U.S. Public School Enrollment-Based Health Insurance Initiatives and America's Uninsured

ABSTRACT: This article reviews current literature on school enrollment-based health insurance programs underway or pending in the United States. This model of affordable family health insurance delivery was first proposed in a 1988 New England Journal of Medicine Sounding Board article, but only a few states - Arkansas, Florida, New Hampshire, and Texas - have begun public sector-driven programs in the 1990s that use school enrollment as a pooling mechanism to purchase group insurance policies from the private sector. Public support of this model is strong, interest is currently growing, and other states, including North Carolina and Iowa, are exploring or have enacted legislation that supports establishment of school enrollment-based health insurance programs. After summarizing these public-sector initiatives, additional information is presented on uninsuredness in America; risk factors for uninsuredness among children; and national public and private initiatives in child health insurance using eligibility criteria other than or including school enrollment that were examined by the GAO in 1994/95.     

Estimating the Cost to U.S. Health Departments to Conduct HIV Surveillance

Objectives

HIV case surveillance is a primary source of information for monitoring HIV burden in the United States and guiding the allocation of prevention and treatment funds. While the number of people living with HIV and the need for surveillance data have increased, little is known about the cost of surveillance. We estimated the economic cost to health departments of conducting high-quality HIV case surveillance.

Methods

We collected primary data on the unit cost and quantity of resources used to operate the HIV case surveillance program in Michigan, where HIV burden (i.e., the number of HIV cases) is moderate to high (n=14,864 cases). Based on Michigan''s data, we projected the expected annual HIV surveillance cost for U.S., state, local, and territorial health departments. We based our cost projection on the variation in the number of new and established cases, area-specific wages, and potential economies of scale.

Results

We estimated the annual total HIV surveillance cost to the Michigan health department to be $1,286,524 ($87/case), the annual total cost of new cases to be $108,657 ($133/case), and the annual total cost of established cases to be $1,177,867 ($84/case). Our projected median annual HIV surveillance cost per health department ranged from $210,600 in low-HIV burden sites to $1,835,000 in high-HIV burden sites.

Conclusions

Our analysis shows that a systematic approach to costing HIV surveillance at the health department level is feasible. For HIV surveillance, a substantial portion of total surveillance costs is attributable to maintaining established cases.An estimated 1.2 million people aged 13 years and older are living with human immunodeficiency virus (HIV) in the United States, and about 47,500 people are infected with the virus each year.^1,2 A recent HIV surveillance report shows that the number of people living with HIV increased by 8% from 2006 through 2009.³ The U.S. Centers for Disease Control and Prevention (CDC) has developed an HIV surveillance system for collecting, analyzing, and disseminating accurate information on the number of people with new HIV diagnoses (new cases) and those living with HIV infection (established cases).^4,5 Access to timely and high-quality surveillance data is essential to detect trends in the HIV burden and develop appropriate prevention and control measures.^4,6,7 The U.S. Department of Health and Human Services has closely aligned the $16 billion it spent in 2010 on HIV care, treatment, and prevention with the number of reported HIV cases in each state.⁸ HIV case surveillance additionally guides the implementation of test-and-treat prevention strategies that require data on timing of diagnosis, entry into and retention in care, and viral load (VL) suppression.^8–10 The Institute of Medicine recently identified HIV case surveillance as one of the data collection systems that could be used to monitor progress in achieving National HIV/AIDS Strategy goals.^11,12The purpose of this analysis was to estimate the economic cost to health departments to conduct high-quality HIV case surveillance, where high quality is defined as meeting or exceeding CDC data quality standards regarding the completeness and timeliness of reporting diagnosed HIV cases and ascertaining duplicate cases and deaths.^6,7 We examined potential variation in costs across health departments based on differences in the number of new vs. established HIV cases, area-specific wages, and potential economies of scale. Results from the analysis could help inform surveillance funding allocation across health departments and enable health departments to more accurately assess their own costs attributable to new and established HIV cases.     

美军初级医疗保健模式改革

本文分析美军开展"以患者为中心的医疗之家"初级医疗保健模式改革的动因、进展,阐述这种新模式的内涵、核心原则和优点,并提出对我军初级医疗保健模式建设的启示。     

The Adoption and Discontinuation of Clinical Services by Local Health Departments

