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Public Health Policy and Access to Care

(Nancy Weber) -- Public policy may be defined as a course of action chosen by public officials, and the principles upon which it is based.  Public policy is expressed in the body of laws, regulations, decisions and actions of government.

In Maryland, the executive branch of state government and the Maryland General Assembly take the lead in developing public health care policy, with the Governor playing a major role.  The Governor sets the budget and appoints the Secretary of the Department of Health and Mental Hygiene (DHMH), who guides health policy for the State.  

The Secretary, in turn, authorizes the directors of DHMH major divisions, called administrations, to develop policies relevant to their individual administrations. DHMH administrations include Community Health, Family Health, Mental Health, Addictions, Preparedness and Response and Environmental Health.  

Multiple factors shape health care policy including federal laws and regulations, national policies and initiatives, health care costs, funding sources, environmental issues and current events. In this article, we will concentrate on some of the issues surrounding State policy on access to health care.

For the past few years, the General Assembly has become increasingly concerned about the rising cost of health care and the number of Marylanders who do not have regular access to health care. According to Howard County Delegate Shane Pendergrass, a member of the Health and Government Operations Committee of the House of Delegates, approximately 800,000 Marylanders lack health insurance and that number grows by 50,000 each year.  Access to health care has been further curtailed in recent years by federal cuts to Medical Assistance, reductions in Medicare and Medicaid reimbursements and increases in medical malpractice premiums.  The last two developments have reduced the number of physicians practicing in Maryland, and more significantly, the number of physicians willing to accept Medicare and Medicaid patients.

People without health insurance typically do not have primary physicians. They frequently seek urgent care in hospital emergency rooms at higher costs.  These individuals are often unable to pay for their care, resulting in increasing uncompensated care costs, which are passed on to every Marylander  in the form of taxes and higher insurance premiums. 

Public health care costs are rising in Maryland. Cost for the uninsured in Maryland totaled $1.47 billion in FY 2002, an average  of $2,371 per uninsured individual without health insurance—paid for by state and federal funds, private insurance companies, physicians, charities and the uninsured themselves (Johns Hopkins Bloomberg School of Public Health, Journal of Health Care for the Poor and Underserved, February 2007).  In the FY 2008 budget, Medicaid alone is funded at $3.9 billion, not including funding for nursing home care; more than doubling the cost in FY 2002 (Fiscal Note, Senate Bill 474, 2007).

Spurred by these rising health care costs, Maryland’s Delegates and Senators introduced 14 bills in the 2007 General Assembly, addressing access to health care.  Many of these bills would have increased access to health insurance and health care and reduced uncompensated care rates.  They varied in focus. Some expanded eligibility for Medicaid and the State Health Insurance Plan (SHIP).  Others established a new Maryland Health Insurance program and required people without health insurance to purchase it from a new state plan.

Delegate Pendergrass noted that passage of HB 754 by the House of Delegates in 2007 was a significant step in combating rising health costs.  The bill expanded Maryland Medical Assistance by increasing the income eligibility ceiling and providing comprehensive medical coverage to parents with a dependent child living at or below 116% of the federal poverty level.  It extended coverage to families at 400% of the federal poverty level and required them to make an adjusted annual premium payment.  The bill further created a Health Care Coverage Fund to pay for the expanded insurance coverage.  Funding would have come from doubling the state tax on a pack of cigarettes to $2.00 per pack.  Unfortunately, this bill failed in the Senate. Senate leaders were concerned about raising a tax to pay for a costly social program with the State facing a $1.3 billion budget shortfall in 2008.  

The 2008 Legislative Session promises to be even more difficult for those seeking to expand health care coverage. The State’s structural budget deficit is now projected at $1.5 billion.  New revenues in the form of taxes and slot machines are being weighed against draconian budget cuts by the Governor and legislators to the current level of funding for programs and services.  It is unlikely that health care reform will occur in the next year.

The issue of health care costs and uncompensated care demonstrates the struggle to develop and implement health policy in Maryland.  There are many competing factors including social, moral, financial and practical considerations.  As with many states, Maryland is facing a crisis in health care that requires political and public will to reverse the trend.  There is no simple solution and no clear direction on the federal horizon.