Washington 'a step ahead' of health law

Washington has already put in place many of the elements of the new federal health-care law, putting it closer than most states to making the federal law work for its residents.

Over many years, the state has built a patchwork of programs, pilot projects and other efforts that resemble provisions and goals now spelled out in the federal law.

The state already has a "high-risk pool" to cover sick people who've been turned down by insurers, for example, and pilot programs in medical centers and clinics to test new ways of getting health care to patients more effectively and efficiently.

Other programs push that intent even further: Washington is the only state in the nation, for example, with a full-blown process to use evidence, instead of advertising, in deciding whether to pay for drugs, medical gizmos and procedures.

U.S. Secretary of Health and Human Services Kathleen Sebelius has cited the state's Basic Health Plan for working poor people as "a model for the rest of the nation," Gov. Chris Gregoire said at a news conference Thursday to announce plans to move quickly to meld the federal program with existing state programs.

"Washington is a step ahead of the parade on this stuff," says Tom Curry, executive director/CEO of the Washington State Medical Association.

The national health-care law, which will be phased in over several years, requires individuals and employers to buy health insurance or pay penalties, and forces insurers to cover everyone, even those with pre-existing conditions.

It subsidizes people who can't pay, expands Medicaid, the state-federal insurance plan for low-income residents, and pays for projects to make care more effective and efficient.

Many of those provisions echo regulations that were enacted in Washington — the state — when it tackled health care in the early-1990s. Like the federal effort, the state focused on repairing the crumbling employer-based private insurance system rather than replacing it. It ultimately failed, leaving leaders in the state wiser about the challenges now before the nation.

One painful lesson learned, says Dr. Robert Crittenden, a politically active family physician at Harborview Medical Center, is that the changes won't work unless "everybody's in the pot."

Otherwise, consumers and insurers "game the system," with companies cherry-picking the healthiest people to insure and consumers waiting until they're sick to buy a policy.

State officials, left with no way to force everyone into the system, have focused instead on programs for the most vulnerable among the state's nearly 1 million uninsured residents, hoping to keep them out of expensive emergency care.

As part of that strategy, the state covers many more children than most states do.

In 2007, state legislators pushed through a program to help another troubled group: small-business employees.

The "Health Insurance Partnership" sets up an insurance "exchange" and subsidies similar to the federal plan. The program, halted by the budget crunch, recently landed a federal grant and plans to open enrollment in the fall.

That's welcome news for many struggling small business owners, including Barry Faught, who's been unable to afford coverage for himself or his two employees at his fledgling SoHo Coffee Company.

"I knew there were going to be challenges, but I didn't think it would be this expensive," says Faught, 33.

The Health Insurance Partnership, like many of the elements in that state patchwork, has a look-alike in the federal law.

"It's not like we were trying to be the model for reform," says spokeswoman Heather Masters. "We were just planning for our state — trying to insure more people through the easiest, least disruptive way possible for both the insurance market and the residents."

"Accountable care"

Other local programs, both public and private, focus on primary care, prevention and patient outcomes — other goals of the federal law.

State lawmakers already have authorized pilots for the coordinated approaches touted in federal law, including "accountable care organizations" — groups of medical providers who get paid per patient, not per visit or per procedure.

One example is a year-old program at Swedish Medical Center's Ballard campus, where a group of primary-care providers is paid by the month by insurers for each patient. Others include Group Health Cooperative's "medical home" model giving primary-care doctors and patients more time together, and "retainer-fee" primary-care practices such as Qliance, where patients pay a set monthly fee for whatever care they may need.

"We believe that the irony of health-care reform is that we've been reforming ourselves for some time," said Dan Dixon, Swedish's vice president for external affairs.

Unlike 15 other states, ours has a high-risk pool for those denied insurance for health reasons. Subsidized by a surcharge on other premiums, it's still expensive.

The new federal law gives states the ability to negotiate directly with insurers. This state already does that in its state-subsidized Basic Health Plan for the working poor.

That plan, crippled by budget cuts, now covers about 69,000 people, with 100,000 on the waiting list. Washington Sen. Maria Cantwell helped get a provision included in the federal law that has allowed the state to seek Medicaid funding to help keep Basic Health running next year.

Washington is also ahead on some of the insurance regulations cited in the federal program.

For example, it bars cancellations for illness and sets premiums for individual policies based on broad age ranges.

"The federal law will make all states adopt a system similar to Washington's," says Diana Birkett, a policy director for Group Health.

The federal law also touts "evidence-based" assessments of health care, another area where this state has pushed ahead of the pack.

For state employees, the state's Health Technology Assessment program has instituted a vigorous process to assess new medical devices, tests and procedures. Another state program rates prescription drugs using evidence-based metrics.

"It's an example of what's being looked for in national health reform," says Roger Gantz, state Medicaid policy analyst. "I do believe we're a national leader on this."

Consequences

Despite the kudos, local leaders also warn of pitfalls and unintended consequences that can come with the changes.

Many recall how a state provision barring insurers from imposing waiting periods for pre-existing conditions caused insurers to abandon the individual insurance market.

At a local car dealership recently, Curry overheard two sales reps discussing the federal law, which would fine people for not having health coverage, but forbids insurers from denying them a policy, even if they are already ill.

One sales rep told the other: "No problem. I'll drop my insurance and pay the penalty if I get sick." Others worry about a looming shortage of primary-care doctors.

"Some folks who get an insurance card will find it's nice to have in the wallet, but it won't get you into a doctor," Curry predicts.

State Medicaid officials predict as many as 500,000 new recipients could be added by 2014, overloading already strained primary-care providers.

"We're aware of how we're going to have to wrestle with this," Gantz says. "It's clearly going to be on our radar screen."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com