesota. All rights reserved.The University of Minnesota is an Equal Opportunity Employer