Income Inequality, the State of the Union, and the Affordable Care Act

The President focused on income inequality in his State of the Union speech.  This is an important issue; as the gap widens between those rich and poor.

But income inequality is built into our public policy at so many levels – and even at the lowest ends of the economic spectrum sometimes the “wealthier” individuals receive better benefits than those who may need them even more. 

A case in point is how the insurance subsidies work in the Affordable Care Act in the aftermath of the Supreme Court ruling of 2012.

In these, the poorest individuals and families – those living below poverty level – fare the worst.

This is an inequality that could be repaired easily and immediately.

Here’s how this particular inequality works.  If you are a single person earning $11,375 per year, you pay the highest percentage of your income for insurance as anyone in any income bracket. 

An example:  If you want to buy “silver plan” health insurance on the open market, it will cost you $2,535 per year – or almost one quarter of your annual income.  Or you can purchase a bronze plan for $2,101.  That is still over 18 percent of your income.

In other words, you can’t afford it.

But if you earn just $230 more per year, or $11,605, then the result is almost magical.  The cost of a silver plan goes down to $232 per year – just two percent of your income.  And if you opt for a bronze plan, it will cost you nothing.

It may seem hard to believe, but it’s true.

The reason is that the first person earns just below poverty level (99 percent of poverty) and the second just above (101 percent of poverty).  And insurance subsidies begin at 100 percent of poverty.

Congress was aware that it was building this severe inequity into the law in 2010, but it was not worried about it. 

That was because it also passed a fix.

It mandated the expansion of Medicaid in all fifty states to people earning 138 percent of poverty.  With Medicaid as an option, few people living near the poverty level would need or want private insurance through an exchange.

But then the Supreme Court created a new problem.  Without acknowledging the inequality in the subsidy, it ruled in 2012 that Medicaid expansion was optional, effectively undermining the fix.

In spite of the eighteen months of political chaos that has resulted from this ruling, many states – and we can now say a majority of them – have moved to remedy the inequality in the only way they can. 

They have chosen to expand Medicaid, taking up the federal government on its offer to pay nearly one hundred percent of the cost.  And over the next several years, most of the remaining states will probably follow, but only after they’ve wasted billions of dollars of their own resources during the delay.

But remedying the inequality isn’t the same as eliminating it.  In states like Connecticut, which have embraced expansion – it just covers it over.

And in states like Florida that have not embraced expansion, it still leaves millions of people out in the cold.

There is a solution for everyone, and the federal government could move forward on it – if it is as serious about reducing inequalities as the President is.

Right now, the federal government exempts people living below poverty in states that have not expanded Medicaid from the mandate that they buy insurance.

But there is a better alternative.  It could offer everyone living below poverty the option of “purchasing” a bronze plan at no cost.  In other words, it could extend the same subsidy to them (when they are not otherwise eligible for Medicaid) as is available to those earning just above poverty.  It would probably also have to waive the deductibles in those plans for this group, and there are ways it could do this.

This would cost the federal government no more than paying for Medicaid expansion.  It would get millions more people covered – many of them adults, and many with chronic conditions.  And it would spare us endless debates in reluctant states.

There are legislators in some of these states who have proposed using new federal Medicaid dollars to purchase private insurance for low-income individuals.  That’s an idea, but expanding subsidies would be a simpler solution.

It would cut out the reluctant state middle man, and reduce inequality directly.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Saving the Medicaid Expansion

Within days of the Supreme Court’s ACA ruling that made the Medicaid expansion optional, the governors of Florida, South Carolina, Iowa, and Louisiana all announced that they wanted to opt out of it.

The governors of six other states were considering the same thing.

However they frame their views for the media, they are in fact an attack on two different constituencies.  The first is lower income uninsured families, elders, and single adults, 17 million of whom expected to become insured as a result of the expansion.  The second is safety net providers - nursing homes, hospitals, community health centers, mental health facilities, and others - who need Medicaid dollars to offset the costs of caring for people who have no insurance.

