The Kaiser Family Foundation’s Role in Today’s Health Care System Drew E. Altman, Ph.D., President and Chief Executive Officer. Updated: August 2014 Follow Dr. Altman on Twitter: @DrewAltman Also read Drew Altman’s essay on Kaiser and the Affordable Care Act. This essay discusses the choices we have made about our…Read Post
In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years. Medicare, Medicaid and potentially the Affordable Care Act will have their turn…Policy Insights Read Post
Estimates are that there are approximately 630,000 people who are homeless on any given night in the U.S. — about two-thirds in shelters and one-third on the street or without real shelter. Several million people are estimated to experience homelessness over the course of a year. About two-thirds are individuals and the…Policy Insights Read Post
Our 2012 Employer Health Benefits Survey found a 4% increase in premiums this year, continuing the recent trend of moderation in health costs and spending reported in several studies. Double digit increases in premiums were once a common occurrence, but we have not seen any since a 10% increase in…Policy Insights Read Post
Pulling it Together: As The International AIDS Conference Convenes, Some Positive News About Public Opinion and HIV
The American people are busy trying to make ends meet and take care of their families and they are constantly bombarded by messaging and spin. They rarely have a full understanding of policy issues and debates. Often it is their strongly held beliefs, whether based on accurate or inaccurate perceptions,…Policy Insights Read Post
The Center for Medicare & Medicaid Services (CMS) and 26 states are moving to launch a large scale managed care demonstration project potentially involving millions of the poorest, sickest, most expensive Medicare and Medicaid beneficiaries, the so-called dual eligibles. The experiment is getting more and more attention from policy experts,…Policy Insights Read Post
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The Kaiser Family Foundation’s Role in Today’s Health Care SystemDrew E. Altman, Ph.D., President and Chief Executive Officer. Updated: August 2014 Follow Dr. Altman on Twitter: @DrewAltman Also read Drew Altman's essay on Kaiser and the Affordable Care Act.This essay discusses the choices we have made about our mission and operating style. It is a revised version of an essay published in the journal Health Affairs in 1998. Of course, I believe deeply in what we are doing at Kaiser, but I offer this and update it every few years for interested readers with the caveat that our choices are not necessarily the right ones for others. Each foundation and non-profit organization has a different set of opportunities by virtue of its history and size, geographic location, the character of its board and staff leadership, and other factors. I have always believed that our society is best served by having foundations that do different things. Organizations also evolve and change (and should). We began as a private foundation, quickly switched to a private operating foundation, and now we are a public charity, a change which signals no shift in mission or operations but gives us a status which more accurately reflects how we operate today.[post_title] => President's Message [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => presidents-message [to_ping] => [pinged] => [post_modified] => 2014-08-14 16:42:06 [post_modified_gmt] => 2014-08-14 20:42:06 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/?page_id=54937 [menu_order] => 0 [post_type] => page [post_mime_type] => [comment_count] => 0 [filter] => raw )  => WP_Post Object ( [ID] => 44216 [post_author] => 25629999 [post_date] => 2012-11-26 14:36:42 [post_date_gmt] => 2012-11-26 18:36:42 [post_content] => In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years. Medicare, Medicaid and potentially the Affordable Care Act will have their turn on the operating table as policymakers look for savings. It is unclear what reductions in Medicare and Medicaid spending policymakers will be able to agree on but whatever they do they will call it “entitlement reform”. Like calling a new tax a revenue enhancement, calling spending cuts and program changes “reforms”, and even better “entitlement reforms”, makes them sound more palatable and forward thinking. News organizations should resist mimicking labels like “entitlement reform” although understandably, policymakers and advocates will use them. The dictionary defines reform as “to improve, remove faults or abuses, habilitate, reclaim or redeem”. You can see why there would be disagreement about applying that term in the current budget debate. I was very involved in the welfare reform movement. Surely that was “reform”. Well, maybe. The essential purpose of welfare reform was to transform the welfare system from an emphasis on cash assistance to work. Whether you were for or against welfare reform there was no question that it fundamentally changed the welfare system. Most observers agree welfare reform has been a success and has moved welfare policy in a much better direction. But not everyone shares that view and welfare reform has more than its share of critics. They don’t think it is reform at all. They see it as punitive, leading too often to low-paying jobs. Welfare “overhaul” would have been a much more neutral description but I admit that when I was selling my welfare reform program in New Jersey and helping promote national legislation, I was more than happy to have the media call it reform. What about “health reform”? It is clear that the law makes fundamental changes to the health insurance and health care systems and will do a great deal of good, but there is obvious and sharply partisan disagreement about whether the law overall is a good thing or a bad thing. For this reason it is the policy at NPR to avoid using the “health reform” label (and along with it the more pejorative Obamacare). This is the practice at our Kaiser Health News as well. What then about “entitlement reform” in the context of the current budget debate? There will be a long