Profile: In-Depth Look at an Initiative that Is Making a Difference
Profile: In-Depth Look at an Initiative that Is Making a Difference
Wisconsin: Private and Public Sectors Partner to Promote Transparency Summary: Public and private stakeholders—including businesses, hospitals, physicians, insurers, state employees, and the state Medicaid program—are collaborating to collect, compare, and publicly report information about the costs and quality of health care in Wisconsin. The state committed public funds to the creation of a database of health care information intended to enhance the transparency, quality, and efficiency of the health care system.
In Wisconsin, there are a number of ongoing efforts intended to promote the transparency and, eventually, improve the performance of the health care system. Public and private stakeholders are collecting information on the quality and costs of health care at the physician, hospital, and health plan levels in order to make reliable, comparative data available to providers, employers, and consumers. The groups are working together and building on each others' work, rather than duplicating efforts. Health Care Transparency Legislation
In late March, Governor Jim Doyle signed the Health Care Transparency Bill (AB 907). The legislation dedicates state funds to the Wisconsin Health Information Organization (WHIO), a coalition of managed care companies, employer groups, health plans, physician associations, hospitals, and doctors. Created in 2005, the coalition is building a centralized health data repository based on voluntary reporting of private health insurance claims. The database will include health care claims as well as pharmacy and lab data from insurers, self-funded employers, and health plans. Such information will be used to develop reports on the costs and, eventually, the quality of care. The goals are to encourage providers to improve their performance and enable employers and consumers to make informed purchasing decisions.
Both the Wisconsin Department of Health and Family Services (DHFS), which administers the state's Medicaid program and State Children's Health Insurance Program (SCHIP), and the Wisconsin Department of Employee Trust Funds (ETF), which as the state's largest employer manages health benefits for state and some local employees and retirees, are participating in the initiative. DHFS and ETF will contribute data on the costs of publicly paid health care through Medicaid and public employee benefit systems. For ETF, this is one component of a "value-based purchasing" model it has been employing for nearly four years. [1
To finance the effort, each private member group makes a contribution, which the state will match through funds derived from assessments on physicians and a small contribution by ETF.
By supporting the WHIO initiative, the state hopes to:
Web-Based Reporting Tool
- facilitate quality improvement efforts by private providers;
- help consumers make well-informed purchasing decisions;
- inform public health efforts such as disease surveillance; and
- secure value for money in public programs such as Medicaid, the state's biggest purchaser of health care.
WHIO complements another initiative, the Wisconsin Collaborative for Healthcare Quality (WCHQ). Founded in 2003, the WCHQ collaborative involves physician groups, hospitals, health plans, employers, and labor organizations that want to enhance transparency and promote quality in the health care system. According to Chris Queram, the group's president and CEO, "the physician and hospital leaders who founded WCHQ were willing to admit that there are too many mistakes, too much variation from evidence-based care, and that the system could and should do better."
WCHQ publicly reports comparative information on its member physician practices, hospitals, and health plans through an interactive Web-based tool.
The reports are organized into measures of five of the six dimensions of health care quality proposed by the Institute of Medicine as well as topics of particular interest to patients, such as access, use of information technology, heart care, pneumonia, and patient satisfaction. [2
] There are also measures of diabetes, hypertension, and postpartum care.
The WCHQ has earned credibility among health care providers because the measures are reported in ways that allow member groups to identify variation by physician practice and target areas for improvement. For example, this chart
on diabetes management displays the percentage of diabetes patients at different physician groups that has achieved optimal blood sugar levels.
Recently, WCHQ developed and unveiled a quadrant analysis to demonstrate the relationship between quality outcomes and risk-adjusted charges. This innovative approach to quantifying the value
each member hospital provides when caring for patients with specific conditions was developed in response to the business community's desire for a more sophisticated measure of a hospital's efficiency.
For example, Figure 1 displays the quality-cost relationship in terms of heart attack care; each hospital is represented by a diamond and letter. It indicates that the vast majority of hospitals are performing above the national median in terms of providing heart attack patients with recommended, evidence-based care, yet their charges for heart attack care vary widely.[3
] This might lead purchasers to question why they should pay twice as much to some hospitals when most are providing recommended care.
Source: WCHQ website,
reproduced with permission of WCHQ.
