Health Care Task Force (08/31/2009)

Final
STAFF SUMMARY OF MEETING

HEALTH CARE TASK FORCE

Date:	08/31/2009	ATTENDANCE

Time:	09:02 AM to 04:12 PM	Apuan	X
		Foster	*
Place:	HCR 0107	Harvey	A
		Kerr J.	X
This Meeting was called to order by		Lundberg	A
	Senator Boyd	Massey	X
		McCann	X
This Report was prepared by		Schwartz	*
	Elizabeth Burger	Frangas	X
		Boyd	X
		X = Present, E = Excused, A = Absent, * = Present after roll call

Bills Addressed:		Action Taken:
Update on Federal Health Care Reform Legislation Statewide efforts for Health Care Reform Health Care Affordability Study Telemedicine Presentation from Colorado Health Foundation Update on the Denver Drug Strategy Plan Chronic Care Collaborative Public Testimony		- - - - - - - -

09:03 AM -- Update on Federal Health Care Reform Legislation

Senator Boyd called the meeting to order and introduced Joy Johnson Wilson with the National Conference of State Legislatures. Ms. Wilson distributed a copy of her presentation to the committee (Attachment A). She noted that Congress is in recess until September 8, 2009, but health care reform efforts have continued during the recess. Ms. Johnson described health care reform efforts considered by Congress in the past 25 years. She stated that it is important that health care reform efforts occur at this time, because it may be a while before there will be the momentum to make changes. Ms. Wilson described the complexity of rebuilding the health care system.

09:12 AM

Ms. Wilson described the key committees that are considering health care reform legislation in Congress. In the House, the relevant committees are the Energy & Commerce, Education & Labor, and Ways & Means committees. In addition, the House Rules committee will combine the bills that have passed out of the three house committees into one bill. The House Rules committee also determine which amendments can be offered during floor debate and set the time of debate. The Senate committees with jurisdiction over health care reform include the Health, Education, Labor, and Pensions committee and the Finance committee. Ms. Wilson described the role of the Congressional Budget Office (CBO). The CBO is responsible for determining the costs and savings of each piece of legislation, a process called scoring. Ms. Wilson noted that this process is especially important because the president has said that health care reform must be deficit neutral. She described the President's role in the passage of health care reform legislation. She explained that the federal Health and Human Services and Labor departments have been working with the Congress regarding implementation of any legislation that is passed.

09:20 AM

Ms. Wilson described the stakeholders in health care reform, including state and local governments, providers, insurers, the pharmaceutical industry, large and small employers, senior and disability advocates, advocates for children's health, and many others. Ms. Wilson described the differences in stakeholder participation during health care reform efforts this year, versus in previous years. She stated that perspectives on the uninsured have changed since the downturn in the economy; however, many people are especially sensitive about costs as a result of the economy. She stated that Congress has a difficult job in both bringing uninsured individual into the system and creating a system that will serve the majority of people who are happy with their current coverage. Ms. Wilson responded to questions from Representative Massey regarding any change that may be made to Consolidated Omnibus Budget Reconciliation Act (COBRA) provisions by the federal legislation. She further responded to questions from Senator Schwartz regarding the extent to which people are happy with their current insurance.

09:28 AM

Ms. Wilson explained that in the House, 218 votes are required to pass a bill. In the Senate, 60 votes are needed because filibusters can occur in the Senate and 60 votes are required to end debate. She stated that there is talk of using the reconciliation process in the Senate to pass legislation. The reconciliation process only requires a majority of votes to pass legislation. However, the topics that can be considered during reconciliation are limited. Issues considered in reconciliation must be germane, and some issues would be excluded, such as insurance reforms, if the legislation was passed through reconciliation.

