STAFF SUMMARY OF MEETING
HEALTH CARE TASK FORCE
|Time:||09:04 AM to 04:07 PM|
|This Meeting was called to order by|
|This Report was prepared by|
X = Present, E = Excused, A = Absent, * = Present after roll call
|Bills Addressed: ||Action Taken:|
|Update on Behavioral Health in Colorado|
Update on Screening and Brief Intervention Program
Portability of Health Insurance
Gender Rating in Health Insurance
Update on Academic Medical Centers
09:05 AM -- Update on Behavioral Health in Colorado
Senator Boyd welcomed the committee and discussed the possibility of scheduling an additional meeting of the Health Care Task Force.
Doyle Forrestal, Colorado Behavioral Healthcare Council (CBHC), distributed a copy of her presentation to the committee (Attachment A). She described the CBHC, which is a nonprofit membership organization that represents Colorado's statewide network of community behavioral health care providers, including 17 community mental health centers (CMHCs), 2 specialty clinics, and 5 behavioral health organizations. In 2008, the statewide network of CMHCs served 89,213 unduplicated clients. She described the types of services provided by Colorado's CMHCs, including assessment, case management, emergency and crisis, and family, individual, and group therapy services. Funding sources for CMHCs include state funds, Medicaid, local government money, and third-party payments. She discussed the impact of past budget cuts on community mental health services. Ms. Forrestal described the impact of the budget cuts and decrease in the services on incarceration rates.
Ms. Forrestal discussed the percentage of individuals involved with the criminal justice system who have moderate to severe mental health needs. She discussed the cost of community mental health services versus the costs of the criminal justice system. Ms. Forrestal described the public costs of untreated behavioral health issues. In addition, she noted that the personal cost of untreated behavioral health issues can include early death and increased contact with the criminal justice system. She discussed some provisions of federal health care reform legislation that concern behavioral health care. She discussed the CBHC's goals related to integrated care, reducing stigma, and working with the criminal justice system. She responded to questions from Representative Kerr regarding the types of criminal behavior that individuals with mental illness may engage in.
09:34 AM -- Update on Screening, Brief Intervention, and Referral to Treatment Program
Carmelita Muniz, Executive Director of the Colorado Providers Association, began the presentation on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program. An outline of her presentation and two packets of information related to the SBIRT program were distributed to the committee (Attachments B through D).
Leigh Fischer, Program Manager, SBIRT Colorado, described the SBIRT program. She explained that in 2006, Colorado received a five-year grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to implement the initiative. She described the public and private partnerships that support the program and gave an overview of the services offered through the program. She described the program's goal, which is to implement standard drug and alcohol screenings at medical interventions. She discussed the brief intervention component of the program, stating that even short conversations regarding drug and alcohol abuse can impact behavior. The target population of the program is nondependent users of alcohol and drugs. About 60,000 individuals have been screened through the program, and about 11 percent of those screened through the program were in the target population of users who are in danger of becoming addicted to alcohol or drugs.
Dr. Kerry Broderick discussed the use of the SBIRT program in medical settings and the importance of screening programs in decreasing the incidence of diseases. Carolyn Swenson, Project Manager, Colorado Clinical Guidelines Collaborative (CCGC), described the CCGC, noting that the collaborative's goal is to disseminate the latest evidence related to the treatment of diseases. She highlighted two clinical guidelines completed by the CCGC, including a guideline on preventative health care and the SBIRT guideline. The guidelines are being promoted to physicians as tools to use in their interactions with patients. Ms. Fischer responded to a question from Representative Frangas regarding long-term outcomes data related to the SBIRT program. Ms. Swenson responded to questions from Representative Massey regarding prevention activities related to smoking. Ms. Fischer responded to additional questions from the committee regarding barriers to implementing the SBIRT program.