On an anecdotal basis, the WCHQ web-based tool is having a positive effect on provider performance; according to Queram, public reporting "catalyzes the commitment to improve quality." The overall trend for most of the measures is moving in the direction of improvement. WCHQ is planning an evaluation to assess the impact of the initiative and inform efforts to make it more effective.Challenges
The WCHQ, WHIO, and similar public reporting initiatives share the challenge of encouraging consumers and employers to use cost and quality information in their purchasing and care choices. WCHQ recognizes the need to make its Web tool easier for consumers to navigate and is considering working with consumer organizations to determine how to do this.
Queram notes that, although employers are interested in the performance data, most do not offer financial or other incentives to steer workers toward better-performing health providers. Some use the data in other ways, however. For example, the Alliance—a Wisconsin employer health care cooperative—draws on the WCHQ diabetes measures in rate negotiations in their pay-for-performance program. Employers might eventually be persuaded to act on the findings in other ways, for example by changing health plans or providers.
Another challenge is to convince all physicians—not just the current few who are actively involved in data collection —that performance data can help physicians to improve their practices.
Over the long run, the Wisconsin initiatives will need to develop a sustainable business model for health information collection and reporting. This will require commitment from the private and public sectors and evidence that these efforts work—that they encourage purchasers, consumers, and health providers to change their behavior and lead to in higher quality and more efficient care.References
] For example, ETF has already implemented a pay-for-performance program, a tiered premium structure, and an evidence-based drug formulary.
] The five dimensions currently included in the database are safety, timeliness, effectiveness, efficiency, and patient-centeredness. Equity, the sixth dimension, is difficult to define and measure consistently with currently available data.
] The composite score median was calculated based on available national data sets while the mean charge and length of stay was calculated based on Wisconsin data.
|For More Information|
|Contact: Chris Queram, President and CEO, Wisconsin Collaboration for Healthcare Quality, Inc, email@example.com, (608) 250-1505|
Susan Wood, Health Chief of Staff, WI Department of Health and Family Services, firstname.lastname@example.org
Nancy Nankivil Bennett, Director of Strategic Health Policy, WI Department of Employee Trust Funds, email@example.com
Snapshots: Short Takes on Promising Programs
Vermont's governor recently signed a compromise bill designed to move the state toward universal coverage and promote chronic care management. The Health Care Affordability Act (H 861) establishes subsidies for uninsured low-income Vermonters to purchase private health plans. Premium assistance will be available to low-wage workers who have access to employer-sponsored health insurance. And for those without access to work-based coverage, the Act creates "Catamount Health" plans. Sold by private carriers, these plans will offer a standard, comprehensive benefit package including primary care, acute and chronic care, hospital care, and other services to be determined by the state.  There will be no patient cost-sharing for preventive or chronic care services. Individuals with income up to 300 percent of the federal poverty level (FPL) will receive premium subsidies based on a sliding scale tied to income, and those with higher income will pay the full cost.
The public subsidies will be financed through fees assessed on employers for workers who are not offered coverage or are uninsured, an increase in tobacco taxes, and federal funds through a planned amendment to its Medicaid waiver. The assessment on employers, which will begin April 1, 2007, is $365 per full-time uninsured employee.  The state expects approximately 25,000 of the 60,000 uninsured Vermonters to enroll in Catamount Health.
The Act also establishes a number of quality improvement initiatives. Through public–private collaboration, the state will develop a system to manage chronic care conditions for individuals in public and private health plans. Other strategies include collection of health care data from all payers, adoption of rules to publicly report price and quality information, simplification of forms and procedures, and promotion of healthy behaviors through community health and wellness programs.
 If private insurers do not voluntarily offer Catamount Health, the state will mandate that they offer the product.
 Assessments on part-time workers are adjusted according to actual hours worked. In 2007 and 2008, the first eight full time equivalent workers are excluded from the calculation of the assessment; this exemption is reduced to six in 2009 and four in 2010. The assessment will increase at the same rate as premium increases in Catamount Health.
Massachusetts is working hard to develop the rules and implement the mechanisms associated with the universal health care reform signed into law by Governor Mitt Romney in April. A team led by Health and Human Services Secretary Tim Murphy and comprised of representatives from multiple state agencies has been developing a health care reform implementation plan. A team within MassHealth is preparing for numerous changes to the state's public health program, including eligibility and benefit expansions, outreach plans, and implementation of the new Commonwealth Care Health Insurance Program, which will be distinct from MassHealth, the state's Medicaid program.
