Presuming federal health care reform gets passed, and presuming that reform looks significantly like the proposal from the Senate, what does this reform mean for Minnesota? Much like the bill coming out of the Senate, the answer to that question is a little murky.
In some sense the reform measures coming from Congress will have little impact to the Minnesota system. That is because in large part the Minnesota model is a functional and integral touchstone in federal health care reform. Historically Minnesota has led the country in the percentage of its citizens with health insurance,1 but that leadership has not come simply from the capitol. While it is true that Minnesota public programs, at least until recently, provide coverage to a wider set of individuals than many other states, Minnesota employers are also more likely than others to provide health insurance for their employees.2 Minnesota was also one of the architects of prepaid comprehensive health care plans, known as HMO’s which set the stage for the state to become home to one of the largest managed care companies in the United States, UnitedHealth Group.
Additionally, health reform came a decade earlier to Minnesota under the auspices of what would come to be known as MinnesotaCare, a lofty piece of legislation directed at both controlling costs and increasing access with a series of initiatives including comprehensive insurance reform in both group and individual markets, establishing a reinsurance pool, providing incentives to improve rural health care, substantial tort reform, the creation of a quality control mechanism in the Health Care Commission and establishing a subsidized health insurance program for the working poor. Delivery of these initiatives occurred through Integrated Service Networks and established regional coordinating boards to facilitate local efforts at improving quality and access.3 A tax on providers was the principal source of financing for the reforms and funding for the subsidized insurance.
Sound familiar? With the proposed coverage mandate, corresponding subsidies, exchanges, non-profit coops, and insurance coverage reforms, national health care reform looks strikingly like the Minnesota model. Of course, since health care reform came earlier to Minnesota than many other parts of the country, Minnesota can offer as many lessons in administrating change as how to construct it.
During the course of the Ventura and Pawlenty administrations MinnesotaCare withered, plagued by its own success at providing high quality care at relatively affordable costs and from a lack of political focus on the ongoing need to maintain a robust public health system. Despite the fact that Minnesota General Assistance Care (GAMC), the state’s subsidized health insurance for working poor without children became a national model for covering low-income adults, it was the target of continued assaults on funding until, under this last legislative session, the Pawlenty administration eliminated the program all together. Built on sliding scale premiums and subsidies, GAMC and all of MinnesotaCare embraced the ethos that assistance is a far cry from handouts. Despite that governing philosophy the program fell victim to politics and the message of individual responsibility and independence, built by bipartisan efforts at crafting an affordable and high quality health care delivery system to the working poor was replaced with one of ending government handouts.
It should also be noted that while Minnesota was, and in some ways remains, a leader in structuring comprehensive health care reform, there are some aspects of the state that make delivering those reforms elsewhere more of a challenge. As a whole the state’s population remains more educated than others, and despite the increase in Hmong, Somali, and other immigrant populations, our public health structure bears less of an assimilation burden as states such as California. That means that Minnesota’s administrative costs in delivering health care are inherently less, and inherently more streamlined than other states. That said, Minnesota has also shown an overall suspicion of large health care institutions and a willingness to investigate fraud and abuse by insurers and providers, a stance that has also positively curbed the cost of health care delivery.
So on first blush it seems as though health care reform is much ado about nothing here in Minnesota. But it is not quite that simple. National health care reform is poised to affect Minnesota in some very significant ways, despite changing very little of the structure of how those services are delivered. As noted earlier, GAMC is the state health insurance program for low-income, childless adults and an integral component of the success of Minnesota’s earlier efforts at reform. The program is set to expire March 1st as a result of repeated, successive cuts by the Pawlenty administration, leaving approximately thirty-thousand more Minnesotans without health insurance. Currently Senators Klobuchar and Franken are reportedly negotiating to restore GAMC in the final form of health care reform. If successful tens of thousands will keep their insurance and the state will save significantly in health care delivery costs.
Minnesota is one of seventeen states that uses Medicaid funds to provide for abortion services in instances beyond cases of rape or incest. Presuming federal health care reform contains the severely restrictive abortion provisions, Minnesotans can reasonably expect a challenge to roll back Minnesota Medicaid to fall in line with federal provisions. With the numbers of Minnesotans joining the Medicaid rolls legislators will be eager to find areas of apparent savings, putting comprehensive reproductive health services for working Minnesota women at risk.
Those are just two examples of the significant impact health care reform would have on Minnesota, despite the fact that little would change to the architecture of how Minnesota delivers and regulates health services. Perhaps then the more interesting question is what would reform look like to a Minnesota health system not fiscally starved over the previous ten years?
At one point Minnesota was at the forefront of innovative health care reform coming out of the states, but because of the combination of the Great Recession and a Pawlenty administration determined to rid the state of “welfare rolls” Minnesota fell behind in efforts to change health care, despite the existence of an economic base significantly invested in shaping any efforts at reform. There can be no doubt that whether reform comes from Washington or not, health care will be a significant issue for Minnesotans and their next governor. Minnesota remains poised to lead the nation in efforts to provide provide high quality health care to the greatest number of people and through a system that is sustainable and affordable, so long as the will to do so returns.
1 MINN. DEP’T OF HEALTH & THE UNIV. OF MINN. SCH. OF PUBLIC HEALTH, HEALTH INS. COVERAGE IN MINN.: TRENDS FROM 2001 TO 2004 (Feb. 2006), http://www.shadac.umn.edu/img/assets/18528/MNAccess2004Reprt.pdf
2 KAISER FAMILY FOUND., http://www.statehealthfacts.org/cgi.bin/healthfacts.cgi
3 The Minnesota Health Right Act ch. 549, art. 1 Sec. 1, 1992 Minn. Laws 1487, 1488