Objectives. We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.Methods. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.Results. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities’ scope over time, increased community partners’ involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.Conclusions. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.The role of local health departments (LHDs) in offering clinical services is hotly contested in public health practice. Some LHD leaders believe that offering clinical services is critical to their mission1 and public image.2 Others embrace the position of the Institute of Medicine (IOM) on the future of public health, which calls for LHDs to focus on core public health functions of assessment, assurance, and policy development and away from clinical services.3,4Most LHDs have decreased clinical service offerings over time (discontinued).1,3,5,6 Some have done so because their leaders believe that offering clinical services is inconsistent with the LHD’s mission,6,7 diverts resources from population-based services,3,8 or distracts from core public health functions.1,7 Leaders of LHDs may rely on non-LHD public health system partner organizations to provide clinical services for vulnerable populations rather than providing them directly.1 They may see the private sector as more appropriate than LHDs in delivering clinical care.1,6,9 For example, in some regions, Medicaid managed care organizations collaborate with LHDs to ensure clinical services.5,10,11However, some LHDs have maintained or increased their clinical service offerings over time (adopted) because their leaders view clinical services as part of their mission,1 derive satisfaction from patient contact,5 or believe that offering such services is part of the core public health function of ensuring access to care to their patients if care is not available elsewhere.2,3,8,12 They offer clinical services if no private sector alternatives exist,6,12 or if the LHD is uniquely qualified in dealing with specific vulnerable populations2,5 or for certain conditions (e.g., infectious disease control).1 These LHDs may offer clinical services if no other safety net providers are available or community need is high. For instance, 63.3% of LHD directors in 2000 believed that LHDs should offer clinical services when no other organization was available to do so, compared with 23.6% of directors who believed that LHDs should offer clinical services unequivocally.7 Other LHDs may offer clinical services to generate revenue to fund other operations.1,13,14We posit that 3 main drivers underlie LHD decisions to offer clinical services. First, a conflicting goal driver suggests that LHD leaders may view offering clinical services as conflicting with core public health functions, particularly when they have few resources.1,7 Performance of these functions by LHDs varies with jurisdiction-level sociodemographic factors, and LHD organizational and public health system attributes.15–18 Second, an assurance driver suggests that LHDs offer clinical services if leaders believe that residents lack access to care, that the LHD has important expertise in providing clinical services to vulnerable patient populations, and that LHDs should provide these services when these services are limited. Third, an entrepreneurial driver suggests that LHDs leverage revenue-generating clinical services to fund needed public health services.5,13,19 The 3 drivers are not mutually exclusive. For instance, an LHD may stop offering comprehensive primary care because of the conflicting goal driver, and simultaneously start offering tuberculosis screening because of the assurance driver.The drivers provide a framework for understanding LHD decisions about the provision of clinical services, elucidating how LHDs change their clinical service offerings in response to strategic and environmental changes. We explored how the 3 drivers relate to 2 decisions: (1) whether an LHD departs from the majority and the IOM recommendations and maintains or offers more clinical services over time (an adoption decision) and (2) conditional on the LHD’s decision to discontinue services, how many fewer clinical services to offer over time (a degree of discontinuation decision). Institutional theory suggests that conformity pressures lead organizations to become more similar in behavior over time,20 but others resist such pressures for strategic reasons.21 Thus, we expected that LHDs adopting clinical services over time (adopters) would do so for different reasons than LHDs following the norm of discontinuing clinical services over time (discontinuers), and that leaders at discontinuer LHDs deciding how many clinical services to discontinue may do so for yet other reasons. Because we compared LHDs that followed the norm of decreasing the number of clinical service offerings1,3,5,6 with those that departed from the norm, we defined adoption to include offering the same number of clinical services over time. Our focus on the number of clinical services does not mean that the actual mix of clinical services offered stayed the same across time.2,5 number of community clinical service providers, and Medicaid reimbursement levels. Public health system attributes measure the LHD jurisdiction’s delivery on core public health functions across 3 dimensions: differentiation, integration, and concentration. Differentiation indicates the jurisdiction’s emphasis on public health needs, with high differentiation indicating that the jurisdiction offers many core programs or services. Integration indicates how different organizations interact in providing these services, with high integration indicating that many partnering organizations offer these services. Concentration measures the LHD’s role, with high LHD concentration indicating that the LHD bears primary responsibility for offering these services. Mays et al.22 described these 3 dimensions in further detail.

TABLE 1—

Conceptual Model Describing the Conflicting Goal, Assurance, and Entrepreneurial Drivers and the Factor Categories Associated With Adoption and Degree of Discontinuation of Clinical Services by Local Health Departments

Health plan implementation of U.S. Preventive Services Task Force A and B recommendations--Colorado, 2010

The Patient Protection and Affordable Care Act (PPACA) is aimed at expanding access to health care and lowering cost barriers to seeking and receiving care, particularly high-value preventive care. The legislation requires Medicare and all qualified commercial health plans (except grandfathered individual and employer-sponsored plans) to cover routine preventive services graded A and B by the U.S. Preventive Services Task Force (USPSTF) at no cost to the consumer, along with recommended immunizations and additional preventive care and screenings for women. In 2009, Colorado passed a law with similar USPTF A and B service coverage requirements. To determine how Colorado health plans had interpreted the state and federal law, the Colorado Department of Public Health and Environment (CDPHE) interviewed representatives of commercial health plans serving Colorado residents. The results of those interviews indicated that different health plans interpreted certain USPSTF recommendations differently, including tobacco screening and pharmacotherapy, colorectal cancer screening, and obesity screening and counseling. One health plan communicated the scope, eligibility criteria, and content of the new preventive services coverage to its members or providers. The differences in interpretation of the USPSTF recommendations and limited communication to consumers or health-care providers in Colorado might be repeated in other states. To ensure optimal consumer and health-care provider utilization of preventive service benefits, the preventive services supported by USPSTF A and B recommendations should be clearly defined in health plan benefit language, with processes put in place for consistent implementation and eligibility criteria communicated to both consumers and providers. The experience in Colorado shows that public health organizations can play a key role in successfully implementing PPACA prevention services provisions.