10:14 AM -- Portability of Health Insurance
Senator Boyd explained that the Health Care Task Force was required to consider issues related to health insurance portability as a result of legislation that passed during the 2009 legislative session. Dick Cauchi, National Conference of State Legislatures (NCSL), provided an overview of issues related to the portability of health insurance and distributed a packet of information related to portability to the committee (Attachment E). He gave a definition of health portability, which is a health insurance plan or coverage that remains in force, or the eligibility to obtain or buy coverage, despite a change in employment or geographic location. He noted that there is no standard or common legal definition of portability. He discussed the federal Health Insurance Portability and Accountability Act (HIPAA), which provides legal protections that require replacement health policies to cover pre-existing conditions in some cases. HIPAA is guarantee of access to a new set of private market health insurance benefits, not to the same policy or benefits. Mr. Cauchi discussed "elimination riders" permitted for individuals who are not eligible for HIPAA. Thirty-seven states allow health problems disclosed at the time of application to be excluded from coverage by an amendment to the individual health insurance contract. Twenty-two states have 18 month or permanent exclusions. Colorado and 23 other states have shorter 12-month pre-existing exclusion and look-back periods. Four states have six- or nine-month exclusions. Mr. Cauchi explained that some health care coverage is portable, including federal Medicare, Medicaid, and Veterans benefits. He discussed the Consolidated Omnibus Budget Reduction Act (COBRA), which is a federal program that provides temporary continuation or portability of health insurance up to 18 months after leaving a job. Some states, including Colorado, have "mini-COBRA" programs which extend eligibility for continuation for small employers with between 2 and 19 employees. He discussed high-risk pools, which are operated by 35 states, including Colorado.
Mr. Cauchi described state innovations related to portability, including state-mandated cafeteria plans. In five states (Connecticut, Massachusetts, Minnesota, Missouri, and Rhode Island), the use of "health reform" cafeteria plans are mandatory for some employers. Cafeteria plans are tax-advantaged employee benefit plans. The use of cafeteria plans to purchase individual health insurance policies allows for some portability since changing employers may allow the worker to keep the same insurance policy. He discussed health insurance connectors and exchanges, using Massachusetts as an example. Massachusetts created the insurance connector in 2007, and this reform merged the small group and individual insurance markets in that state. Mr. Cauchi stated that the connector creates a "safe world" for small employers in particular because employers are relieved of having to run an insurance plan while still contributing to it and are assured that employees have quality coverage to pick from. Portability of health insurance through the connector is guaranteed by law, and full- and part-time workers are eligible. Mr. Cauchi discussed the Cover Florida Health Care Program, which is intended to provide coverage to residents ages 19 to 64 who are without insurance. He also described the Cover Tennessee program, which is a "three-share" program in which the state, employers, and employees contribute to the cost of the coverage. He discussed federal health care reform legislation. Mr. Cauchi responded to additional questions from Representative Kerr regarding problems with the Massachusetts and Tennessee health insurance plans. He responded to questions from Senator Schwartz regarding COBRA.
Chris Lines, Colorado Division of Insurance, Department of Regulatory Agencies, discussed two handouts distributed to the committee: a table describing Colorado's health insurance markets and portability and a table describing COBRA versus Colorado continuation/conversion coverage (Attachments F and G). Dayle Axman, Colorado Division of Insurance, Department of Regulatory Agencies, described Colorado's health insurance markets and portability options. She discussed the differences between COBRA and Colorado's continuation coverage requirements. Ms. Axman responded to questions from Senator Foster regarding the cost of COBRA, and from other committee members regarding coverage for pre-existing conditions.
Kelly Esselman, Mountain States Employers Council, Inc., began her presentation related to health insurance portability issues for employers. She stated that it is important to understand the connection between employers and insurance, stating that employers want to do the right thing and provide health insurance to their employees, but some regulations impede this. She discussed HIPAA, noting that it only applies to the group market. She stated that HIPAA does have some provisions that ensure that employers can renew their coverage, but does not restrict premium increases when coverage is renewed. She discussed special enrollment periods provided under HIPAA, and explained the provisions of COBRA and the cost of coverage provided through COBRA. She noted that the federal stimulus act, the American Reinvestment and Recovery Act, provided money to subsidize the cost of the coverage obtained through COBRA. She stated that a lot of individuals are not eligible for the subsidies because they qualify for other group coverage, such as coverage through a spouse's employer. She discussed the events that are not considered qualifying events to become eligible for COBRA, including if an individual is transferred to a position without benefits, or if an employer goes out of business. She stated that efforts related to portability, including HIPAA and COBRA, have addressed issues related to access to coverage, but not the cost of the coverage. She emphasized the importance of also considering cost when developing legislation related to portability.
