Health Reform Comes to Colorado
Lorez Meinhold is leading Colorado's efforts to implement health reform.
Lorez Meinhold isn't new to public policy -- her resume includes stints at the Colorado Public Interest Group, the Colorado Consumer Health Initiative and the Colorado Health Foundation -- but she is new to government service. Last October, she joined Gov. Bill Ritter's office as a senior health policy advisor. And earlier this year, Ritter tapped Meinhold to serve as Colorado's Director of Health Reform Implementation. I recently caught up with Meinhold to ask how Colorado is preparing for the challenges ahead. Below is an edited transcript of her comments.
What has Colorado done to prepare for health reform?
We passed the Colorado Health Care Affordability Act in 2009. That includes an assessment of a fee on hospitals, and it gets matched with federal dollars. That's allowed us to do two things: One, to increase payments to hospitals -- both in patient, outpatient and the indigent care program -- and two, to expand coverage to individuals to 100 percent federal poverty in the state. So we have made the decision as a state that we wanted to cover people to 100 percent prior to health-care reform passing.
How challenging was it to expand coverage in the current fiscal climate?
It was challenging. But we were lucky to have the support and partnership of the [Colorado] Hospital Association. Had we not had that it would have been much more difficult. Colorado's constitution requires a balanced budget. Over the last several fiscal years, we've had to cut $3 billion from the state budget. To be able, at the same time, to partner and do these expansions is pretty amazing.
Let's climb the Olympian heights and look down on health reform. What do you see as exciting opportunities? And conversely, what concerns you most?
The coverage expansions [are exciting] -- and I mean not just the Medicaid expansions, but the subsidies available through the exchange. To say, "Okay, we're going to ensure that everybody to 400 percent [of the federal poverty level] gets some level of assistance to afford health insurance," is a real shift for us as a nation. In addition, it will be the same in all 50 states. Having 50 states with 50 different policies has made it hard and confusing for families. But it also meant that we have created 50 different systems, which is pretty inefficient. I think the pilot opportunities in cost containment are exciting, but it's also a challenge. As states, we need to make sure we stay focused on turning these pilots. Right now, the reason we don't have more concrete ways to figure out cost containment is we just don't know what works across all populations.
We've done things around transitions of care for Medicare. We know, for instance, that for seniors transitioning out of hospitals, if we provide an in home visit and two follow-up phone calls, we can reduce readmissions by 50 percent. That's a huge cost saving. But we only know that works in Medicare; we don't know if that works in Medicaid. So the pilots give us the opportunity to really test some things out. If we don't figure out how to stabilize or start to bend the cost curve, we're not going to be successful with health-care reform.
What do you think the biggest implementation challenges are going to be?
I think there are several. There are the ambitious timelines for grants. The insurance exchanges are one of the next big endeavors of health reform, and while 2014 can seem far away, it's already starting to feel pretty close, especially with some of the provisions about how these new exchanges have to interface with public programs and the IRS. From a technology standpoint, that can be complex and it can take a couple of years. We with other states are now just trying to figure out, what are the values and goals of the exchange? Is it just an electronic interface? Most states are saying, no, it needs to be more that that but how to also keep in mind that it needs to be sustainable and affordable over time.
How are you prioritizing these tasks? What's on your plate right now?
We just finished our high-risk pool. We started taking applications on July 6, and we've already had close to 100 people apply for it. The coverage will start on September 1. We think that there will be a total of 4,000 people that can be covered through our allotment from the federal government.
We're also focused on an implementation plan to ensure the next administration has a clear roadmap of health reform at a state level. We are doing forums on exchanges with community members and key stakeholders. We just had our first one on July 23, and had 150 attendees from provider, consumer, broker and business communities to identify goals and values for a state exchange that will help drive some of the decisions about governance. Is it housed in state government outside? Is it multistate? Single state? So we are using these forums to develop a consensus paper that we can give to the next administration, the next legislature, the community -- something we can leave behind as a route to move forward with implementation.
You've spoken about health insurance exchanges; let's talk a bit about the health information, electronic health records exchanges.
Sure. So the Recovery Act is what really funded a lot of the health information exchange and technology. We have a state designated entity, CORHIO [Colorado Regional Health Information Organization]. So we have one entity that is both receiving the money to become that entity, as well as helping organize the regional extension centers. CORHIO received about $20 million from the stimulus package. As a state, we had made some pretty significant investments in health IT, not just state funds, a local foundation has given them some pretty significant funds. Grand Junction is pointed out as a model in the country, and part of the reason for this is that they have an active information exchange, Quality Health Network. CORHIO is able to build off the knowledge and expertise of the Quality Health Network to build a successful model for information exchange in Colorado.
Thanks to Atul Gawande's story in The New Yorker, the innovations of places like Grand Junction have received a great deal of attention. Are there other Colorado innovations that you think would be of interest to other states?
Prior to health-care reform, Gov. Ritter used an executive order to create the Center for Increasing Value in Health Care or CIVHC. We're using this as the entity to help us figure out payment and delivery system reform. It's a work group supported with state and foundation resources that has focused on ways to improve care, delivery and costs. The governor's office worked with CIVHC this past year to pass an all payer claims database. You can't get to payment reform and delivery reform until you really understand how you're spending your money.
Any parting words of advice?
I think the biggest thing is to have patience. We've reached out to a lot of the business and provider community, and we know there still are a lot of questions and concerns about health-care reform. People are asking, "How much are my premiums going to go up by?" The reality is, without health-care reform, premiums were already going, especially for small businesses, up by 15 to 20 percent. There is going to be some political pressure to say every increase in insurance premium is due to health-care reform. It's really important to remember why we got here in the first place. It is because of these double-digit increases. And that we know we can't sustain this kind of growth in premiums. And that it's growing to be 20 percent of the GDP, which is just unsustainable. And so we really need to address cost containment and figure out how do we manage care better? How do we deliver care differently? How do we not just pay for things -- under fee for service system we have the more a provider does, the more they get paid. We have designed a system that is unsustainable and health care reform provides us with new opportunities and paths.
Each month, John Buntin compiles the best reads in health news and research.
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The Commonwealth Fund offers a concise timeline laying out what needs to happen in order for states to comply with the Affordable Care Act.(Here's another version, formatted by year.) The timeline also provides an overview of the different ways states are organizing their preparations.
One thing that is going to have to happen is that states will need to pass lots of new health care legislation: The Los Angeles Times finds that most states have little ability to regulate premiums. The New York Times says that most states lack the legal authority to carry out the tasks given them by the Affordable Care Act. Meanwhile, Stateline.org exams how Wisconsin manages to make big Medicaid cuts while sidestepping the usual controversies.
At the national level, Democrats are getting worried. Politico reports that Democrats are shifting their pitch on health reform, emphasizing cost containment less and quality improvement more.
And finally, a light endnote: researchers have concluded that for the non-immunocompromised, drinking rainwater is safe.