1. State and Local Efforts to Close the Gaps Between Public and Private Insurance Coverage Vickie S. Gates Vice President Academy for Health Services Research and Health Policy Director The Robert Wood Johnson Foundation’s State Coverage Initiatives Program

2. Current State Environment Reduced revenues Expenditures over budget Rising Medicaid caseloads Rising health care costs Maintenance, low and no cost options November elections (36 Governors)

3. State Options to Expand Health Care Coverage Public programs, including new Medicaid options Public-private partnerships Market based reforms/strategies

4. Public Program Options Medicaid 1931 SCHIP 1115 Demonstration Waivers  SCHIP  Medicaid  HIFA State-only

5. Closing the Gap Between Public and Private High risk pools Programs to improve employer offer rates Premium subsidies for employees Full cost buy-ins and pools

6. Major Obstacles to Expansion Funding and fear of commitment Benefit design, cost sharing for existing and expansion populations Increasing costs Provider support and participation Administrative complexity, low participation ESI (HIFA may help)

7. State Research Needs What is affordable coverage? Understanding employer decisions Crowd-out Uncompensated care and the safety net Link between health insurance and health status

8. Insights and Lessons No silver bullet; multiple strategies Shifting resources between populations is extremely difficult “Right” benefit design and cost sharing are research and political issues Uninsured still stereotyped; lack political leverage Importance of partnerships, collaboration

9. Contacting SCI State Coverage Initiatives c/o Academy for Health Services Research and Health Policy 1801 K Street, NW Suite 701-L Washington, DC 20006 SCI@ahsrhp.org www.statecoverage.net

10. States and Communities The “ready” community, the community with special needs, the pilot Community as a health insurance pool Demonstrated success in improving health outcomes at lower cost Ability to reach employers, uninsured, medical community; bring resources together

11. HIFA: Plus and Minus Benefit and cost sharing flexibility Ability to use SCHIP allotments to meet budget neutrality Responsive, simpler waiver process Mixed State reaction to ESI option Concerns on budget neutrality