Some hospital providers will even get hit twice - once when they lose direct Medicaid dollars and again when they lose their Medicaid Disproportionate Share (DSH) payments that were cut by ACA in anticipation of the Medicaid expansion.

The Court’s opinion characterized the ACA Medicaid expansion mandate as “a gun to the head” of states.  I have included the full quotation at the end of this column. 

It said that this was because the “financial inducement” the federal government created to get states to participate – the loss of all Medicaid funding – went far beyond “relatively mild encouragement.”

So how might the federal government save the Medicaid expansion in states reluctant to embrace it, and deliver on its promise of coverage to millions of American citizens? 

It could thump its chest and hope providers will rise up in opposition to the governors.  Or it could be guided by the Supreme Court’s majority opinion and come up with a better idea that might actually work.

This is what it might look like.

The federal government should just keep the expansion “option” in place for all the states, paying almost all the bill for those states that accept it. 

And it should make a slight modification in the existing Medicaid funding formula to reduce its reimbursements by one-quarter of 1% to those states that reject the expansion.

Right now, the federal government pays at least half of the costs of every state’s Medicaid program.  But it also rewards failure, by paying much more to states that have done worse jobs of developing and maintaining a good economy for everyone. 

Not by chance, the federal share is higher in the states that want to opt out of the expansion.  South Carolina gets 70%, Louisiana gets 61%, Iowa gets 59%, and Florida gets 58%. Wealthier states like Connecticut, by contrast, get only 50%.

It’s a lot easier to turn down the funding for the Medicaid expansion when you’re already getting tens and hundreds of millions of dollars more than other states for your basic Medicaid program! 

The governors of these states know what a good deal they already have, and how much more Medicaid money they get at the expense of others who do more for their residents.

If the federal government were to change the formula in the way I’ve suggested, they would still have a very good deal.  Florida would still get 57.83% of its Medicaid costs from the federal government.  Iowa would still get 59.24%, Louisiana would still get 60.99%, and South Carolina would still get 70.18%.

Such modest adjustments would surely meet the Court’s definition of “mild encouragement” versus a “gun to the head.” 

Taxpayers would be happy, because it would save us real money if a state chose not to take on the expansion.  Concern for taxpayers was exactly what Florida’s Governor Scott, among others, suggested was his motivation for dismissing the expansion. 

But, most importantly, it would change the economic incentives for these states.

Let’s use Florida as an example.  For the sake of the illustration, we’ll pretend that there’s no inflation. 

In its Supreme Court brief, Florida contended that the Medicaid expansion would cost $351 million. 

Over the next ten years, Florida’s share would average of 7% of that, or just under $25 million per year.

Florida’s existing Medicaid program currently costs around $21.2 billion a year.  The federal government pays $11.6 billion of this.  If it were to reduce its reimbursement to Florida by one-quarter of 1%, it would save $29 million annually.

Under this scenario, Florida’s Governor would have a true choice.  He could embrace the expansion at a cost to the state of $25 million per year, or turn it down at a cost to the state of $29 million per year.

If it’s really only about the money, these governors will know exactly what they need to do.

Here is the extended quotation from the Roberts ruling on the constitutionality of the Medicaid expansion:

“We have upheld Congress’s authority to condition the receipt of funds on the States’ complying with restrictions on the use of those funds, because that is the means by which Congress ensures that the funds are spent according to its view of the “general Welfare….” When… such conditions take the form of threats to terminate other significant independent grants, the conditions are properly viewed as a means of pressur­ing the States to accept policy changes….”