09:35 AM

Ms. Wilson described the general points of consensus regarding health care reform, which include: maintaining the employer-based system; expanding Medicaid to include nontraditional groups with incomes at or below some percentage of the Federal Poverty Level (FPL); adopting insurance reforms to make insurance more accessible and affordable; requiring individual coverage, and establishing a premium subsidy/tax credit program to make health insurance affordable. She described the goal of health care reform, which is essentially to provide health insurance coverage to all or most Americans. Some of the groups that are not covered now include: low-income individuals/families; individuals with pre-existing medical conditions; people who work for employers that do not provide health insurance benefits; retirees, before they are eligible for Medicare; young adults who choose not to purchase coverage; and people who do not want to spend the money. She described the elements of the legislation designed to increase coverage, which include insurance reforms, a requirement that individual purchase coverage, and expansion of public health care programs. Some of the insurance reforms being discussed include a mandate for individuals to purchase coverage, with some exceptions; a requirement that employers contribute to the cost of coverage; and various insurance rating reforms.

09:43 AM

Ms. Wilson described proposals for "health insurance exchanges," which are mechanisms through which individuals can compare health insurance options and choose among competing plans. She noted that there has been no agreement on whether the exchanges should be national or regional. She noted that there has been much discussion of a so-called "public option," or a government sponsored health insurance plan. Some of the controversy regarding the public option is whether it will be able to compete on the same level as other plans, such as in setting rates. She stated that the House legislation as introduced included a public option with preferred treatment, but a House committee removed those provisions from the bill. The final House bill hasn't been determined, and thus, it is not known what the final public option will look like. She also noted that cooperatives have been discussed as an alternative to the public option, but there are not a lot of details as to how the cooperatives will function. Responding to a question from Representative McCann, Ms. Wilson noted that families with incomes up to 400 percent of the FPL could receive subsidies to purchase health insurance through the exchange, and clarified how individuals could purchase insurance, either through a private insurance company or through the public option, through the exchange. In response to a question from Senator Schwartz, Ms. Wilson explained that all plans offered through an exchange must offer a minimum set of benefits, and that all plans offered through the exchange would be guarantee issue. Ms. Wilson responded to a question from Representative Massey regarding how current state insurance regulations could be affected by federal health care reform legislation.

10:01 AM

Ms. Wilson continued her presentation by describing the penalties that individuals who do not obtain coverage may face. Failure to comply with the requirement to obtain qualified coverage could result in a penalty of 2.5 percent of modified adjusted gross income, up to the cost of the average national premium for self-only or family coverage under a basic plan in the health exchange. There are exceptions for dependents, religious objections, and financial hardship. Military personnel and veterans would not be required to participate in the exchange. Ms. Wilson described the premium subsidies available to individuals with incomes up to 400 percent of the FPL. Such individuals may also receive cost-sharing credits. She described the required contribution for employers, which is 72.5 percent of the cost of the premium for individuals and 65 percent of the premium for family coverage. Employers who choose not to pay the required premium cost must pay 8 percent of their payroll into the Health Insurance Exchange Trust Fund. The legislation provides for a hardship exemption for employers that would be negatively affected by job losses as a result of this requirement. For small employers, the payroll contribution is pro-rated based on aggregate wages.

10:13 AM

Ms. Wilson described the benefits that may be included among the "essential benefits" that must be offered in insurance policies. Some of the benefits for which coverage may be required are: hospitalization; outpatient hospital and clinic services, including emergency services; services of physicians and other health professionals; services, equipment, and supplies incident to the services of a physician or other health professionals; prescription drugs; rehabilitative and "habiliatative" services (services for individuals with developmental disabilities); mental health and substance abuse services; certain preventative services and vaccines; maternity care; well baby and well child care; oral, health, vision, and hearing services, equipment, and supplies for those under age 21; Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services, and durable medical equipment, prosthetics, orthotics, and related supplies.

