Georgia Planning Grant for the Uninsured Annual Report to the U.S. Department of Health and Human Services and H.R.S.A. State of Georgia September 2006 Funded by a Grant from the U.S. Department of Health and Human Services 1
Executive Summary The state of Georgia was the recipient of an initial HRSA State Planning Grant for the Uninsured in FY2002. That work was extended to and completed in FY2004. Georgia was also the recipient of a Pilot Planning Grant in FY2004 that was extended through FY2006. The final report for that grant is sent under separate cover and includes much of the information requested for this report. This report provides an update of activities for Georgia s last Planning Grant for the Uninsured awarded in FY2005. Originally awarded through August 31 2006, the project received a no-cost extension and will conclude February 28 2007 with a final report submitted no later than March 31 2007. The Georgia Health Policy Center (GHPC), at Georgia State University s Andrew Young School of Policy Studies, is charged with leading Georgia s efforts under direction of the Governor s Office of Planning and Budget. Funded by a Grant from the U.S. Department of Health and Human Services 2
Background and Previous HRSA SPG Accomplishments N/A: Please see Georgia Pilot Planning Grant for the Uninsured Final Report under separate cover. Grant Activities The State of Georgia, working in a continually changing economic and policy environment, acknowledges that the growing problem of Georgians without health insurance cannot be addressed solely with the resources of one Planning Grant. Therefore, the Planning Grant Team designed a five-year plan that will provide Georgia with ongoing decision-making capacity beyond the term of the State Planning Grant in its efforts to reduce the number of its uninsured citizens (Figure 1). The plan includes sequences of employer surveys, population surveys, and statewide focus groups every three years in addition to ongoing data analysis, community-level coverage development, key findings dissemination, and grassroots policy development. The Team continues to work with the State to identify resources to support such ongoing decisionmaking capacity. In SFY2006, the Georgia Health Policy Center secured private funding to work for three years with the Georgia State Legislature in building its evidence-based decision-making capacity, including the topic of coverage for uninsured Georgians. The GHPC is also close to securing support to field its next statewide population survey of insurance status. Figure 1: Five-Year Decision-Making Infrastructure Components Data Collection Knowledge Building Knowledge Transfer Policy Development Population Survey Employer Survey Focus Groups Analysis Modeling Experiential Learning Best Practice Dissemination Reports Issue Briefs Targeted Briefings Legislative Hearings Consensus Building Community-driven Coverage Solutions Legislative Advisement Because of a challenging economic environment, Georgia is focused on preserving existing public services, building a Medicaid capitated managed care system that strengthens the statewide safety net, and supporting the creation of community-based public-private coverage partnerships through regulatory, administrative, or legislative means, where possible. The state believes in the power of community to make a lasting difference in the number of uninsured Georgians. The current State Planning Grant is focused on building on that power of community to drive policy decisions at the state level by sharing research findings in a structured manner with 30 diverse audiences of local business and government leaders around Georgia and measuring the impact of those findings on their preferences for developing policy options for covering the uninsured. Experiential Learning Module Design and Policy Ranking Exercise Refinement Beginning in the fall of 2005, the Planning Grant team began to synthesize the findings of the previous State Planning Grants to extract the most pertinent information that might impact Funded by a Grant from the U.S. Department of Health and Human Services 3