 “In this case, the financial “inducement” Congress has chosen is much more than “relatively mild encourage­ment”—it is a gun to the head. Section 1396c of the Medi­caid Act provides that if a State’s Medicaid plan does not comply with the Act’s requirements, the Secretary of Health and Human Services may declare that “further payments will not be made to the State.” 42 U. S. C. §1396c. A State that opts out of the Affordable Care Act’s expansion in health care coverage thus stands to lose not merely “a relatively small percentage” of its existing Medi­caid funding, but all of it…. We cannot agree that existing Medicaid and the expansion dictated by the Affordable Care Act are all one program simply because “Congress styled” them as such. Post, at 49. If the expansion is not properly viewed as a modification of the existing Medicaid program, Congress’s decision to so title it is irrelevant.”  Roberts Decision, p. 50, 51-52

How We Really Hope the Supreme Court Will Rule on the Affordable Care Act

The Affordable Care Act has finally had its days in court this week.

And commentators who were certain on Monday that the Supreme Court would uphold the individual mandate were just as certain on Tuesday that it would not.  Perhaps they have some special insight into the thinking of the Justices. I don’t.  I’ll just wait for the decision. 

In the meantime, I’m wondering not how each of us thinks the Court will rule, but how we hope it will rule.

The answer isn’t so simple, because we divide into – and often move among – three competing minority camps about health reform in general:

• The Affordable Care Act represents the best compromise for insuring more people while preserving most of our current public/private payer system.
• Expanding reform to a single payer system like those favored by other developed nations would be better. 
• Replacing ACA with a private market-based system is at least worth a try.

If we’re as uncertain as polls cited by the Kaiser Family Foundation suggest, I suppose we all could just close our eyes, vote for Mitt Romney, and assume from his record and rhetoric that we’ll get all three.

But the Court will decide first, so let’s consider the rooting interests of several interested and sometimes overlapping groups.    

If you favor a single payer, “Medicare-for-all” program:

You want the Court to find the individual mandate unconstitutional, but severable from the rest of the bill. 

Why?  The individual mandate was originally the alternative to “single payer,” so you would like to get the individual mandate out of the way.  Then single payer becomes an option again, but only if the rest of the law, including the Medicaid expansion and the consumer protections, remain in effect.  This is because our private insurance market will become too expensive if people use those consumer protections to wait to buy insurance until they are sick.

If you want to reduce the size and scope of the state Medicaid programs:

You want the Court to rule the Medicaid expansion unconstitutional, but the individual mandate constitutional. 

Why?  This combination will most constrain Medicaid growth because lower income people will have to purchase health insurance in the private market.  They’ll qualify for a subsidy, but not for Medicaid.

If you want more universal coverage, but don’t care whether it’s private or public:

You want the Court to uphold the entire law.

Why?  Although philosophically impure, the combination of Medicaid expansions, Medicare cost containment strategies, Medicare tax increases for the wealthy, and subsidized private insurance for the middle class will lead to more coverage, and fewer uninsured.

If you or a child of yours has a chronic condition, such as diabetes, mental illness, or cancer:

You may not care whether the individual mandate is constitutional or not, but if it isn’t, you want it to be severable from the pre-existing condition coverage and community rating portions of the law.

Why?  If the PCIP experience is any indication, you may not want to be forced to buy insurance.  But when you do try to buy it, you don’t want to be denied affordable coverage because of your pre-existing condition.

If you are an early retiree on your former employer’s health insurance:

You want any provisions found to be (1) unconstitutional and (2) not severable from the pre-existing condition and community rating portions of the law to be severable from the rest of the law.

Why?  This could gut much of the law, but not the provisions that subsidize your coverage.  You won’t have to worry that you could either lose your health insurance or be forced to pay a lot more for it.

If you are a Medicare recipient:

You want any provisions found to be unconstitutional to be severable from Medicare expansions.

Why? If they aren’t, you’ll need an immediate bipartisan agreement in Congress to keep your donut hole prescription drug coverage and your free annual check-up in place.

If you want insurance that will cover long term care needs:

You’re already out of luck. 

Why? That provision was axed from the law before it was ever implemented – and you don’t hear anyone talking about restoring it.