list of reductions in Medicare and Medicaid spending considered as this debate unfolds, from straightforward cuts such as reducing payments to hospitals and nursing homes, to changes in the rules of these two big entitlement programs such as rolling back the age of eligibility for Medicare, income relating Medicare premiums, or converting the Medicaid program to a per capita cap. Each of these will have advocates and opponents and many of these proposals will be hotly debated. All can appropriately be called “entitlement cuts”, or “spending reductions”, or “changes to entitlement programs”. Some proposals - premium support for Medicare, a Medicaid block grant or per capita cap - will rise to the level of an “entitlement overhaul” or “restructuring”. But whether a change is “reform” or good or bad will be in the eye of the beholder. Is premium support a badly needed reform that will introduce fiscal discipline and market competition to the Medicare program as conservatives believe, or a backhanded way to cap federal spending, reduce the role of the federal government and end the Medicare entitlement, which is how many liberals view it? Is a Medicaid block grant a way to give states more flexibility they have long wanted, or to sharply reduce federal funding to the states and eliminate the Medicaid entitlement under the guise of giving states greater flexibility? Is raising the age of Medicare eligibility a reform whose time has come or a way to shift costs from Medicare to seniors and employers? As we begin this new budget debate there is substantial agreement on the need to reduce spending but no agreement on what constitutes “reform” or on which “reforms” are the right ones to make. Taking an insider debate with mind numbing numbers and complex policy options and making it understandable for the American people is always a huge challenge for the news media. That challenge will take on new importance in the upcoming budget debate. It is understandable that policymakers and advocates would frame what they believe in or have concluded is the best budget tradeoff to make in the most positive light, but calling every spending reduction a “reform” can obfuscate the hard choices that need to be made. Let’s hope the news media will avoid loaded labels and help the public understand the consequences of different approaches to deficit reduction. [post_title] => The News Media and “Entitlement Reform” [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-news-media-and-entitlement-reform [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:36 [post_modified_gmt] => 2014-03-04 16:14:36 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/?post_type=perspective&p=44216 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw )  => WP_Post Object ( [ID] => 26311 [post_author] => 25629999 [post_date] => 2012-09-21 13:35:40 [post_date_gmt] => 2012-09-21 17:35:40 [post_content] => Estimates are that there are approximately 630,000 people who are homeless on any given night in the U.S. -- about two-thirds in shelters and one-third on the street or without real shelter. Several million people are estimated to experience homelessness over the course of a year. About two-thirds are individuals and the balance are in families. These numbers are virtually identical to national estimates we used when I worked intensively on the issue of homelessness in the 1980s in state government in New Jersey and at the Robert Wood Johnson Foundation. Back in the 1980s homeless families were the face of the homeless problem. Today, after two wars, it is the homeless vet. Then, homelessness was often featured on the front covers of major national news magazines and on national TV news shows. Today it has largely slipped from the national consciousness and remains a prominent but local issue mainly in some urban areas where the homeless are on the streets in significant numbers. There may be many reasons for this. The problems of the homeless may seem less urgent to the country when the middle class are struggling in a weak economy, and there may be less national emotional space to think about deep poverty, chronic mental illness, substance abuse, and the challenging combination of all three of these we often see in chronic homeless populations. The problems of urban America and low-income housing have also become less prominent, even as there seems to be more discussion of income inequality. At the same time, with cutbacks in state and federal funding, the budgets of cities and counties and community organizations who deliver services to the homeless could not be tighter. When I worked on this problem previously, I focused mostly on establishing health and other outreach services for the homeless across the country through a national program operating in 19 cities I developed at the Robert Wood Johnson Foundation in partnership with the Pew Charitable Trusts and the U.S. Conference of Mayors. Later I worked on developing affordable housing options for homeless families as Commissioner of Human Services in New Jersey, trying to get homeless families out of “welfare hotels” and off of emergency homeless assistance and into more permanent arrangements. The overriding lesson I learned in all of this work was the importance of effective outreach to connect homeless people to services (and the difference housing, income support, and health care services could make if the connection was effectively made and sustained). Much of the debate about the homeless focuses on the chronically homeless population so visible in big cities and there is no doubt that this population can be very challenging. But several cities have shown good results with programs that aim to get even the hard core homeless off the streets and into better life situations, as chronicled in Malcolm Gladwell’s nice 2006 New Yorker piece, “Million Dollar Murray.” The fact that several million people move in and out of homelessness each year also suggests that for most who experience homelessness, it is not a long term situation; more can be done to address the larger problem of people living on the margin in our country – the