decision-making around policy options for covering the uninsured. The module includes findings from: The 2002 Georgia Household Survey March 2005 CPS Estimates of Uninsured Georgians The 2002 and 2004 Georgia Employer Surveys 2002 Focus Groups with Georgians and Small Employers The Assessment of Georgia s Safety Net Modeling High-Risk Pools, Health Savings Accounts, and Tax Credits The Experiences of Four Georgia Communities Designing Public-Private Coverage Partnerships with FY04 Pilot Planning support The module s design was led by Dr. Karen Minyard with assistance from Drs. William Custer, Patricia Ketsche, and Chris. Parker, and Glenn Landers and Beverly Tyler all members of the Planning Grant Team since FY2002. The module was revised several times throughout December 2005 and piloted with a test audience in February 2006. The final version follows. Funded by a Grant from the U.S. Department of Health and Human Services 4
Covering the Uninsured: A Community Perspective Georgia State Planning Grant Team Funded by a Grant from the U.S. Department of Health and Human Services 5
Possible Help for the Uninsured Encourage Change in What and How Health Insurance is Sold in Georgia Change the regulations governing health insurance to make it more affordable and easier to purchase, such as: establish a high risk pool, allow association plans, promote health savings accounts, etc. Tax Incentives/Subsidies Financially assist employers and/or individuals/families with the purchase of health insurance through direct payments or tax reductions. Funded by a Grant from the U.S. Department of Health and Human Services 6
Possible Help for the Uninsured Employer Mandates Require employers of a certain size to offer coverage to their employees. Individual Mandates Require uninsured individuals to purchase health insurance for themselves and their families, similar to car insurance mandates. Funded by a Grant from the U.S. Department of Health and Human Services 7
Possible Help for the Uninsured Public Expansion Expand tax-funded programs such as Medicare, Medicaid, and PeachCare to cover more low-income Georgians. Single-Payer System Establish a system that pays for the health care or health insurance premiums for everyone in Georgia. Do Nothing to Expand Health Insurance Coverage Keep the current system as is. Funded by a Grant from the U.S. Department of Health and Human Services 8
United Health Foundation 2004 Rankings Georgia is 45 th in the nation in overall health status Last in Public Health Spending Last in Per Capita Health Spending Tied for 6 th as the Most Obese State 4 th worst in Infectious Disease Tied for 8 th worst in Premature Death Tied for 7 th highest in Infant Mortality Tied for 10 th worst in Cardiovascular Deaths Funded by a Grant from the U.S. Department of Health and Human Services 9
What Does Health Care Cost in Georgia? In total, Georgians spent almost $45 billion on health care in 2003. The average annual cost for employment-based family coverage is approaching $10,000 per year. Georgia s Medicaid program cost $5.7 billion in 2003. Funded by a Grant from the U.S. Department of Health and Human Services 10
How Do Georgians Pay for Health Care? 70% 60% 59% 50% 40% 30% 20% 14% 17% 10% 7% 10% 3% 0% Employer Other Private Medicare Medicaid SCHIP Uninsured Funded by a Grant from the U.S. Department of Health and Human Services 11
Employer Coverage Most Georgians with private coverage get it through their employer. Large firms and firms located in urban areas are more likely to offer coverage. Funded by a Grant from the U.S. Department of Health and Human Services 12
Employer Coverage Employer sponsored coverage is eroding: 3% decline in firms offering between 2002 and 2004 Most decline in coverage at firms with 25 to 99 employees Most firms that do not offer coverage say it costs too much. Funded by a Grant from the U.S. Department of Health and Human Services 13
Who Are the Uninsured? About 1.5 million Georgians are uninsured. 2/3 of the uninsured work or are the dependents of full-time workers. Funded by a Grant from the U.S. Department of Health and Human Services 14
Who Are the Uninsured? Workers at small firms or who earn low wages are most likely to lack coverage. 71% of workers without coverage work for an employer who does not offer coverage, or they are not eligible for coverage when it is offered. Funded by a Grant from the U.S. Department of Health and Human Services 15