Dr. Robin Baker, The Bell Policy Center, introduced herself and distributed handouts related to nongroup health insurance (Attachment H), the adequacy of health insurance benefits (Attachment I), and the affordability of health care (Attachment J). A copy of her testimony was also distributed to the committee (Attachment K). She noted that the nongroup or individual health insurance market is increasingly being looked at as a solution to the cost of health insurance, but that the market has problems related to equity. Dr. Baker noted that individuals overwhelmingly prefer employer-based health insurance coverage. She stated that nongroup coverage is primarily used as a bridge between employer-based plans. She discussed the costs of nongroup coverage, including the unfavorable tax treatment of nongroup plans. Dr. Baker noted that inconsistent coverage leads to a number of problems. She described some ways to increase the portability of health insurance, including extending the state's mini-COBRA law, requiring health insurers to cover decisions of prior health insurers, allowing children to stay on their parent's coverage longer, using cafeteria plans, and other options.
Dede de Percin, Colorado Consumer Health Initiative, discussed how portability relates to continuity of health care. She discussed the various ways in which employers provide health care coverage to their employees, including through medical, dental, vision, and workers' compensation insurance. She discussed the barriers individuals may face in obtaining health insurance coverage. Ms. de Percin discussed rescission with regard to individual health insurance policies, stating that policies are at times rescinded if the covered individual failed to disclose certain medical conditions at the time the coverage was issued.
Vanessa Hannemann, Colorado Association of Health Plans, noted that there hasn't been evidence of the rescissions described by Ms. de Percin in Colorado. She noted that many health insurance rules are meant to address situations in which individuals do not purchase health insurance until they are sick. She discussed the ways in which federal health care reform legislation is attempting to address portability issues. She noted that the national association of health insurers, America's Health Insurance Plans, supports guaranteed issue of coverage as long as individuals are required to purchase health insurance, and emphasized that the insurance industry is supportive of health care reform.
Jamie Scholl, Colorado State Association of Health Underwriters, began his presentation related to the portability of health insurance. He distributed a concept paper regarding the viability of long-term funding for CoverColorado (Attachment L). He discussed issues associated with access and affordability of health insurance. Mr. Scholl noted that access to health insurance is not a problem in Colorado. He emphasized that coverage of pre-existing conditions is not a problem as long as individuals are not "standing on the sidelines" and only purchasing health insurance when they are sick. Mr. Scholl discussed the cost of coverage in the individual and small group markets, and in CoverColorado. He distributed a document on health care options in Colorado (Attachment M). Mr. Scholl discussed the use of federally-qualified health care centers to provide care to individuals without health insurance and asked the committee to focus on the affordability of health insurance. He responded to questions from the committee related to the coverage of pre-existing conditions and the affordability of health insurance. Mr. Scholl responded to questions from Representative Massey regarding implementing a system of guaranteed issue for individual insurance policies, stating that CoverColorado would become obsolete, but that individual rates would increase. He responded to questions from Representative Frangas regarding funding sources for CoverColorado.
The committee recessed.
01:31 PM -- Gender Rating in Health Insurance
The committee reconvened. Senator Boyd introduced the topic of gender rating in health insurance and discussed legislation from the 2009 session that referred the issue of gender rating to the Health Care Task Force. Dick Cauchi, NCSL, began his presentation on other states' actions in the area and NCSL's survey of states. He then defined the concept of gender rating as the practice of using gender as a factor when setting insurance premiums, which can result in higher premiums for women to obtain insurance. Mr. Cauchi gave some statistics on where people get their insurance (employer, individual market, etc). Mr. Cauchi described case law that has effectively banned gender rating in the employer-sponsored group health insurance market. He said that only 10 states have bans on gender rating in the individual market and 2 states use rate bands to limit the premium difference by gender. Mr. Cauchi described the prohibitions in 12 states that have banned gender rating in the small group market. Mr. Cauchi described the opposition to the banning of gender ratings that has occurred in some states. Opponents say that gender rating bans result in lower-risk people paying higher premiums to support higher-risk groups. He also described the requirement in some states that any differences in rates due to gender be based on sound actuarial statistics.
