Health Affairs, 25, no. 3 (2006): w150-w161 (Published online 11 April 2006) doi: 10.1377/hlthaff.25.w150 © 2006 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Charge Of The Right Brigade? Communities, Coverage, And Care For The Uninsured

Abstract

 
The Robert Wood Johnson Foundation’s Communities in Charge (CIC) program funded projects in fourteen communities that aimed to expand health insurance coverage and improve care for their uninsured residents. Our examination of seven program sites suggests that despite solid community leadership and carefully crafted plans, political, economic, and organizational obstacles precluded much expansion of coverage and constrained reforms. Redistribution of financial and organizational resources among both mainstream and safety-net institutions in these communities was hard to achieve. CIC’s record offers little evidence that communities are better equipped than are other sectors of U.S. society to solve the problem of uninsurance.

When can their glory fade?

O the wild charge they made!

All the world wonder’d...

—Alfred, Lord Tennyson, "The Charge of the Light Brigade," 1854

DESPITE A STRONG ECONOMY, by the late 1990s the number of Americans without health coverage hovered around forty million; federal and state proposals for universal coverage had long since collapsed; and reformers wondered whether community forces might reignite progress by crafting new programs for the uninsured. Within three years (1998–2000), the Robert Wood Johnson Foundation’s (RWJF’s) Communities in Charge (CIC) program, the Kellogg Foundation’s Community Voices program, and the federal Community Access Program (now known as the Healthy Communities Access Program, or HCAP) came into being, and several hundred million dollars were invested to develop local models of improved coverage and care for the uninsured. (HCAP alone has 158 sites and a 2003 congressional appropriation of $105 million.)¹

This paper examines the CIC program, which during 2000–2003 funded fourteen communities that assembled coalitions of providers, public officials, business leaders, and consumer groups, to design projects that either devoted financial resources to supplying new coverage or reconfigured their delivery systems to improve access to care for the uninsured. By conducting case studies of seven of the CIC sites (Portland, Oregon; Brooklyn, New York; Jacksonville, Florida; Portland, Maine; Birmingham, Alabama; Alameda County, California; and Jackson, Mississippi), we sought to learn what circumstances are "right" for local leadership on behalf of the uninsured and whether such conditions are likely to be found in enough sites to support the contention that putting communities in charge of this mission makes good policy sense.

Theory and practice (notably, the national health insurance systems of all Western nations save the United States) suggest that universal coverage presupposes large pools, which implies in turn that true (that is, smallish) communities will rarely be up to the job. On the other hand, health is famously a "community affair" in the United States. The example of Hillsborough County, Florida, which since the early 1990s brought coverage to nearly 30,000 uninsured residents with the proceeds from a half-cent increase in the sales tax, shows that communities can at least make a dent in the problem.² Moreover, local innovations that improve the delivery of medical care may not only per se benefit the uninsured but also liberate new resources with which to expand coverage. What happens, then, when communities, aided and abetted by foundation support, work to mobilize resources sufficient to expand coverage or care for the uninsured?

To answer these questions, we interviewed key stakeholders in person at each site twice and supplemented our site visits with telephone interviews and examination of documents. The mix of modest progress, stalemate, and collapse that we found after four years of tracking suggests, in brief, that even community leaders who are deeply dedicated to addressing the problems of the uninsured face a sharp uphill struggle. A few communities have engineered small expansions of coverage or care, but nothing in the concatenation of circumstances that supported this modest progress or in the general record of our seven sites argues that U.S. communities have the capacity to make much of a dent in the problems of the uninsured.³

Institutions And Resources

Top Institutions And Resources Strategies And Strains Assessments And Insights NOTES

 
Improving coverage and care for the uninsured is inescapably an exercise in redistribution from the haves to the have-nots. Institutions, public or private, that command resources must agree to shift some share of them to medically disadvantaged individuals or households (coverage) or organizations (care). Whether the strategy envisions, for example, shifting patients from tertiary hospitals to community health centers (CHCs), spending tobacco settlement funds on covering the uninsured instead of on immunization campaigns, or increasing the sales tax to aid those without coverage instead of improving the transportation infrastructure, some local institutions and residents will—absent the infusion of new resources from outside the community—gain while others lose.

That broader coverage entails redistribution is a truism—to be sure, money spent for one purpose is not available for others—but in political terms, this truth is not trivial. Funds for coverage get (re)channeled, not along optimal lines charted by analysts but, rather, through dark thickets of political conflict that must be mapped before they can be successfully navigated, and CIC illuminates the travails that attend alternative visions of redistribution.

