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Country Getting Healthier, Policy Experts Told

KANSAS CITY — Despite budget woes, political wrangling and the rising cost of care, people in the U.S. are getting healthier “and that’s great cause for celebration,” according to Howard Koh, HHS assistant secretary.

“The health of the individual is almost inseparable from the health of the community and both individuals and communities are getting healthier,” Koh told more than 600 attendees at the National Academy for State Health Policy’s 24th Annual State Health Policy Conference this week.

Koh said HHS plans to release statistics this week showing the country is making progress toward the department’s “2020 vision — the place where we want our country to be at the end of the decade.”

HHS last year identified some 900 objectives for the decade. The progress report will show that “our country has reached or is making progress toward 71% of those goals,” Koh said.

“Some people might look at that and say, ‘Well, you failed.’ The way I see it is if you aim for the stars but only hit the moon, you’re still out of this world,” Koh said.

Like many speakers at the three-day conference, Koh acknowledged that these are tough times for health care policy with national health care reform being challenged in courts, budget cuts — some of which are being challenged in courts — and a lingering recession that makes long-term planning difficult.  

“The common refrain is we have infinite need but only finite resources,” Koh said. “So, how do we deal with that contradictory situation? I’m an optimist and I choose to look at it this way: These giant obstacles are really brilliant opportunities brilliantly disguised as giant obstacles. We have to keep our passionate advocacy passionate. I know that’s not easy in times like these,” Koh said.

Of particular interest to conference participants are the deliberations of the congressional “super committee” working on a plan to reduce national debt. Reductions in Medicaid, Medicare and parts of the Affordable Care Act are all on the table.

Asked if there are specific parts of ACA the administration is ready to protect, Koh said, “the establishment of the prevention fund is a huge milestone for the country. That’s a new opportunity that can’t be forfeited.” He added, “We have a new, unique, unprecedented opportunity and we have to protect it with everything we’ve got.”

Earlier this year, HHS released $750 million in funding for efforts to prevent tobacco use, obesity, heart disease, stroke and cancer. The money comes from the Prevention and Public Health Fund, which was created by ACA.

California Contingent

Kim Belshé, who previously attended national policy conferences as California’s HHS secretary, brought a new perspective to this year’s event as one of five directors of the new California Health Benefit Exchange.

“These meetings are wonderful places to get new ideas, see new ways of doing things,” Belshé said. “California’s a leader in a lot of ways, but there are lots of states doing some pretty cool things that California can learn from — even a tiny little state like Rhode Island. They’re doing some very innovative things in Rhode Island.”

Tricia Leddy, senior policy adviser to the director of the Rhode Island Department of Health, described some of the ways her state is getting ready for “a change in culture.”

“Exchanges are going to change the culture in a big way,” Leddy said during a session examining how states are moving forward with exchanges. “We’re going to be moving from a pretty slow, cumbersome process based on the question, ‘Are you eligible for anything?,’  to a real-time question of, ‘What are you eligible for and how can you get it?’ That’s going to change everything,” Leddy said, “starting with another new acronym — MAGI.”

Many exchanges are going to determine eligibility using a new set of calculations known as MAGI — modified adjusted gross income. Coupled with new information technology systems, MAGI is expected to streamline and simplify enrollment and eligibility processes.

One conference session focused on lessons other parts of the country could learn from San Mateo County’s experiences with expanding coverage for uninsured adults. In 2007, San Mateo elected to cover all adults below 200% of the poverty level. The move triggered changes in six county clinics, such as a new system of team-based care, electronic health records and new approaches to chronic disease management. San Mateo’s changes were a precursor to many of the changes states face now under ACA.

Unraveling ‘Essential Health Benefits’  

John Lewis, principal analyst with the California Health Benefits Review Program, tried to help states get a handle on how the federal government may define “essential health benefits” under ACA.

“Mandates are extremely complicated and their effects are not always what you would expect them to be,” Lewis said in a panel charged with “Looking Into the Crystal Ball: Preparing for Essential Health Benefits.”

A committee from the Institute of Medicine is expected this week to deliver a set of essential benefit recommendations to HHS Secretary Kathleen Sebelius. Plans operating under the state insurance exchanges will have to adhere to the final regulations.

“There’s probably going to be a floor that will potentially be the same for all states,” Lewis said. “All mandates in states will have to be considered in relationship to that floor. But even having that starting point, things will be complicated,” Lewis predicted. “There will be a lot of unclarity in a number of areas for a period of time.”

Asked how California might deal with that level of uncertainty, Lewis — whose organization is a bipartisan coalition of university faculty providing the state Legislature with independent analyses — was circumspect.

“It is unclear at this time. Our exchange, which was recently set up, has certainly embraced openness and inclusiveness, but it’s a long road to 2014. We’ll see what happens next. Our political process is intriguing and full of extreme positions on all sides. We invented political gridlock,” Lewis said.

Austerity, Uncertainty

Two ominous themes percolated to the top of many discussions over the three-day conference: fiscal and legal challenges make planning for health care reform very difficult at every level — local, state and federal.

“There’s no question that this is a challenging environment we’re all operating in,” said Alan Weil, executive director of the National Academy for State Health Policy. “But despite strong political rhetoric in some places, most states face common health care challenges and it makes sense for all of us to be moving forward to meet them.”

He added, “If next year the Supreme Court or Congress strike down all or part of the ACA, we at NASHP will neither dance on the tabletops nor cry in our soup. We’ll do what everybody in every state will do, we’ll move forward and continue to work to improve our system.”

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