NYSHealth Special Report

Transcription

1 NYSHealth Special Report Making Public Health Insurance Programs Work Better: Partnering with The New York State Department of Health To Reform Medicaid April 2011

2 Contents Background 1 Foundation Strategy 3 Summary of Grants Funded Under the Authorization 4 Summary of Key Findings of Grants Funded 8 Lessons Learned 11 Final Reflections 13

3 Background Public health insurance programs are essential building blocks in the effort to reduce the number of uninsured Americans. In New York State, such programs are a cornerstone of the insurance system; it is hard to overstate both their importance and complexity. Collectively, Medicaid, Child Health Plus (CHP), and Family Health Plus (FHP) cover approximately 4.9 million New Yorkers. At least another 1 million New Yorkers are estimated to be eligible for public coverage but not enrolled. Medicaid covers one in two births, one in three children, and one in four New Yorkers. If New York State s Medicaid program were a private business, it would be a Fortune 50 company. If it were a private insurance company, it would rank among the nation s top 10 as measured by covered lives. New York s Medicaid program is also the most expensive in the nation; total annual spending is approaching $50 billion and per enrollee spending is almost twice the national average. Medicaid accounts for more than one-third of the entire State budget. Medicaid also represents more than one-quarter of all annual health care spending in New York. Collectively, Medicaid, Child Health Plus (CHP), and Family Health Plus (FHP) cover approximately 4.9 million New Yorkers. At least another 1 million New Yorkers are estimated to be eligible for public coverage but not enrolled. Medicaid covers one in two births, one in three children, and one in four New Yorkers. If New York State s Medicaid program were a private business, it would be a Fortune 50 company. In 2007, the New York State Department of Health (NYSDOH) and its newly formed Office of Health Insurance Programs (OHIP) was committed to reforming Medicaid to: 1) ensure that eligible children and adults are able to obtain and maintain health insurance coverage; and 2) ensure that Medicaid used its purchasing power to buy quality, cost-effective care. The Foundation began discussions with the Medicaid Director to determine how NYSHealth could be supportive towards reaching those goals. TACKLING MEDICAID REFORM The Foundation was confident that the timing was right for the State to tackle Medicaid reform because: the State Fiscal Year Budget laid the groundwork for reform by expanding insurance coverage for children; streamlining Medicaid coverage renewal requirements; and mandating a review of the $847 million in indigent care payments to hospitals; many states, rather than the Federal government, were acting as the primary venues for coverage reform and expansion; NYSDOH had a new level of authority over Medicaid payment policies across all agencies and licenses; and a new Governor was committed to the expanding and simplifying the program. 1

4 Background (continued) New York s Medicaid program is also the most expensive in the nation; total annual spending is approaching $50 billion and per enrollee spending is almost twice the national average. Medicaid accounts for more than one-third of the entire State budget. It was clear that reforming such a massive program with multiple stakeholders would be exceedingly complex as it would take many years and would require more than one State budget. The reform process had to be inclusive and transparent, with all stakeholders involved. The Legislature, in particular, had to be informed and involved because many elements of reform would require statutory change. New payment policies had to take into account the emerging technologies, medical advances, and evidence-based practices that advance the quality and efficiency of care provided to patients. The autonomy that local social services districts have in implementing Medicaid and enrolling eligible participants in place for 40 years needed to be revisited. Finally, proposed changes in Medicaid enrollment and renewal processes, as well as in provider payment rate methodologies, would need to guard against the possibility of fraud and abuse. The initiative sought to provide program officials with practical, actionable, and timely information to enable wise programming and implementation decisions and policy changes. Addressing these challenges required the best and most knowledgeable thinking on key aspects of Medicaid reform. In response, the Foundation authorized funds for the initiative Medicaid Reform in New York State: Supporting Analyses to Expand, Simplify, and Reform the System. 1 NYSHealth and NYSDOH agreed that quick-strike analyses were required for the many issues that would affect implementation of different policy changes. The technical expertise that could perform these analyses resided outside NYSDOH and, in some cases, outside New York State. The initiative sought to provide program officials with practical, actionable, and timely information to enable wise programming and implementation decisions and policy changes. Further, the Foundation hoped that the authorization would create a partnership between the Foundation itself and the administrators of the Medicaid program, but wanted to avoid funding projects that, in effect, were substitutes for what the State government should do, could do, or should fund with its own resources