And, if you’re okay with denying or capping coverage for pre-existing conditions, allowing insurers to make as much profit on insurance as they can, having gaps in prescription drug coverage for elders, and paying for the sick and uninsured through increased premiums on people who have insurance:

You want the Court to find the whole law unconstitutional.

Why?  That’s where we were when all this began.

Note: Click here for simple explanations about some of the Supreme Court issues that are discussed in this week's column.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

The Disintegration of Health and Mental Health Care

How will the Supreme Court respond to an argument next week that might lead to the disintegration of health care in America?

In recent years, we have been making slow policy progress in better coordinating and integrating primary and specialty care, and health and mental health care.  Two milestones were the passage of the federal Mental Health Parity Act in 2008 and the Affordable Care Act provisions in 2010 that prohibit insurance discrimination against people with pre-existing conditions, both in coverage and in cost.

These are opening more primary care doors to people with mental illnesses. 

80% of all mental health problems are first seen in a primary care office.  And it now pays for a primary care clinician to screen for mental health problems.  According to one recent projection completed by the Mental Health Association of Palm Beach County (available on request from that organization), a primary care practitioner can generate in excess of $100,000 in insurance payments for every 2,500 behavioral health screenings he or she completes.

Integration also appears to pay off for patients in earlier and more effective care.  Between 2006 and 2009, the number of primary diagnoses of mental illness in general hospitals dropped from 2.4 million to 1.6 million, as more clinicians recognized the need to treat health and mental health symptoms – which are often indistinguishable – together.

Now the Supreme Court is being asked to weigh in on the question of integration.

Next Wednesday, on its third day of oral arguments about ACA, the Court will hear arguments about whether the individual mandate is “severable” from the rest of the Act.  How it responds may well determine whether the recent progress we’ve made to integrate care will stall.

Here’s why. 

The Obama Administration is arguing that the individual mandate is intertwined with two other provisions – the mandate to provide coverage without regard to pre-existing conditions and the mandate to provide coverage at no additional cost to those with chronic conditions.

These are important consumer protections, but the Administration’s view is that without the individual 

mandate healthy people will choose not to purchase insurance that covers expensive chronic conditions.  Instead, they will just wait until they get sick and then buy the coverage that will still be guaranteed to them if the other mandates remain.  This will in turn force up the price of insurance for everyone. 

The Administration supports ACA, but most ACA opponents also agree with the Administration on this point, as have some judges who have already ruled on the law.

If the Supreme Court finds the individual mandate unconstitutional, and then also agrees that it is not severable from the other provisions, it would overturn these two additional mandates.  This would result in a worst-case scenario for people with mental illnesses – a return to the private insurance market we’re just now leaving behind, where premiums are too high for them to afford, and coverage is too low for them to obtain effective treatment.

It won’t help people with other chronic conditions, either, as they head back out of primary care settings and into hospitals for treatment.  We’ll all lose out, because properly diagnosing and treating chronic conditions early means less cost down the road, more effective care, and better patient outcomes.

The historical pressure against integration in the health care delivery system isn’t philosophical or constitutional, but is often the product of increasing specialization among health care providers.  In 1960, there were approximately 7.5 primary care physicians and 7.5 specialty care physicians in the United States for every 10,000 citizens.  Fifty years later, in 2010, there were just under 7 primary care physicians per 10,000 citizens, but over 13 specialists. 

Specialists by training know a narrow area of medicine well.  As a result, we have grown to think about chronic diseases one at a time, and we often treat them this way, too. 

But this isn’t very efficient or effective, because patients usually bring more than one problem at a time to their primary care clinicians.  And by the time they are in care, almost two-thirds of patients with at least one chronic condition have at least one more.

That’s why we need integrated health and mental health services, and fair coverage for chronic diseases.  And that’s also why – if policymakers aren’t ready with an alternative – the disintegration of health and mental health care could result from the Supreme Court’s decision about severability.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Is Medicare for All on the Horizon?

