State Health Access Reform Evaluation

State Health Access Reform Evaluation Lynn A. Blewett, Ph.D. State Health Access Data Assistance Center AcademyHealth State Coverage Initiatives (SCI) State Coverage Institute Chicago, Illinois September 26, 2007 Funded by a grant from the Robert Wood Johnson Foundation

Overview of Presentation
Quick Review-State Health Reform
Evaluation 101
Examples: Performance Outcomes for Health Reform
Data sources – State vs. National
Technical Assistance
State Health Access Reform Evaluation
State Health Access Data Assistance Center

Presentation Objectives
To get you to think about measurable outcomes during your discussions of health reform
To be specific about your expectations for reform initiatives
How you will know if the program achieved its objectives? What data will you need?
To talk to each other and reach consensus on expectations…..
Think about state-specific data needs and build those into your legislation

Quick Overview of State Health Reform

Drivers of State Health Reform Activity
Increasing number of uninsured
Drop in employer-sponsored coverage
Kids impact moderated by SCHIP
No safety net for adults
Increasing number of underinsured
Higher out-of-pocket costs
Relatively positive state revenue climate
Lack of national efforts for reform
Iraq, immigration, etc. dominating Congress

Continued Increase in Uninsured Source: U.S. Census Bureau, Current Population Surveys (March), 1989-2006 New verification question Millions of Uninsured, all ages 15.8% of Population

Drop in Employer-Sponsored Coverage (U.S.) Source: US. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2006.

Increase in Uninsured Children, 2005-06 710,000 New Uninsured Children <200% FPL 200-399% FPL 400%+ FPL 220,000 340,000 150,000 31.3% 47.5% 21.2% Note: 200% to 399% of the federal poverty level (FPL) is roughly $40,000-$80,000 in annual income for a family of four in 2006. Source: KCMU/Urban Institute analysis of the March 2007 CPS .

Increase in State Revenues Source: Quarterly Summary of State and Local Government Tax Revenue, U. S Census Bureau. Annual Change in 2nd Quarter State and Local Tax Revenue Drop in 2007?

Source: Congressional Budget Office Federal Relief?

States Are in Different Phases of Reform Process Illinois (kids) Maine Massachusetts PA (kids) Vermont WI (kids) California Oregon WI Colorado Minnesota Illinois (all ) New Jersey New Mexico PA (all) WI (all) Post –Implementation Legislation Passed/ Implementation Legislation Introduced In Discussion

Framework for Reform
Public Sector
Initiatives
Employer-Based Initiatives Insurance Reform Tax credits HIFA expansion waivers SCHIP premium assistance Small employer purchasing pools

Health Reform Evaluation -101

Ideal Policy Making Process
Informed Decision-Making Process
Made based on best available data and analysis
Decision maker is knowledgeable, interested and has best information and advice
Science and methods are sound
Thoughtful discussion of alternatives
Public is informed

POLICY FORMULATION
Agenda Setting
Assessment of Options
Political Setting
POLICY IMPLEMENTATION POLICY Adoption POLICY MODIFICATION Program Evaluation , Assess impact of policies Influence future policy formulation INPUTS Preferences of individuals, organizations, interest groups , along with cultural Demographics, ethical, legal, social and technological inputs Rulemaking Operation Legislation Window of Opportunity Source: Longest, 1998 Longest, 1988.Policy Making Process in the US

Performance Assessment/Evaluation
OBJECTIVE
to provide information/data/evidence…
to support resource allocation and other policy decisions….
to improve service delivery and program effectiveness.

Performance Assessment or Program Evaluation?
Performance Measurement
ongoing assessment
use of performance standards
early warning system to management
vehicle for improving accountability to the public
Program Evaluation
typically more in-depth examination of program
broader context of environment and alternatives
overall assessment of whether the program works
identification of adjustments that may improve its results
Source: U.S. Government Accountability Office, 1998.

The Importance of Reform Evaluation
Inform future state policy
Justify program budget/financing
Satisfy legislative requirements
Identify successful initiatives
Change course if program not meeting benchmarks
Inform state and national debate on health reform
What works at the state level?
Source: CMS Evaluating Demonstrations: A technical assistance guide for states.

Program Objectives
Measurable results that the program sets out to achieve
SMART Objective
S – Specific
M – Measurable
A – Appropriate
R – Realistic
T – Time bound
Focus of objective
What will change?
Not what the program will do

Levels of Measurement
Population-based
Data collected from sample of target population
Survey data, focus groups
Program-based
Data collected from program recipients, clients, or participants
Administrative data

Program Evaluation Data
Quantitative Data
Surveys, secondary data
Measures activities carried out
Use to assess extent of program utilization, behavior change, or cost per unit of change
Qualitative Data
Interviews, focus groups, observations, document review
Use to understand attitudes, beliefs, reactions, to assess quality, to explain perceptions

Performance Assessment
How do you know if your health reform was successful?
Key Areas to Assess:
Coverage
Cost and Efficiency
Fairness and Equity
Choice and Autonomy
Develop goals that are measurable, assessable and realistic.
Consider short-term and long-term outcomes.