5 Foundation Strategy The strategy of using philanthropic funds to inform government policy is not a new one. Many statewide and national foundations have used it, including the California HealthCare Foundation, the Commonwealth Fund, and the Robert Wood Johnson Foundation. It is an important aspect of NYSHealth s approach to increasing health insurance coverage for all New Yorkers by funding analyses to inform key policymakers in the New York State government, the Foundation has an opportunity to influence positive changes in this area. The Foundation decided to create this partnership with NYSDOH because, if successful, it could demonstrate how NYSHealth could play a role in creating useful information to shape sensible public policy. This project was the first significant Foundation initiative to employ a strategy of creating a partnership with State government to move the needle in areas central to the Foundation s programming in this instance, health insurance coverage. At the same time, NYSHealth s staff and Board realized that there is a fine line between funding projects to augment or complement the work of State government, and funding projects that simply substitute for work that could be a part of State government s ongoing responsibilities and paid for through tax levy funds. The Foundation recognized this project as complementing the State s work because it would have been impractical for the State to identify or receive legislative approval for each individual project, and navigate the time-consuming State contracting process. The Foundation further assessed that the external expertise each individual project called upon would be crucial for expanding coverage and access to efficient and effective care. This project was the first significant Foundation initiative to employ a strategy of creating a partnership with State government to move the needle in areas central to the Foundation s programming in this instance, health insurance coverage. The initiative also represented an example of where the State government recognized the Foundation s ability to assist them in achieving an important policy goal and recognized that the Foundation s funding and participation in the initiative might bring greater credibility, quality, and reliability to the information needed to make important public decisions over the next few years. EXPECTED OUTCOMES Though the Foundation and NYSDOH did not identify specific expected outcomes upfront for the overall authorization of these projects, NYSDOH was poised to lead reform of the State s Medicaid program to advance two important goals: 1) to ensure that eligible children and adults are able to obtain and maintain health insurance coverage; and 2) to ensure that Medicaid s payment policies advanced quality, cost-effective care. In essence, the expected outcomes were that the administrative studies would provide the State with tools to simplify the enrollment and retention procedures related to public insurance programs and increase access to more cost-effective care for high-cost beneficiaries. 3

6 Summary of Grants Funded Under The Authorization NYSDOH program officials and Foundation staff collaborated to select project topics and to seek advice from outside experts. Once topics were chosen, specific organizations were identified and asked to apply for funding because they held expertise in the area of interest. In some cases, the Foundation solicited competitive proposals, and in others, directly commissioned work with a sole organization. This process reduced the amount of time it would normally take to get a project underway. In the spirit of quick-strike and actionable analyses, the goal was to get expert advice and act on the recommendations in an expeditious manner. The grants funded under this initiative addressed a range of issues affecting New York State s Medicaid program: The Center for Children and Families at Georgetown University s Health Policy Institute led a study of the New York State Medicaid program s multiple and overlapping eligibility categories, and recommended options to collapse and simplify those categories. The project resulted in two reports. The first and more extensive report focused on families, children, parents, pregnant women, and childless adults who were neither elderly nor disabled (these groups account for the majority of New York State coverage groups). This report included a range of recommendations that New York State could consider in light of its policy goals and available resources. The second report focused on the elderly and disability-related eligibility categories. The reports enabled OHIP to develop a blueprint for moving toward implementing many of the recommendations, and several of the changes were included in the Governor s Executive Budget and subsequently adopted by the Legislature. This project resonates with other states similarly interested in simplifying their eligibility rules to improve coverage results. In addition, it has importance at the Federal level as part of broader health reform efforts. [Grant # ; $50,000. A more extensive summary is available on NYSHealth s website]. The Lake Research study uncovered reasons for losing health coverage that ranged from beneficiaries not actually knowing they had lost their coverage, to being turned off by the hassle factor of renewing, to not receiving the necessary materials for recertification in the mail. Michael Perry of Lake Research Partners (Lake Research) conducted eight focus groups with former beneficiaries of public health insurance programs who had recently lost public health insurance coverage. The goal of the study was to better understand why many beneficiaries are not successfully completing the annual renewal process for Medicaid, Family Health Plus, and Child Health Plus. Prior to this project, the perspectives and preferences of beneficiaries themselves had been largely absent. Lake Research worked closely with both the Foundation 4

