Improving Health Insurance Coverage in the District of Columbia

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Executive Summary

While the uninsurance rate in the District is lower than the national average, there remains an unacceptably high number of residents who are not covered. Among residents under age 65, on average about 74,000 people did not have coverage at some time during the year. Within this population, about 15,000 have family incomes above 200 percent of the federal poverty level, disqualifying them for public insurance programs such as Medicaid and the Alliance. Among families that do qua lify for these programs, some have been successfully enrolled, but a large number have not. Families that qualify for public coverage but are not currently enrolled make up a large portion of the uninsured in the District.

The purpose of health insurance is to improve access to health services to improve health status. Death rates and morbidity are demonstrably lower among the insured. Insured people are also more efficient and effective consumers of health services, in that they are more likely to have a regular source of care and to seek help when first needed rather than showing up at a hospital with more advanced problems. Regular care, especially for chronic conditions, can also help prevent or postpone longer-term worsening of health. Healthy residents are more productive workers and students, and contribute to the economic well-being of the community.

To help assess ways to improve coverage, the Department of Health convened the Health Care Coverage Advisory Panel under the District's State Planning Grant (SPG). The Panel represents residents of the District as well as associations, private-sector groups, and public agencies. Over the course of 10 full meetings and additional meetings of working groups, Panel members weighed evidence on who is uninsured and why, what other jurisdictions have done to expand coverage, and what is the full range of options for increasing coverage in the District of Columbia. Based on this information, it developed eight recommendations for expanding health insurance in the District.

The Panel adopted three key criteria for options worthy of recommendation. Members agreed that any intervention recommended should achieve a reasonable impact for the expected cost, be politically feasible, and encourage the maintenance of private support for existing and expanded insurance coverage. Change needs to be perceived as making the District a better place to live, work, and do business. The Panel also took as a guiding principle that providing or ensuring health insurance coverage was the most effective means to improve health outcomes for vulnerable populations; investment in improving the delivery system was identified as a second priority. Panel members share the vision of coverage for all residents but recognize this as a long-term goal. The recommendations proposed here offer more immediately feasible approaches that do not require the kinds of mandates for coverage and federal action that would be needed to achieve 100 percent coverage. They represent the consensus of the Panel.

Recommendations 1, 2, and 3 address ways for the District to do better what it is already doing to enroll eligible residents in applicable programs and to help employers find appropriate health insurance plans. Recommendation 4 addresses improving the public coverage available to residents below the poverty line.

Recommendations 5 and 6 both target the working poor who do not currently qualify for publicly sponsored coverage programs, the former through public programs and the latter through development of private coverage options. The Panel recommends that the public program be implemented but notes that the private option needs additional study before it can be recommended for implementation.

Recommendations 7 and 8 address issues that will be critical to the implementation of all of the recommendations. One deals with personnel and the other with evaluation and monitoring.

Specifically, the DC Health Care Coverage Advisory Panel recommends

1. that the Department of Human Services, Income Maintenance Administration, develop a unified system for enrollment into publicly financed health programs working in conjunction with the Department of Health, Medical Assistance Administration, and the Health Care Safety Net Administration;
2. that the District establish an in formation clearinghouse on health insurance products;
3. that the District improve outreach and enrollment for the Alliance and Medicaid in order to enroll eligible residents who are not yet enrolled;
4. that the District improve the public coverage available to nondisabled adults with family incomes below 100 percent of FPL through a public program that has benefits and access comparable to Medicaid;
5. that the District develop a mechanism to allow uninsured residents with family incomes between 200 and 400 percent of FPL to buy into Medicaid or the Alliance;
6. that the Department of Health provide analytic support to the further development of the Healthy D.C. proposal, a public reinsurance program for small business health insurance plans under consideration by the Council;
7. that the Mayor ensure that implementing agencies have adequate staff with appropriate training and other necessary resources, dedicated to supporting implementation of these recommendations; and
8. that the District make tracking and assessment of new coverage initiatives part of their design and implementation.

Each of these recommendations is described more fully in the body of this report identifying the target group, where appropriate, and the supporting rationale. Following some recommendations is a list of outstanding questions needing further investigation. These generally relate to implementation and so were beyond the scope of the Panel to address. These are left to the Department of Health and other policymakers to address in the final design of the recommended programs.

Each of the proposed programs comes with a cost, the size of which will be determined by its final specifications. Any could be implemented with a budgetary limit. The Panel did not identify funding for the recommendations. The Panel recognizes that the District will always have competing uses for any available funding and that, even within the funds available to fund health, there will be competition among alternative ways to promote access to services and improved health outcomes. Members feel strongly that expenditures on expanding health coverage for District residents is one of the most effective investments the District can make toward improving health outcomes and health status. However, decisions about funding must be made as part of the overall budget process and in collaboration with affected stakeholders.

Note: This report is available in its entirety in the Portable Document Format (PDF).

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

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