Institutions that do the redistributing are of two general types: "mainstream" (government agencies, business firms, community hospitals, medical societies, and managed care organizations, for example); and "safety net" (entities that traditionally care for the disadvantaged—CHCs, public clinics, and public or voluntary hospitals with a high volume of uninsured or publicly insured patients). Resources to be redistributed also come in two broad categories: funds (new tax dollars and private insurance premiums) and "organization" (revised procedures, donated professional services, redeployed personnel, and service innovations such as group-based patient education). To be sure, changes in funding tend to have organizational implications, and vice versa, but these variables are distinct enough for our analytical purposes.

These categories combine into four main strategies. First, mainstream institutions may commit new moneys (funds not previously used for this purpose; Portland, Oregon, and Brooklyn). Second, mainstream institutions may reorganize their time and work for the intended advantage of the uninsured. This strategy entails a redistribution of professional energies that improves care largely in lieu of new monies (Portland, Maine). (Time, of course, is famously money, so these redistributed services are arguably equivalent to new funds, but the distinction is worth maintaining.) Third, safety-net institutions may redistribute their budgets in ways that extend coverage or care for the uninsured. Redistribution in this case generally shifts funds among institutions and purposes within the safety net itself in hopes of forging a better system (Birmingham and Alameda County). Fourth, safety-net institutions may reconfigure the division of labor among themselves or redesign workflow within their organizations, to provide better care for the uninsured.⁴

Strategies And Strains

Top Institutions And Resources Strategies And Strains Assessments And Insights NOTES

 
Strategy I. Portland, Oregon. Portland’s CIC program is a public variation on our first strategic theme: raising new "mainstream" dollars to benefit the uninsured. In a setting accustomed to regional (tri-county) thinking and institution building for transportation, recreation, and other "collective" goods, defining the uninsured as a regional issue had strong a priori appeal in Portland. In liberal Multnomah County, moreover, creation of a taxing district that might emulate the accomplishment of Hillsborough County, Florida, was not entirely beyond the political pale. Talk of new taxes, however, soon ran afoul of an economy so sour that Oregon laid doleful claim to the nation’s highest unemployment rate by mid-2002. The declining tax revenues that ensued meant, of course, that the state and counties were hard pressed to maintain current levels of public service; finding new funds to cover thousands of uninsured residents looked quixotic. Moreover, the region’s counties displayed different political personalities and distinct institutional approaches to providing health services: Multnomah County had a liberal and activist tradition and sizable public health institutions, but Washington County was essentially a middle-class suburb, conservative and cautious about adding new public services to such basics as schooling and law enforcement. Clackamas County fell somewhere in between.

By 2002, having agreed that political prospects for a new taxing district for the uninsured were negligible, CIC planners floated a regional "port authority" that might somehow take existing resources in hand and reconfigure them for the benefit of the uninsured. Tensions over intentions aggravated jurisdictional distrust: Was the "authority" mainly a means by which activist Multnomah might redistribute funds from its two county "partners" to itself, home to many of the region’s uninsured citizens and its safety-net providers? Finding little taste for anything so structurally imposing, reformers instead proposed tri-county "cooperative agreements" to address the problems of uninsurance. Jettisoning the authoritative connotations of an "authority," leaders in the public health agencies in the three counties quietly worked to convince their skeptical and mostly detached "electeds" (county commissioners) of the merits of a safety-net "enterprise," a term meant to suggest, said one source, a business venture—an "organization of influence."

In early 2004, nearing agreement in all three counties on language that would bring such an entity into being, the principals were trying to decide what exactly it might do. High on most lists were (1) the use of data to paint a detailed picture of the distribution of care for the uninsured among institutions in the counties, (2) concerting plans to leverage new federal dollars, (3) coordinating grant seeking among safety-net clinics and hospitals, (4) identifying ways to make care for the uninsured more equitable and efficient, and (of course) (5) reducing inappropriate use of emergency departments (EDs). Even these seemingly innocuous projects could threaten the autonomy of county leaders, however, so promoters of the enterprise weighed their words carefully. In fall 2003, said one, "It’s just talk of funneling resources through this ‘thing’." Portland’s mainstream institutions had, in effect, exchanged strategy I, raising new funds, for strategy IV, reorganizing the safety net under the guiding hand of the emerging "enterprise." But whether or not CIC could produce something substantial remained to be seen.

Brooklyn, New York. CIC in Brooklyn ran a private variation on strategy I. Here new funds to cover the uninsured are expected to come from the private sector (small employers), not from taxpayers. The Brooklyn project breathed new life into an old idea: If the U.S. private sector contrives to cover most employees, rocket science should not be needed to devise appealing, affordable private insurance products to cover the rest. To be sure, previous efforts to develop such options have amounted to a party to which small firms rarely choose to come, but hope springs eternal, and Brooklyn tweaked the core elements of small-employer insurance in promising ways.⁵

Specifically, Brooklyn’s CIC plan—Brooklyn Health Works (BHW)—combined strong public support by the borough president, enthusiastic endorsement by the local Chamber of Commerce, and the prospect of state waivers that would exempt the new coverage from taxes imposed on most carriers. The plan mobilized an impressive cast of participants. The Group Health Insurance plan, which had much experience in the small-group market, agreed to underwrite the coverage. The Chamber of Commerce helped brokers identify eligible firms. The borough’s hospitals, which hoped that new paying customers would brighten their fiscal picture, agreed to accept deep discounts. The office of the borough president could engage community organizations, which conferred the legitimacy of citizen participation on the plan. If, as one CIC planner proclaimed, "it’s all about relationships," the project seemed to have lined up its ducks admirably. The need, moreover, was unquestionable: Brooklyn housed few private providers, plentiful poor and uninsured residents, and a growing number of immigrants who could not otherwise qualify for coverage.

