Funding Area: Expanding Health Care Coverage

In the second of two grants from the New York Health Foundation’s Coverage Consortium initiative, the Nelson A. Rockefeller Institute of Government implemented Phase 2 of a project that focused on reform options for New York’s small-group insurance market . This project built on the knowledge base developed in the first grant phase, with specific analyses focused on insurance product standardization, advantages and disadvantages of high-risk pools, and sustainable methods for financing coverage expansions.

This project was part of a larger NYHealth Coverage Consortium that funded 10 grants to seven universities, policy institutes, and community agencies across the State, supporting projects that could inform State health reform efforts, offer ways to streamline enrollment in public programs, significantly reduce costs and improve quality, and test ideas for expanding coverage among small employers, sole proprietors, and self-employed people.

Read an NYHealth special report that contains a summary of findings from this consortium.

Read about the first of two grants to the Rockefeller Institute from the NYHealth Coverage Consortium initiative.

In Phase 2 of this project, the Nelson A. Rockefeller Institute of Government will focus on reform options for New York’s small-group insurance market and build on the knowledge base developed in the first grant phase. As the research arm of the State University of New York since 1981, the Nelson A. Rockefeller Institute of Government conducts studies and projects to help states and localities meet critical challenges.

Phase 1 of the Reforming the Small-Group Insurance Market project included a 50-state synthesis of small-group reform strategies. This encyclopedic analysis describes a “menu of options” that states across the country have adopted to address their small-group insurance markets. The experience of three innovative states (Maine, Minnesota, and New Jersey), were analyzed and recorded as case studies. Specific analyses of Phase 2 will focus on insurance product standardization, advantages and disadvantages of high-risk pools, and sustainable methods for financing coverage expansions.

As the number of uninsured has increased and employer-based coverage has declined, policymakers have begun to focus their attention on the small group market. This focus suggests the need for closer analytical assessment of State activities aimed at improving cost and accessibility in the small group market. In the first of two grants from the New York Health Foundation’s Coverage Consortium initiative, the Nelson A. Rockefeller Institute of Government conducted an in-depth analysis and investigation of the applicability of various initiatives and policy options for New York State.

This project was part of a larger NYHealth Coverage Consortium that funded 10 grants to seven universities, policy institutes, and community agencies across the State, supporting projects that could inform State health reform efforts, offer ways to streamline enrollment in public programs, significantly reduce costs and improve quality, and test ideas for expanding coverage among small employers, sole proprietors, and self-employed people.

Read an NYHealth special report that contains a summary of findings from this consortium.

Read about the second of two grants to the Rockefeller Institute from the NYHealth Coverage Consortium initiative.

The Rockefeller Institute will study the small group health insurance market and investigate the applicability of various initiatives and policy options for reforming this market.

As the number of uninsured increases and employer-based coverage declines, policymakers are beginning to focus attention on the small group market. This focus suggests the need for closer analytical assessment of state activities aimed at improving cost and accessibility in the small group market. To better guide decision-making, the Rockefeller project team will conduct an in-depth analysis and investigation of the applicability of various initiatives and policy options for New York State.

During the first phase of the project, the team will review existing information on states’ experiences with small group reform and a national assessment of current state small group activities. This review will contribute to the content of a New York-focused primer on small group market policies, coverage options, and challenges. Given that many states are already implementing actions to improve the small group market, the second phase of this project will identify major design, management, and implementation issues that could influence the design and actions in New York State.

The Rockefeller Institute project team will collect and synthesize information to inform discussion, analysis, and debate among policymakers and State officials about the small group and individual insurance market during working seminars held at different points in the project period. The Rockefeller Institute’s working seminars will be targeted primarily at state officials and policymakers. The seminars will address the major challenges expected to arise from attempts to improve the small group market and identify those issues most likely to be relevant to public discussions in New York.

As part of the NYHealth Coverage Consortium, the United Hospital Fund project will also support developing some proposals and projections for restructuring the small group and individual insurance markets. The Rockefeller project team will provide the baseline information needed for these analyses by describing how the markets function today and how other states have addressed problems in these markets.

Finally, results of this overall project will be disseminated to an appropriate set of stakeholders who can shape and mold policy based on the results. According to the Department of Insurance, information developed from this project will be very helpful in providing a starting point for reforming the State’s small group and individual health insurance markets.

This project is part of the NYS Health Coverage Consortium.

Medicaid is the single largest funding source for long-term care, paying for half of all nursing home and community based long-term care in the nation. Given the disproportionate use of Medicaid as a funding source for long-term care, the New York State Department of Health’s Office of Health Insurance Programs was looking for potential policy improvements to better target Medicaid spending and services.

In addition, many states are looking for ways to reduce asset transfers as a means for reducing long-term care costs. Under this grant, New York State Health Policy Research Center at the Rockefeller Institute of Government (Rockefeller) undertook two studies. The first study compared New York State to other states on a range of long-term care issues. The second study reviewed the prevalence of denials for Medicaid-funded nursing home care and found wide variation in reported denial rates across the State’s counties. Both reports resulted in widespread press coverage across the State.

This project was part of a larger NYHealth authorization that funded a series of quick-strike analyses to help the New York State Department of Health’s (NYSDOH’s) Office of Health Insurance Programs find ways to streamline and expand its public health insurance programs.

Read an NYHealth special report that contains a summary of findings from this authorization.

Read Medicaid and Long-Term Care: New York Compared to 18 Other States, a Rockefeller-produced report about how New York compares with other states on a range of long-term care issues, such as demographics, spending, and quality.

Read Assessing Asset Transfer for Medicaid Eligibility in New York State, a Rockefeller-produced report about the incidence of asset transfers for Medicaid-funded long-term care.