sometimes homeless. Another lesson I learned working on these programs was the effectiveness of peer outreach, especially in programs for homeless and runaway youth. This was a lesson we adopted at Kaiser in working on the loveLife HIV prevention program in South Africa, which deploys about 1,500 young people each year called Groundbreakers, who work in villages and urban neighborhoods across the country as the vanguard of the HIV prevention effort for youth and young adults. The Groundbreakers, all well trained young leaders, do absolutely stunning work in their distinctive purple and black loveLife t-shirts operating out of a network of youth-friendly clinics and youth centers established by the program. This kind of outreach, whether here or in South Africa, is work that can only be done at the grassroots level by exactly the front line service workers who are endangered by today’s tough budgetary environment at the state and local level. I remember talking with a homeless teenager in South Jersey, probing about whether this service or that would be more useful in health clinics we wanted to set up. His response: “Commissioner you don’t understand. What I need is not this or that service. What I need is someone I can trust.” His remark and many others like it caused us to develop intervention models that heavily emphasized social and mental health services in our “health care” clinics. I go through this background now because there is a new opportunity to connect homeless people to services through the Affordable Care Act (ACA), which many people may not be aware of. That is because many homeless people are both poor and uninsured and will qualify for Medicaid coverage under the ACA in states that opt to expand Medicaid with mostly federal money. The ACA will provide coverage, in most states for the first time, for low-income, childless adults, which is who the majority of the homeless are. The vast majority of people who are homeless will be eligible for Medicaid under the ACA expansion since they generally have little income (except undocumented immigrants who are ineligible). We have just published a new report co-authored by Samantha Artiga and Rachel Arguello of our staff and Barbara DiPietro and Sarah Knopf of the National Health Care for the Homeless Council, which discusses in very practical terms what it will take to connect homeless people to an expanded Medicaid program under the ACA and get them the broad range of health care services they need. Many homeless families may also already be eligible for Medicaid under their state’s current rules, and other homeless adults qualify for Supplemental Security Income (SSI) but are not enrolled. Better outreach facilitated by the ACA could assist them as well. Providing better health coverage can help connect the homeless to needed health services. That is important not only to relieve suffering, but because untreated medical and mental health problems are significant contributing factors to unemployment and homelessness. Increased Medicaid coverage can also relieve burdens on safety net clinics and hospitals who serve the uninsured homeless now. But the biggest payoff will come if the availability of health coverage under the ACA also provides a new outreach opportunity that serves as a gateway to housing, employment, and other services state and local agencies and community organizations use to help the homeless get back on their feet. Just as importantly, this new effort could bring renewed attention at the state and local level to the problem of homelessness itself. [post_title] => Pulling it Together: How the ACA Can Help The Homeless [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-how-the-aca-can [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:37 [post_modified_gmt] => 2014-03-04 16:14:37 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-how-the-aca-can/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw )  => WP_Post Object ( [ID] => 27744 [post_author] => 25629999 [post_date] => 2012-09-05 18:18:40 [post_date_gmt] => 2012-09-05 22:18:40 [post_content] => Our 2012 Employer Health Benefits Survey found a 4% increase in premiums this year, continuing the recent trend of moderation in health costs and spending reported in several studies. Double digit increases in premiums were once a common occurrence, but we have not seen any since a 10% increase in 2004 and 13% growth in 2003. Rates of increase in total health spending have been holding at 4-6% per year recently, and per capita spending -- which is most analogous to premiums -- has been rising about a percentage point below that. These are strikingly low numbers to those of us who have been studying health costs for a long time. A 4% increase in health premiums is good news, although good news is seldom “news.” But will it last? No one has yet been able to disentangle the causes of the slowdown persuasively. Health care use and the economy have always been closely tied, and my sense is that the recession and slow recovery are responsible for much of the recent health spending and premium trends. Increases in recent years in cost sharing through high deductible plans have probably played a supporting role. In tough times, when wages are flat, people avoid using the health care system if they can. We also know that higher out-of-pocket costs deter utilization, so it’s reasonable to assume that the growth of high-deductible plans and other forms of cost sharing has had an impact on health care use, magnifying the effect of the economy. There is no perfect database that will enable us to spot a new wave of utilization building back up just over the horizon. Insurers can often spot trends in their claims and the publicly held companies sometimes give clues as to what’s going on in their quarterly earnings statements. Recent reports suggest that utilization may be starting to pick up modestly, at least for outpatient services. Using data from our employer survey, Exhibit 1 shows cumulative premium increases for the years before and after the recession, suggesting (but not proving) the influence of economy on premium trends.
