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Addressing the Needs of the Uninsured in a Challenging Economic Environment

Slide Presentation by John Santa, M.D.

On March 14, 2002, John Santa, M.D., made a presentation in a Web-assisted teleconference at Session 3, which was entitled "Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages."

This is the text version of Dr. Santa's slide presentation. Select to access the PowerPoint® slides (281 KB).

Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages

John Santa, M.D.
Office for Oregon Health Policy and Research

Slide No. 1

Oregon 2001

  • Pre 9/11
  • Uninsurance rising
  • Economy in recession
  • Post 9/11
  • $800 million deficit
  • Highest unemployment in the United States

Slide No. 2


  • Benefits/eligibility flexibility
  • Maximize leverage—access all $$ sources possible
  • Use resources—expand eligibility
  • Cap enrollment for expansion populations

Slide No. 3

Making Tough Choices

  • Ration services rather than people
  • Explicit, public decision process
  • Oregon data for reference and relevance
  • Rely on evidence when available

Slide No. 4

Prioritized List—Lessons Learned

  • Priorities made explicit—prevention high on list. Futile and inefficient care lowest
  • Overall rankings make sense
  • Less valued services excluded—about 3 percent more than usual exclusions
  • Difficult to administer
  • Still complex and emotional process

Slide No. 5

Listening to the Public

  • Multiple public sessions—over 2,000 participants
  • Oregonians understand tradeoffs
  • Prefer cost-sharing to benefit elimination
  • Prescription drugs highest valued
  • Dental and mental health similar

Slide No. 6

Dental—"on the Cusp"

  • Dental—first benefit with substantial resources "on the cusp"
  • Motivated managed dental plans
  • Data shows minimal preventive, substantial high cost use
  • Focus on maintaining function
  • 6 month $ limit, copays on restorative

Slide No. 7

Importance of Research

  • Good research on low income, churning, subsidy for ESI
  • Lack of research on cost-sharing at lowest incomes other than Rx
  • Using evidence-based analysis done by Oregon Evidence-based Practice Center for high cost prescription drugs

Slide No. 8

Lessons Learned

  • Taking benefits away is tough work
  • Uninsured have little leverage
  • Keep presenting options, keep participants talking, be a catalyst
  • Identify basic services
  • Identify less valued, less effective services
  • Pursue every option until you get pushed back

Slide No. 9

Important Questions

  • Cost sharing in poor adults
      -What works, what doesn't?
      -How can delivery systems and communities help?
  • Effect of premiums on poor adults
  • Does trading off benefits for expansion of eligibility result in net benefits to the population as a whole?

Slide No. 10

Resources for Poor/Low Income

  • Focus on adults—no premium/nominal copays for children
  • No discretionary income
  • Family/friends/other sources
  • Financing options
  • Other resource help—food, housing

Slide No. 11

Strategies to Moderate Impact

  • Premium subsidy
  • Premium financing
  • Copay financing
  • Continuous enrollment
  • Medical culture
  • Community culture

Slide No. 12

Alternatives to Cost-sharing

  • Eliminate coverage for specific treatments—return to list
  • Site of service strategies—individual visit to group, subacute detox
  • Limits on visits
  • Guidelines

Current as of July 2002

Internet Citation

Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages. Presentation by John Santa at Web-Assisted Teleconference, "Addressing the Needs of the Uninsured in a Challenging Economic Environment". July 2002. Agency for Healthcare Research and Quality, Rockville, MD.

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