Read additional analyses NYHealth funded Rockefeller to conduct based on its findings on rates of asset transfers.

One important lesson emerged from this project regarding data extractions. Although the data necessary for this project were collected for administrative purposes, they were difficult to use for research. One way to address this shortcoming is to fund upfront work to see if the desired analysis is possible and whether the limitations present too much of a barrier to make a larger study worthwhile. Read about how this issue has come up on another NYHealth grant to date.

New York spends more public money on health care per capita than any other state. Yet, despite this investment, the State faces challenges to improve patient outcomes, modernize health care delivery, reduce costs, and increase access and coverage. Rockefeller Institute will support the New York State Department of Health in studying options for Medicaid reform.

Rockefeller Institute will undertake two key activities to support the State Department of Health. Institute staff will provide assistance in shaping the administrative studies that outside experts will conduct. Staff also will solicit proposals from experts, coordinate the review of the proposals, and manage the grantees funded under this initiative. The second category of activities involves undertaking “quick turnaround” data analyses for the State Department of Health related to its efforts to expand enrollments in public insurance programs.

To undertake this project and to stimulate other work related to state health policy, the Rockefeller Institute, the public policy research arm of the State University of New York, will create the New York State Health Policy Research Center. The institute will seek to mine in-state expertise, employ national expertise, and conduct thorough analyses of health care in New York State.

The State has many organizations and experts working on health care—including staff in the legislature and the governor’s office, trade organizations, staff at the New York State Department of Health (DOH) and other state agencies, and nonprofit organizations, such as the United Hospital Fund, the Manhattan Institute, New York University, Columbia University’s School of Public Health, and the Rockefeller Institute. These efforts, however, are not sufficiently connected. Unlike other states (e.g., Massachusetts, California, and New Jersey), New York does not have a single or predominant networking entity for health care policy research.

Known for its expertise in the conduct and dissemination of public policy research, the Rockefeller Institute’s efforts will take advantage of its in-house talent to pursue short- and long-term research projects on health care challenges in New York State. At the same time, the Institute will also seek out some of New York and the nation’s top scholars and health care experts to write research papers and perform research projects focused on New York’s health care system. The end result of this endeavor will be the creation of a clearinghouse for New York’s health care experts that will work in collaboration with the NYHealth Coverage Consortium to address New York’s health insurance coverage crisis.

This project is funded under the NYHealth authorization: Medicaid Reform in New York State: Supporting Analyses to Expand, Simplify and Reform the System.

Under Medicaid’s rules, an individual’s income and assets are taken into consideration when determining his or her eligibility for long-term care coverage.

Those having either income or assets that exceed the annual limits are not eligible. Applicants who transferred their assets (to other family members or to a trust, for example) within five years of applying for Medicaid long-term care coverage are also not eligible. According to a March 2009 report published by the Nelson A. Rockefeller Institute of Government (Rockefeller Institute) and funded by the New York Health Foundation (NYHealth), there is substantial variation and difference in the magnitude of Medicaid denial rates of long-term care coverage across New York’s 62 counties. With a Phase 2 grant from NYHealth, the Rockefeller Institute conducted a study to uncover possible reasons for discrepancies in denial rates and provide actionable recommendations to standardize practices throughout the State.

To be eligible for Medicaid long-term care, applicants must meet income and asset rules, and not have transferred assets (e.g., to another person, a trust, or annuity) within five years of the application. According to the Phase 1 grant, statewide, the transfer of personal financial assets resulted in denying an average of 7% of Medicaid long-term care applications during the last 10 years. However, the study found wide variation in the rate of denials due to asset transfer with some counties denying close to 50% of applications and others denying less than 1%. Among the State’s larger counties, the study found higher-than-average rejection rates in Rockland (24.2%), Ulster (22.6%), Saratoga (14.6%), and Suffolk (14.5%) counties. In Westchester (0.5%), Dutchess (1.0%), Schenectady (1.2%), Rensselaer (1.3%), Orange (1.4%), and Erie (2.1%) counties, rejection rates were well below the statewide average. These disparities may stem from differences in how the rules are understood and applied across the counties. The Phase 2 grant will seek to identify the factors driving this variation, the potential cost impact to the State, and specific actions the State and counties can take to minimize variation in denial rates. Smoothing out county-level differences has large cost implications; Medicaid is the largest funding source for long-term care in New York State, and more than 40% of the $49 billion being spent on Medicaid in 2009 is for long-term care.

Governor Cuomo established the Spending and Government Efficiency (SAGE) Commission in one of his first acts (Executive Order No. 4) to create a more efficient and effective state government.

In the health arena, the SAGE Commission is examining how to better manage care for patients across similar agencies, and how to reduce unnecessary and redundant regulatory burdens on care providers. Under this project, the SAGE Commission is completing a reorganization plan for health-related agencies that has the potential to significantly impact health care delivery in New York State for many years, particularly with Medicaid—a $53 billion program that must be run more efficiently. The reorganization plan has the potential to not only create efficiencies and better coordination among the agencies that operate Medicaid-funded programs, but to create better coordination of care that will benefit consumers of these services.

The SAGE Commission supported an experienced and knowledgeable researcher and assistant who collected information and conducted analyses and briefings for the SAGE Commission’s health reorganization task force. The health reorganization task force is charged with analyzing the problems that arise from the existing organizational structure, as well as determining how to remedy shortcomings. It produced a detailed analysis of current agency functions and where functions overlap; organized the work of other task force participants on these issues; compared New York’s agency structure with best-practice solutions found in other states; and articulated and quantified the benefits and costs of alternative organizational structures.

As part of this grant, The Nelson A. Rockefeller Institute of Government also hosted a workshop on November 22, 2013, entitled Open Health Data, Open Opportunities.