Mr. Cauchi said that the policy positions regarding gender rating have moved quickly and discussed an agreement reached with health insurers to end gender rating. Mr. Cauchi then shared a NCSL report on gender rating. (The report and Mr. Cauchi's presentation are in Attachment N). He said that none of the states surveyed have reported negative effects from banning gender rating. A handout in support of removing gender-based rate setting in the individual insurance market was distributed to the committee (Attachment O)
Lisa Codispoti, National Women's Law Center (NWLC), began her presentation. A copy of her presentation and a copy of her testimony were distributed to the committee (Attachments P and Q). She also shared a report from the NWLC titled "Nowhere to Turn" concerning gender rating in the individual market (Attachment R). She urged the Colorado General Assembly to enact law to prohibit higher insurance rates for women. She said that nationally, gender rating results in wide variation in insurance prices for men and women. She said that the premium cost differences between men and women exist up to age 55. Representative Massey asked why costs drop at age 55, as compared to age 40, considering child-bearing age and women's longevity. Ms. Codispoti said that she could not explain how the insurance industry sets these rates, and that the wide variation and arbitrary nature of the gender ratings raise many questions. She said that premiums varied greatly by state and within a state. She described the methodology for her report and showed that even plans with the same features had varying costs. Representative Kerr asked about the discrepancy and Ms. Codispoti said that women would not be aware of the price discrepancy unless they shopped for a man's policy as well as for their own. She said that the individual market had many problems beyond gender rating. Representative Massey asked about the cost discrepancy for victims of domestic violence, and Ms. Codispoti said that Colorado doesn't allow that type of rating, but that some companies think women who have been victims of domestic violence could be at risk for future injury. Senator Foster asked about the difference in men's and women's health and why there are premium differences. Ms. Codispoti said that the insurance industry would say that on average women use more health care. Ms. Codispoti said that maternity benefits alone couldn't explain the rate difference.
Ms. Codispoti described NWLC's survey of insurance policies in Colorado, and said that only one insurer (Kaiser Permanente) did not charge different rates for men and women. Among the insurers that charged differing amounts for men and women, the cost difference by gender varied greatly, but the cost difference was consistent across the state. Ms. Codispoti described the results by age. She described Kaiser Permanente's market share and said that Kaiser's experience shows that a company can be successful without resorting to gender rating. Ms. Codispoti said that NWLC supports community rating for health insurance and that women nonsmokers are sometimes charged more than men who do smoke. Ms. Codispoti said that sex is genetically determined and that federal law prohibits premium determination based on genetics; therefore, gender rating should be prohibited. Representative Massey asked about the wide disparities in premium costs and asked how the actuarial data could support such variation. Representative Frangas asked about guaranteed issue and access to insurance, and asked how that relates to gender rating. Ms. Codispoti said that there are proxies for gender rating (such as occupational rating which can target women-dominated occupations). She also discussed how guaranteed issue can result in higher costs and could limit access. Representative McCann asked whether insurance companies leave markets when bans on gender rating are enacted. Ms. Codispoti said that change in availability of insurance could not be directly linked to banning gender rating since there are many factors that influence what policies are offered in a state. Representative Massey asked how insurance companies can protect against cost shifting if gender rating is banned. Ms. Codispoti said that they did try to see how the prohibition of gender rating affected men's premium costs, but many states did not track this data when the bans took place.
Cathy Alderman, Planned Parenthood of the Rocky Mountains, said that her organization opposes gender rating. She said that 94 percent of her clients are women and described their insurance situation. She stated her belief that gender rating restricts access to insurance and can result in financial strain for women. Toni Panetta, NARAL Pro-Choice, began her presentation and shared data on the health needs of women in Colorado. She described her organization's research concerning lack of insurance, reproductive health, and family planning. Ms. Panetta said that costs for birth control are not covered equally between men and women. She described the lack of maternity benefits in many insurance plans and the need for prenatal care in Colorado. She stated that NARAL supports ending gender rating as a first step towards more equal access to health insurance. She described how birth control often requires a doctor's visit which can result in an insurance claim, and how a woman can be penalized later by an insurance company for filing a claim.