The Uninsured in Georgia Are : More likely to report fair or poor health. Less likely to receive preventive care. More likely to miss school or work. Less likely to have a usual source of care. Sicker when they are admitted to the hospital. More likely to be readmitted for same illness. Funded by a Grant from the U.S. Department of Health and Human Services 16
Poor Health Status and Being Uninsured Seem to be Related Percent of Uninsured Population By County 16% 25% 23% 24% 23% 16% 18% 25% 22% 15% 15% 18% 10% 30% 24% 10% 27% Lumpkin Gordon Floyd 29% Bartow 21% 22% 14% 18% 22% 24% 22% Clayton 13% Spalding Pike 20% 14% Harris 21% 18% 22% 13% 16% 20% 23% 15% 15% 21% 22% 14% 22% 18% 18% 24% 12% 16% 18% 11% Calhoun 18% 31% Effingham Tattnall Chatham Liberty Jeff Davis Ben Hill Irwin Coffee Berrien Atkinson Dougherty Long Appling Bacon Wayne Tift McIntosh Pierce Mitchell Colquitt Cook Ware Brantley Glynn Lanier Seminole Clinch 22% Bulloch Evans Bryan Telfair Lee Baker Decatur Grady Thomas Charlton Camden Brooks Lowndes 14% 41% 30% 9% 37% 29% 31% 19% Clay Miller 32% 34% 16% Terrell Turner 20% Candler Toombs Wheeler Crisp Quitman 22% 29% 22% 24% 20% Treutlen Dodge Sumter Worth 29% 19% Laurens Montgomery Pulaski Early 18% 30% Emanuel Bleckley Webster Screven Johnson Wilcox 16% Jenkins Macon Dooly Randolph 23% Burke Wilkinson Twiggs 22% 14% 21% 20% 16% Washington Jefferson Peach Houston Schley 13% 19% 30% 52% 14% Stewart 19% Marion Chattahoochee 10% 23% 23% 20% Taylor Muscogee 21% 17% Jones Crawford Talbot 26% 18% 18% 24% 23% 25% 13% 14% Monroe Richmond Glascock Baldwin Upson 23% 14% Hancock Lamar Bibb 19% 23% 17% Meriwether 26% 22% 23% Columbia McDuffie Warren Putnam Jasper Butts 26% 17% 21% Taliaferro Greene Fayette Coweta Heard 13% 19% Morgan Newton Henry 10% 16% 12% 20% Lincoln Wilkes Rockdale 25% 16% Oglethorpe Walton Douglas Fulton 29% 23% 31% Elbert Clarke Oconee DeKalb Haralson 27% Troup 16% Georgia Health Status Score: 54.7 Gwinnett Paulding 33% Hart Madison Barrow Polk Carroll 11% 11% Franklin Banks Forsyth Cherokee Cobb 15% 11% 16% Pickens Hall 20% + 19% 51% 18% 8% Habersham Stephens Dawson 24% 9% 9% 23% 25% 25% 12% 10% White Jackson 21% 7% 6% 35% Walker Chattooga Health Status Excellent 76-100 Good 53-75 Fair 37-52 Poor 0-36 Rabun Union Gilmer 17% 24% 17% 23% Towns Fannin Murray Whitfield 11% - 19% 23% 23% Catoosa GA Uninsured Estimates 0% - 10% 27% 21% 15% Dade 23% 25% 21% 12% 15% Health Status by County, Georgia, 2003 Echols 14% 43% Prepared by: G.E. Alan Dever, Ph.D., M.T., M.D. (Hon.) & Leah Sm ith, M.P.H. Mercer University- Health Sciences Center Data Source: Inforum, 2004 Funded by a Grant from the U.S. Department of Health and Human Services 17
How Do the Uninsured Get Care? The uninsured pay out-of-pocket for some of their health care services, but they pay more per unit of service because they do not receive the discounts that are given to insurance companies, Medicare, or Medicaid. The uninsured are more likely to delay seeking care, are less likely to get needed medications for chronic diseases, and are more likely to seek emergency care. Therefore, they access less care, on average, than insured individuals. Funded by a Grant from the U.S. Department of Health and Human Services 18
How Do the Uninsured Get Care? Hospitals that accept Medicare or Medicaid are required to treat and stabilize anyone who comes to their emergency rooms in a health crisis. Although the uninsured receive less care than those with coverage, the care provided to uninsured Georgians costs about $1.5 billion annually, Funded by a Grant from the U.S. Department of Health and Human Services 19
Who Pays for the Uninsured? Higher Costs for Health Care 41% Out-of-pocket 20% Taxes 39% Funded by a Grant from the U.S. Department of Health and Human Services 20
Who Pays for the Uninsured? People who pay more taxes and those who use more health care services pay more for the uninsured. A family of three with a household income of $50,000 pays about $800 annually toward the cost of the uninsured. Funded by a Grant from the U.S. Department of Health and Human Services 21
