POSTED ON JULY 10, 2013:
Tiptoeing into Expansion
Health care study viewed with optimism, frustration
Many have called it a step in the right direction. But the much-anticipated Leavitt Partners report still leaves plenty of unanswered questions.
"If this was an attempt to make things more simple for people without insurance, I don't think that was accomplished," said John Silva, chief executive officer for Morton Comprehensive Health Services, a health care provider with clinics in Tulsa. About half of patients treated at Morton clinics have no health insurance, he said.
In 123 pages, the Utah-based consulting group laid out recommendations for what's known as a Medicaid demonstration proposal.
The firm had been asked in February by state authorities to figure out "how to optimize access and quality of health care in the State."
But Gov. Mary Fallin seemed to lay out a big caveat in her Feb. 4 State of the State speech: "Moving forward, my administration will continue to develop an 'Oklahoma Plan' that focuses on improving the health of our citizens, lowering the frequency of preventable illnesses like diabetes and heart disease, and improving access to quality and affordable health care."
Earlier, Fallin had dismissed the idea of Medicaid expansion -- a key component of the Affordable Care Act, also known as Obamacare -- calling it unaffordable both for Oklahoma and the nation. In her speech, she also added that "Medicaid expansion offers no real reform to a flawed and inefficient system."
Four months later, the Leavitt Partners sketched out in broad strokes what such an "Oklahoma plan" might look like. The report recommends taking principles from an existing effort known as Insure Oklahoma to help low-income Oklahomans get health insurance.
So far, it's won over some who previously advocated for Medicaid expansion.
"We think this would be a good opportunity for Oklahoma to really expand the coverage for the uninsured and continue to build on the success of the Insure Oklahoma program by purchasing private health insurance to get that uninsured population covered," said Tiece Dempsey, a policy analyst with the Oklahoma Policy Institute, a Tulsa-based think tank that's advocated for Medicaid expansion.
Insure Oklahoma, a state-based effort funded in part with federal Medicaid dollars, has several components. But under the largest program, costs are split between employees, employers and the government to pay for the cost of insurance premiums -- a program described in the Leavitt Partners report by the acronym "IO ESI."
Insure Oklahoma is in danger of ending Dec. 31, as it's currently configured with a cap on enrollees that is at odds with federal authorities. But the report recommended continuing such a model on a larger scale for Oklahomans who only earn up to 138 percent of the federal poverty level.
"The State would provide premium assistance to eligible enrollees to purchase qualified health insurance through the federally-facilitated exchange or employer-sponsored insurance through the current IO ESI program. Eligible enrollees would include relatively healthy, low-cost, uninsured individuals with income up to 138 percent FPL," the report states.
The report isn't labeled as a Medicaid demonstration project for nothing. It recommends that Oklahoma accept federal Medicaid funding to get such an effort off the ground. While Insure Oklahoma currently assists in providing health coverage to just under 30,000 people, the Leavitt Partners project that, by 2013, more than 200,000 Oklahomans will receive health care coverage through this program.
For Dempsey, the acceptance of federal dollars is a crucial part of the plan, calling Medicaid expansion "a term of art." In effect, the plan amounts to Medicaid expansion, she said.
Howard Barnett, president of Oklahoma State University-Tulsa, said the numbers of new enrollees could be similar to those who would be covered should the state embrace the plan put forward by the federal government.
"I've seen various estimates of the Medicaid expansion numbers, and they aren't dramatically different. They're all based on assumptions of how many people take advantage of whatever's being offered," Barnett said.
The college operates OSU-Medical Center, a hospital in Tulsa. Without Medicaid expansion, several hospitals have expressed concern about not having anything offset the burden of treating the uninsured.
"If this came to pass in the way they describe, it would certainly have a positive bottom-line impact on the hospital, just because of the high percentage of uninsured patients that they see. Therefore, some percentage of those -- who knows how many -- would have some coverage," Barnett said, also noting that "there's lots of discussion in the report about incentives trying to incentivize people to make choices that are positive to their health outcomes."
But what kind of insurance coverage? Silva said he wants to know more details about what would be available to this newly eligible group.
"What should be the minimum health plan in Oklahoma if Insure Oklahoma is expanded?" Silva asked. He noted that the Affordable Care Act establishes minimum standards for health care plans, but said he wants to know more details about what insurers might actually offer and if they'll be held to all of those standards.
Silva said he's concerned that the entire system may exceedingly difficult to navigate. "How do I know what a good health plan is? How do I know that the baseline of benefits meets whatever national standards are attached? How do I know and really make sense of, 'You have a deductable for this and a co-pay for that'?" Silva said.
The report "seemed to me to dance around all of the substantive issues related to health care access for the poor," Silva said. He added: "It's a step in the right direction in that there is a dialog about the state of Oklahoma's obligation to provide health insurance access to its citizens, but it's kind of like ... there's really not a lot of substance."
Jan Figart, associate director with the nonprofit Community Service Council, has perhaps an even bigger concern: that the private market simply won't bother putting forth any plans for low-income Oklahomans.
"If this group would have been interesting to the insurance market in the past, they would have had a product out there," Figart said. She noted that insurance companies have actuaries who can study the characteristics of any group, including poor Oklahomans -- and, despite the Leavitt report including the words "relatively healthy" in describing them, Figart said she wonders if insurers will agree.
"Oftentimes ... their health is challenged, that's why they're economically-challenged. So you're taking on a high-risk pool," Figart said.
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