Forces in the environment of the program soon shook these well-laid plans. An economic downturn, severely aggravated by the impact of the 11 September 2001 terrorist attacks, further stressed the precarious profit margins of small firms in Brooklyn. The borough presidency changed hands, and the new incumbent viewed this complex project from the previous regime with understandable caution. Providers sought formal assurance that the new plan would not enroll people holding less deeply discounted insurance, but state law precluded such "anti-crowd-out" provisions.

In 2002–2003 the economy gradually began to revive; the Chamber of Commerce assumed leadership of the project, supplying energy formerly emanating from the borough president’s office; and discussions between project staff and the state’s superintendent of insurance yielded an ingenious solution to the crowd-out problem: putting BHW under the programmatic umbrella of Healthy New York, a state program that helped small firms gain health coverage. This move bought BHW both the protections its providers wanted and valuable stop-loss protection. The key, remarked a participant, was to "leverage public spirit" by "aligning the interests of the uninsured with those of other entities." CIC wanted the state Department of Insurance to help make its product acceptable to providers and affordable to purchasers; the state government wanted a shot in the arm for the lagging enrollment of Healthy New York.

Bringing the state on board was a crucial breakthrough, yet there was no rest for CIC’s weary planners. As they prepared to cut the ribbon on BHW, the health system that ran a hospital key to the plan’s network forbade the institution to accept the discounted rates, and the tense negotiations that followed delayed the plan’s unveiling for six months. The product finally hit the market in early 2004 but, after seven months of enrollment, had signed up only fifty-five employees in eighteen firms.

Jacksonville, Florida. Jacksonville’s CIC trajectory illustrates the interplay between strategy I (increased funding, which is a heavy lift) and the more tractable strategy II (reorganization of the delivery of care). Initially, CIC hoped to emulate Hillsborough County’s success by winning an increase of a half-cent on the county sales tax to cover the uninsured. This hope evaporated when the mayor opted instead to use the increase for his "Better Jacksonville" initiative, which featured a range of civic improvements. CIC’s Plan B—some combination of public and private revenues with which to expand coverage—held little promise. Local government already pumped sizable sums into the local safety-net hospital, to cover the costs of caring for the medically indigent, and was disinclined to commit further funds to a new program. Moreover, chief executives of the city’s other major hospitals were unwilling to cough up new monies of their own.

In Jacksonville, however, CIC staff found strategic assets that were absent from Portland, Oregon. The site’s consolidated city-county government averted intergovernmental battles, and a thriving economy both elevated health coverage on the agenda of private employers who wanted to attract good workers and spared the city from the ravaged revenues that constrained policy innovations in many local venues.

Through 2002, CIC staff, aided by an influential local foundation, convened a string of forums in which the components of the uninsurance problem in Jacksonville were examined and options to address it were carefully canvassed. The influential chief executive of the city’s largest hospital, eager both to reduce of the burden of the uninsured on his hospital and to advance its religious mission, embraced the project and tirelessly urged both the mayor and other hospital leaders to attend the forums and stay the course. Gradually, consensus settled on a public-private partnership, and the protagonists worked to whittle one into shape. The resulting model, JaxCare, is a reorganized delivery system in which an expanded network of providers (safety-net and mainstream hospitals), offering a specified set of benefits, discounted prices, and improved information technology and promoted in the marketplace by a cooperative Chamber of Commerce, will provide efficient care for the newly insured. As endorsed by the mayor and the city council, JaxCare will use $2.5 million of new public funds (supplemented by hospital contributions and management assistance from Blue Cross Blue Shield of Florida) to pilot a program that brings new coverage to 1,500 working uninsured Jacksonville residents. JaxCare’s sponsors expect that evaluators will find improved health outcomes coupled with less rapidly rising costs of care once ED use declines and primary care case management takes hold. A positive verdict, they hope, might persuade local, state, federal, foundation, and private funders to sustain and expand the program. Strategies I and II were thus conjoined. The prospect of efficiency generated by the reorganization of the safety net would entice contributions of new money from government and providers and then, as the system evolved, gradually replace (at least partially) those city and hospital funds with savings generated by more effective use of resources. In August 2004, however, demonstrated savings were the least of the project’s worries: JaxCare had only seventy enrollees and was pondering how to find its market niche.