Everyone s Healthcare is Subsidized Covering the uninsured is costly, but everyone shares in the cost of everyone else s healthcare. Most employers pay a portion of their employees insurance premiums. Insured people who seldom go to the doctor subsidize the care of insured people who go to the doctor more often. Tax dollars, including those paid by the working uninsured, pay for the Medicaid and Medicare programs Funded by a Grant from the U.S. Department of Health and Human Services 22
Trade Offs to Consider Making adjustments to how we sell insurance will not disrupt the current system but will enable a relatively small number of Georgians to gain insurance. Tax credits and subsidies can help those with low incomes afford coverage. To be fair, they must be provided to all who are eligible - even those already insured; thus, the overall cost per newly insured is high Funded by a Grant from the U.S. Department of Health and Human Services 23
Trade Offs to Consider Employer mandates may decrease tax expenditures to cover the cost of the uninsured but may also result in lower take-home pay, and that effect may be greater for small employers than large employers. Mandating individual coverage would require major changes in the market to make insurance affordable and potentially increase the cost for sicker individuals due to reduced pooling of risks, but it might promote greater individual responsibility. Funded by a Grant from the U.S. Department of Health and Human Services 24
Trade Offs to Consider Public expansion may decrease health insurance premiums and out-of-pocket expenditures for everyone, but may also increase taxes for everyone. A single-payer system may eliminate health insurance premiums and out-of-pocket expenditures for everyone and increase access to primary care but will increase taxes and may reduce access to some types of specialized care. Funded by a Grant from the U.S. Department of Health and Human Services 25
Trade Offs to Consider Doing nothing does not disrupt the system but will result in continued health care cost inflation and more uninsured Georgians. Funded by a Grant from the U.S. Department of Health and Human Services 26
Assessment Tool Design While the primary purpose of the experiential learning module is to transfer knowledge that forms the basis of community-driven, evidence-based decision-making around policy options for the uninsured, a secondary purpose is to raise the level of knowledge at the community level of the problem and challenges presented by uninsured Georgians. In order to assess whether or not this objective is achieved, the Planning Grant Team designed an assessment tool to measure the degree to which community group members changed their opinions of various options presented during the community modules. The assessment instrument was administered at the start and end of the experiential learning module. The tool s design was led by Dr. Minyard with assistance from Drs. Custer, Ketsche, and Parker, and Mr. Landers. The design process took place through December 2005 and was piloted along with the module in February 2006. Experiential Learning Module Activity The learning module, led by Beverly Tyler and assisted by the Planning Grant Team, was taken to 30 Georgia communities by Georgia Health Decisions, between March and July 2006. The 30 communities visited are listed below. NUMBER DATE/TIME 1 2 3 4 5 6 7 8 March 9, 2006 8:30 am March 23, 2006 3:30 to 4:30 p.m April 12, 2006 April 20, 2006 1:00 p.m. May 1, 2006 12:00 p.m. May 1, 2006 12:00 May 9, 2006 5:30 p.m. May 11, 2006 11:00 to 12:00 SPONSORING ORGANIZATION Leadership Albany Fannin s Future Team Leadership Americus Black Leadership Forum Memorial Health System City of Hinesville & Health Planning Board McDuffie Medical Associates - Dublin-Laurens County Chamber of Commerce PLACE AREA FACILITATOR Palmyra Medical Centers - Albany Fannin Hospital Blue Ridge Americus Savannah Savannah Hinesville Thomson- McDuffie Chamber - Thomson Dublin- Laurens Chamber Southwest Northeast Central 2 nd Tier City 2 nd Tier City Southeast Central Central Karen Wakeford Lynne Kernaghan Jill Ward Jill Ward Karen Wakeford Lynne Kernaghan Lynne Kernaghan Lynne Kernaghan Funded by a Grant from the U.S. Department of Health and Human Services 27