We’re now just a little more than a month away from the day the Supreme Court will hear the arguments that determine the fate of the Affordable Care Act.  

The fight will be narrow – about the constitutionality of the individual mandate and Medicaid expansions.  

The consequences for health care financing, however, will be widespread.

And, ironically, both states rights conservatives and pro-national health insurance progressives may end up rooting against their own positions.

To understand why, consider the four ACA Supreme Court issues that will be argued. 

The first is the constitutionality of the individual mandate under the Commerce Clause of the Constitution. 

To be constitutional under the Commerce Clause, a law has to regulate economic activity that “has a substantial effect” on interstate commerce. 

While it may seem that all the activity under ACA will have a substantial effect on interstate commerce, Judge Vinson in Florida disagreed.  In considering the individual mandate, he found that the failure to purchase insurance by an individual is economic “inactivity,” not “activity.” For Judge Vinson, there’s no distinction between economic inactivity and non-economic activity. (I’m not so sure.)

Two times – in 1995 and again in 2000 – the Supreme Court held that non-economic activity wasn’t covered under the Commerce Clause.  So if the Supreme Court agrees with Judge Vinson, then the individual mandate won’t be constitutional under the Commerce Clause, and the Court will have to consider the second issue.

Is the individual mandate constitutional under the taxing authority of Congress?

If the Commerce Clause doesn’t make the mandate constitutional, then the Anti-Injunction Act might.  It prevents anyone from challenging the right of Congress to collect taxes. 

But even though ACA forces people who don’t buy insurance to pay higher income taxes, Congress specifically referred to these as “regulatory penalties.”  So is a tax by another name still a tax?  If it is – as the Fourth Circuit Court ruled – then the individual mandate is probably constitutional. 

But let’s say it isn’t.

Then the third issue becomes important – whether the individual mandate can be “severed” from the rest of the law. 

Some laws state explicitly that if one section of the law falls, the rest still stand.  But ACA doesn’t.  So it’s up to the Court to decide what happens to ACA as a whole if it finds the individual mandate unconstitutional.

So far judges who have ruled the mandate unconstitutional have disagreed about its severability.

One judge (Hudson) said it was severable, citing a 2010 Supreme Court ruling. When portions of a law are unconstitutional, all that should be thrown out were “problematic portions while leaving the remainder intact.” 

Another judge (Connor) also found it severable, but not from the entire law.  He said that the sections of the law that prevent insurance companies from denying coverage based on pre-existing conditions and prevent higher rates based on health condition, geography, or gender are intertwined with it.  So he found these unconstitutional, too.

A third judge (Vinson) ruled that the individual mandate wasn’t severable, but essential to ACA’s overarching goal.  He therefore decided that the whole law was unconstitutional.

The individual mandate was originally developed as an alternative to single-payer, government-funded, universal health care coverage.  But the fourth issue – whether ACA’s Medicaid expansion is constitutional – may now glue the two together.

The 26 states opposing the Medicaid expansion aren’t arguing against it per se, but against the federal government “coercing” them into implementing it.  In other words, government health care is fine, but not if states have to pay. 

This year, these and other states are proposing disturbing cuts to safety net health services.  Florida is considering a proposal to turn most state health services over to counties .  The Governor of Maine wants to remove 65,000 adults from the Medicaid program.  Louisiana just announced a new round of cuts to local mental health providers.  And Connecticut has begun denying some Medicaid coverage to kids with disabilities.

It’s as if they collectively believe that any problem can be solved by taking money away from it.

Here’s what they’re ignoring.  When you oppose requiring either individuals or states to pay for health care, you’re left with only one viable future option – federally-financed Medicare-for-all.

On the other hand, when you defend ACA as it is, you’re arguing that a two-tiered system of government-subsidized private health insurance for those who can afford it and public insurance for the poor and elderly is the solution to our health care financing crisis.