10:18 AM

Ms. Wilson described Medicaid reforms that are included in the health care reform legislation. A minimum eligibility floor of either 133 or 150 percent of FPL would be set. The legislation would require coverage for single, childless adults and parents. The legislation requires states to maintain the coverage that is in place in states as of June 16, 2009. There is an enhanced match to cover the costs of coverage for the new individuals covered as a result of the legislation. Under the current legislation, the federal government will pay 100 percent of the costs for FY 2013 to FY 2015 for individuals with incomes between the current income standard and 133 percent of the FPL. After FY 2015, and for subsequent fiscal years, the federal government will reduce the enhanced match from 100 to 90 percent. States are prohibited from using an asset or resource test for determining or redetermining Medicaid eligibility for most eligibility categories. It also eliminates the use of income disregards, and income eligibility would be based on modified adjusted gross income.

10:27 AM

Ms. Wilson explained that under current proposals, the State Children's Health Insurance Program (SCHIP) program would end in 2013, and the families would then receive coverage through Medicaid or through the exchange. She discussed possible reductions to Medicaid Disproportionate Share Hospital (DSH) payments beginning in 2017. She described the logic behind such reduction, stating that if health care reforms make an impact on the number of individuals without insurance, then DSH payments may not be as necessary. Ms. Wilson explained that the DSH debate has also focused on the need to provide some care to illegal immigrants. She explained that hospitals are lobbying for the continuation of the DSH program to provide funding for treatment costs for illegal immigrants. She discussed proposed rate increases for Medicaid providers, noting that the federal government will provide enhanced matching funds for these costs. An additional provision of the legislation provides enhanced funding for graduate medical education. She discussed another prohibition which disallows reimbursement through Medicaid for hospital-acquired infections.

10:40 AM

Ms. Wilson discussed options for financing health care reform. Options include a tax on millionaires, a tax on high-end health plan premiums, Medicare and Medicaid savings, administrative savings, and savings through a primary care and prevention strategy. Ms. Wilson responded to questions from Representative Massey regarding the state costs of Medicaid expansions, and how states will manage costs after federal stimulus funding to states ceases. Representative McCann asked for more information on how the health care reform proposals will contain costs. Senator Foster commented on a single-payer health care system. Representative Kerr commented at the speed with which health care reform legislation is being considered. Senator Schwartz asked if a letter of support for certain aspects of health care reform would be helpful, and Ms. Wilson stated that it would be. Ms. Wilson especially encouraged the committee to comment on the provisions of the legislation regarding Medicaid expansions and the impact to states of ending federal stimulus funding.

11:09 AM -- Health Care Reform - Health Advocates Alliance

Kelly Shanahan, Colorado Consumer Health Initiative, described the Health Advocates Alliance (HAA) and distributed a handout regarding the organization (Attachment B). She stated that the HAA is a coalition of consumers, providers, and health care advocates committed to health care for all that is affordable, sustainable, timely, safe, equitable, effective, efficient, and patient-centric. She discussed the alliance's Road to Health Care Reform strategy and asked the committee to support these strategies.

11:14 AM

Dr. Bruce Madison, Colorado Medical Society, discussed the problems with the current health care system. He explained that the current employer-based system was not planned or designed.

11:19 AM

Kelly Shanahan stated that there are a number of things that the state can do to improve the health care system. She described the sources of health care coverage for Coloradoans. She described the spheres of influence for the Colorado General Assembly.

11:23 AM

Kelli Fritts, AARP, described previous health care reform efforts in Colorado. She described previous legislation that affected the regulation of health insurance in Colorado and discussed the principles that HAA supports for health care reform.

11:29 AM

Kelly Shanahan stated HAA's supports public safety net programs, including Medicaid. Dr. Madison described Accountable Care Organizations. He described how costs have increased in the health care arena in recent years, and identified some of the cost drivers in the health care system, including fee-for-service payments. He described Rocky Mountain Health Plans, an insurance company which operates on the Western Slope, and which he described as an Accountable Care Organization. He referred to a copy of an article in the New Yorker regarding health care costs where Rocky Mountain Health Plan was mentioned (Attachment C).

11:37 AM

Kelly Shanahan stated she supports a system that includes all individuals and broadly pools risk. She also encouraged care coordination, and giving reforms the time to work. She listed the framework questions members can ask themselves when considering health care reform legislation, including Does it increase access? Does it protect vulnerable populations? Does it improve quality and value?