9 May 23, 2006 10 11 June 1, 2006 Time TBA June 2, 2006 8:00 a.m. 12 June 2, 2006 13 June 6, 2008 8:00 am 14 June 7, 2006 15 16 17 18 19 20 June 7, 2006 8:00 a.m. Week of June 8 8:00 am Week of June 9 8:00 am June 12, 2006 June 14, 2006 June 15, 2006 21 June 20, 2006 22 23 June 26, 2006 8:00 am June 27, 2006 Leadership Columbus Becky Gordon Leadership Macon Team Jasper Douglas County Chamber of Commerce Regional Atlanta Civic League Office of Health Services Board of Directors Regional Atlanta Civic League Regional Atlanta Civic League Regional Atlanta Civic League Cartersville-Bartow Chamber of Commerce Griffin Spalding Co Chamber of Commerce Washington County Regional Hospital Authority Augusta Metro Chamber of Commerce Partners for a Prosperous Athens South Georgia Health Partnership Columbus Chamber of Commerce - Macon Jasper Chamber of Commerce Monticello Douglasville Gwinnett Medical Center - Lawrenceville Macon Cobb County Chamber of Commerce - Marietta Henry County Chamber of Commerce - McDonough DeKalb County Chamber of Commerce - Decatur Cartersville Griffin Sandersville 2 nd Tier City 2 nd Tier City Central Metro Atlanta Metro Atlanta Statewide Metro Atlanta Metro Atlanta Metro Atlanta Atlanta Metro Atlanta Metro East Jill Ward Lynne Kernaghan Lynne Kernaghan Jill Ward Karen Wakeford Karen Wakeford Beverly Tyler Karen Wakeford Karen Wakeford Jill Ward Jill Ward Lynne Kernagahan Augusta 2 nd City Jill Ward Athens Valdosta East South Lynne Kernaghan Karen Wakeford Funded by a Grant from the U.S. Department of Health and Human Services 28
24 25 26 June 29, 20006 12:00 July 11, 2006 6:00 p.m. July 13, 2006 11:00 27 July 14, 2006 28 July 25, 2006 29 30 July 25, 2006 9:00.am July 27, 2006 9:00 a.m. Dooly County Chamber of Commerce 100 Black Men of Milledgeville Oconee Area - James Lunsford Tifton Chamber of Commerce Greater Rome Chamber of Commerce Perry Area Chamber of Commerce Newnan Coweta Chamber of Commerce Archbold Hospital Vienna Milledgeville Tifton Rome Perry Newnan Thomasville South Central South Northeast Central East South Jill Ward Lynne Kernaghan Jill Ward Jill Ward Lynne Kernaghan Jill Ward Karen Wakeford The Planning Grant Team anticipates that at the end of each of the 30 experiential learning modules, community groups will: 1.) Gain a greater depth of understanding about uninsured Georgians and the impact that the lack of health insurance has on health care financing overall and the direct effect it has on the local health care delivery system; 2.) Learn of various policy options for addressing the high rate of uninsured residents in Georgia and understand the trade-offs involved in implementing each; 3.) Understand their opinions about the policy options. Findings Analysis Analyses of findings have begun and will be complete in November 2006. Findings Dissemination and Policy Development Initial findings were published in the Atlanta Business Chronicle August 2, 2006. Findings will also be shared with legislators during the 2006 Legislative Biennial in December 2006. Academic publications and presentations are planned, and the findings will be shared with the Governor s Office and legislators for policy considerations during the 2007-2008 legislative session. Implementation Status N/A: Please see Georgia Pilot Planning Grant for the Uninsured Final Report under separate cover. Funded by a Grant from the U.S. Department of Health and Human Services 29
Recommendations to the Federal Government and HRSA N/A: Please see Georgia Pilot Planning Grant for the Uninsured Final Report under separate cover. Funded by a Grant from the U.S. Department of Health and Human Services 30
Appendix 1: Summary of Policy Options N/A: Please see Georgia Pilot Planning Grant for the Uninsured Final Report under separate cover. Funded by a Grant from the U.S. Department of Health and Human Services 31