How Kaiser Determined Its Strategic DirectionThe modern day Kaiser Family Foundation was established in the early 1990s when KFF made a transition to an independent national organization and I came to the Foundation to implement a vision of a different kind of foundation the Board and I shared. The “founding” board chair of the modern day KFF, Hale Champion, was an especially important partner in charting the early directions for the new Kaiser. At that time we asked one overriding question: “How can we best have an impact with (then) about $30 million to spend each year in a rapidly changing, trillion-dollar health care system?” We were not large enough to try to change things through direct action — by undertaking large, multi-site demonstration programs, supporting large numbers of community organizations, or bankrolling the development of new independent national institutions — as some larger foundations did. With a $3 trillion health system now, from the question we asked over 20 years ago is even more relevant. Just as important, not only was the U.S. health care system bigger than it was in the 1980s, but it was radically different as well. When I was a vice president at the Robert Wood Johnson Foundation in the early 1980s, we saw ourselves as key players in a largely not-for-profit health care community that had great interest in working with the philanthropic community, and in the demonstration, research, and training projects that foundations funded. Those days are largely gone. Today’s health care system is dominated by large commercial interests driven by investors’ demand for profit, by non-profits almost equally focused on revenues, and by government policy decisions that are sometimes shaped by larger ideological, political, and budgetary concerns. For better and worse, health care has become big money and big politics, and health foundations initially struggled to adapt. We saw a glaring need in this changing health care system for an independent, trusted, and credible source of information that could provide facts, policy analysis, balanced discussion, and expert commentary in a field otherwise dominated by large interests, and we have tried to play that role. While foundations certainly have agendas — ours is to use information to speak for people and to be a counterweight to all the vested interests in health — it is our independence, our lack of a commercial or political interest, and our efforts to provide the most accurate information possible (both from us and others) that give us an opportunity to play a special role. We maintain a steadfast commitment to never take a position on a policy issue or to become a combatant ourselves on one side or the other in the “health care wars.”
The Foundation’s StrategyFrom this basic decision about a strategic direction came most of the characteristics of the Kaiser Family Foundation today.
InformationWe are in the information, not the grantmaking business. While most foundations see their principal product as grants, we are an operating organization and ours is information — from the most sophisticated policy analysis and survey research, to basic facts and numbers, to the highest quality health journalism, to information young people can use to protect their health. We focus our work on the major health policy issues facing the nation. This means that we do not completely control our own agenda. We need to “be there” with information and analysis and timely journalism on whatever major health policy issues are on the national agenda. We have also chosen to focus on other issues that are critically important but may not decide elections or make or break budgets or appear as frequently on the national news — such as HIV/AIDS and health disparities. Overall, we try to inform discussion and debate on major issues that affect millions of people, and to elevate the national level of debate on health issues. Our approach is almost equal parts policy analysis and communications: developing new information on national health issues, synthesizing the best information from others, and helping to explain health policy issues to an understandably confused public by ourselves and with news organization partners. When you step back from our many projects and programs, we basically do four things to produce the spectrum of information that enables us to play our role: we are a producer of policy analysis on domestic and global health policy; we are a producer of public opinion and survey research, which is work for which we are well known; we are a “go to” clearinghouse, synthesizer and translator of all the best information on the issues we work on, whether we produce it or others do; and we operate a major health news service dedicated to producing the best in-depth coverage of health care and health policy called Kaiser Health News (KHN), the nation’s first not-for-profit health policy news service. KHN is a foundation program and its journalists are foundation employees, but it is also a fully credentialed news service which operates with full editorial independence. We also organize and operate large scale public information campaigns which have been recognized with multiple Emmy and Peabody awards. The most prominent current campaign is GTA – Greater Than AIDS.
Internal CultureWe are a professional organization, staffed by experts in health policy, public opinion and survey research, media, communications, journalism, and other areas in which we operate. To encourage an entrepreneurial spirit and avoid the internal “fiefdoms” that have historically been a problem in many foundations and think tanks and in universities from which many of us originally come, we do not have separate budgets for program areas; our uncommitted funds each year go to the best opportunities we can identify across all of our program interests (about half of our budget supports our expert staff). This has created an entrepreneurial environment which has generally served us well. We also have a very actively involved Board of Trustees. The Trustees provide oversight, approve spending levels and all major funding and investment decisions, and work closely with me to set directions and determine strategy. Board members serve two five-year terms. Because we are an operating organization, our Trustees have an extra responsibility; we are directly accountable for what we do. We also work to keep past Trustees involved with KFF: for example, by inviting them to retreat meetings.