11:50 AM -- Health Care Affordability Study

Becky Miller Updike, Colorado Council of Churches and Colorado Voices for Coverage, described the study "The Cost of Care: Can Coloradans Afford Health Care?". A copy of the report regarding the study, an Executive Summary of the report, and a copy of her presentation were distributed to the committee (Attachments D, E, and F respectively). She gave a brief overview of the results of the study.

11:53 AM

Elisabeth Arenales, Colorado Center on Law and Policy, described the study. She described the expenses for individual households, including necessary expenses (food, housing, utilities, child care, alimony and child support, transportation, and taxes) and other financial responsibilities (debt payments, tuition and education expenses, charitable donations, savings, and support to family members). She discussed the key findings regarding individual households, including that: families within a given income category differ in what they can afford and 25 percent of families at all income levels except for the highest have negative balances. The survey further found that, at the median, after necessary expenses and other financial responsibilities were paid, families with incomes under 200 percent FPL can contributed little or nothing to the cost or health care. 50 percent of families with incomes between 200 and 400 percent of the FPL can contribute something towards the cost. Families with incomes between 400 and 500 percent of the FPL could make a more substantial contribution toward the cost. She emphasized that having money after expenses does not mean a family can afford health care. She described data showing, from a group perspective, how many households can afford insurance, noting that only at the highest incomes could a majority afford individual insurance. In addition, employer subsidies provided in the group market significantly increases the ability of households to afford insurance, but the subsidies are still not large enough for many.

12:05 PM

Ms. Arenales described the opportunity costs associated with health care. She stated that the study's key finding was that as health care claims a larger percentage of a family's budget, spending in other categories goes down. She described data showing that monthly contributions to savings decrease as the percent of income spent on health care increases. The task force recessed for lunch.

01:32 PM -- Discussion of Telemedicine Programs

The committee reconvened. Senator Boyd discussed a letter concerning Social Security Disability Insurance that the committee drafted.

01:35 PM -- Centura Health at Home

Ellen Caruso, from the Home Care Association of Colorado, began her presentation on home care services and telehealth/telemedicine. She described the home care industry and her organization. She distributed two handouts to the committee (Attachments G and H). Ms. Caruso introduced a film on telehealth prepared by Centura Health at Home. The video discussed a pilot telehealth program. The pilot dealt with congestive health failure and how the program can help patients become independent and maintain treatment in the home. The video demonstrated measuring blood pressure and oxygenation using the telehealth system. The video discussed reduced patient admissions and other benefits from the pilot program.

01:45 PM

Dianne Newberry, from Centura Health at Home, introduced herself and described the areas that the organization serves. She distributed a handout to the committee on the organization (Attachment I). She stated that telehealth is an effective way to address chronic diseases. Ms. Newberry stated that treating chronic heart disease accounts for a large portion of Medicare spending and that older patients with heart failure face multiple readmissions to hospitals. She described how telehealth reduces hospital readmissions. She stated the Centura Health started a pilot program to evaluate the effectiveness of telehealth, and that after the pilot ended, the program was expanded to the treat other chronic diseases including diabetes, hypertension, and other chronic conditions.

Representative Massey asked about the cost of telehealth equipment. Ms. Newberry described how new equipment costs the same as older equipment from several years ago, but has more features. Patients use the equipment and then when stabilized, the equipment can be cleaned and given to a new patient. She described how caregivers can ask questions through telehealth equipment to monitor patient's health. Senator Schwartz asked what type of internet connection patients needed in order to use telehealth. Ms. Newberry responded that the equipment can be connected to an ordinary telephone line. She spoke to which patients are good candidates for the program. Ms. Newberry discussed how the telehealth caregiver can teach patients, monitor health, and intervene when necessary, including prompting physician visits. She described how the telehealth program is staffed by nurses.