7 Summary of Grants Funded Under The Authorization (continued) and OHIP staff members to develop the research approach. The Lake Research study uncovered reasons for losing health coverage that ranged from beneficiaries not actually knowing they had lost their coverage, to being turned off by the hassle factor of renewing, to not receiving the necessary materials for recertification in the mail. Focus group participants offered their suggestions for improvement. The report itself led to a New York Times story on the difficulties associated with renewing Medicaid coverage in New York. In addition, the results of these focus groups reinforced the State s decision to move ahead with its telephone renewal project. OHIP also continues its simplification efforts to make the public health insurance program renewal process less confusing. [Grant # ; $98,175. A more extensive summary is available on NYSHealth s website] Melinda Dutton of Manatt Health Solutions (Manatt) conducted an analysis of the Excess Income Program in New York State, which allows individuals who have large or ongoing medical expenses access to Medicaid coverage even though their household income is too high to meet the regular Medicaid income eligibility standards. Currently, local departments of social service (local districts) across New York State are responsible for gathering health care receipts and payments, and tracking these enrollees continued eligibility. Manatt identified opportunities to improve the administrative efficiency and programmatic implementation of the enrollment and eligibility processes of the Excess Income program. Manatt found wide variation at the local district level in the way the spend-down is processed and recommended that the State offer several options designed to improve the system for subsets of the population served by the program. Manatt also found that situations where consumers bring in monthly bills, intended to aid consumers in meeting their spend down, are the most labor intensive for the local districts. The results of this report were widely disseminated by the media, and galvanized the consumer advocacy community, which is using the report as leverage to push for reforms of the Excess Income program. The work has also had some immediate impact. The State is developing a new guidance document to local districts on administering the program (the last one was issued in 1999). The State made changes to the application to better describe the program, and OHIP has formed a workgroup to prioritize other recommendations in the report for potential implementation. Though this grant resulted in actionable and well publicized information, Manatt encountered difficulties in obtaining and using the data necessary for completing its research. Manatt worked closely with OHIP to extract information from State data systems about the Excess Income population, including enrollment, demographics, and utilization. All of the extra work related to the data analysis added significantly to the project timeline and resources required to complete the project it went from a three-or four-month project to an approximately nine-month project. [Grant # ; $48,204. A more extensive summary is available on NYSHealth s website.] The results of the Manatt report were widely disseminated by the media, and galvanized the consumer advocacy community, which is using the report as leverage to push for reforms of the Excess Income program. 5