AudiencesWe have a clear sense of audience: policymakers, opinion leaders and the media are our core audience, and we try to reach the general public through our news service and a growing body of consumer information we produce, from cartoon animations explaining the Affordable Care Act to a widely used calculator that enables people to put in their zip code and some basic information to see what kind of deal they will get on an insurance policy under the ACA. While we produce a lot of our own research and analysis, I believe that our most important contribution to the research community is as a representative, translator, explainer and information broker. Like the adage about the tree falling in the forest, studies that are only read by those of us in the policy research community who follow a particular issue will not have much impact. Much of the most relevant and timely research in health policy is never published in journals, but can be found instead in policy reports and other publications and communications put out by a small number of organizations in our field. Entire policy debates can now play out in a matter of days or hours largely on Twitter. We need more and better and constantly updated research on health issues, but even more, we need better communication of the research and policy analysis that is done. For this reason, the Kaiser Family Foundation places a special premium on communications and uses a wide range of strategies to cut through the information overload in health. These include operating a variety of large-scale online information resources, including kff.org, our main organizational website, kaiserhealthnews.org, our free, health news service, as well as several web portals and an active social media presence for our organization as well as our experts. Our overall goal is to provide free access to the same kind of information and events insiders have to national and global audiences interested in health policy. Our philosophy has always been to integrate communications into our program activities. This means that communication is everybody’s job at our foundation and is viewed as a central part of everything we do. The job of drafting a press release, answering a reporter’s question, designing public-service campaigns or putting something on the web is not something simply handed off to a communications officer at the end of the hall or an outside consultant; everybody is involved. We take press releases especially seriously; they are the place, in a page or at most two, where we need to decide what a complex study actually says and what the "news" is.
ProfileIt is a fact of life that if policymakers and persons in the media don’t know who you are, they are not likely to pay much attention to what you do or say. Having a trusted “brand” was especially important to us given the role we play. And a clear identity was also important in our case to distinguish ourselves from Kaiser Permanente, with whom we have no connection, except for the founding family name we share and the occasional misdirected letters I get from the HMO’s enrollees — both disgruntled and pleased. In 2003 we completed construction of a new building in Washington, D.C., which has added tremendously to our ability to communicate about health issues. The building was financed with very low-interest, AAA rated tax-exempt District of Columbia bonds. It is located in downtown Washington, D.C. just a few blocks from the White House and around the corner from the National Press Club. The building is the home of our Washington, D.C. offices and Washington, D.C.-based staff; our Barbara Jordan Conference Center, named after our former Trustee, which we use to facilitate discussion and debate about health issues; a fully equipped studio with the latest in broadcasting and webcasting technology; and an interactive health exhibit lobby — a street-level space designed to provide visitors with up-to-the-minute information on our programs and information. We are making our conference and broadcast facilities available to other non-profit organizations with no facilities or technical fees charged. Thousands of events have already been held in the building since we opened it in late March of 2003.
StyleTo accomplish our goal of developing the Kaiser Family Foundation as a special and, we hope, needed information resource, we became an operating foundation and then more recently the IRS approved our switch to public charity status to better reflect the fact that in any given year, ten to fifteen percent of our operating budget comes from outside funders. They are mainly foundations and we have a particular approach to outside funding. We seek and accept outside funding only from sources who will not in any way compromise our independence or mission (and in fact may add to our work as partners), and we use outside funding primarily to support the incremental costs of time limited projects we could not otherwise undertake on our own and not to cover core operating costs which we sustain with our own endowment. As an operating organization (operating foundation or now public charity), staff direct most of our major programs and conduct much of the work in-house. For example, foundation staff direct the Kaiser Commission on Medicaid and the Uninsured, our fellowship program for health journalists, our partnerships with both entertainment media and news organizations, and KHN, which is a foundation program staffed by foundation employees, but is editorially independent. Likewise, the many national surveys and polls on health issues we conduct each year are designed and analyzed in house, sometimes with the involvement of partnering news organizations such as The Washington Post and The New York Times. We became an operating organization because doing so was inherent in achieving the most basic goal we set out to accomplish when we began to chart new directions in the early 1990s. The goal was to build an institution which itself played a special and hopefully permanent role as a trusted source of information on the national health care scene. Every operating program we create at Kaiser represents an investment in the development of this organizational capacity. Our purpose was and is to build an institution we felt was needed as a counterweight to health care’s vested interests and as a data-based voice for people in a health system driven by money and politics. Media Partnerships We have developed a broad range of partnerships with media organizations over the years, from The Washington Post and The New York Times, to NPR, USA Today, Viacom, MTV, BET, Univision, and Fox. With news organizations, we undertake joint, in-depth, special projects such as our polling projects with The Washington Post, with whom we have conducted twenty seven major survey projects. In our projects with The Washington Post and The New York Times, for example, the Foundation and the news organization pick the topics and design the survey instruments together, and then jointly analyze the results. Then, as they should, the news organizations have editorial control over the content of their reports and cover the results as they see fit, but always substantially. One of the main ways in which Kaiser Health News distributes its content is through partnerships with news organizations. KHN, which launched June 1 of 2009, now distributes stories every day through major national news organization partners, including The Washington Post, NPR, The New York Times, USA Today, and many, many more, including a new partnership to provide health reporting for the Newshour.