01:58 PM

Ms. Newberry discussed some lessons learned and obstacles to telehealth. For example, in order to receive services, a patient must be homebound limiting the access of the program. She stated that another problem is that some seniors have poor quality or corroded phone lines which limits access. She explained that telehealth providers and Qwest Communications are working to find solutions for the problem, including evaluating whether wireless access could increase access. Representative Frangas asked for data on cost savings. Ms. Newberry said that cost savings can be looked at in two ways: reducing hospital readmissions, and reducing nursing staff home visits. She also commented that telehealth allows nurses to spend more time with patients who have more acute needs. Representative McCann commended Centura Health and asked about whether all patients in the program were on Medicare. Ms. Newberry responded that they do not have a specific funding source for telehealth services and operate under the Medicare cap for home-based health services. She described working with United Health to provide coverage of such services.

Representative Kerr asked about the cost of hospitalizing a patient with congestive heart failure. Ms. Newberry described how the program encourages patients not to call 911 or go to the emergency room, and to call their nurse first to get evaluated and determine the best treatment.

02:09 PM

Ms Caruso concluded her presentation and spoke to SB 07-196, which established the Health Information Technology Task Force. She described the task force and its recent recommendations. She stated that the task force found that there is a conflict between a federal requirement under Medicaid that telehealth cannot substitute for a 'regular' nurse visit. She described efforts between the Department of Health Care Policy and Financing and the Centers for Medicare and Medicaid Services to resolve the conflict.

02:15 PM -- Connected Care

Beth Soberg from United Health Group described the Connected Care program, which partners with CISCO, Centura Health, and others to provide high definition video and audio telehealth services. Ms. Soberg described some obstacles to health care access in rural areas, such as distance, weather, and lack of specialists. She described the process for selecting pilot sites and collaborating with selected clinics to implement the project. She believes that the sites will be selected in September 2009 and United Health will purchase the telecommunication equipment for the four sites. The pilot will last for three years.

02:22 PM

Senator Foster asked about the type of equipment used in the system, and Ms. Soberg provided an example of how the system could be used for dermatological appointment. For example, an assistant in the clinic would take a photo using a dermoscope, and the image would be sent to the specialist. After review by a physician, the physician could submit a prescription as needed. Representative Massey commended the selection of sites. Ms. Soberg continued by describing outreach to clinics. She described how the Connected Care program integrates with the rest of the health system. She described the interaction of the program with the Colorado Regional Health Information Organization (CORHIO) and the Colorado Hospital Association. Representative Kerr asked about the process of site selection. Ms. Soberg described the criteria for site selection which included population density, existing capacity in the clinics/communities, and demographics of the communities. Ms. Soberg responded to a question from Representative Kerr regarding the costs of the system.

02:44 PM -- Presentation from Colorado Health Foundation

Anne Warhover, president and CEO of the Colorado Health Foundation, introduced herself and provided several handouts to the task force including a power point handout of her presentation, the Colorado Health Report Card 2008, Connecting Colorado's HIT Building Blocks, and a report concerning health insurance benefit adequacy in Colorado from March 2009 (Attachments J, K, L, and M respectively). She described how it is a common misperception that Colorado is already the healthiest state. She stated that Colorado may have the lowest rate of obesity, but a large percentage of the population is overweight. Similarly, she stated that the state attracts healthy people, but the state is not improving the health of its residents overall. She described the foundation's health-related symposium and other healthy living efforts of the foundation. Ms. Warhover described the efforts to improve health in Colorado schools, and funding for community-based health initiatives. She also described how the number of uninsured people hurts health in the state.

Ms. Warhover described the lack of medical staff and facilities in some counties. Representative Massey asked about funding for school-based health centers, and the sustainability of such health centers. Ms. Warhover described efforts to work with other organization to find a model of sustainability for school-based health centers. Ms. Warhover described how centralized billing could help school districts deal with insurance billing codes and other issues. Ms. Warhover discussed grants that were part of the federal stimulus package and the foundation's effort to help community health centers access these funds. She described the inaccessibility of health care in the state, and how it requires collaboration between government, businesses, and nonprofit organizations.
.
03:01 PM

Grant Jones from the Center for African American Health and the Colorado Health Foundation, discussed access to physical education and good nutrition in schools, and described other issues discussed by the foundation's policy committee. He discussed chronic care management and expanding health coverage. Mr. Jones stated that coverage is an indicator of overall health, and described efforts to increase enrollment of individual eligible for public programs. He discussed the fiscal reform debate in Colorado, and how his organization is involved in these efforts. He described the foundation as a resource for information, not just for funding.