So when the Supreme Court decides, who wins?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, contact gionfriddopaul@gmail.com.

The Medicaid Elephant in the Supreme Court Room

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll.

Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.  

And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions. 

The two battles raise similar questions about how states avoid Medicaid costs today.

The Supreme Court brief is supposed to be an argument against the Affordable Care Act-mandated Medicaid expansion to cover everyone up to 133% of poverty beginning in 2014.

Bondi builds her argument around a simple point.  States depend so heavily on Medicaid money from the federal government that they can’t afford to drop out of the program.

And the ACA-mandated expansion, she argues, will cost Florida almost $1 billion.

But then there’s a stunning revelation in her brief.

Most of the costs she cites have nothing to do with ACA.  They represent the cost of enrolling currently eligible people in the Medicaid program, not those who will become eligible as a result of the Affordable Care Act. 

On page 17 of the brief, she writes that “Florida anticipates spending approximately $351 million on its share of the cost for newly eligible program participants who are presently uninsured and $574 million on the currently eligible but unenrolled.”

In other words, 62% of the costs she’s claiming will result from ACA are actually costs the state should be paying today, but avoids by failing to enroll Medicaid-eligible residents.

The Connecticut class action suit attacks essentially the same issue – failure to enroll currently eligible people.

In paragraph 25 of the complaint, the plaintiffs allege that Connecticut “has set up a system to circumvent the federal timeliness requirements by making it appear that the applicant has failed to provide required documentation.” 

Throughout the nation, these practices result in the avoidance of billions of dollars of costs at the expense of elders, low income children, and people with chronic diseases and conditions – and the health and mental health providers who serve them.

Bondi’s brief suggests that new Medicaid enrollments could cost Indiana about $2 billion over ten years, Arizona and Louisiana over $7 billion, and Texas close to $25 billion.  But these numbers all appear to include the currently eligible populations.

States understandably and justifiably want to contain their Medicaid costs.  But they cross the line when they do it by turning away literally millions of people who already belong on the program.

Bondi works hard to make the currently eligible group relevant to the Affordable Care Act by stretching a silken thread of the individual mandate around them. 

She writes that “the considerable cost for the [currently eligible group] reflects the fact that, unlike for the newly eligible, Congress has not increased federal funding for those newly enrolled (but previously eligible) by virtue of the ACA’s individual mandate.  As a result, the States will continue to pay for up to half of the costs generated by the latter group’s now mandatory enrollment.”

But she stretches the thread to the breaking point.  The individual mandate doesn’t apply to the group of people currently eligible for Medicaid.  Their Medicaid enrollment is “mandatory” by virtue of existing state and federal laws that pre-date ACA.

So what happens when the Supreme Court makes its ruling this spring?

If the Court finds the Medicaid expansion constitutional, then the states will have to implement it in 2014 – and also enroll those currently eligible without further delay. 

But even if it doesn’t, the currently eligible group isn’t going away – and we now know what they will cost.  Florida will still owe at least $574 million and Connecticut will still have to enroll up to 7,000 more eligible people.

That’s the best case scenario.  The worst is that such a ruling could induce the federal government to reduce its role in the Medicaid program to avoid the “coercion” argument in the future.  Then states might have to provide coverage and care to the poor and elderly all by themselves.  

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

The Best States for Your Health

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.  

A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health. 

Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades.

We would all like a more effective health and health care system.  But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a new ranking of the states that reflects which states invest most effectively in our health and health care. 

It was created by combining four existing rankings and three new ones.  It includes mental health as well as health, the work of other health professionals in addition to doctors, and availability of community care as well as quality institutional care.  It ultimately rates the states based on how good they are at simultaneously:     

• keeping their children and adults healthy; and 
• taking care of their residents when they are sick or have chronic conditions; and 
• providing for both health and health care at a price their residents can afford. 

