Access to care in Pennsylvania: The impact of health reform

We evaluated the impact of state comprehensive insurance reforms on private and public health insurance coverage, out-of pocket costs, “crowd out” and population factors in the State of Pennsylvania before and after implementation. Using data gathered from a random sample population telephone survey conducted in 2008 for the Pennsylvania Insurance Department (N = 20,000 households) compared to a similar survey we conducted in 2004 (N= 8000) we evaluated the impact of the Cover All Kids (SCHIP), adultBasic and the enhanced Medicaid program on the uninsured population of Penna. The two surveys provide data on trends in insurance coverage by demographic and geographic characteristics; the effectiveness of recent health insurance initiatives in the State, including the Cover All Kids Program and the adultBasic Program; and information on remaining gaps in insurance. Overall health insurance coverage between 2004 and 2008 did not change and there was little reduction in existing private coverage through employer sponsored insurance plans (ESI). This is an indication that the private insurance market overall was not substantially impacted by state health reforms, economic slowdown or other externalities. Study data indicate that Pennsylvania's efforts to expand insurance coverage have served as a successful safety net for residents with low family incomes and particularly for African Americans. State sponsored plans, especially Medicaid increased significantly during this period due in part to aggressive marketing strategies among certain population groups. The largest decline in insurance coverage was among the Spanish speaking population. This was attributed in part to greater immigration of this population coupled with lower market exposure. The study also highlighted a variety of challenges for Pennsylvania in its current policy initiatives to achieve universal coverage. These include: funding the expansion of the adultBasic Program to meet the high level of demand for the program; continuing to maintain employer-sponsored insurance coverage levels in the future in the context of economic challenges; promoting insurance enrollment among young adults; reducing administrative barriers for enrollment in state insurance programs; and continuing to improve health care quality through chronic care management initiatives in the public and private sector. Results of this study have explicit policy implications for both state and federal efforts to expand coverage. Policy benefit design, marketing strategies and sustainability are important issues learned from this study.