As the year begins, a critical issue facing elected officials and policy makers is the large and growing uninsured population. The latest data indicate that 18% of the U.S. population is uninsured. Because most uninsured Americans—about two-thirds—have incomes below 200% of the poverty level, the policy debate must focus on how best to provide coverage for low-income individuals.
A new report by the Kaiser Commission on the Uninsured reminds legislators and policy makers that we already know a great deal about how to design a public coverage program for low-income people. The program is Medicaid, and for more than 40 years a wealth of knowledge has been accumulating regarding the program and the needs of people with low incomes.
The Kaiser Commission's aim was to put a summary of this knowledge in the hands of decision makers, and it did so by compiling a 112-page report with more than 500 references. Health Coverage for Low-Income Americans: An Evidence-Based Approach to Public Policy first addresses "the threshold question": What is the role for publicly sponsored health insurance? This initial section documents the limits of the private health insurance system as a source of coverage for low-income Americans. It looks at alternatives, such as tax credits and personal health spending accounts, and presents evidence that Medicaid is the more cost-efficient investment of public dollars.
The report's second part turns to how to best structure a publicly sponsored health insurance program for people with low incomes. Separate sections examine seven central issues: eligibility, participation, use of premiums, scope of benefits, use of cost sharing, access to care, and financing. Each section reviews relevant evidence and articulates a perspective based on the evidence. The report concludes by presenting the perspectives on the seven issues in a framework of a well-designed program of coverage for low-income Americans.
The Commission's conclusions in regard to the seven central issues are as follows:
• Eligibility. Basing eligibility solely on low income and eliminating categorical restrictions that now apply to Medicaid, such as the exclusion of nondisabled adults who have no children, could substantially reduce the number of uninsured Americans.
• Participation. Simple enrollment and recertification processes that minimize burdens on applicants, such as extensive documentation and procedures that necessitate time off from work, are likely to promote participation without fundamentally weakening program integrity.
• Use of premiums. Few people living in or near poverty can manage to pay for coverage. The use of premiums to contain public costs needs to be balanced carefully against the goal of increasing coverage for this population.
• Scope of benefits. Because people with low incomes tend to have more health problems than others, a benefit package that is comprehensive in scope, including rehabilitation and long-term care, is needed. Experience with Medicaid does not support the claim that broad benefits are associated with overutilization of care. Reducing benefits for covered groups to support slim benefits for a new group can result in inadequate access for both groups.
• Use of cost sharing. Even at low levels, cost sharing can adversely affect access to care for people with low incomes. If adopted, cost sharing should be related to income.
• Access. Having insurance is necessary but not sufficient to ensure access. Continuous coverage, adequate provider networks, coordination of care, and elimination of barriers to access are needed to realize the full potential of coverage.
• Financing. Financing that is determined by enrollment and utilization directs public dollars most efficiently. Experience with capitated funding shows that accurately matching funds to needs is difficult and that funding levels tend to deteriorate over time. Federal matching of state spending has several advantages. It permits the costs of coverage to be shared and can promote national priorities while preserving states' discretion in terms of policy. The most robust federal-state financing partnership is one that takes into account not only national trends causing health care costs to rise but also fiscal pressures on state budgets during a weak economy, when Medicaid enrollment increases.
The report's authors acknowledge that "public policy to deal with the thinning fabric of health insurance coverage in the United States is forged under political, economic, philosophical, and other pressures." Decision makers who are faced with such pressures—many of which will pull them in opposite directions—require a strong empirical foundation for a firm analytic foothold, and the report is designed to provide it. The report is available on the Kaiser Commission Web site at www.kff.org.
Health care workers who employ physical restraints and seclusion when treating patients must undergo new, more rigorous training to ensure the appropriateness of the treatment and to protect patients' rights, according to much-awaited final rules on use of seclusion and restraint issued by the Centers for Medicare and Medicaid Services (CMS). The new rules limit episodes of physical restraint or seclusion to four hours for adults, two hours for children and adolescents ages nine to 17, and one hour for children under age nine. Previously there were no limitations.
