The healthy Washington initiative: blue-ribbon process, red-herring result.

• Author: Williams, Vickie J.

"Quality, affordable health care is a right, not a privilege, and the Healthy Washington Initiative will make changes that bring us another step closer to serving all Washingtonians." (1)

INTRODUCTION

In 2006, empowered by the perceived public support for change in the state, (2) the Washington State Legislature established the Blue Ribbon Commission on Health Care Costs and Access (the "Commission"). (3) The Commission was charged with delivering a five-year plan for substantially improving access to affordable health care for all Washingtonians. (4) After performing an extensive examination of the problems of access and affordability of health care in Washington, the Commission issued its final report to the Washington State Legislature in January 2007. (5) Unfortunately, rather than taking the opportunity to move Washington boldly into the forefront of innovation in health-care access and affordability for all citizens, the Commission recommended relatively conservative, non-controversial, and generally ineffective policies. These policies included enrolling state health-program beneficiaries in disease-management programs, instituting pay-for-performance systems in state health programs, organizing the private-insurance market to be more accessible to consumers, and making the system Washington uses to insure its highest-risk citizens only slightly more affordable. (6) The Commission's recommendations noticeably lacked initiatives designed to change the behavior of individuals or private insurers to increase access and coverage.

One month after the Commission issued its final report, legislation to implement many of the Commission's recommendations was introduced in both houses of the state legislature. (7) The legislative committees made only one significant revision to the initial legislation, removing a potentially controversial provision. This provision would allow exceptions to state coverage mandates for health carriers offering health plans to individuals, small businesses, and young adults. (8) The revised legislation sailed through the legislature, and was signed into law with much fanfare by Governor Christine Gregoire shortly thereafter. (9) Unfortunately, rather than representing a victory for advocates of meaningful health-care reform for the uninsured and underinsured, the legislation authorized mostly palliative policies that will have little effect on many currently uninsured and underinsured Washingtonians. It will have even less effect on those whose risk of becoming uninsured grows at the fastest rate, young adults. At best, the legislation implemented will nibble away at the access and affordability problems for poor and middle-income Washington citizens. It will not make significant strides towards solving the problems of the state's uninsured and underinsured. Despite all of its promise and promotion, the Healthy Washington Initiative squanders a rare opportunity of public and political will coalescing in favor of effecting real change.

Part I of this Article explores the process that gave rise to the Healthy Washington Initiative and analyzes the key provisions of the initiative that are directed towards the problems of limited access to, and excessive costs of, health-care coverage in Washington. It then suggests that the Healthy Washington Initiative will fail to increase coverage for the key demographic of uninsured young adults. Part II describes what an effective Healthy Washington Initiative should look like. It argues that the legislature could better expend the current resources devoted to the Healthy Washington Initiative. Finally, Part II suggests that the legislature change the manner in which health-care coverage is delivered to reflect the changing role of work and employment in our society, particularly among young adults, who are at an increasingly great risk of being uninsured.

1. THE HEALTHY WASHINGTON INITIATIVE

   1. The Blue Ribbon Commission

      1. Process

         The Commission's process for soliciting input and gathering data was thorough, thoughtful, and inclusive. The Commission formally met eight times throughout 2006. (10) Most of the meetings lasted full days. (11) The agendas from the meetings indicate that the Commission considered a large amount of varied data to develop its five-year plan to substantially improve access to affordable health care. (12) The Commission solicited input from a wide variety of stakeholders, including health care consumers, health care providers, special interest groups, public and private health insurers, and Washington businesses. (13) The Request for Proposals specifically asked for stakeholder input on six topics, ranging from aspirational questions about the Commission's appropriate goals, to concrete questions about the proposals. (14) The stakeholders submitted seventy-three proposals, totaling over 700 pages. (15) The proposals ranged from encouraging the continuation of the current employer-based system of health insurance through additional tax credits for employers and rolling back coverage mandates to facilitate the development of more affordable health insurance plans for small employers and their employees, to establishing a universal health coverage system for all Washingtonians, de-linked from employment. (16) Many of the proposals aimed to expand coverage for specific consumer groups, such as children and senior citizens. (17) A few of the proposals were self-serving and specific, for example the Institute for Healthcare Advancement's proposal to have the State of Washington purchase a series of books it publishes called "What to Do for Health," and distribute them through various health-care providers in Washington. (18) Other proposals adopted more community-oriented and broad-based approaches, such as the proposal from Group Health Cooperative, the largest non-profit, integrated health-care system in Washington. Group Health suggested reforms that would mandate medical homes for low-income children, improve the insurance marketplace for small employers and individuals, and focus on promoting effective care and healthy lifestyles, among other things. (19)

         The Commission had a large variety of data and proposals at its disposal throughout the six-month period during which it met regularly to formulate its final report and recommendations. The Commission also examined other organizations' and states' health-care vision statements, and surveyed health-care reform efforts throughout the nation. (20) It viewed presentations by a wide variety of interested persons, including former Oregon Governor John Kitzhaber, representatives of the Robert Wood Johnson Foundation, the Washington Office of Insurance Commissioner, and various other providers and employers. (21) The Commission also viewed a presentation on the history of health insurance and current trends in coverage. (22) It received data from other government-sponsored sources on the identity and characteristics of the uninsured in Washington. (23)

      2. Goals, Strategies, & Recommendations

         In January 2007, the Commission issued its final report on health care costs and access. (24) Noting that there are approximately 593,000 Washingtonians without health care coverage, including 73,000 children, the Commission set forth five goals that it had adopted early in its deliberations in 2006: (1) all Washingtonians will have access to health coverage that provides effective care by 2012, with all children having such coverage by 2010; (2) Washington will be one of the top ten healthiest states in the nation; (3) population health indicators will be consistent across race, gender, and income levels throughout the state; (4) increased use of evidence-based care brings better health outcomes and satisfaction to consumers; and (5) the rate of increase in total health-care spending will be no more than the growth in personal income. (25)

         To implement these goals, the Commission identified four strategies: (1) build a high-quality, high-performing health-care system; (2) provide affordable health-insurance options for individuals and small businesses; (3) ensure the health of the next generation; and (4) promote prevention and health-lifestyles. (26)

         To further these strategies, the Commission made sixteen recommendations, each of which directs the state to take certain actions. (27) The recommendations can generally be divided into three groups: (1) those directed towards state payors, such as Medicaid; (2) those directed towards the private insurance market; (3) and those directed towards providing tools and information to consumers. (28) A number of the recommended actions required other state administrative agencies, such as the Washington Office of the Insurance Commissioner ("OIC"), to provide further reports to the governor and legislature. (29) A few recommended actions directed state health purchasing agencies to act. (30) Others specifically charged the governor and the legislature to introduce and pass legislation to improve the health of the population. (31) The Commission specifically noted that its work was only a "starting point," and that the Commission was not expected to include all the ideas that the governor or legislature might consider to address Washington's health-care challenges. (32)

      3. Pre-Legislation Reports

         The Commission's final report tasked the OIC with providing three reports to the governor and legislature to help implement legislation designed to effectuate the Commission's recommendations. (33) One report responded to the Commission's Recommendation #8: "Give individuals and families more choice in selecting private insurance plans that work for them." (34) The Commission directed the OIC to provide a report identifying the impacts and likely tradeoffs in terms of cost and coverage if state laws were modified to provide health carriers more freedom from extensive benefit mandates in order to target insurance products to small businesses...