8 Summary of Grants Funded Under The Authorization (continued) John Billings of the NYU Wagner School of Public Service assisted with developing a nearly $30 million initiative to address the quality and cost of caring for some of the most vulnerable patients in the State. Known as the Chronic Illness Demonstration Project (CIDP), this State initiative is a major effort to manage the care and costs of some of the sickest and most expensive Medicaid patients. Part of Billings work involved analyzing the State s Medicaid data to identify its high-cost, fee-for-service patients, who would be the focus of the program s request for proposals. Billings also assisted the State by completing a variety of other related tasks, such as analyzing State Medicaid data to determine whether it is possible to assess provider performance, coordinating the evaluation of the CIDP grantees, and exploring ideas for improving coordination of care for patients with serious mental illness who are enrolled in managed care. Though less than $100,000, this Foundation grant helped to influence a large State investment geared toward reducing the high cost of Medicaid. [Grant # ; $99,352. A more extensive summary is available on NYSHealth s website.] Patricia Boozang of PMB Consulting (PMB) conducted technical work to inform the development and implementation of a new statewide telephone renewal system for public health insurance beneficiaries. PMB outlined the scope of work for the development of the Healthcare Enrollment and Renewal Tool (HEART), including the necessary features and functionality of the new system from a policy perspective. PMB also developed the list of questions needed before programming HEART, which will: 1) guide Enrollment Center staff through the telephone renewal interview with beneficiaries; and 2) connect to State eligibility and enrollment systems. [Grant # ; $50,710. A more extensive summary is available on NYSHealth s website.] Courtney Burke of the New York State Health Policy Research Center at the Rockefeller Institute of Government undertook two studies. The first study compared New York State to other states on a range of long-term care issues. Among its findings were that New York s Medicaid spending on the medically needy elderly is among the highest in sampled states, though the quality of its longterm health care is only average. The report also found that New York has the lowest percentage of for-profit certified nursing facilities compared to other states. The second study reviewed the prevalence of denials for Medicaid-funded nursing home care and found wide variation in reported denial rates across the State s counties. No clear reasons for these variations emerged counties with higher denial rates did not necessarily have higher per capita average incomes or lower rates of poverty. Both reports resulted in widespread press coverage across the State. In particular, the variations in denial rates for Medicaid coverage of nursing home care generated statewide attention. Rockefeller Institute staff members also hosted a number of discussions with State health policy centers around the nation to determine the feasibility and potential structure of a New York State health policy center. NYSHealth subsequently awarded a follow-up grant to conduct field research and identify reasons for county-level variation. Finally, this grant to the Rockefeller Institute provided funds to support a staff member who served as a liaison between NYSHealth and OHIP to help determine and coordinate the series of analyses 6

9 Summary of Grants Funded Under The Authorization (continued) that were funded under the larger authorization. Similar to Manatt s experience, the Rockefeller Institute encountered some difficulties in obtaining a useable dataset for its analysis. Repeated interactions with NYSDOH staff and multiple data extractions were required to assemble a final dataset for their analyses. [Grant # ; $129,157. A more extensive summary is available on NYSHealth s website.] Among the Rockefeller Institute s findings were that New York s Medicaid spending on the medically needy elderly is among the highest in sampled states, though the quality of its long-term health care is only average. Hollis Calhoun and Colleen Chapman of Spitfire Strategies (Spitfire) designed and supported focused enrollment drives for the State s public health insurance programs. Spitfire developed a strategic communications plan, complete with the messages, approaches, and tactics necessary to create a sufficient buzz around enrollment drives in the target communities. Their media outreach efforts resulted in 25 media hits about the drives. The enrollment drives themselves reached more than 5,000 New Yorkers and resulted in 278 follow-up activities (including future appointments and/or application processes started). [Grant # ; $102,125. A more extensive summary is available on NYSHealth s website.] 7

