Psychiatr News August 17, 2007
Volume 42, Number 16, page 12
© 2007 American Psychiatric Association
States Vary in Commitment to Their Uninsured Residents
Rich Daly
A health care "scorecard" finds that despite the steadily
growing ranks of the uninsured, some states have identified ways to provide
high-quality services at lower cost.
Economic factors have been a key ingredient in the rapid growth of the
number of uninsured adults in recent years, according to a new scorecard of
statewide health factors. The declining levels of insurance coverage were
linked to poorer health among the populations of many states.
The good news is that expanded federal and state spending on children
through Medicaid and the State Children's Health Insurance Program have led to
better insurance coverage and improved health among children in many states in
recent years.
States in the Northeast and upper Midwest had more effective policies and
programs to promote health among users of public and private health care,
according to the report "Aiming Higher: A State Scorecard on Health Care
System Performance," by the Rutgers University Center for State Health
Policy and the Commonwealth Fund.
States with the best overall health care outcomes consistently outperformed
the weaker states in every specific health care category measured, such as
high quality and safety. These statewide trends suggested to the authors that
policies and programs that encouraged better health care were the cause. The
scorecard used a variety of data sources to measure health care quality,
access, crisis-related hospital use and costs, and healthy lives. The measures
were designed to identify which states are the closest to a "high
performance health system" that is able to help residents achieve lives
that are as long and healthy as possible.
The core finding, the researchers said, was the crucial role played by
changes in health insurance coverage, which reduced health care access. The
number of states with 23 percent or more of their adults uninsured tripled
from four in 1999-2000 to 12 in 2004-05. In the same period, the number of
states with less than 14 percent of adults uninsured dwindled as employer
coverage became less affordable and costs outstripped wages.
"One of the themes we see running throughout the scorecard is this
close correlation of access and quality," said Cathy Schoen, senior vice
president at the Commonwealth Fund and one of the report's authors, during a
June press briefing on the scorecard. "States that do well on access are
also doing well on quality."
Economy Often Key Factor
The problems with access are linked to economic trends in many states. One
state with declining health measures, Oklahoma, experienced a series of
economic setbacks in the last 20 years as its core oil industry hit hard
times. That state is one of a growing number with at least 23 percent of
adults aged 18 to 64 who are uninsured.
"We have one of the highest rates of uninsurance in the
country," said Peter Budetti, M.D., a professor at the University of
Oklahoma College of Public Health.
Age-adjusted mortality rates in Oklahoma used to be very close to the
national mortality rates, but they suddenly separated a decade ago, he said,
when his state's rate exceeded national norms.
Even states that did better in the scorecard experienced declines in recent
years. Chris Koller, Rhode Island's health insurance commissioner, said a
variety of factors contributed to the rise in the number of uninsured adults
in his state.
Koller said 45,000 state residents lost insurance from 1999-2000 to 2004-05
because employers tightened eligibility to exclude part-time workers.
Companies took this action to control the rising costs of insuring their
full-time workers.
Mary Wakefield, associate dean for rural health at the University of North
Dakota School of Medicine, said good scorecard results for her state were
linked to several factors, including a higher-than-average ratio of primary
care providers to population. Research studies, she said, have identified
primary care as the key to managing chronic and expensive-to-treat conditions
such as diabetes and asthma.
"States that rely more on primary care to manage chronic illness tend
to have lower Medicare spending and use fewer hospital beds," she
said.
Schoen noted that the scorecard did not find a "systematic
relationship" between health care costs and quality. The report
identified several instances of states that had widely available, high-quality
care that were spending less than states where quality of care lagged.
Solutions Differ
Highlighting some state efforts to improve the overall health measures
assessed in the scorecard report, Koller noted that Rhode Island has launched
an effort to fund expanded disease-prevention efforts and will seek more
federal assistance to augment that effort.
Oklahoma has started an insurance-subsidy program for employees of small
businesses to compensate for the declining number of such businesses offering
health insurance. It also is using increased cigarette taxes to fund health
care programs and a healthy-living initiative to raise its residents'
awareness of health-related issues.
Increased use of health-information technology and telemedicine, Wakefield
said, should improve statewide health care outcomes, especially in states with
large rural areas. The most promising approaches will increase coordination of
the health care provided, such as expanded use of "medical homes,"
which assign one clinician to coordinate all of a patient's health care
needs.
"I would encourage health staff to think about this, to think about
filtering every policy, piece of legislation, program that you are evaluating
through a prism that helps you to distinguish whether the policy or piece of
legislation you are looking at will further fragment or splinter health care
delivery and payment policy, or whether [it] could help to build system-ness,
cohesion, and coordination into health care," she
said.
"Aiming Higher: A State Scorecard on Health Care System
Performance" is posted at
<http://allhealth.org/briefing_detail.asp?bi=108>.
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