Strategy II. Portland, Maine. In Portland, mainstream institutions created a plan, Care-Partners, that reorganized the delivery system to expand care for the uninsured. The partners included MaineHealth (an integrated nonprofit hospital system that served three-fourths of the state’s population), affiliated hospitals in three counties, Anthem Blue Cross (which supplied claims management at no cost), and more than 700 primary care and specialty practices. Providers delivered uncompensated care to a limited number of uninsured patients via primary care "medical homes," office-based specialty care, and hospitalization when needed. MaineHealth committed funds for prescription drugs. Eligible patients were enrolled in disease management programs, and care managers would generate savings on hospital and ED use that were expected partially to offset the program’s cost.

Implementation of the model revealed the complexities of even small-scale system reorganization. One county, Waterville-Augusta, enjoyed reasonable levels of provider participation and enrollment of beneficiaries. A second, Portland, found good participation among primary care physicians and hospitals but surprisingly sluggish enrollment. In the third, rural Lincoln County, providers were few and feared the costs of serving a (presumably) rising number of uninsured patients, who were (these fears notwithstanding) notably slow to enroll.

Three challenges, moreover, cut across all three settings. First, physicians were ambivalent about participating. A mix of motives induced hospitals to join CarePartners: namely, mission (all hospitals in Maine save one are voluntary nonprofits and by state law must care for the medically indigent), margin (readier primary care and case management for the uninsured should lower the costs of uncompensated ED services), and Medicaid (a source of revenue for which some CarePartners enrollees would prove to be eligible). Physicians were a tougher sell. In a state with few CHCs, many physicians already quietly gave primary care to the uninsured, but some were said to fear that signing up with CarePartners would make them a magnet for more than they could handle. Specialists were especially slow to commit to the program. That physicians tended to be widely dispersed across rural populations further complicated the plan’s efforts to recruit them. On the other hand, primary care physicians were pleased that CarePartners would supply or improve such tools as diagnostic services and medications, which their uninsured patients needed but were often obliged to forgo.

Second, as in such undersubscribed programs as Medicaid and the State Children’s Health Insurance Program (SCHIP), those who were eligible had to learn about CarePartners and how to enroll. This process began with proof that they did not qualify for Medicaid, a time-consuming and stigmatizing determination that some uninsured people declined to pursue. The number of uninsured people who sought to sign on was also unimpressive because, as one respondent observed, many of them "were satisfied with episodic care." Aggressive outreach by the plan might have boosted the ranks of enrollees, but constraints on the number it could support held its zeal to recruit in check.

The size of the coverage gap that the Maine CIC project sought to plug changed before its eyes, moreover, as its objectives were discombobulated by the shifts in public eligibility criteria that go with the territory of incremental gap-filling programs. When state expansions in Medicaid coverage (unexpected in light of Maine’s budget woes) took away hard-won CarePartners enrollees, the plan had to revisit its own standards for eligibility, and CIC planners debated whether to cast their net more widely, perhaps offering CarePartners to workers who stayed uninsured because they could not afford to take up their employer’s offer of coverage. That course risked crowding out private coverage, however, which no one wanted to do. Late in 2003, CIC tentatively agreed to open CarePartners to workers who could not afford the coverage offered by their employer, but only if the workers’ premiums, deductibles, and copays would exceed 5 percent of their adjusted gross income. As a price of compromise, providers (mainly the rural hospitals) insisted on enrollment caps in each site, lest they be flooded by new enrollees.

The disinclination of providers and patients to change their behavior presented a third challenge. In theory, by improving the use of resources, care management would yield savings with which to expand CarePartners. But physicians, voluntarily rendering uncompensated care, were reluctant to complete the paperwork that generated the data on which sound coordination of care depends. Moreover, erratic participation of patients in the program (doubtless born partly of comfort with fragmented care and partly of shifting eligibility rules) further diluted the promise of coordination and care management.

By the end of 2003, Maine’s CIC project was treading water. A state plan to expand coverage would yet again redefine the gap CarePartners aimed to fill. Pharmacy costs had risen to 40 percent of the plan’s budget and threatened to drain the coffers of its main sponsor, thus clouding the program’s financial future. Disease management was just getting off the ground. "We just wanted to do our share," one of the project’s prime movers reflected. "We never claimed to be solving the problem of the uninsured here in Maine."

Strategy III. Birmingham, Alabama. In two sites, safety-net institutions tried to engineer a sizable redistribution of dollars within their systems. In Birmingham the core of the safety net is Cooper-Green Hospital, a county entity of 1970s vintage, built largely to ensure care for African Americans who had been made to feel unwelcome in "community" hospitals during years of segregation. Cooper-Green, to which the county devotes about $40 million annually, came increasingly under attack as an obsolete facility that rendered care of questionable quality. Birmingham’s other hospitals, with plenty of unused capacity, contended that they could provide inpatient care for African Americans; that bitter memories of segregation had (or should have) faded; and that what Cooper-Green’s patients needed above all was accessible, high-quality primary care. CIC planners therefore hoped to forge agreement that the county’s annual outlay would shift from Cooper-Green to the building of "network service areas" among community hospitals and clinics, and an expanded primary care system cosponsored by the County Health Department and a much-downsized Cooper-Green.

