Health policy roundtable panel discussion: translating health insurance studies into policy proposals

Health Services Research, June, 2004 by Christina E. Folz

A BRIEF DESCRIPTION OF THE PARTICIPANTS

Chair: Sherry Glied, Ph.D., is professor and chair of the Department of Health Policy and Management at Columbia University's Mailman School of Public Health. Dr. Glied conducts research on health insurance reform. She worked as a senior economist for the Council of Economic Advisers in the Administrations of George H.W. Bush and Bill Clinton.

Panelists: Kathryn Haslanger, M.S., J.D., is vice president at the United Hospital Fund in New York. Dr. Haslanger analyzes health insurance programs and other aspects of the health care system in New York City. She has held senior positions in city government.

Richard Kronick, Ph.D., is professor in the Department of Family Preventive Medicine at the University of California at San Diego's Research and Policy Center. Dr. Kronick helped develop the managed competition aspect of the health reform plan for the Clinton Administration.

Jeanne Lambrew, Ph.D., is associate professor of health policy at George Washington University. Throughout the Clinton Administration, Dr. Lambrew worked in various capacities in the Department of Health and Human Services, the Office of Management and Budget, and at the National Economic Council.

JoAnn Lamphere, Dr.P.H., is senior manager in health care finance at The Lewin Group, Inc. Dr. Lamphere worked with the Treasury Department and the Internal Revenue Service to develop and implement a health coverage tax credit program which was enacted in the Trade Act of 2002.

Sherry Glied: Please give an example of health services research that has substantially changed health insurance policy in the United States.

Richard Kronick: I conducted some analyses in the mid-1990s that evaluated patterns of expenditures among Medicaid recipients with disabilities. The results suggested that among Medicaid beneficiaries who are disabled, high-cost users in one year tended to remain high-cost users the next year--much more so than was observed in the general population or among Medicare beneficiaries.

This work resonated with teaching hospitals that were serving people with disabilities under capitated contracts with Medicaid. It helped them to push Medicaid agencies to adopt diagnostically adjusted payment systems for people with disabilities. When these analyses were first published, there were no state Medicaid programs making health-based payments to HMOs; now there are about a dozen.

Another example of research that has informed policy dates back to 1985, when I worked for Michael Dukakis. He was governor of Massachusetts at the time, and his administration had proposed legislation to create a bad debt/free care pool to change the way that state hospitals get reimbursed. The idea was to remove the competitive disadvantage associated with hospitals that serve uninsured people. When the bill was introduced into the legislature, some representatives from western Massachusetts expressed concern that the proposal would cause their hospitals' money to be redistributed into Boston. Hospitals and employers from western Massachusetts were similarly apprehensive.

We conducted an analysis that demonstrated that, contrary to those fears, the bill would not cause any net redistribution of money from western Massachusetts into the Boston area. The findings gave legislators from the western part of the state the reassurance they needed to vote for the bill--and it was enacted.

Jeanne Lambrew: When I went to the White House National Economic Council in 1997, I went primarily to work on children's health issues. This was around the time that creating a children's health insurance program became a priority for the Clinton administration. As the in-house person who knew research and was familiar with this topic, I was asked to find relevant evidence to guide development of the proposal.

It was surprisingly difficult to find any research that had been designed to answer the simple question: Does health insurance matter for children? Fortunately, I was able to ask for new analysis from the National Center for Health Statistics and draw on state-level research from Horida and New York suggesting that children who have health insurance are more active in school, for example, and more likely to participate in sports. In the end, we were able to piece together enough information to justify the proposal.

On the other hand, there was one piece of research that had a huge effect on the debates surrounding children's coverage. David Cutler and Jonathan Gruber (1) suggested that Medicaid expansions during the late 1980s and early 1990s had, to some extent, "crowded-out," or replaced, private coverage. Conservative groups such as the National Center for Policy Analysis and the Heritage Foundation used those results to argue that extending coverage to children was a bad idea because it would only substitute for private coverage. The Congressional Budget Office argued that the findings implied that the bill to create the State Children's Health Insurance Program (SCHIP) may cost more money and cover fewer uninsured than had been anticipated.