Taking everything into account, here are the ten best States for Your Health, and why:

1. Massachusetts.  Massachusetts is the only state with five top five finishes among the seven rankings.  It takes good care of its children, invests in wellness and prevention, has many top-rated hospital programs including one of the highest rated mental health facilities in the country, and insures its population well.  Where health and health care are concerned, every state should want to be more like Massachusetts.
2. Connecticut.  Connecticut is near the top in six of the seven rankings.  Its children, working adults, and elders all thrive on a rich set of high-quality prevention and health care services. The only ranking in which it did not excel was one that measured affordability – the high amount its Medicaid program historically spends on hospital and nursing home care. 
3. New Hampshire.  New Hampshire rates as the best state in the nation in three of the individual rankings I combined – the 2011 Kids Count child health and well-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per 100,000, and the percentage of people who are privately insured.
4. Vermont.   Vermont is number one in the Healthy State rankings and in keeping its Medicaid hospital and nursing home costs under control.  It has figured out that the best way to control Medicaid spending is to keep its population healthy.
5. Utah.  Utah proves that good health is a conservative value.  It takes good care of its children, promotes healthy lifestyles among its residents, and is home to a high percentage of residents with private employer-based insurance – a key measure of affordability.
6. Minnesota.  Strong in the prevention and public health rankings, Minnesota is also home to a top hospital.  It gives its residents access to quality public health and quality health care at the same time.
7. Washington.  Washington cracked the top ten in only one individual ranking, so it may be a surprise that it is ranked so high when they are all combined.  But it does just about everything well compared to other states, and isn’t close to the bottom in any category. 
8. Hawaii.  Hawaii scores high in prevention and keeps Medicaid institutional spending under control.  It doesn’t have any of the top rated hospital programs.  If it did, it would rank even higher.
9. New Jersey.  New Jersey does especially well by its children and its elders, and is in the top ten in three individual categories.  But it is an expensive state for Medicaid recipients to get sick in, and a lot of that money goes to hospitals and nursing homes. 
10. Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individual rankings.  If its residents were able to spend relatively more of their Medicare dollars on community services and less on institutional ones, it would move up.

There are two states that topped individual rankings that didn’t make the top ten.  California, according to US News and World Report the best state in the nation to find high quality hospital programs, tied for 15^th.  Florida, first in per capital Medicare spending on community services, finished 30^th. 

To see the full ranking of all the states, click here.

Next week:  More about why Florida finished where it did, and a closer look at the ten states that finished near the bottom.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Note: Here are the rankings I used, the reasons I used each of them, and a link to the 

original data: 

• the 2011 Healthy State Rankings and the 2011 Annie E. Casey Foundation Kids Count state rankings – to measure the effectiveness of public health and overall prevention (including mental illness prevention) activities; 
• the Kaiser Family Foundation (KFF) State Health Facts ranking of the percentage of people with private employer-based insurance – to measure health care access and affordability for workers and families; 
• the KFF State Health Facts ranking of the number of nurse practitioners per 100,000 residents – to measure support for non-physician providers and high quality primary care;
• To measure quality of care and medical professional development, I calculated and ranked the states by the number of times a hospital in a state was included in the 2011 U.S. News and World Report rankings of best hospitals in the country across specialties, including mental health and overall rankings of children’s hospitals (33 states had at least one hospital mention);
• To measure the availability of community-based services for elders, I used the most recently available data from the Centers for Medicare and Medicaid Services reporting per capita state spending in each state on Medicare minus hospital and nursing homespending;
• To measure the effectiveness of state intervention to keep people with disabilities in their homes and out of institutions and as a measure of affordability, I used CMS data to calculate per capita state spending on Medicaid hospital and nursing home care as a negative measure.

Because prevention and health care each account for approximately 50% of the gains in life expectancy over the last century, I gave the two prevention-oriented rankings – the Healthy State and Kids Count rankings  – a combined weight equal to that of the other five.