Appendix 2: Project Management Matrix Green = Complete Yellow = Revised Time Line Project Management Plan Task 1: Comprehensive Oversight Activities Quarterly Meeting with Governor's State Planning Grant Advisory Committee Monthly Project Team Meeting Timetable September and December 2005, March and June 2006 September 2005 August 2006 Responsible Agency or Individual Governor's Advisory Committee, Office of Planning and Budget (OPB), Georgia Health Policy Center (GHPC), Center for Health Services Research (CHSR) OPB, GHPC, CHSR Task 2: Design Experiential Learning Module Anticipated Results Guidance on planned activities Tasks and schedules reviewed and adjusted, if necessary Measurement Meeting held and feedback/guidance incorporated into project 11 monthly meetings completed Timetable Responsible Agency Result Measurement Identify Key Findings from 2002 2004 SPG Activities Condense Key Findings into One Learning Session Identify National, State, and Local Coverage Options to be Included in Insurance Plan Exercise Refine Insurance Plan Building Exercise Produce Experiential Learning Module Materials Pilot Experiential Learning Module with Governor s Advisory Committee Refine Experiential Learning Module September October 2005 September October 2005 October November 2005 November December 2005 November December 2005 December 2005 December 2005 GHPC, CHSR GHPC, CHSR GHPC, CHSR GHPC, CHSR, GHD GHPC, CHSR, GHD GHPC, CHSR, GHD, OPB GHPC, CHSR, GHD Key findings Identified Educational component designed National, state, and local coverage options are included in insurance plan exercise Insurance Plan exercise is refined Materials produced Governor s Advisory Committee experiences experiential learning module Experiential learning module is refined based on experience with Governor s Advisory Group Key findings included in educational component Educational component completed Coverage options are representative of national, state, and local efforts Insurance plan exercise ready for use Number of learning module materials Exercise design completed Experiential learning module is complete Funded by a Grant from the U.S. Department of Health and Human Services 32
Task 3: Design Participant Assessment Tool Timetable Responsible Agency Result Measurement Determine Coverage Knowledge Baseline Questions September October 2005 GHPC, CHSR Baseline questions determined Short list of baseline questions Pilot Participant Assessment Tool with Governor s Advisory Committee December 2005 GHPC, CHSR, GHD Refine Assessment Tool December 2005 GHPC, CHSR, GHD Task 4: Conduct 30 Experiential Learning Modules Governor s Advisory Committee completes pre- and postassessment Assessment tool is refined based on experience with Governor s Advisory Group Assessment completed Assessment tool is completed Timetable Responsible Agency Result Measurement Identify and Recruit Participants November December 2005 GHD 30 local business and government groups agree to participate Local business and government leaders attend experiential module Coordinate Schedule and Meeting Logistics November December 2005 GHD Facilities are confirmed for all modules Experiential learning modules are conducted Facilitate and Record Experiential Learning Modules January June 2006 GHD Insights from local business and government leaders are provided for further coverage partnership development 30 experiential learning modules are completed Funded by a Grant from the U.S. Department of Health and Human Services 33
Task 5: Analyze Experiential Learning Module Findings Timetable Responsible Agency Result Measurement Transcribe All Learning Module Findings January July 2006 GHPC, GHD All findings are transcribed Written record of learning module sessions is produced Code all Findings Into Atlas.ti January July 2006 GHPC Transcriptions are coded Complete Atlas.ti file Analyze Findings and Common Themes June July 2006 GHPC, CHSR Findings are analyzed Common themes are identified Prepare Report July 2006 GHPC Completed report synthesizing 30 experiential learning sessions Report ready for distribution Disseminate Report July 2006 GHPC Report widely distributed Report distributed statewide With a no-cost extension granted through February 2007, the transcription, coding, and analysis will take place in August, September, and October of 2006. Report preparation and dissemination will occur November 2006 February 2007. Funded by a Grant from the U.S. Department of Health and Human Services 34
Appendix 3: Reports N/A: Please see Georgia Pilot Planning Grant for the Uninsured Final Report under separate cover. Funded by a Grant from the U.S. Department of Health and Human Services 35