In late May, Jon Kingsdale, a senior vice president at Tufts Health Plan, was chosen to lead the Commonwealth Health Insurance Connector Authority, which will establish minimum benefit standards for "lower-cost" health plans. Health providers and consumers want to ensure these plans provide a reasonable level of coverage and do not leave providers with unpaid bills.
The Connector Authority is also determining the level of premiums that should be considered "affordable" for uninsured residents. Secretary Murphy announced in early June that the Romney administration estimated premiums for most low-income residents purchasing a new coverage plan would range from $40 to $130 a month, with premiums fully subsidized for individuals with incomes below the poverty line. The Authority is considering a variety of methods to keep premiums low, such as limiting provider networks, eliminating certain health care mandates, creating health savings accounts, or charging higher amounts for smokers.
Finally, the Division of Health Care Finance and Policy is in the process of defining terms such as "fair and reasonable" premium contributions by employers. Under the new reform, businesses face a $295 per worker annual assessment if they do not make a "fair and reasonable" premium contribution for their workers. The Division is also determining the fees for employers if they do not offer coverage and their workers access care through the state's "free care" pool.  It is also determining which companies will be eligible for pre-tax insurance deductions; the law allows employees at companies that don't offer coverage to pay their premiums with pre-tax dollars, similar to the manner in which some employees use pre-tax dollars in flexible spending accounts to pay for health expenses.
 Massachusetts' "free care" or Uncompensated Care Pool reimburses hospitals and health centers for providing free or partially free care to uninsured or underinsured patients.
|For More Information|
|Contact: Massachusetts Executive Office of Health and Human Services, (617) 573-1800.|
New Jersey now requires all health insurers in the state to raise the age limit of dependents eligible for coverage under their parents' plan to 30—the highest in the nation. Employer-based health insurance traditionally terminates dependent coverage at age 19 or upon college graduation. Young adults are a disproportionate share of the uninsured, but a generally healthy population.
The new law, effective since May, covers uninsured, unmarried adults under age 30 who have no dependents and are either state residents or full-time students. It does not require employers to contribute to coverage for young adults, and it does not apply to large companies' self-insured plans or plans issued and delivered outside of the state, even if they cover New Jersey residents. The state expects about 200,000 young adults to receive coverage under the new law.
Under the bill, signed by former Governor Richard Codey, the cost of the extended coverage is capped at 102 percent of the premium previously paid for that dependent's coverage prior to them aging out. There are concerns that the law could make employer group coverage more expensive, or make dependent premium rates unaffordable. Estimates for the additional amount parents would pay for premiums to cover their adult children vary greatly, ranging from $1,200 to $6,000 annually. Connecticut, Kentucky, Massachusetts, and New York are considering similar measures, and other states, including Colorado, Illinois, New Mexico, South Dakota, Texas, and Utah, have all expanded dependent coverage to 24- to 26-year-olds in recent years.
Arkansas received federal approval to begin a low-cost, limited benefit health insurance plan for businesses. In early March, the Centers for Medicare and Medicaid Services approved a Health Insurance Flexibility and Affordability waiver that allow federal funding for the Arkansas Safety Net Benefits Program. Under this initiative, firms with fewer than 500 employees that have not provided health coverage for at least one year will be eligible to purchase a "safety net" plan, as long as all uninsured workers who are eligible participate.
The plan will cover six physician visits, seven days of inpatient hospital care, and two outpatient hospital procedures or emergency department visits each year and two prescriptions per month. The state will also enhance efforts to reduce smoking and obesity. Employers will be required to contribute monthly premiums of $15 for workers with annual income up through 200 percent of FPL and $100 for higher-income workers. Participating workers will pay annual deductibles of $100 and 15 percent of the cost of services; their out-of-pocket costs for the covered services will be capped at $1,000 per year.
The program will be funded with $18 million from the 1998 national tobacco settlement as well as federal government Medicaid and SCHIP contributions.  The state plans to make the program available in the fall of 2006 and begin offering benefits to eligible employees and families in early 2007. Although there are concerns among some consumer groups that the plan provides inadequate protection, its supporters claim that some coverage is better than none. Enrollment is capped at 15,000 parents and childless adults during the first two years. The state estimates that, over five years, 50,000 workers with annual incomes under 200 percent of FPL and 30,000 workers with higher incomes will enroll in the safety net plans.