10 Summary of Key Findings of Grants Funded The projects funded under this authorization were expected to provide practical information that could be acted upon by State officials to streamline administrative processes and thereby increase enrollment in public insurance programs and also improve the care and reduce the cost of chronically ill beneficiaries. The projects did, without a doubt, inform policymaking and advance both the Foundation s and NYSDOH s coverage goals. In fact, by working with the State directly, the Foundation leveraged its dollars so that relatively small investments resulted in far reaching improvements to the Medicaid program. Three projects generated some of the most compelling, tangible results of this group of grants: For less than $100,000, the grant to NYU s Wagner School of Public Service directly influenced a nearly $30 million State investment to improve quality of care and spending on the State s most vulnerable and often chronically ill patients. The most important result of this grant was the development and implementation of the CIDP, which represented one of the first times that NYSDOH used an approach similar to an insurance company for its fee-for-service beneficiaries it started to review Medicaid claims data; identify patients at risk of repeated hospitalization; and identify means for improving their care and, hopefully, reducing costs. Billings work on this program will most likely contribute to the national agenda on health care quality and costs because it is a clear and actionable approach that uses a standardized way to identify patient risk and tailored interventions and, its focus is high-cost, high-need patients. John Billings was absolutely critical to the development of the Chronic Illness Demonstration Project, says Jay Laudato, former Director, Division of Managed Care at the NYSDOH. Every step of the way, John has been involved. For less than $100,000, the grant to NYU s Wagner School of Public Service directly influenced a nearly $30 million State investment to improve quality of care and spending on the State s most vulnerable and often chronically ill patients. As a result of the $50,000 grant, the Center for Children and Families at Georgetown University s Health Policy Institute provided many technical recommendations for collapsing Medicaid s complex system of eligibility categories consistent with Federal rules and requirements. These recommendations were turned into specific budget proposals for aligning Medicaid eligibility between children and their parents and converting income standards that would simplify the program. These recommendations passed under that budget and the changes are currently underway. The study produced actionable information that we were able to turn into legislative proposals that were embraced by the New York State Legislature, says Deborah Bachrach, Deputy Commissioner of OHIP. The impact of this particular Foundation investment is far reaching, resulting 8

11 Summary of Key Findings of Grants Funded (continued) in changes to Medicaid s enrollment and renewal policies that affect millions of low-income New Yorkers. Other recommendations would require Federal waivers, and OHIP continues to work on them with the current administration s Centers for Medicare and Medicaid Services. For less than $50,000, the Manatt grant provided groundbreaking understanding of the administrative complexities of the Excess Income program. Though its participants comprise only approximately 4% of the total Medicaid population, they have high health care needs and require a disproportionate amount of county time and resources. For instance, the State spends approximately $19,000 per beneficiary residing in the community per year. The program is potentially a place to implement changes that result in big impact, and so far, the work has had some immediate impact. The State is developing a new guidance document to Local districts on administering the program (the last one was issued in 1999). The State has also made changes to the application to better describe the program, and OHIP has formed a workgroup to prioritize other recommendations in the report for potential implementation. The report has also had the effect of refueling the consumer advocacy movement on this issue and placing a typically under the radar program in the forefront of NYSDOH s mind. The results of this report exceeded my expectations, says Judith Arnold, Director, Division of Coverage and Enrollment at OHIP. Though many of the recommendations in the report require a Federal waiver, we can potentially implement some of them to help make the Excess Income program work better. These changes could make the program easier for local districts to administer and more customer-friendly. The Foundation later learned that in November 2010, the NYSDOH rolled out a consumer-friendly website explaining how to obtain Medicaid through the Excess Income program. The website was created with input from a workgroup of advocacy organizations that had banded together to issue formal comments and recommendations in the wake of the Manatt report. The State has also issued for the first time in many years guidance to the counties on how to administer the program. Two grants made important contributions to OHIP s streamlining and simplification projects: Findings from the Lake Research grant strongly supported the State s decision to move ahead with its telephone renewal project. OHIP also continues its simplification efforts to make the public health insurance program renewal process less confusing another outcome of the report. What was unique about this project was the partnership between the Foundation and the State s Medicaid agency, says Perry, Partner at Lake Research. So, we were able to test ideas on focus group participants that were not theoretical, but very much under consideration by the State the focus groups were very much tied to action. In a related grant, Patricia Boozang of PMB advanced the development of the telephone renewal system. Though the system was not implemented by the end of her grant period, the State plans to begin rolling it out in phases starting by fall PMB Consulting was essential to this project, says Arnold. We could not have accomplished what we did without Patti s work 9