This win-win scenario proved to be a political loser. Cooper-Green was, rightly or wrongly, a potent symbol of racial equality, and although its defenders no longer feared that black women would give birth on the lawns of "white" hospitals that refused to admit them or would be consigned to substandard segregated basement wards, they were by no means convinced that these mainstream institutions would welcome blacks, treat them with dignity, and give them good care. Moreover, the county commissioners who oversaw Cooper-Green were reluctant both to lose the $40 million of county funds that bought jobs for their constituents and to divert funds to institutions outside their control that might return repeatedly to demand more money as the price of caring for the uninsured. Acrimony between Cooper-Green’s defenders (mainly black) and proponents of new arrangements predicated on primary care (mainly white) grew steadily, yielding a nasty public fight that the primary care forces lost. Unable to reassemble Humpty Dumpty, Birmingham’s CIC program shut down late in 2002. The lesson seems to be that although the safety net has sizable resources to "play" with, the status quo’s many defenders can play hardball politics that sharply limits the fungibility of those resources.

Alameda County, California. Alameda County’s CIC program delivers a similar message by a different route. Building on a provision of California law that guarantees MediCal (California Medicaid) beneficiaries the choice of a safety net–sponsored managed care organization (MCO), the county created Alameda Alliance for Health, a nonprofit MCO built on the area’s abundant CHCs. The plan proved to be a financial success, and the county’s hospital, CHCs, community activists, and government officials, collaborating as the CIC grantee, debated how to invest the Alliance’s reserves. "The community would have squawked if we didn’t use those reserves for the community good," one stakeholder explained.

Community leaders in the CIC collaborative agreed that both expanding health coverage and strengthening the safety net were unimpeachable priorities, but they differed on how to strike a balance between the two. One school maintained that the county’s heavy spending on the safety net ought to be redistributed toward insurance coverage. A proponent of this strategy conjectured that

when the gap gets small enough between money for the uninsured and what you spend on safety-net institutions, maybe you can take some of the money now targeted on providers and go to insurance. Yeah, they [the safety net] will scream bloody murder, but if you’ve got $60–$70 million annually in the safety net, can’t you convert some of it? But public hospitals in California think bigger is better. The public hospital lobby is part of the liberal wing of the Democratic Party, and they’re powerful, so you’re fighting the people who support you the most. They want to build big institutions—jobs and political support are there. Then besides the county hospitals, you’ve got the community-based clinics, the county workers, and the minority doctors with forty-to-fifty-year traditions, who say, "We do 70 percent of the care for moms and kids, so why are we being left out?" Add it up, and the safety net is big.

For advocates of insurance, CIC was a window of opportunity. Its funds would supply the staff, data, expertise, and managerial capacity both to help boost enrollment in MediCal and to design and market new coverage, "Family Care"—subsidized by $14 million from the Alliance’s reserves (plus $1 million per year from state tobacco settlement funds and $400,000 from the California Endowment). CIC constituted new resources that could broaden the insurance beachhead without "messing with existing money for the safety net," as one player put it.

Although defenders of the safety net dutifully acknowledged that coverage and care were not zero-sum alternatives, the new prominence that CIC conferred on the former threatened the latter. One participant remarked on the community’s "consensus that we don’t want hospitals to go under or close beds. To shrink the hospitals conflicts with the community’s preference for choice." Not too much choice, however: Insurance that permitted subscribers to get care from providers beyond the safety net cruelly rebuffed those who dutifully treated the uninsured when others declined to do so. One CHC executive thought it "irresponsible just to give them insurance and let them go where they please. You’ve got to nourish the safety-net infrastructure, too." A public hospital executive joined the chorus:

Even if everyone is insured, they still [have to] get care somewhere, and a lot of the private providers just don’t want these folks. And for the safety net, it’s not just health care—it’s social work, nutrition, and lots more. The safety net will do these things; the private providers just don’t and won’t.

As Family Care rolled out, state and county budget surpluses began to vanish into ominous deficits, and stressed hospitals in the county laid moral claim to a portion of the Alliance’s reserves, thus challenging the ascendance of the new insurance strategy. In a contentious and wrenching session, the Alliance’s directors voted to bail out the hospitals with $12 million of Alliance reserves. When the county’s medical center successfully demanded another $7 million to keep operating, observers wondered whether redistribution of safety-net resources to insurance coverage had found its legs politically and whether care and coverage could reverse their customary roles at the center and periphery of the system.