Bob Semro, Colorado Consumer Health Initiative, stated his organization's opposition to gender rating. He described the three health reform bills being considered in Congress and stated that those bills, if passed, will likely end gender rating. However, he said that any bill, if passed, would not take effect until 2012 or 2013. He said that until then, women in the individual market would be subject to gender rating. Mr. Semro described the wage discrepancy between men and women and how higher premium costs and lack of maternity coverage exacerbate the problem. He described insurance policies offered in each of the Health Care Task Force members' districts, and noted that the information shows a premium discrepancy for men and women in Colorado. He said that none of the plans he assessed cover maternity, prenatal, or delivery costs. He further described the cost differences by gender and age. Mr. Semro described other states that have prohibited gender rating with few negative results. Senator Schwartz about small insurance markets and commented that there didn't appear to be a disparity in the premium differences for men and women in rural and urban areas. Mr. Semro noted that geography did not seem to have an effect on cost. He said he was surprised that there was such a wide discrepancy in costs even though maternity benefits were not included. Representative Massey asked what were the cost drivers since maternity isn't included. Mr. Semro said that he didn't know and could not identify an obvious reason for the wide discrepancies.
A.W. Schnellbacher, AARP, testified that gender rating was an important topic because many of his members are below the age of 65 and are not yet eligible for Medicare. He said that many AARP members below age 65 are retired, and do not have adequate health insurance. He said that women are more likely to lack insurance, and that lack of insurance strains the budget for other programs like Medicaid. He distributed information to the committee on the rates for CoverColorado and other materials (Attachments S through U). He described a study on insurance claims that found differences in underwriting by geography. Based upon these factors, Mr. Schnellbacher expressed his belief that gender should not continue to be a factor in setting insurance rates.
Vanessa Hannemann, Colorado Association of Health Plans, testified that she was not for or against gender rating. She discussed the use of actuarial rating and said that the Division of Insurance requires that premiums be actuarially sound. She said that modified rating factors can increase coverage and that young women use more health services than men of the same age. Ms. Hannemann said that women go to the doctor more often, go to their annual checkups, have more prescriptions, and are often on birth control. She referenced the lower costs for a male smoker and said that the health care costs of smoking will not occur until later in life. She said that premiums are set based on current anticipated usage. Representative Massey discussed premiums paid by individuals who smoke. Ms. Hannemann said that the current premiums are not based on future needs, but on anticipated needs at the moment. Ms. Hannemann described her support for coverage of preventative services in health care plans.
Ms. Hannemann described the rate filing and examination process, noting that rates are determined by mathematicians. She said that a majority of states allow premiums to vary by gender to ensure access to coverage. Ms. Hannemann provided two handouts to the committee on costs (Attachments V and W). She said that women subsidize the cost of coverage for men earlier in life and men subsidize the cost of coverage for women later in life. She said that all Americans should have access to coverage and said that her organization supports bipartisan reform. Senator Foster commented on the need to reward positive behavior and preventative actions.
Jamie Scholl, Colorado State Association of Health Underwriters, described his organization and its goal to increase health insurance coverage. He provided a handout to the committee (Attachment X). Mr. Scholl described the group costs of health care and said that costs are allocated among the members of the group, and that changes in ratings shift costs among users. He said that young men are more likely to be uninsured and are not as responsible about having coverage. Senator Boyd commented that lower rates for young males seems to be rewarding bad behavior. Mr. Scholl said that it is important to consider the costs from a group perspective and described shifting costs as pushing on a balloon.
Senator Schwartz commented that ratings are based on actuarial models. She also asked about male smokers and what actuarial considerations go into setting rates and whether insurance companies need to take a longer view on health costs. Mr. Scholl discussed wellness programs, describing how federal law allows employers to charge different rates to promote wellness. He said that smokers are charged more for health insurance coverage. Representative McCann asked about smoking and the costs for treating preventable disease from smoking and obesity. She asked for data that justifies higher costs for women who do not smoke than for men who do smoke. Mr. Scholl discussed the rating system in the individual market. He said that women who want to buy a maternity policy intend to use it, but that a male smoker likely won't need to use his health insurance coverage for smoking-related diseases for 20 to 30 years. He said that maternity coverage is more expensive that paying out of pocket for a normal delivery, and that standard insurance will cover any complications during a delivery. Representative McCann asked why there is a cost difference for men and women in the policies, even when maternity coverage is excluded. Mr. Scholl said that women have more health needs and tend to take care of themselves better. He also said that a lot of women's health needs occur earlier in life, whereas men's costs occur later.