Assessing Kaiser’s RoleI am often asked how we know whether our efforts are having an impact. In some cases, it is relatively easy to judge. For example, it is clear that the Kaiser Commission on Medicaid and the Uninsured has become an authoritative source of analysis and information on health care for low-income people and has played a significant role in debates about these issues, or that our Daily Health Policy Briefing on KHN is widely read and valued or that our monthly Tracking Poll is a widely respected barometer of public opinion on health. Everyday we are in the press and we can see how we are characterized and we are playing the role we want to play. But success or failure is definitely a difficult thing to assess in our world. Foundations are not accountable in the traditional sense. They do not make a profit or a loss that can be evaluated by investors. Unlike government agencies, they are not constantly scrutinized by the press or by legislative bodies that must approve their programs and budgets, though in a world of instant feedback on the web and in the blogs, outside scrutiny has certainly increased. This difference gives foundations their freedom to take risks and to try new things not generally possible in the commercial or public sectors. But it also means that accountability is essentially self-imposed; the evaluation of performance and impact is a judgment call that must be made by a foundation’s board, CEO and staff. The Kaiser Family Foundation is trying to play a special role as an independent, trusted source of information and analysis on the national health care scene, and we evaluate our performance against that objective. We believe that role is sorely needed in the health care system today, and, based on the reception our work receives; we are convinced that we are on the right course for us. It bears noting, however, that choosing to be an information provider has real implications. First, information is costly. Analysts, policy and media and polling experts, web experts and journalists staffing a full-fledged news service all need to be paid, and it takes a real investment in in-house staff expertise to know what information to produce, how to organize it, and how to get it into the right hands. Second, even the best analysis and most balanced report can be unwelcome by those who have a special interest or an ideological point of view. We are, I would like to believe, influential and respected. But we may not be appreciated in quite the same way traditional grantmakers can be, because it is in the very nature of our mission to sometimes be inconvenient to all sides. In terms of the potential for both attention and criticism, there is a big difference between funding the work of others, and being the source of information and analysis and front page stories yourself. It is the difference between direct and indirect accountability. For foundations interested in moving in a direction similar to ours, the willingness to invest in staff capacity and expertise and an understanding that the role by its nature can bring criticism from time to time are necessary preconditions for success and peace of mind. Finally, a philosophical comment on foundations and their role in health. An insiders’ debate has been bubbling just beneath the surface for years between those who believe that foundations should be quiet charities that support the good work of others and those who believe that foundations should play a more proactive role in whatever areas they choose to work and with whatever operating styles they chose to have. I believe that the nation is best served by having a strong independent sector and that foundations should take leadership in that sector. Nonpartisan does not mean timid or invisible, and there is no way to play a meaningful role in today’s health care system without occasionally raising someone’s ire. I also believe that society is best served by having foundations of different kinds, with different philosophies and program agendas. Foundations can be liberal, or conservative, or eclectic. But in my judgment the country is best served when they are independent and not tied to organized political or commercial interests. The need for an aggressive independent sector and for a strong foundation role is perhaps greater in health than in any other area. In no field is there a greater need for an independent voice that is not driven by the desire to make money or to win votes. In no field would a role as simply a charity be less useful; foundation funds are a drop in the bucket in today’s $3 trillion health care system. That realization led us to become an operating foundation with a very targeted mission, and in our latest change in status, a public charity. But whether we were a private foundation in the very beginning, or a private operating foundation, or now a public charity, our mission and the core elements of our operating style have not changed. At the same time, it is also important to be realistic about what foundations can and cannot achieve in today’s health care system. During the years I have both worked in the foundation world and viewed it from the outside, I have often felt that foundations are overly impressed with their own importance. In health, the challenge to foundations is to understand that they are bit players in a giant health care system, but also that foundations can have a unique and vitally important role to play if they make wise choices.
