Who Knew?  

or 

Yes, It Really Is This Complicated!

By Marcia Stedman

Image Credit: Matt Wuerker, Politico

Meeting #4 of the Universal Health Care Commission (UHCC) included  an overview of recent legislation including advancements in behavioral health, housing, and Medicaid and two bills strongly supported by HCFA-WA: SB 5532, creating the Prescription Drug Affordability Board, and SB 5589, requiring annual reporting of primary care spending, and many others. 

• A comprehensive review of Federal coverage structures
• A review of past analyses and current health care coverage in Washington
• A daunting list of elements for the UHCC to cover as they develop our plan

The entire meeting is well worth watching.

Meanwhile, here are our top takeaways.

Takeaway #1:  

States need access to Federal funding to enact their state-based health care systems, and this is challenging. 

A bit of background was presented by Dan Meuse, Princeton University Lecturer in Public Affairs: Medicaid is jointly funded by the federal government and states, therefore the state already has access to these funds. However, Medicare is a federally administered program that funds individuals which is why waivers are needed. 

Medicare innovation waivers offer the best savings opportunities, but are difficult to get. He gave two examples of state based strategies for the waivers:

• Maryland’s statewide waiver allows them to set a ceiling for healthcare payments and leverage the savings to other state populations
• Pennsylvania’s waiver allows rural hospitals to switch from fee-for-service billing to global budgeting

Medicaid demonstration waivers cover a state-run program that already exists. Options to utilize these waivers include:

• Adding populations
• Changing funding and payment models

Employer Sponsored Insurance includes Washington’s public employees and is the largest pool of portable dollars, as employers overpay by 200 - 400% of public programs. However there are challenges: 

• ERISA and Taft-Hartley unions are protected by federal regulations
• Multi-state employers such as Boeing and Microsoft seek coverage plans that are uniform nation-wide which would be difficult for a  state administered program to reconcile

Individual and small group markets are state-regulated, well-established, and easy to scale, however they rely on the current insurance system.

• 1332 federal waivers can be requested to address affordability in the state administered plan

Takeaway #2:  

Elements of a single statewide payment structure would need to include: 

• Global budgeting for hospitals
• A state-run Pharmacy Benefit Manager

Takeaway #3: 

While Washington has made many improvements in health care delivery there are unmet needs as presented by Liz Arjun, Health Management Associates:

• Workforce shortages, especially nursing and behavioral health  
• Racial and ethnic disparities in access to care
• The Draft Report requires more work

Takeway #4:  

CAUTION: Much Work Ahead as presented by Gary Cohen, Health Management Associates: 

• Integrate coverage disparities into a single list of covered benefits
• Think about Medicare early on
• Decide on a single reimbursement model: Value-based payment (MCO’s) or fee for service (CMS).  This is destined to be a hot-button topic. 
• Infrastructure needed, e.g., a public Pharmacy Benefit Manager. Fortunately, WA is a step ahead with the passage in 2021 of SB 5203 Producing, distributing, and purchasing generic prescription drugs.
• Governance – who administers the system? Here again, Washington is a step ahead thanks to HCFA-WA’s signature Washington Health Security Trust bill outlining an administrative structure. 

Takeaway #5: Public comments are crucial to open meetings.
Several public comments mentioned: 

• The mysterious omission in the UHC Work Group Report of the $5.5 billion in health care savings achieved annually in a publicly funded and administered system 
• The immediate need to establish the finance advisory committee to begin the application process for the necessary Federal waivers
• In the meeting Ms. Arjun, the consultant from HMA, acknowledged the public comments
• An editable Word document of the Draft Report will be made available to UHCC members to facilitate any necessary revisions