12 Summary of Key Findings of Grants Funded (continued) she helped us to sharpen our vision for the renewal system. Ultimately, telephone renewal promises to increase continuous enrollment among Medicaid beneficiaries, reducing the problem of churning. Ultimately, telephone renewal promises to increase continuous enrollment among edicaid beneficiaries, reducing the problem of churning. Another project reviewed some particularly thorny issues within the Medicaid program asset transfers related to long-term care: The Rockefeller Institute s study on asset transfer denial rates under the Medicaid program revealed wide variation between counties. Most counties reported that less than 5% of elderly Medicaid enrollees were denied benefits because of an asset transfer, but 14 counties reported asset transfer denial rates of 10% or more. In addition, no clear patterns emerged to explain the variation in asset transfer denial rates. While the report has not yet directly impacted policy, it has kept the issue on regulators radar screens. Further, the Foundation invested in a follow-up grant for field research that should identify discrete action steps to be taken. Most counties reported that less than 5% of elderly Medicaid enrollees were denied benefits because of an asset transfer, but 14 counties reported asset transfer denial rates of 10% or more. The final grant directly targeted potential enrollees. It funded Spitfire to create a strategic communication plan to promote public health insurance programs, particularly for children: Spitfire helped to plan and support 15 enrollment drives in four cities across New York State. Working with the Children s Defense Fund-New York, Spitfire was able to engage corporate partners and community-based organizations to support and promote these drives. Further, Spitfire secured media coverage promoting the enrollment drives in local radio, television, and newspaper outlets. In total, the enrollment drives reached more than 5,000 New Yorkers and resulted in 278 follow-up activities (including future appointments and/or application processes started). Though it is impossible to tease out the impact of these enrollment drives on Medicaid coverage more generally, children s enrollment in New York increased consistently throughout We believe that some of our simplifications to the enrollment process in combination with public awareness campaigns have contributed to this increase in enrollment, suggests Arnold. With the decline in the economy, enrollment continued to grow, despite the fact that we cannot do as much as we d like to do in terms of marketing the program. In total, the enrollment drives reached more than 5,000 New Yorkers and resulted in 278 follow-up activities (including future appointments and/or application processes started). 10

13 Lessons Learned In addition to the individual project outcomes and their broader impact on the State s public health insurance program, some more general philanthropic lessons emerged from this overall authorization. 1 Partnership with government can produce a significant return on investment when the Foundation s goals and those of the State are aligned. Partnering with government requires engagement and some technical knowledge on the part of the Foundation s staff. In this case, the program staff at the Foundation had extensive technical knowledge of the public health insurance system, as well as familiarity with and strong working relationships with NYSDOH staff. The commitment of both NYSDOH officials and Foundation staff to forging a meaningful partnership was an ingredient of success. Partnerships can produce bigger results than working alone. The work supported here first and foremost advanced the Foundation s health insurance coverage agenda, which was closely aligned with the State s agenda. State agencies can benefit from technical knowledge and expertise that resides outside of government expertise they would not have been able to access without the support of the Foundation. 2 Hiring a liaison to work between the Foundation and OHIP to implement and manage an authorization like this one requires the right timing and personnel. In addition to its analytic projects, the Rockefeller Institute grant included funds for it to help implement and manage the Foundation s authorization for these streamlining and simplification projects. Everyone involved agrees that while this was a good idea in theory, it did not work well in practice. A contributing factor was the young age of the Foundation; NYSHealth had not yet established smooth grantmaking and monitoring processes. It was not the right time to insert an external person into a process that was still evolving. 3 Relatively small grants can make a big difference. Grants were generally under $100,000 (well below the $200,000 average-sized grant made by NYSHealth), but were among the most significant of the Foundation s work to date on health insurance coverage. For example, the grant to NYU s Wagner School of Public Service that supported John Billings work for OHIP influenced the design of an almost $30 million State investment. 4 Working with technical experts on the topics of interest meant well timed findings that could be brought up for budget discussions. Most of the projects funded under this authorization were successful in that they were executed as planned and resulted in a rich set of findings and recommendations. Because the right technical experts were selected and the grants were funded relatively quickly, this meant that government had the right information at the right time for important budget discussions and statutory changes. 11