Some observers think the cumulative effects of delivery and payment reform efforts across the country may also be playing a role in holding down costs. Employers, insurers, and providers have been organizing a range of efforts to reduce costs and improve quality. These efforts are promising, but they also tend to be locally based and small scale. Some focus on one employee group, or disease group, or on the efforts of one insurance plan in a state. The largest effort to encourage payment and delivery reform, the Medicare payment and delivery experiments funded under the Affordable Care Act, are only just beginning. Our colleagues at the Commonwealth Fund recently estimated that there are today about 2.4 million Medicare beneficiaries being served by providers participating in Accountable Care Organizations, far too few to impact costs nationally. The Congressional Budget Office has thus far been unwilling to score savings for delivery reform, at least as it has been embodied in legislative form. Whatever the promise of these efforts to reduce costs, experience to date is mostly small scale. Previous efforts produced mixed results according to the most rigorous evaluations we have, and we don’t have much new evidence yet.
Then there are chronic disease management programs. And wellness programs. And tighter managed care. It is possible that it is not any one thing but somehow the combined effect of all of these things that is holding back cost increases. Like other theories, the “all of the above” theory is not provable, at least not yet. Many claims are being made about current efforts to hold down costs – some in the interest of understanding what is happening in a complex health care system, others not entirely disinterested. The truth is that what we don’t know about the causes of the slowdown and the efficacy of current efforts exceeds what we do know by a wide margin. Our colleague, the health economist Gail Wilensky, said essentially the same thing in The New York Times not too long ago: “If there’s something else going on, we don’t know what it is yet. The most honest thing to say is that, one, the reduction in use is greater than the recession predicts; two, we don’t understand why yet; and, three, you’d be foolhardy to say that we can understand it.” My sense, from watching these trends for many years, is that explanations that focus on the recession and the economy, and secondarily on the recent growth in cost sharing and high deductible plans, are the most plausible. In the small group market where fewer firms are self-insured, it is also possible that recent medical loss ratio and rate review regulations are having some effect.
With the economy only slowly recovering and wage stagnation depressing utilization, there is no reason to expect a return to double digit increases in health insurance premiums anytime soon, if at all. Other new variables could also change the cost picture moving forward, including the implementation of the Affordable Care Act and reductions in Medicare or Medicaid spending that might arise out of budget talks. At the same time, there has been no obvious change in the fundamental underlying drivers of medical costs or in the delivery of, or payment for, medical services that should lead us to think that the recent historically low increases in health costs represents a “new normal.” There is no bigger or more challenging problem in health care than controlling costs, and the recent good news about premium increases is no reason to assume the problem is solved or to back off of new efforts to address it.[post_title] => Pulling it Together: Reflections on This Year's Four Percent Premium Increase [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-reflections-on-this-years [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:37 [post_modified_gmt] => 2014-03-04 16:14:37 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-reflections-on-this-years/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw )  => WP_Post Object ( [ID] => 22753 [post_author] => 25629999 [post_date] => 2012-07-19 13:37:34 [post_date_gmt] => 2012-07-19 17:37:34 [post_content] => The American people are busy trying to make ends meet and take care of their families and they are constantly bombarded by messaging and spin. They rarely have a full understanding of policy issues and debates. Often it is their strongly held beliefs, whether based on accurate or inaccurate perceptions, which color what they think about issues. The classic case is the public’s perception of foreign aid, something they don’t like and that they believe consumes a far larger share of the federal budget than it actually does. (If people are given a specific and more popular purpose for aid, such as funding for global health or to alleviate hunger and poverty, their views flip and they are much more positive.) So it is something of a surprise, and more than a little bit heartening, to see in our new Kaiser Family Foundation-The Washington Post survey published in the paper this week that the American people get most of the essentials about the HIV epidemic right (but not necessarily all of the details). On the eve of the first International AIDS Conference in the U.S. since 1990 (the year we started the modern day Kaiser Family Foundation and made HIV one of our core priorities), there is a lot that is positive about public opinion on HIV. The state of public opinion on HIV, once an issue marked by great fear and misperception, contrasts sharply with the much more toxic environment on many other health issues we poll on, such as health reform, where we see much higher levels of confusion, misperception and division in public opinion.
- Half of Americans (51%) see progress in combating the domestic epidemic, with 18% saying we are losing ground. Blacks (41%) are less likely than whites (52%) to believe progress is being made, which, of course, reflects the reality in the black community which has been much harder hit by HIV/AIDS. The public has it right; there has been great progress, although there is still a long way to go.
- Most Americans (58%) think the world is making progress on HIV/AIDS, with 18% saying we are losing ground. Again, right on target.
- People from communities who are most affected by the epidemic are the most likely to say they are worried about it. For example, blacks are five times as likely as whites to worry about a family member getting HIV.