Events in 2003 brought disconcerting clarity. Tackling a huge budget deficit, the state deferred implementation of a federally approved waiver that would have brought new coverage to parents of SCHIP-eligible children—coverage on which Family Care had been counting as it estimated the number of lives it could afford to cover. As its own costs rose and its MediCal rates faced contraction, the Alliance insisted that its reserves (no longer readily replenishable) should not be expected to carry Family Care forward. By year’s end, CIC’s leaders were scrambling to assemble from California foundations, county tobacco settlement sums, and other coffers resources sufficient to sustain coverage for 3,200 lives, about half of its peak enrollment. By mid-2004, no more than 2,000 covered lives seemed sustainable. Meanwhile, a $78 million deficit in the Alameda County Medical Center, the core of the safety net, left no doubt that the county’s statutory duties to sustain care inescapably dwarfed its good intentions to expand coverage.

Strategy IV. Jackson, Mississippi. In Jackson’s CIC program, safety-net providers formed the Hinds County Health Alliance (HCHA), which sought to expand care for uninsured patients by improving the flow of care. Although increasing Medicaid enrollment and exploring the design of a new insurance product were part of the agenda, the centerpiece was a plan to shift nonurgent ED use to less expensive and more clinically appropriate primary care services rendered at neighborhood clinics and a convenient health complex called the Medical Mall. The four major voluntary hospitals in Jackson set aside their rivalries to gather data on use patterns and fashion new referral services among the hospitals, the CHCs, and the Medical Mall. Although the project’s staff hoped that the four key hospitals might commit $50,000 apiece to these plans (making Jackson also an exemplar of Strategy II), funding mainly entailed "coordination of existing resources," which, a participant explained, made sound political sense: "It’s key to maximize the system you’ve got, or people won’t listen when you ask for more money."

Jackson’s CIC staff hoped to reduce fragmentation of care by creating a sophisticated program in which volunteer hospital employees referred patients who used EDs inappropriately to one of the HCHA’s primary care centers. The HCHA proposed to increase the access of patients to primary care providers by means of such extra services as transportation to clinics, a mobile phone system (to reduce broken appointments), a discount prescription drug program, and disease management (mainly for diabetics and cardiac patients). This model of increased coordination within the safety net and between safety-net providers and their patients seemed so promising that in early 2003 the Mississippi State Division of Medicaid contracted with the Alliance to channel Medicaid patients to primary care settings.

The strategy fell short, however. Fearful that the HCHA might be a bill collector or welfare office, almost half of the ED patients gave incorrect addresses or phone numbers, leaving project staff unable to contact them about primary care referrals. Reorganization of care, moreover, failed to penetrate far enough throughout the safety net. Uninsured patients trying out CHCs and the Medical Mall found four-week waits for appointments and long delays in waiting rooms once they reached their primary care medical "homes." Meanwhile, competition had spurred the four hospitals to reengineer their EDs, which reduced average waiting times to an hour. Faced with primary care alternatives that kept them waiting longer and collected mandatory copayments on the spot, many of the uninsured stuck with the ED, leaving the future of the Jackson project in doubt.

Assessments And Insights

Top Institutions And Resources Strategies And Strains Assessments And Insights NOTES

 
The basic strategic tools for improving health coverage and care for the uninsured—more public or private money (or both), reallocation of funds within the safety net, and better organization of care within the safety net or the larger community system—are available to any community that cares to deploy them. Although CIC is now winding down, many communities across the country have tried to adopt one or more of these strategies. CIC’s checkered career offers a useful, though limited, commentary on the pros and cons of such community-centered initiatives.

A streamlined structure/process/outcome assessment of the seven CIC sites studied here goes like this: Highly intelligent and mission-driven local leaders carefully planned and heroically pursued initiatives that yielded modest results. The program’s fondest hope—that the funded sites would follow Hillsborough County’s lead by raising new "mainstream" funds for covering the uninsured—was largely disappointed in the few sites (notably Oregon’s three counties, Brooklyn, and Jacksonville) that sought to realize it. In this "cell," power too widely diffused over too many independent institutions bedevils the most committed and energetic local leaders. Redistributing funds within the safety net for new coverage (Alameda County) or patterns of care (Birmingham) fares little better. Funding patterns in safety-net institutions that might strike critics as inefficient and ripe for revision look to insiders like admirable (albeit misunderstood) embodiments of their vital roles and mission.

The CIC program in southern Maine shows notable, although limited, success in organizing new care for the uninsured by enlisting an expanding cadre of mainstream providers. One lesson might be that "more is better" remains the most feasible formula for redistribution in the U.S. health care system, but getting that "more" was not easy. And the main lesson of CIC’s redesign of caregiving within Jackson’s safety net is all too familiar: Changing the behavior of complex formal organizations is difficult, and changing the care-seeking preferences and patterns of disadvantaged consumers is no easier.

