Heather Howard, JD, a Quality Institute board member, is director of State Health and Values Strategies and a Lecturer in Public Affairs at the Woodrow Wilson School at Princeton University.
You just returned from testifying before the California legislature. Can you tell us why you traveled to California?
I was invited by the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage. I was asked to give an overview of state efforts to get to universal coverage. California is a state interested in providing coverage to more of its residents, and although California is obviously different than New Jersey in many ways, it was interesting to see that they face many similar challenges.
No doubt your overview was extensive and anyone can see a video here. Can you also share some key highlights?
California is asking, “How do we get to universal coverage, and how can we deal with the growth of health care costs?” I spoke about the creation of Medicaid in 1965 and how the program was at first optional for states. But over time, all the states came in. And federal funding created the scaffolding that most state coverage initiatives depend upon. I was trying to paint a picture of state innovation — that states adopted the program in different years and with different flavors. Similarly, states adopted CHIP (the Children’s Health Insurance Program) in different years and with different eligibility levels. New Jersey, for example, has a robust program that covers many children and their parents. I also talked about universal coverage efforts in Hawaii and Massachusetts — states that were successful in their efforts because they leveraged significant federal funds or secured waivers of federal rules. I concluded that, while states do have a lot of levers and I’m heartened by the interest in states taking action to increase coverage, we’ve learned that you need the federal government as a willing and engaged partner. You need federal resources and you need flexibility from federal rules.
What makes this conversation critical right now?
Federal policy is uncertain and highly dynamic now. There have been proposals to cut the Medicaid program substantially, and this tax bill may result in cuts to Medicaid. So clearly, the wild card for state innovation is the role of the federal government. It’s hard for states to go out on their own, and I am not sure the federal government right now wants to be a partner. So states will need to explore ways to move the needle on costs and coverage without federal support.
What can California learn from New Jersey?
If the federal tax bill repeals the individual mandate for health insurance, that’s a real risk to the Affordable Care Act. We learned that first hand in New Jersey in the 90s, when we adopted guaranteed issue but did not have a mandate. The ACA is based on a three-legged stool: you need fair rules, especially no discrimination against people with pre-existing conditions, you need subsidies to help people afford insurance, and you need everybody in — especially young and healthy people, which is why you need an individual mandate. We learned that in New Jersey when the individual market went into a death spiral. So we know how this movie ends. If the individual mandate is repealed, states like New Jersey will need to think about state-level incentives for people to purchase and maintain coverage.
Are other states finding innovative solutions that may translate to New Jersey?
Yes. I talked about how Alaska, Minnesota and Oregon have instituted reinsurance programs and were able to lower insurance premiums as a result.
Peter Shumlin, former governor of Vermont, also testified at the hearing in California. He talked about the failure of a single payer system in Vermont, and he commented that there are no political winners in health reform — something we have learned over a century of efforts to health reform. So you don’t create health reform for a political win. You do it because it’s the right thing to do.