14 Lessons Learned (continued) 5 Changing public policy is a long-term proposition. While some projects produced tangible results fairly quickly, it may be too soon to determine the ultimate impact of others. Changing large programs and policies can be a lengthy process, and it takes time and effort to turn recommendations into reality. The groundwork has been laid for changes that are yet to come. 6 Data-driven projects require much time and commitment on the part of both the contractor conducting the analysis and the department providing the data. The projects that were highly dependent on data being provided by NYSDOH (i.e., Manatt and the Rockefeller Institute) took longer to complete than expected. Future projects requiring these types of data should include additional planning time to determine the feasibility of conducting the desired analysis with this administrative data. 12

15 Final Reflections Did this portfolio of grants help to move the Foundation toward its goals for insurance coverage in New York? Without a doubt, this slate of grants addressed two of NYSHealth s programmatic indicators for insurance coverage: 1) streamlining enrollment and retention procedures for public coverage programs; and 2) developing and evaluating cost containment strategies. These programming strategies were designed to be a positive influence on statewide efforts to: 1) reduce the percentage of uninsured New Yorkers; and 2) get more uninsured New Yorkers enrolled in the public programs for which they are eligible. While the analyses done through these grants will take time to translate into extensive action by the State and to move social outcomes, the prospects seem strong that the grants will be a positive force in the State s efforts to enroll a larger share of New Yorkers eligible for public insurance coverage. As is the case for much of grantmaking, only time will tell whether these longer-term goals will be met. The value of the relationship established between the Foundation and NYSDOH should not be underestimated. All of the projects funded under the authorization advanced the goals of both the Foundation and OHIP, which closely intersected on the topic of access to health insurance coverage. The grantmaking that took place was a positive example of how a private foundation can effectively partner with and influence government. The value of bringing in outside technical experts was clearly demonstrated; the experts brought technical knowledge and analytical skills that let them bridge the worlds of research and State government policy and practice in a real and concrete way. The grantmaking that took place was a positive example of how a private foundation can effectively partner with and influence government. It is clear that in this set of initiatives, this important work would not have been done in the absence of leadership by the Foundation. State agencies often cannot move quickly enough to engage technical experts required to address a pressing policy or operational need. A private foundation has the flexibility to execute a grant in real time and ask questions from a range of angles, in addition to making mid-term corrections when necessary. These projects were all about tackling difficult problems where no obvious solutions existed, says Bachrach, Deputy Commissioner of OHIP. We needed access to specific expertise to inform our thinking and enable us to craft sound strategies to increase coverage and improve access to cost-effective care. I have no doubt that some of the Medicaid reforms that we were able to effectuate would have been delayed, in some cases indefinitely, had the Foundation not stepped in with support. Across the board, when asked whether they could have done this work without the Foundation s help, NYSDOH staff members said that this work would not 13

16 Final Reflections (continued) have been possible. We are not a research entity. With so much operational work in running these programs, we don t have the time, staff, or expertise to do, for example, focus groups and studies of eligibility categories, says Arnold, Director, Division of Coverage and Enrollment at OHIP. Theoretically, we could lock ourselves in a room and do it, but that s not what we do. Our job is to implement and regulate. Laudato, Director, Division of Managed Care at the NYSDOH, underscores Arnold s point: It s very difficult to take our staff persons off the day to day issues that affect beneficiaries like a flu outbreak or an insolvent managed care plan to step back and think about big policy changes and program improvements. You just get pulled right back into running the biggest insurance program in the country. 14

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