 The federal government will pay 82 cents of each dollar spent by the state for workers with children through SCHIP, and 73 cents of each dollar spent for workers without children through the Medicaid program.
In June, Governor Phil Bredesen signed into law the Cover Tennessee Act (SB 3895). Its centerpiece is CoverTN, a low-cost insurance plan for uninsured, low-income small business workers and self-employed individuals. An individual policy will cost about $150 per month. Among employers who choose to participate, the plan will function as a variation of the "3-share" model, with the state, the worker, and the employer each contributing one-third of the premium.  If an employer declines to participate, an employee can enroll by paying two-thirds of the cost.
CoverTN plans will be portable, following the enrollee from job to job. They will be offered by private carriers and meet state guidelines, and will reward people with healthy lifestyles through premium adjustments tied to smoking, obesity, and age. Plans will provide basic health insurance to individuals who have been uninsured for at least six months, with income up to 2.5 times the FPL. The program is available to employers with 25 or fewer employees if at least half of the employees meet a specified income requirement. Although the governor has expressed intentions that the policies should have no large deductibles and only modest copayments, concerns have been raised by consumer groups about whether plans costing an average of $150 per month could provide adequate coverage.
In addition to the CoverTN 3-share program, the new legislation includes a pharmacy assistance program, an effort to reduce obesity and diabetes, and initiatives that expand health coverage to uninsured children in families with annual income up to $50,000 and chronically ill "uninsurable" adults who can not obtain private insurance due to preexisting conditions.
Together, these provisions are expected to expand health coverage to 100,000 adults, 75,000 children, and 15,000 chronically ill residents, at a cost to the state of about $350 million over three years.  The governor is seeking federal participation in the program for future years. He will begin accepting bids from insurance carriers to provide coverage starting this fall and, to ensure competition, plans to sign at least two contracts. State officials expect to start enrolling individuals in October and begin coverage in January 2007.
 The "three-share model" was pioneered in the Access Health program in Muskegon County, Michigan, where health coverage costs are shared by employers, employees, and a public contribution.
 The CoverTN 3-share program is expected to cost about $100,000 of the total.
Former Governor Dirk Kempthorne signed the Idaho Medicaid Simplification Act (HB 776) in late March 2006. Submitted to the federal government as a state plan amendment through the new provisions of the Deficit Reduction Act, it was approved on May 25, 2006, and implemented July 1.
The bill takes over 50 Medicaid eligibility categories and reduces them to three separate programs with their own distinct benefit packages, which are intended to serve the groups' needs:
- The Benchmark Basic program, for low-income healthy children and adults, will cover most traditional Medicaid benefits except long-term care, organ transplants, and intensive mental health treatment. Children under 19 can still receive all of these services through Early Periodic Screening Diagnostic and Treatment.
- The Enhanced Benchmark program, for the elderly and individuals with disabilities or special health needs, will cover all traditional Medicaid benefits, including long-term and institutional care.
- The Coordinated Benchmark program, for dual-eligible elderly (those eligible for both Medicare and Medicaid), will cover all benefits in the state's traditional Medicaid program for dual eligibles. Enrollees will be required to register for both Medicare Part B (outpatient coverage) and Part D (the new prescription drug benefit).
To determine the appropriate program and take a baseline measure of a beneficiary's health, the state will conduct comprehensive health risk assessments of all program enrollees.
The governor's plan also institutes copayments for Medicaid recipients, implements a pilot pay-for-performance program in community health centers, advocates private financing options for long-term care through a variety of methods (including reverse mortgages and tax deductions), and establishes personal health accounts that offer credits for good health behavior. The state plans on removing asset tests for all eligible children with family incomes below 185 percent of poverty.
Advocates of the bill say the previous "one-size-fits-all" Medicaid package is inefficient, and the new benefit packages will better meet the needs of participants. Critics claim the new plan will achieve cost savings largely by limiting benefits and fear that the increased cost-sharing will cause low-income Medicaid recipients to forgo needed care.
Updates: New Developments in Ongoing Programs
The Maine Quality Forum (MQF) has rolled out a Safety Star Recognition Program that will enable employers and consumers to recognize hospitals in the state that are providing the safest care to patients. A team of safety experts will verify whether hospitals applying for recognition (on a voluntary basis) have implemented 28 specified safety practices, chosen from standards developed by the National Quality Forum (NQF). Hospitals that meet or exceed the established thresholds will receive "Safety Star" certification. Applications are expected this fall. Maine's large, self-insured employers intend to use Safety Star status as a criterion in tiered networks and a factor in pay-for-performance programs.