Coverage versus care. Contemplation of the four strategies yields a cross-cutting insight: Communities tend to find it "easier" (though not easy) to expand care than to extend coverage. Organizational politics within and among community health care institutions that aim to redesign care encounter fewer (though not few) pitfalls than do tax and budgetary politics among elected officials and public agencies that hope to generate new coverage. The institutions that deliver care to community residents without coverage are up close and personal. Uninsured people morph into "patients" in waiting rooms and EDs. Care really is a "community affair," whereas the institutions that govern coverage lie here, there, and everywhere—a "field of inaccountabilities."⁶ That the coverage buck so often starts and stops elsewhere is of course one reason why communities are compelled to pump sizable sums of their own money into safety-net institutions.

Moreover, power comes more readily to hand in reforms of care than in those that extend coverage. Local providers and payers in Maine, for instance, controlled enough levers to implement the agreements they negotiated among themselves to donate services. The new information system that Jacksonville convinced its hospitals to accept speaks to a function these hospitals control. Care-improving innovations may nonetheless carry costs both economic and political—disputes between "old" safety-net entities and "new" ones like CHCs, for example. Nor are such innovations guaranteed immunity from costs imposed from above the community—for instance, hospitals that reduce the number of uninsured people treated in their EDs may jeopardize their federal disproportionate-share hospital (DSH) payments. On balance, however, it is probably fair to generalize that persuading mainstream providers to donate services to a new plan (Maine) is less arduous than reconfiguring operations within existing safety-net institutions (Jackson), which is in turn less torturous than shifting millions of dollars within safety-net institutions and between these and mainstream ones (Birmingham)—which still might face slightly rosier prospects than raising local taxes for new coverage for the uninsured or inducing small firms to buy it.

Where the power lies. Even when artfully amassed, local power might not suffice to secure local coverage projects. New models of coverage require certification by state insurance authorities. BHW could not hit the market until insurance authorities (belatedly) eased its way. The launching of JaxCare was much delayed first by long debates over whether the plans constituted "insurance" and then by honoring the demands of state insurance regulators. And as California’s decision not to implement a crucial coverage-expanding federal waiver reminded CIC staff in Alameda County, local plans may depend heavily on state and federal powers of the purse. Such variables as state criteria for eligibility in Medicaid and SCHIP, private employers’ willingness to offer health insurance to their workers, and the vagaries of regional economies powerfully influence the number of uninsured, but communities can do little about them. The raw materials of universal coverage—Medicare, Medicaid, SCHIP, mandated employer purchases, and monies forgone by tax expenditure polices—lie outside community hands.⁷

Improvements in the delivery of care also furnish a more fruitful arena for the exertion of mission-driven local leaders than expansions do. Cases in point are Maine, where CIC augmented donated care, and Jackson, where leaders of a quartet of hospitals were determined to show that their image of better-organized safety-net services could work. CIC protagonists in Portland, Oregon; Brooklyn; and Alameda County were no less dedicated to their plans for the creation of new coverage, but following the money they needed was one thing, securing it quite another.

Levels-of-government question. On all three counts, then—institutions, power, and leadership—reconfigurations of care tend to lie more firmly within the purview of community control than do coverage expansions. It would be hasty to infer that this good news about care offsets the bad news about coverage, however: In most communities the need to maintain (never mind enhance) the local safety-net establishment retains first claim on community resources and consigns redistribution of safety-net resources and organizational patterns to the outer margins of the system. As long as they contain more or less functioning safety nets, community leaders seldom show much taste for pitched battles over their reconfiguration and instead rest content to keep them (more or less) intact, preferably with as much federal and state money as may be leveraged, leaving safety-net providers to fight among themselves over the (re)distribution of labor and largesse.

Notwithstanding a couple of medium-wattage points of light, CIC offers little hope that communities can or will make major breakthroughs in expanding coverage or care for the uninsured. To infer that communities are therefore the wrong answer to what is essentially a question of the proper division of labor within the U.S. federal system would be misleading, however. Although Hillsborough-like programs are rare, communities invest large sums in care for the uninsured. How much coverage those funds might buy were they redistributed from safety-net institutions is largely a moot point, because, first, such reprogramming is not in the political and institutional cards and, second, the need for accessible care for the (newly) insured would demand some retention or reinvention of current safety-net capacity.

The states, too, present a blurred picture of inhibition at war with innovation. Medicaid is the first or second most costly item of spending in most state budgets and is crucial for local safety-net providers. Medicaid now spends far more than most states would prefer to commit to health coverage, but Hawaii has had an employer mandate since 1974, California keeps flirting with a mandate, Massachusetts and Washington enacted laws that (had political tides not shifted dramatically) would have approached universal coverage, and Minnesota has adopted public programs that combine with its broad private coverage to drive its percentage of uninsured residents below 10 percent.