- People know where the epidemic is now hitting hardest. For example, over half the public (54%) – and even a larger share of blacks (63%) – recognize that the epidemic has had a greater impact on blacks than whites in the U.S.
- Most people know that providing access to treatment is a problem in developing countries, with 87% percent of the public saying most people in developing countries don’t have access to HIV medications. This has been a theme in media coverage of the global epidemic. New data just out from UNAIDS finds recent gains have been made, although still almost half of people in low and middle income countries who need HIV medications are not getting them.
- A majority (56%) says that more spending on HIV treatment will lead to meaningful progress in slowing the epidemic here at home, something experts would certainly assert. (About a third – 34% – say it won’t make much difference.)
- Recent research has shown the important benefits of treatment as prevention – that those with HIV on treatment can reduce the chances of spreading the virus to sexual partners by as much as 96%. Half of Americans (49%) are aware of this link between treatment and prevention, a surprisingly high number for a fairly recent research finding that will not affect most of the public.
Analysis by researchers on our staff and at the Urban Institute shows that while the duals as a group are higher utilizers than other Medicare beneficiaries, a smaller subset of duals are very high utilizers: 2 million of 9 million duals in 2007 (the last year for which merged Medicare and Medicaid data were available) were responsible for 60 percent of Medicare and Medicaid spending; the remaining 7 million duals accounted for 40 percent of spending (The Diversity of Dual Eligible Beneficiaries). Some states will pursue broad demonstrations while others may pursue more targeted approaches, focusing on groups with recurring high expenses, such as nursing home residents. If states and health plans could target their efforts and more effectively coordinate the care of the very high utilizers, the benefits to both beneficiaries and the programs could be quite large. In the capitated model, managed care companies will strike deals providing front-end savings to Medicare and Medicaid to manage the care of this population. The real challenge will be to assemble the delivery networks at the local level to effectively manage the broad range of services duals use, including behavioral health, pharmacy, community-based and institutional long-term care services, and a full range of acute care services. Managing care for a population that includes some who are very reliant on long term care, in particular, will require developing new networks of services for many managed care companies. So will managing care for a population with a high incidence of cognitive and mental health problems. Very few health plans now have the necessary experience to manage the care of this complex population and it will take time to develop new arrangements for appropriate services. Medicaid is a federal-state program administered by the states and Medicare is a federal program, both with different populations and benefits (Medicare’s Role for Dual Eligible Beneficiaries; Medicaid’s Role for Dual Eligible Beneficiaries). It is predictable that there will be federal-state control issues to work through as a demonstration program involving a merger of both programs with private plans evolves. None of these challenges are reasons not to undertake the demonstration, only to recognize that implementation will take careful planning and time because the details of delivering care and services will matter. I learned first-hand about the challenges of developing new service networks in the early days of Medicaid managed care in the 1980's, as Human Services Commissioner in New Jersey. We established the first state-run, federally-qualified HMO for Medicaid. It achieved front-end savings and some ability to reallocate more of the Medicaid dollar to primary care. But we never were able to build the network of providers to more effectively manage care to improve outcomes or lower costs, for a population far less complex than the dual eligibles are. Across the country Medicaid managed care slowly replaced fee for service for children and their parents but it never became the huge cost saver it was originally expected to be. Thirty years after it began to gain momentum Medicaid managed care is now moving to higher cost populations where the potential for savings are thought to be larger but the risks to sick patients are also greater. With the spotlight on the ACA and Medicare and Medicaid budget challenges, this experiment involving millions of some of the highest cost, sickest people served by public programs has so far been under-reported. Eventually, covering this story will require getting inside delivery systems and interviewing policymakers, providers, and especially patients and their families, just the kind of journalism news organizations are hard pressed to do with their frayed budgets. This is not a breaking story a reporter can cover in one day. It will never have the drama of the highly politicized ACA and Medicare wars. But it deserves attention beyond our world of health policy. Success in the dual eligibles demonstration could help reduce federal and state health spending in both big health care entitlement programs and improve the health of a very needy population. But the pressure to save money always cautions prudence, patience, and in this case careful targeting and customization of services, when large numbers of low-income people with disabilities and serious illnesses are involved. [post_title] => Pulling it Together: Duals: The National Health Reform Experiment We Should Be talking More About [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-duals-the-national-health [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:39 [post_modified_gmt] => 2014-03-04 16:14:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-duals-the-national-health/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 65685 [post_author] => 48572675 [post_date] => 2013-01-01 17:55:11 [post_date_gmt] => 2013-01-01 22:55:11 [post_content] =>