MQF, an independent division of the Dirigo Health Agency established as part of the comprehensive Dirigo Health Reform of 2003, serves as a public source of information about the quality of health care. It collects, analyzes, and publishes comparative data on quality of care by providers in the state, collaborating with the Maine Health Data Organization and other private and public institutions. MQF reports to the state legislature and consumers through its Web site, advised by a 17-member council comprised of leaders from provider, business, insurance, and consumer groups.
The MQF operates under the principle that provider transparency and accountability are the keys to improving the quality and safety of care; public reporting is their method of enhancing provider responsibility.
California counties continue to make significant progress in ensuring that all children in low- to middle-income families have access to health coverage. As of May 2006, 18 counties have implemented and another 12 are planning Children's Health Initiatives (CHIs). CHIs are funded by private philanthropies, local and state contributions, tobacco tax revenues, hospitals, business, and individuals.  The counties are waging extensive outreach campaigns to enroll eligible children in Medi-Cal and Healthy Families (California's Medicaid and SCHIP programs, respectively) or the new "Healthy Kids" programs, which are implemented and funded in each county and intended for children who are not eligible for the state's public programs. Together, the counties have enrolled more than 88,600 children in their Healthy Kids plans and 165,000 more under Medi-Cal and Healthy Families.
Evaluation of the first CHI in Santa Clara County found significant reductions in unmet need for medical and dental care, and success in enrolling eligible but uninsured children into existing programs, thus infusing millions of state and federal dollars into the community. 
In April, advocates submitted over 1 million signatures to qualify as a ballot measure the Tobacco Tax Act of 2006 that levies a $2.30 tax on cigarettes and tobacco products as a sustainable financing source for children's health coverage. If the Tobacco Tax of 2006 is passed by California voters in November, funding would be available in 2007 for a statewide California Healthy Kids program. In the May 2006 revised state budget, Governor Arnold Schwarzenegger proposed state financial support for outreach, enrollment, systems improvements, and transitional premium support for the local Children's Health Initiatives.
 California Endowment, the David and Lucile Packard Foundation, Blue Shield of California Foundation, The California HealthCare Foundation, First 5 California and local First 5 Commissions. The California Endowment has funded a technical assistance consortium to work with counties to help them implement their CHIs.
 Trenholm, C.A., Howell E., Hughes D., and Orzol S. Santa Clara Healthy Kids Program Reduces Gaps in Children's Access to Medical and Dental Care, Mathematica Policy Research, Inc., April 2005; Trenholm, C.A. Expanding Coverage for Children: The Santa Clara County Children's Health Initiative, Mathematica Policy Research, Inc., June 2004.
State to Watch
Pennsylvania's Governor Ed Rendell recently proposed the "Cover All Kids" initiative, aimed at providing health insurance coverage to nearly every child in the state. It comes on the heels of Illinois' "All Kids" program, set to be implemented this summer.
Cover All Kids targets the 133,589 Pennsylvania children whose families earn too much to qualify for Medicaid or SCHIP, but too little to afford private coverage through their employer or the individual market. Similar to All Kids, Cover All Kids would charge premiums on a sliding scale, based on family income. An expansion of the state's SCHIP program, Cover All Kids would provide comprehensive care, including doctors' office visits, hospitalization, prescriptions, vision, home health care, mental health care, and substance abuse services. The governor estimates that 15,000 children could be covered in the first year of the program (2006–07), and that starting Cover All Kids would require $4.4 million in state funds, to be coupled with $10.2 million in federal funding for the first year of operation.
Federal Activity Affecting Performance of State Health Care Systems
On May 11, the Senate blocked the Health Insurance Marketplace Modernization and Affordability Act of 2006 (S 1955), also known as the Enzi bill. The bill would have helped small business join together to create association health plans, giving them greater purchasing power to negotiate affordable premiums and achieve administrative efficiencies. The Enzi bill also would have allowed insurers to preempt state laws that mandate inclusion of certain benefits and limit premium variability between small businesses.  Serious concerns were raised by states, which helped derail the bill. But bill sponsor Mike Enzi (R-Wyoming) said he would work with Democrats in an effort to bring a compromised bill up for vote later this year.
