State Health Policy Analysis MHA 620 Final Project

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
ProQuest Cost tops managed care concerns Dennis J Roszak.
Hospitals & Health Network. Chicago Apr 2003
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

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

February 2009
February 2009
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

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