The federal government, which has the greatest capacity of the three government levels to raise funds and pool insured lives, has conspicuously failed to achieve universal coverage. The feds, however, spend handsomely on Medicare, Medicaid, and SCHIP and subsidize the safety net in many ways. Across the intergovernmental system, then, runs a common theme: All three levels are financially preoccupied with their existing duties for coverage and care and have been able neither to build the political consensus nor to find the political will to get forty-six million more Americans covered and served. If identifying the right level of government for the job were the central challenge, the nation would be lucky indeed.

Cultural and political question. The levels-of-government question is secondary to a primary cultural and political question: Why does the United States, unique among Western peers, persist in permitting so many citizens to go un- and underinsured? A short list of answers would doubtless include the nation’s tenacious clinging to the sacrosanct picture of a private-sector, market-centered, employment-based system that confers health coverage as a fringe benefit; the proposition that government’s rightful role is to fill gaps in private arrangements; chronic fear of "too much government," regularly inflamed by demagoguery about alleged "rationing" and "federal government takeovers"; the insistence of all major interest groups that reform is necessary but acceptable only if its costs fall on any group but one’s own; the comforting conviction among the public that those without coverage can and do get adequate care in the safety net; and a distinctly American social construction of citizenship that does not recognize the moral claims of solidarity and hence does not legitimize the redistribution and cross-subsidies that universal coverage requires. Simply to scan this list is to see how and why the concrete contributions of a program like CIC cannot be more than marginal. But insofar as the program helped immerse local notables in the intricacies and trade-offs that perplex health policy and stiffened their resolve to work them through politically, its structures and processes might eventually promote outcomes more impressive than CIC could achieve on its own time and turf.

Editor's Notes

 
Larry Brown (ldb3{at}columbia.edu) is a professor in the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, in New York City, and on the staff of the International Center for Health Outcomes and Innovation Research (InCHOIR). Beth Stevens is a senior researcher at Mathematica Policy Research in Princeton, New Jersey.

The authors thank Terri Stoller, Catherine McLaughlin, James Knickman, Nancy Fishman, Sherry Glied, and two anonymous reviewers for helpful comments on an earlier draft. This work was supported in part by the California HealthCare Foundation.

NOTES

Top Institutions And Resources Strategies And Strains Assessments And Insights NOTES

 

1. A useful overview is D. Andrulis and M. Gusmano, Community Initiatives for the Uninsured: How Far Can Innovative Partnerships Take Us? (New York: New York Academy of Medicine, August 2000).
2. L.D. Brown, "Impermanent Politics: The Hills-borough County Health Care Plan and Community Innovation for the Uninsured," Health Affairs 25 (2006): w162–w172 (published online 11 April 2006; 10.1377/hlthaff.25.w162).[Abstract/Free Full Text]
3. The only major new local programs for the uninsured have developed in several California counties in the past two years. Aiming to supply coverage to uninsured children ages 0–5, these programs are funded by a state tax on the use of tobacco and are supplemented by philanthropic grants.
4. Although the analysis of the strategies in this paper concentrates on the major program elements of the seven sites, these elements do not exhaust the sites’ CIC-sponsored activities. For example, under strategy I, the federal Health Resources and Services Administration (HRSA) gave Brooklyn an HCAP grant for drug coverage, and in Alameda County, two foundations gave Family Care a total of $1.85 million—a small but not unimportant addition to the $14 million with which the Alliance capitalized the plan. In strategy II, Jacksonville providers donated care to help keep JaxCare affordable, and in Brooklyn, both public and private hospitals agreed to accept discounted fees (which can be treated as being equivalent to donated time). Strategy III contains the donation by Jacksonville’s safety-net hospital of $400,000 and of certain tertiary services to JaxCare. Examples of strategy IV include Alameda County’s "frequent user" program, which aims to bring counseling and other social services to exceptionally high users of ED care. CIC can properly claim credit for these (and other) initiatives, but their importance is decidedly secondary to those discussed in the text.
5. W.K. Zellers, C.G. McLaughlin, and K.D. Frick, "Small-Business Health Insurance: Only the Healthy Need Apply," Health Affairs 11, no. 1 (1992): 174–180[CrossRef][Medline]; and L.D. Brown, "The Medically Uninsured: Problems, Policies, and Politics," Journal of Health Politics, Policy and Law 15, no. 2 (1990): 413–426.[Web of Science][Medline]
6. J. Schwartz, All in Good Time: A Memoir (New York: Random House, 2004), 211.
7. Not the least important contribution of CIC and kindred community interventions to expanded coverage is to identify residents who are eligible for Medicaid, SCHIP, and other public programs and speed them on their way to enrollment. A case in point is Alameda County’s No Wrong Door program, in which CIC, working with new leadership in the county’s social services agency, encouraged a newly "proactive" approach to matching eligible people with public coverage.

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