The primarily Republican proponents estimated that over 1 million people would gain insurance coverage as a result of lower premiums. However, the bill would allow insurers to offer plans that don't cover benefits required by some states, such as screenings, diabetes supplies and education, mental health parity, and drug abuse treatment. Also, it would allow greater premium variation that could result in as high as a 26:1 ratio between premium rates based on individual health conditions, business size, and other factors, according to Mila Kaufman, associate professor at the Health Policy Institute of Georgetown University.  Such a disparity could potentially price-out sicker workers from purchasing insurance. Numerous groups, including the AARP and the American Cancer Society, opposed the bill, along with 41 state attorney generals.
Given the interest, need, and financial difficulties associated with health coverage among small businesses, along with Senator Enzi's interest in working with Democrats on a compromise, it is likely that small business reform will continue to be a focus in Washington. For example, a bill sponsored by Senator Durban (D- Illinois), The Small Employers Health Benefits Program Act of 2006, would allow small businesses with up to 100 employees to join together for lower health care prices by pooling their purchasing power and spreading their risk over a large number of participants, while maintaining state mandated benefits.
There will be much at stake for states in this debate, especially if state regulations are preempted (as in S 1955). The potential for additional businesses to purchase coverage would need to be weighed against potential negative consequences, such as sicker people being priced out of the market or individuals having inadequate insurance protection, which would add stress to states' safety net and public coverage programs.
 With the caveat that they would have to offer a plan with the same benefits as a state employee plan in one of the five most-populated U.S. states: California, Florida, Illinois, New York, and Texas.
 Kaufman M, Pollitz K. Health Insurance Regulation by States and the Federal Government: A Review of Current Approaches and Proposals for Change. Georgetown University Health Policy Institute, April 2006.
A provision in the Deficit Reduction Act signed by President Bush in February requires all persons applying for, or renewing, their Medicaid coverage after June 30, 2006, to provide proof of their citizenship and identity. This provision is a response to growing concerns that many illegal immigrants have been fraudulently claiming U.S. citizenship in order to receive Medicaid benefits.  Approximately 50 million people will have to go through this process to qualify for Medicaid.  Citizenship would only have to be proven once.
The U.S. Department of Health and Human Services (HHS) recently released interim guidance to help states implement the new provision.  It establishes four distinct levels of documentation to verify citizenship and identity. A person may use a passport or certificate of citizenship. If these are not available, the individual may provide proof of identification, such as a driver's license, in addition to a birth certificate, health insurance records, medical records, institutional admission papers, school records for children, or, as a last resort, written affidavits from at least two individuals verifying claim of citizenship. 
The guidance allows for a "reasonable opportunity" for citizens currently enrolled in Medicaid to locate the proper documentation. It calls on states to help new applicants secure their paperwork if they have been unsuccessful doing so on their own, but prohibits coverage until the proper documentation is presented.
The new rules will reduce state and federal Medicaid costs by excluding people—primarily illegal immigrants and some legal immigrants—who are not eligible for the program. There are concerns, however, that the rules will inadvertently cause hardships for eligible U.S. residents who do not possess or cannot locate appropriate documentation. A recent survey from the Center on Budget and Policy Priorities estimated that 3.2 to 4.6 million citizens could experience delays in coverage, or lose it altogether, as a result of the new rule.  Health advocates and hospital leaders have pointed out that certain groups will be disproportionately affected, including African Americans born in the South, mentally disabled and elderly individuals, and victims of natural disasters.  Also, misunderstandings about the rules may deter eligible, legal immigrants from attempting to enroll in Medicaid.
A recent report by the Kaiser Family Foundation recommends delaying implementation of the new rules, requiring states to provide assistance in obtaining necessary documents, and relaxing other aspects of the requirements. The report is based on lessons learned from New York's experience requiring documentation of citizenship for Medicaid.
States face the difficult challenge of complying with the rules to retain federal Medicaid funding, but implementing them in ways that minimize delays or loss of coverage for eligible persons. States will save money on lower Medicaid enrollment, but the new documentation processes will add administrative burden and costs. Also, loss of Medicaid coverage to both ineligible and eligible individuals will place greater stress on the states' safety net systems.
 In the past, federal law has permitted applicants to self-attest their U.S. citizenship under penalty of perjury, and most states do not aggressively pursue documentation unless they suspect an applicant is lying.
