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1. Several newspapers recently published articles related to lawmakers’ efforts in Iowa, Pennsylvania, New Jersey and New York state to expand health care services. Summaries appear below.
   * Iowa: Iowa Democrats are considering expanding several health programs next year and establishing a health commission to recommend broader changes in 2008, the Des Moines Register reports. According to state Sen. Jack Hatch (D), Democrats could expand income eligibility requirements for the Healthy and Well Kids in Iowa program to allow an additional 20,000 children to enroll. Lawmakers also are considering extending coverage under the program for the first time to 9,000 parents. In addition, state Senate Democrats are proposing that insurance companies be required to provide coverage for certain mental illnesses that is comparable to coverage for physical conditions and, eventually, want to add more categories to the list of covered illnesses. Incoming Gov. Chet Culver (D) is expected to recommend a cigarette tax increase of up to $1 per pack, which Hatch said could be used to help fund health program expansions, such as “safety-net” programs for low-income state residents (Roos, Des Moines Register, 12/12).
   * New Jersey: State legislators are drafting a proposal that would provide health insurance to all state residents, the New York Times reports. The proposal, which could be introduced in March 2007, would require New Jersey residents to purchase health insurance or enroll in a state-sponsored health plan. State officials estimate that the plan would cost $1.7 billion in the first year and that the cost would decline after excluding the premiums of those who already have private insurance, according to the Times. A legislative group formed in July has been studying universal health insurance policies in Maine, Massachusetts and Vermont as it drafts the proposal, according to state Sen. Joseph Vitale (D), a co-leader of the group. Vitale said the group has not determined how to pay for the plan or other specifics that would need to be in place to gain approval. A spokesperson for Gov. Jon Corzine (D) said the governor supports expanding health coverage but might want more details about the plan (Jones, New York Times, 12/12).
   * New York: The state Legislature likely will allow a commission’s recommendations to reorganize New York’s hospital system to become law and revisit some of the proposed changes when lawmakers reconvene in January 2007, state Rep. Ronald Canestrari (D) said Monday, the Albany Times Union reports (Crowley, Albany Times Union, 12/12). The report was released in November by the New York state Commission on Health Care Facilities in the 21st Century, which was created last year by Gov. George Pataki (R) and the state Legislature to recommend changes to the state’s health care system. The recommended changes include closing nine hospitals and reconfiguring 48 additional hospitals. The commission estimated that these changes would reduce the number of hospital beds in the state by at least 4,200, or by 7% (Kaiser Daily Health Policy Report, 12/7). The state Legislature can act only on the entire report, not its individual recommendations; the report will become law on Jan. 1, 2007, if the Legislature does not reject it. At a state Assembly hearing on Monday, Canestrari said lawmakers can re-examine parts of the proposal “retroactively to make sure certain things do not happen, including not having our [State University of New York] hospitals run by a corporation or losing the only women’s hospital in New York state.” He added that the report’s recommendations might not be implemented for more than a year. Officials at the hearing from Bellevue Woman’s Hospital and Albany County criticized the commission’s report for using what they said was inaccurate financial information. Daniel Sisto, president of the Healthcare Association of New York State and a member of Spitzer’s transition team, said he believes the commission will allow for some flexibility in implementing the recommendations (Albany Times Union, 12/12).
   * Pennsylvania: Gov. Ed Rendell (D) on Monday said that in January 2007 he will release a proposal to provide health coverage to about one million uninsured state residents and reduce health spending through cost-containment measures targeting health care providers, the Philadelphia Inquirer reports. Rendell offered few details about the proposal but said it would include measures to reduce hospital-acquired infections and add new sections to hospital emergency departments in which nurse practitioners would be able to treat minor illnesses and injuries. He added that he would not seek to establish a single-payer health care system in the state and that his model for expanding health care coverage is similar to changes he made earlier this year to the state SCHIP program “with pay-ins depending on your income level” (Worden/Couloumbis, Philadelphia Inquirer, 12/12). Rendell also said that to reduce costs, he wants to change regulations to allow nurse practitioners to perform more duties without the supervision of a physician (Mauriello, Pittsburgh Post-Gazette, 12/12).

