Portune proposal to improve public health

MEMORANDUM

To: Commissioners Phil Heimlich and John Dowlin
From: Commissioner Todd Portune
Date: June 23, 2004
Re: Creation of a New Health Care Review Commission and Explore the Possibility of eliminating the lack of health insurance in Hamilton County

Dear Phil and John:

I write to you to discuss the important issue of Health Care in Hamilton County and to ask for your consideration of two specific proposals that can dramatically change the face of health care in our county in ways that will promote public health, small business, the uninsured and taxpayers. The proposals are as follows:

Create a New Health Care Review Commission:

First, I believe we need to take a different look at how we are spending and investing public money in health care. The dramatic rise in costs and requests upon us in the form of Special Levies is such that is likely not sustainable in the future. Aside from the potential increase in cost or taxation comes perhaps a far more important question – namely, if we had it to do all over again would we spend the public’s money the way we are doing so today?

I believe we need to ask that question and to do so in a way that allows for a thorough examination of all issues and in a time frame that is free from the demands and constraints that the levy process places upon us.

Accordingly, I propose that we create a new Health Care Review Commission of no less than 5 nor more than 9 Members. We need to have a good cross section of disciplines represented on the Commission. It naturally should include Members of the health care community from all angles – providers, insurers, consumers and public officials. I propose that we ask for Prosecutor review regarding the establishment of such a Commission and the legality of using unallocated health care levy dollars to underwrite its expense. We should answer these questions by the first of November to allow for a thoughtful appointment process thereafter.

The Commission should be appointed at the end of this year and charged to convene next year with the intent of delivering a year end report to the Board that becomes the blueprint to guide the Board’s decisions on health care related levy requests beginning in 2006. The Commission should receive full county administrative staff support and legal assistance from the Prosecutor’s office. Funding for the work of the Commission should come from available and existing levy funds.

I have already had discussions of this concept with Ken Hanover of the Health Alliance in April and with Chris Finney, Chair of the county TLRC in May. Both are favorably inclined toward the concept.

Hamilton County taxpayers have a history and record of being generous in the field of taking care of those least able to care for themselves. We owe our taxpayers the duty to critically examine how those dollars are being spent and whether improvements can be made in the efficient and effective use of them. It may be that an entirely different way of utilizing and distributing dollars is recommended. or it may be that the current model is in fact the best. I do not know and express no opinion other than the opinion that we owe it to our citizens, our taxpayers and the success of our Mission to critically examine this issue with the help of the best minds available on the subject.

The Potential to eliminate the Uninsured in Hamilton County:

As we move forward toward examining the overall question of health care and public dollars I would like for the county administration to evaluate the possibility of using existing and available dollars to eliminate the critical health care problem of the uninsured in Hamilton County. It is possible that we can develop a program in the county that provides for health insurance of one sort or another for our entire population at no added cost to county taxpayers.

I would like for this concept to be reviewed preliminarily by county administration so that it may be an element of the Health Care Review Commission’s evaluation and, if it is deemed worthy, could be a part of the levy recommendation for 2006 insofar as how we utilize public levy health care dollars.

First, a bit of history. When we adopted the work plan and approved the contract on how the Indigent Care hospital levy proceeds would be divided between, and spent by, University Hospital and Children’s Hospital Medical Center, advocates such as Eileen Cooper Reed of the Children’s Defense Fund and Trey Daley of Legal Aid urged that a portion of dollars should be reserved for Medicaid outreach and enrollment. It was left that we would do an annual assessment and review of the levy expenditures with an opportunity to revisit the issue. That review has yet to be done. However, an examination of existing expenditures is very revealing and demonstrates that the expenditure of a small portion of available levy dollars will increase exponentially the benefit that those dollars will be able to provide.

The vehicle to do this is Medicaid. Medicaid is the federal health insurance program that is available to people based upon income and federal poverty levels. It is a program, nonetheless, that requires an eligibility assessment and enrollment.

In Hamilton County there are 17,863 Medicaid eligible people that are not enrolled. Of that figure are 12,874 children and 4,989 are adults. It is calculated that area health care providers lose $55,303,848.00 in Medicaid reimbursements each year. Of that figure $15,784,791.00 is lost by area hospitals for inpatient care in the form of un-reimbursed charity care. Charity care that is not reimbursed is, of course, the criteria for sharing and distribution of the county’s indigent care levy dollars.

In 2003 approximately $1.3 Million of the CHMC allocated Hospital Levy dollars were not used and returned. They have not been spent but are, for want of a better word, escrowed for the moment. According to research done by Trey Daley and Keith Melson of the Children’s Defense Fund, approximately the same amount of dollars would underwrite a Medicate enrollment program that would eliminate the Medicaid gap.

Closing that gap then reveals a picture of Hamilton County’s uninsured. They constitute 13,548 children and 60,854 adults. Under a model program involving Hamilton County’s working poor[defined as those wage earners not eligible for Medicaid and earning less than 200% of the federal poverty level, totaling 35,793 adults], and county businesses that currently offer no insurance, a 3 payer program could be developed to eliminate the uninsured working poor in our county. For the cost of $1.00 each to business, insured and county, a health insurance program could be developed that would generate an incremental $26,625,600.00 to hospitals for services. The amount available for other care providers has yet to be determined.

Such a program produces a $1.29 rate of return for hospitals for every $1.00 invested. When coupled with the new revenues generated by a Medicaid outreach program, as discussed above, the combined new revenues generated to offset existing charity care mathematically covers the cost of the insurance program. I would ask that our administration work closely with providers and with Mr. Daley and Mr. Melson to explore this concept and report to us this year so that the possibility of such a program could be examined by the Health Care Commission when it commences its work next year.

I also ask that such a review occur as it was contemplated under the discussions the Board had in 2002 because, regardless of whether an insurance plan discussed above could actually be realized, the Medicaid outreach and enrollment program makes sense under any analysis.

Thank you for your consideration of these items. If you concur we can begin the process of giving the administration the proper instruction to begin work in both of these areas.

Sincerely,

Todd Portune

Cc: David Krings; Rob Seddon; Karen Ball; Rob Fredericks; Eric Stuckey