03:12 PM -- Denver Drug Strategy

Karla Maracini, Director of the Denver Office of Drug Strategy, and Dr. Jamie Van Leeuwen introduced themselves and described their collaboration between the Denver Drug Strategy Commission, the Denver police, and the Denver District Attorney's office. A handout of the presentation was provided to the committee (Attachment N). Ms. Maracini described the syringe exchange program and emphasized the public health risk of contaminated needles. She relayed the number of injection drug users in the state and stated that the large percentage of them have Hepatitis C. Ms. Maracini spoke to the cost of medical care for individuals with HIV and Hepatitis C. She stated that needle exchange programs aims to reduce the amount of needles discarded in the city parks. Ms. Maracini said that the program's goal is to get 10 percent of Denver drug users, or about 400 users, to participate in the needle exchange program. Representative Massey asked about the effectiveness of the syringe exchange program. Dr. Leeuwen responded that the commission is preparing to make its recommendations while evaluating various prevention efforts. Representative Kerr asked about abuse of the exchange program. Dr. Leeuwen stated that the coalition is working with Denver Health and the Denver police to evaluate the effectiveness of the needle exchange pilot program.

03:27 PM -- Chronic Care Collaborative

Carrie Nolan from the Colorado Chapter of the National Multiple Sclerosis Society and Linda Mitchell from the Alzheimer's Association of Colorado introduced themselves and described the Chronic Care Collaborative membership (Attachment O). She described the collaborative's goals and discussed some of the diseases that patients with chronic disease may have. Ms. Nolan discussed the priorities of the collaborative, including promoting long-term care. She stated that the organization supports home- and community-based services, rather than nursing home care, which typically is more expensive. Ms. Nolan encouraged the General Assembly to require the licensure of home care placement agencies and national background checks for home care workers.

03:32 PM

Ms. Nolan described the need for mental health care when treating chronic diseases which can cause depression. She described funding for health prevention. Ms. Nolan described how people with chronic conditions are in need of increased access to health coverage and that without it, some patients incur substantial medical debt by not seeking treatment. Ms. Nolan acknowledged the difficult budget environment and stressed the important of maintaining funding for preventative care and expanding coverage.

03:46 PM -- Public Testimony

Devorah Kappers discussed the Aid to the Needy Disabled (AND) program. She said that there will be an increase in homelessness if funding is cut to the AND program.

03:50 PM

Irene Aguilar provided a handout on Healthcare for All Colorado and the benefits of a single-payer health system (Attachment P). Dr. Aguilar stated she is a primary care provider and advocates for a single-payer system. She described the lack of health care coverage among minorities and vulnerable populations. She expressed concern that the national health care reform legislation will not contain a robust public option, which she supports.

03:58 PM

Diane Lucas stated that she is a retired physician and described her concerns regarding medical malpractice insurance. She explained that pediatricians are exposed to liability for treating patients for up to 22 years after treatment. She stated that when a physician retires, they typically purchase "tail insurance" to cover suits that come up in subsequent years. Dr. Lucas further explained that if a physician re-enters practice, they have to pay back the insurance company. She stated that she views this as a barrier for physicians re-entering practice. She described compensation committees under a single-payer system and stated that system is preferable to the tort-based system currently in place.

Senator Boyd stated that the next meeting of the Health Care Task Force is September 14, 2009. The committee scheduled the meeting from 8:30 am to noon. Representative Frangas spoke to the forthcoming report from the Task Force to Study Home Placement Agencies. Senator Boyd stated that draft legislation will be taken during the next meeting. The task force adjourned.