Examples: Performance Outcomes for Health Reform

Goals of Vermont Reform
Increase Access to Affordable Health Care Coverage
More than 96% of Vermonters will have coverage.
Improve Quality of Care
100% of Medicaid, Dr. Dynasaur, and VHAP beneficiaries living with a chronic condition will receive health care services that are based on nationally recognized clinical best-practice guidelines for health treatments and self care.
Contain Costs
The cost shift resulting from insufficient Medicaid reimbursement rates will be reduced.
Source: Vermont Health Care Reform: 5 Year Strategic Plan

Goals of Maine Reform
Increase Access to Affordable Health Care Coverage
Aim to insure up to 31,000 individuals during its first year and provide access to coverage for at least another estimated 110,000 individuals by 2009.
Improve Quality of Care
Contain Costs through Voluntary Caps
Dirigo Health requests hospitals and other providers to limit their cost growth to 3% per year and their operating margins to 3.5%. Insurers are asked to limit their operating margin to 3.5%.
http://www.dirigohealth.maine.gov/dhlp01.html

Additional Examples
Process Measurement
Time from first contact to enrollment
Waiting list, backup list
# of contacts per outreach effort
# of contacts that result in enrollment
Outcomes Measurement
Increase coverage for low-income children by 30%
Increase the number of plans offering insurance
Reduce growth in public program spending by 10%
Increase immunization rates for non-white populations to meet 2010 goals
Estimates of direct substitution of public for employer-based plan (i.e., Crowd Out)

Key Dimensions of Reform
Increase access and coverage plus demonstrating that reform initiative is:
Affordable
Sustainable
Efficient

Data Sources – State vs. National

Assumption “ Good policy needs good data and collecting good data is good policy.” Source: Ernie Ingles, Chief Librarian, University of Alberta

Current Population Survey (CPS)
Annual estimate of distribution of health insurance coverage
Released by the Census Bureau every August
Only federal survey with uninsurance estimates for all 50 states and DC
Used to compare coverage and change in coverage across states and for nation

CPS Also Key to SCHIP Funding
Formula inputs: estimates of low-income children and low-income uninsured children in each state
Pooled years of CPS data
Still small sample size, especially for small states
Bias in data skews distribution of funds
State administrative data is not used in SCHIP funding formula
More kids enrolled, less uninsured, less allotment
Is there a better state-level data source to inform formula inputs?

SCHIP Evaluation Requirements
States required to monitor changes in levels of uninsurance for low-income kids
Back to CPS?
State survey?
Some state using administrative counts to show increase in public program enrollment
New- D emonstrate that public program expansion does not lead to drop in employer sponsored coverage
Enrollee surveys?
Employer surveys?

HRSA-SPG Funded Survey Activity 2000-2005 Household and Employer Survey Employer Survey Household Survey

Why States Conduct Surveys
Typically more sample than CPS
Ability to drill down to subpopulations
Children
Geographic Units
Race/ethnicity
Analysts have data in hand
Better knowledge of data
Ability to do analysis in-house

On Average Uninsurance Estimates from State Surveys are 22% Lower than CPS Uninsurance Estimates for Select States

Increased Sample Size in State Surveys

States Use of Data
Four primary areas of policy development:
(1) To develop reliable and accurate estimates of the number of uninsured
To facilitate state-specific policy discussions
(2) To identify the demographic, economic and health-related characteristics of the uninsured
To help target programs and outreach

Focus Groups
(3) To collect information about opinions, attitudes, and values
-- To facilitate the design policy options
-- To assess political feasibility
(4) To understand the motivations of uninsured populations and employers
-- To design approach and incentives
States Use of Data (2)

Technical Assistance - State Health Access Reform Evaluation - State Health Access Data Assistance Center

State Health Access Data Assistance Center
Funded by the Robert Wood Johnson Foundation
University of Minnesota, School of Public Health
Goals:
Help states monitor rates of health insurance coverage using state and federal data
Research factors associated with access and coverage
Provide targeted policy analysis and technical assistance to states
Bridge between state and federal agencies; between survey data and state health policy
Technical assistance on use of federal survey data and best practices on state surveys

State Health Access Reform Evaluation
National Program Office of the RWJF
Co-located with SHADAC at University of MN, SPH
Goals:
Fund and coordinate evaluations of state health reform
Identify and fill gaps on research to identify what works and why
Organize and disseminate findings in a manner that is meaningful and user-friendly
Inform state and national policy on health care access and coverage
Technical assistance on program evaluation and assessment

State Health Reform If States are the Laboratories….. Where are the lab reports?

Concluding Comments
Staff - Ask key legislative leaders what they will want to know next year?
Discuss long- and short-term program objectives and identify the monitoring process up front
Make sure staff understand legislative/policy objectives
Make sure policy makers understand limitations of data/measurement
Build performance assessment into legislative initiatives

More Concluding Comments
Don’t forget to think about….
Performance assessment and
Monitoring along the way
Likely within state government
Program evaluation
How are we going to know in 2-3 years if the program achieved its objectives?
Possible outside vendor/contractor
Think now about what you will want to know later
It’s more difficult to go back and evaluate a program without good baseline data and information

The SHADAC Vision Federal Data (e.g., CPS) Better Understanding of the Characteristics of the Uninsured State Data (e.g., State Surveys) Increase Coverage and Access THANK YOU!

Contact Information www.shadac.org www.statereformevaluation.org University of Minnesota School of Public Health Division of Health Policy and Management 2221 University Avenue, Suite 345 Minneapolis Minnesota 55414 (612) 624-4802 Principal Investigator: Lynn A. Blewett, Ph.D. (blewe001@umn.edu)

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