The rules, which were published in the December 8, 2006, Federal Register, apply to all hospitals participating in the Medicare and Medicaid programs, including short-term, psychiatric, rehabilitation, long-term, children's, and alcohol and drug treatment facilities. The rules were issued seven years after a five-member committee was created by CMS to study deaths of patients undergoing restraint and seclusion. National attention was focused on this issue by a series of articles published in 1998 in the Hartford Courant, which revealed that 142 U.S. patients died between 1988 and 1998 as a result of being restrained.
In response to more than 4,000 public comments received on the 1999 interim final rules, the final regulations strengthen the staff training standard. Staff who carry out these practices must be trained and able to demonstrate competency in the application of restraints and in implementation of seclusion, monitoring, assessment, and provision of care for a patient in restraint or seclusion. Staff must be trained to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion; to use nonphysical intervention skills; to choose the least restrictive intervention on the basis of an individualized assessment of the patient's medical or behavioral status; to recognize and respond to signs of physical and psychological distress, such as positional asphyxia; to identify behavioral changes that indicate that restraint or seclusion is no longer necessary; to monitor the physical and psychological well-being of the patient, including respiratory and circulatory status, skin integrity, and vital signs; and to use first-aid and cardiopulmonary resuscitation.
The rules also expand the category of practitioners who may conduct patient evaluations during an episode of restraint or seclusion. CMS currently requires that a face-to-face evaluation be conducted within an hour of a patient's being restrained or secluded. Before the new regulations, these actions had to be reviewed within that hour by a physician or "other licensed independent practitioner." The new rules expand that list to include a trained registered nurse (R.N.) or a physician assistant (P.A.). However, when an R.N. or P.A. conducts the one-hour-rule evaluation, the new rules require that a physician or other licensed independent practitioner be consulted as soon as possible. Hospitals are required to document in a patient's record the situation for which the practice was needed, any attempts to use less restrictive methods, and the patient's response to the intervention.
Stricter standards now apply for reporting a death associated with the use of restraint and seclusion. Not only must a facility report a death that occurs while a patient is in restraint or seclusion, it must also report any death known to the hospital that occurs within one week after physical or chemical restraint or seclusion when it is reasonable to assume that use of these practices contributed to the death. Deaths must be reported by telephone to the CMS regional office no later than the close of business on the next business day following knowledge of a death.
The full text of "Medicare and Medicaid Programs: Hospital Conditions of Participation: Patients' Rights, Final Rule" is available on the Government Printing Office Web site at www.gpoaccess.gov/fr/index.html.
Nominations SAMHSA Science to Service Awards: The Substance Abuse and Mental Health Services Administration (SAMHSA) is seeking applications for its Science to Service Awards, a new national program that will recognize community-based organizations and coalitions that have shown exemplary implementation of evidence-based mental health and substance abuse interventions. A maximum of three awards will be made in each of four categories: treatment of mental illness and recovery support services, mental health promotion, substance abuse prevention, and treatment of substance abuse and recovery support services. Eligible organizations must have successfully implemented a recognized evidence-based intervention. Both public- and private-sector organizations, including community-based organizations and coalitions, are eligible to compete. Complete information is available on the SAMHSA Web site at www.samhsa.gov/spotlights/sciencetoservice.pdf. The application deadline is February 28, 2007.
New approach for SAMHSA antistigma campaign: The Substance Abuse and Mental Health Services Administration (SAMHSA), in partnership with the Ad Council, has launched a national awareness public service advertising campaign designed to decrease negative attitudes about mental illness. The designers decided that instead of telling people why they shouldn't discriminate against people with mental illnesses, the campaign would show friends how they can be supportive of those who have disclosed that they are having a mental health problem. Created pro bono by Grey Worldwide, the campaign aims to reach 18- to 25-year-olds. The television and radio spots feature a voiceover by actor Liev Schreiber and illustrate how friendship is the key to recovery. The campaign also includes print and interactive advertising that directs people to a new Web site, www.whatadifference.samhsa.gov, to learn more about mental health and what they can do to play a role in their friend's recovery. An impetus for the campaign was a recent Porter Novelli survey showing that only one-quarter of young adults believe that a person with a mental illness can eventually recover and slightly more than half (54 percent) of those who know someone with a mental illness believe that treatment can help people with mental illnesses lead normal lives.