2. Peter – The issues raised in the report are present in all of our major cities, and the fact that Medicare and Medcaid pay more generously for high tech interventions like heart surgery than for primary care and trauma also applies nationwide. Yet New York’s Medicaid program spends more than twice as much per capita as any other state.
   One of the hospitals in Manhattan slated for closing (Cabrini Medical Center) is less than 0.1 mile from both Beth Israel Medical Center and the Hospital for Special Surgery. It is within easy walking distance of both Bellvue Hospital and NYU Medical Center. On any given day, 20,000 of the 60,000 beds in the state are vacant, and that’s with the average length of stay more than a full day above the national average. If anything, the proposed closings are timid and constrained by politics. The system here in NYC is in a class by itself in both a positive (leading acamdemic medical centers) and negative (way too much capacity) sense.

3. Barry, I’m not going to read all 62 pages of the report but the Opening Statement reads like a – here’s whats wrong with the entire U.S. health delivery system.
   “We see our work as the first chapter in a longer term planning effort to more systematically assess the accessibility, effectiveness and efficiency of the health care delivery system for all New Yorkers. We also see our work as creating a more efficient system in the future to meet the needs of populations that may, in fact, entail rebuilding.”
   “In looking at New York City, one is immediately faced with issues of poverty, diversity and health care disparity in the midst of one of the most sophisticated collection of centers of excellence in research, service and education in the world. These dynamics must inform and influence public policy.”
   “…there is another reality that is facing New York City and that is the health status of its citizens. According to the New York City Department of Health and Mental Hygiene, the City is faced with an increase in demands for access to diagnosis and care for diabetes, cardiovascular disease, childhood asthma, hypertension, substance abuse and mental health, renal failure and the list goes on. These health status issues will directly impact access to hospital inpatient, outpatient
   and emergency rooms and must be taken into account in looking to reduce beds and hospitals and skilled nursing facilities.”
   “It should also be highlighted that an aggressive prevention can reduce the prevalence and incidence of major diseases like obesity.”
   “Restructuring and Rightsizing the Hospital System”
   “excess inpatient capacity”
   “Maintaining the “Public Good” Functions of Hospitals”
   “Addressing the Rate Paradigm — Current Medicaid reimbursement rates for “high-end” services, such as cardiac and vascular surgery, are disproportionately generous when compared to the reimbursement rates for “safety net” services such as emergency services, births, and trauma services. This unevenness naturally prompts hospitals to acquire and over-utilize high technology specialty services to offset the low
   reimbursement rate of services that enhance the public welfare.”
   “Improving Hospital Quality ”
   “Improve Health Information Technology (HIT) — To ensure that health care providers develop the essential technology required to operate high quality, efficient facilities in the 21st-century.”
   “The federal government will realize significant savings as a result of the reform and restructuring
   program we recommend.”

4. When even local union president Dennis Rivera is preparing his membership for coming job cuts, the restructuring is probably for real. New York now spends $45 billion per year on its Medicaid program which is far more than any other state, and its citizens are no healthier and do not live longer. The system is clearly out of control, and a serious effort to rein it in is finally at hand. It’s about time!

5. The Commission’s proposals actually serve as politcal cover for the all but certain cuts to Medicaid, and this is actually a good thing for Spitzer. The closing recommendations have to be approved as a whole (or rejected as a whole, unlikely) before he’s even in office. Also, dealing with cuts through a more rational, analytical framework, actually enables the new governor to stay completely out of the business of closing hospitals, and to scale back on what otherwise would have been more devastating cuts to Medicaid for all hospitals. The public relations around this are tricky, but the process is already being closely watched (and followed) in other states.