Senator Foster asked about mental health and adult diagnosis of mental health issues and if there are gender differences in costs for mental health coverage, especially preexisting conditions. Mr. Scholl said that in the group market a person will maintain coverage for preexisting conditions, but in the individual market insurance companies can decide whether to cover a certain disease. He said that this is why CoverColorado is a necessary part of the health insurance system. He said that there needs to be some kind of a subsidy in the system to provide affordable access to health insurance for everyone. He described how Colorado is one of the healthiest states in the nation, but has some of the highest insurance rates due to various regulations. He described how the automobile and life insurance markets also take gender into account when setting rates. Senator Schwartz asked about tort reform. He said that tort reform doesn't really come into the equation, but there are many ways to reduce the costs of medical care in the country. He said that insurance companies aren't driving the cost of health care.
Dayle Axman, Department of Regulatory Agencies, Division of Insurance, read a statement from the Commissioner of Insurance opposing gender rating in setting insurance rates (Attachment Y).
03:21 PM -- Committee Logistics
The members discussed having a sixth meeting of the task force. Senator Boyd proposed September 14. The committee agreed to add another meeting date to its schedule on Monday, September 14.
03:22 PM -- Update on Academic Medical Centers
Dr. M. Roy Wilson, the chancellor of the University of Colorado - Denver, described academic health centers and provided a handout to the committee (Attachment Z). He said that an academic health center is usually at a medical school and an associated hospital, but the key factor is the focus on research, education, and clinical services. In addition, Dr. Wilson gave an overview of how academic medical centers serve underserved communities and provide specialized care, such as burn centers. He described the shortage of health care workers worldwide and a study showing that 35 million lives were saved through advances that were facilitated by academic medical centers. Dr. Wilson described the Anschutz Medical Campus in Aurora and named several accomplishments of the medical center. Dr. Wilson discussed the economic impact of the medical center and research funding and the health care labor shortage in Colorado, especially in rural areas.
Dr. Wilson gave an overview of the Anschutz campus' role in providing continuing education. He said that the nursing shortage isn't just a shortage of nurses, but also a shortage of teachers who can provide training to new nurses. Dr. Wilson discussed the funding challenges that affect the campus. He said that state funding issues can affect accreditation of universities, the ability to retain faculty and staff, and the ability to serve medically needy populations. Dr. Wilson discussed rising tuition costs and student debt. He said that higher debt can influence the type of medicine that doctors will practice, and that higher salaries for specialists can compound the shortage of primary care physicians. Dr. Wilson said that expanding student enrollment cannot make up for the lack of state support. He described the recruitment of faculty away from the University of Colorado, and how universities, including other state institutions, can offer more secure funding for faculty that is less dependent on securing research grants.
Dr. Wilson stated the need for a new funding source to support the Anschutz campus, and that the certificates of participation were crucial for funding the facility's expansion. He said that the campus should be funded differently than other high education institutions. Representative Massey commented on creating incentives for rural health providers and the specialization of doctors. Dr. Wilson said that the disparity between primary and specialized care is more pronounced in the United States than in other countries. He said that there is no way to change the dynamic unless there is some redistribution from specialists to primary care practitioners, and stated that incentives need to be changed. Senator Foster discussed loan reimbursement programs for medical students who agree to serve rural areas. She also commented on the reduction of mental health beds at University Hospital. Dr. Wilson said that many federal programs that provide incentives to serve in rural areas have been reduced. He said that it is possible these programs could be revamped as part of federal health care reform efforts. He further discussed the role of academic medical centers in the health care labor supply and with regard to health care reform.
Senator Schwartz asked about the role of academic medical centers in reining in health care costs, and also about finding a way to identify a funding stream for the medical school. Dr. Wilson told the committee he would like the opportunity to share his opinions on cost containment. Dr. Wilson stated his hope that the public will realize the importance of the medical center and support it due to its unique mission and contribution. Representative Frangas asked about underserved areas and students, and about how to address the loss of mental health bed space. Dr. Wilson said that there is a shortage of mental health bed space and there are possibilities for expansion in the future. Dr. Wilson discussed how the lack of diversity in the student population affects the accreditation process and how the lack of state support makes it difficult to attract minority applicants who can get full scholarships to other schools.
Senator Boyd announced that the date for members to request draft legislation would be moved to Monday, September 14. The task force adjourned.