 It is important to note that the new rule does not affect Medicaid application for legal immigrants; they will still have to show the same documentation verifying their immigration status. Legal immigrants are ineligible for non-emergency Medicaid services until they have lived in the U.S. for over five years. The Emergency Medical Treatment & Labor Act, enacted by Congress in 1986, ensures "public access to emergency services regardless of ability to pay." As such, even illegal immigrants can receive emergency care, funded by Medicaid. For more information, see: http://www.cms.hhs.gov/EMTALA/.
 See http://www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp for more details.
 For the written affidavit, at least one of the two individuals must not be related to the applicant.
 Ku L, Cohen-Ross D, Broaddus M. Survey Indicates Deficit Reduction Act Jeopardizes Medicaid Coverage for 3 to 5 Million U.S. Citizens. Center on Budget and Policy Priorities, February 17, 2006.
 Many African Americans born in the South were not delivered in hospitals and lack documentation. The mentally disabled and elderly may not be in a position to physically locate their documents, or recall where these documents may be, particularly those in institutions. Victims of natural disasters, such as Hurricane Katrina, may have lost the appropriate documentation.
P. A. Buescher, J. T. Whitmire, S. Brunssen et al., Children Who Are Medically Fragile in North Carolina: Using Medicaid Data to Estimate Prevalence and Medical Care Costs in 2004, Maternal and Child Health Journal, June 3, 2006.
S. R. Collins, C. Schoen, J. L. Kriss et al., Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated May 24, 2006.
J. Gabel, R. McDevitt, L. Gandolfo et al., Generosity and Adjusted Premiums in Job-Based Insurance: Hawaii Is Up, Wyoming Is Down, Health Affairs, May/June 2006 25(3): 832–43.
J. R. Goss, C. Maynard, G. S. Aldea et al., Clinical Outcomes Assessment Program. Effects of a Statewide Physician-Led Quality-Improvement Program on the Quality of Cardiac Care. American Heart Journal, May 2006 151(5): 1033–42.
N. Jensen, A. Suchman, R. Dart. Partnering with Citizens to Reform Wisconsin Health Care: A Report of Citizen Congress II, Wisconsin Medical Journal, May 2006 105(3): 41–4.
T. J. Johnson, M. Rimsza, W. G. Johnson, The Effects of Cost-Shifting in the State Children's Heath Insurance Program, American Journal of Public Health, April 2006 96(4):709–15. Epub 2006 Feb 28.
B. Kaskie, N. Wallace, S. Kang et al., The Implementation of Managed Behavioral Healthcare in Colorado and the Effects on Older Medicaid Beneficiaries, Journal of Mental Health Policy and Economics, March 2006 9(1): 15–24.
S. Nageswaran, M. S. Roth, C. E. Klutzz-Hile et al., Medical Homes for Children with Special Healthcare Needs in North Carolina, North Carolina Medical Journal, March/April 2006 67(2):103–9.
H. Pelletier, How States Are Working with Physicians to Improve the Quality of Children's Health Care, National Academy for State Health Policy and The Commonwealth Fund, April 2006.
M. J. Reeves, S. R. Bohm, S. J. Korzeniewski et al., Asthma Care and Management Before an Emergency Department Visit in Children in Western Michigan: How Well Does Care Adhere to Guidelines? Pediatrics, April 2006 117(4 Pt 2):S118–26.
P. J. Roohan, J. M. Butch, J. P. Anarella et al., Quality Measurement in Medicaid Managed Care and Fee-for-Service: The New York State Experience, American Journal of Medical Quality, May/June 2006 21(3): 185–91.
G. D. Stevens, M. Seid, N. Halfon, Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association with Health Status and Primary Care Access, Pediatrics, April 2006 117(4):e751–9.
A. Weil, Can Medicaid Do More with Less? The Commonwealth Fund, March 2006.
B. Wolfe, T. Kaplan, R. Haveman et al., SCHIP Expansion and Parental Coverage: An Evaluation of Wisconsin's BadgerCare, Journal of Health Economics, March 2, 2006.
State Coverage Initiatives Summer Meeting
Chicago, IL, August 3–4
For information, visit State Coverage Web site
National Academy for State Health Policy, Annual State Health Policy Conference
Pittsburgh, PA, October 15–17
For information, visit NASHP Web site