August 28, 2006

It's not hard to see the influence the MA health reform law is having in the Ohio gubernatorial campaign. Just check out the editorial from Sunday's Akron Beacon Journal.

Democratic Candidate (and Congressman) Ted Strickland proposes an Ohio Healthcare Exchange, to bring together small businesses and private insurers to design low-cost health-care packages that would be available to all uninsured Ohioans. Participation would be voluntary. Low-income families earning up to 150 percent of the federal poverty level would get help paying the premiums. The exchange, costing $550 million over two years, would be paid by employer and individual contributions and state funds that now assist programs for the uninsured. State money would be used to draw federal matching funds.

Republican Candidate (and Sect. of State) Ken Blackwell proposes a new Buckeye Health Plan, featuring a private insurance market offering approved, low-cost plans. It requires everyone to buy some form of health coverage, the program financed by employer contributions, individual contributions with pretax dollars and existing state funds. Blackwell would create a Buckeye Health Connection to facilitate activities in the new insurance market.

The editorial notes:

Both plans reveal, overtly and otherwise, the influence of the Massachusetts model, policymakers collaborating with private insurers and small business to create a market for the uninsured, pooling private and available public funding sources to cover the cost. Neither plan breaks new imaginative ground. The challenge, as always, lies in the details, in attracting private insurers to offer decent coverage at costs the working poor can afford.

We're not wild about imposing an individual mandate without significant insurance market protections that don't exist now in Ohio. We think the level of subsidies proposed is way too low, and that the Blackwell plan would punish a lot of folks who are legitimately priced out of decent coverage today. Still...

What's great is to see gubernatorial candidates slugging it out over how best to expand affordable coverage to the uninsured. Ohio has never been a state in the lead on health care access reform. 1.2 million uninsured. This level of attention and competition in a gubernatorial campaign raises the stakes and prospects for Ohio to play a significant role in the health reform conversation over the next two years.

Welcome to the fray.

John McDonough

August 26, 2006

A few milestones this past week on health care quality.

First, HCFA now has our first full time staffer, Deborah Wachenheim, working on quality. She's got a full plate, and one of her first missions is to develop a Massachusetts Consumer Health Quality Council to create a bonafide consumer voice on quality, medical errors, and patient safety. We're looking for regular consumers who want to understand this arena and work as consumer voices to make a real difference. Setting this up has been a passion of mine since arriving at HCFA in 2003. You can reach Deborah at dwachenheim@hcfama.org.

Second, this was the week the new Quality and Cost Council, set up under the MA health reform statute, held its first meeting. See Thursday's blog by Deborah for a first person account. We'll be continuing these accounts just as we're doing for the Insurance Connector meetings. Setting up the Council was first proposed in the ACT! coalition's legislative filing in December 2004. We're happy to see it off the ground. We're not sure what will come out of, and we're disappointed the Legislature relegated consumer representation to an advisory committee and not to the full Council. We think this is an early signal that quality AND cost will be front tier issues in 2007 and 2008.

Third, the federal Agency for Health Care Research and Quality has posted an interview with Dr. Lucian Leape of the Harvard School of Public Health, and if you care about quality, this is a keeper. Lucian is a pediatric surgeon who invented the notion of "error in medicine" in a seminal JAMA article in 1994. He's a fantastic resource and treasure to have in Massachusetts, and I highly recommend this interview. Here's a tidbit:

RW: As I was reading your apology document, I was struck by the clear statement on the first page, that this is not about a business case, it's a moral and an ethical case. How do you see the relative role of these two types of motivations in terms of the overall safety movement?

LL: On the apology front, I'm very concerned that people put too much emphasis on the fact that this may reduce your chance of being sued. I happen to think it will, but I don't think that's the reason to do it. I've been struck by the fact that openness, transparency, and full disclosure and apology when indicated is not only an essential part of treatment for the patient, it's also an essential part of treatment for the doctor or caregiver. And I don't think that case has been made. Because when you're not open and honest with people, you're lying. And lying corrupts your own integrity. So honesty, transparency, and apology are just as important for the doctor as for the patient.

But the primary reason to do it, of course, is our obligation to the patient. We need to think of it as a form of treatment. The patient has a serious medical condition: an incipient loss of trust, and emotional turmoil because of what's happened. We need to do what we traditionally do, which is to think of what's in the best interest of the patient and prescribe and carry out that therapy. My hope is that if we can frame it that way, then we can help physicians recognize the importance of doing it. A side benefit is that they will indeed be much less likely to be sued and, if they are sued, the payments will be much less. But that's not the primary motivation.

John McDonough

August 24, 2006

The John D. and Catherine T. MacArthur Foundation today awarded RealBenefits (a technology company started by HCFA’s partner, Community Catalyst) one of its first-ever MacArthur awards recognizing small non-profit organizations with a proven track record of creativity and effectiveness. The Foundation is awarding $500,000 to RealBenefits for its ability to change "social services as usual."

RealBenefits is among nine international winners for small organizations that are "particularly effective at delivering services and challenging old paradigms," according to Foundation Pres. Jonathan Fanton. "These awards recognize nine extraordinary organizations and, we hope, allow them to unleash their inspiration and impact on a larger scale in the future."

Since RealBenefits was introduced in Massachusetts and Illinois three years ago, community-based organizations and health care providers have used the service to reach 80,000 families, connecting them to over $300 million in benefits such as Medicaid and Food Stamps.

HCFA used RB in our outreach and enrollment activities to sign folks up for MassHealth, Food Stamps, and other public benefits. After we do a ten minute screening interview, RB assesses instantly a client's eligibility for public benefits, and then produces completed, ready to sign and mail/fax applications.

Two key advantage RB has over the state’s “Virtual Gateway” – 1. Unlike VG, anyone and any organization can be trained to use RB; and 2. Unlike VG, RB users keep their own database to track applications and do follow-up.

For about three years, RB worked in good faith with the Romney Administration to allow RB users to file applications electronically, just like the VG. Last June, Romney officials informed RB they were canceling further work on a “third party interface.”

RB is now used in five states. RB is a Massachusetts-grown, high tech start up company – the kind the Romney Administration says it likes to encourage. Today’s Globe describes the frustration of dealing with the Administration on this. Too bad it takes a national foundation to recognize what the Romney folks can’t see under their own noses.

August 24, 2006

On my second day at Health Care For All as the new Consumer Health Quality Coordinator, I had the opportunity to attend the initial meeting of the Health Care Quality and Cost Council (see agenda, and introductory powerpoint). The Council was established under the health reform legislation (see August 14 blog entry for a list of the Council’s members) with the mission of establishing quality improvement and cost containment goals for Massachusetts. The main objective is to promote health care that is safe, effective, timely, efficient, equitable and patient-centered (the 6 key aspects of health care quality laid out in the 2001 Institute of Medicine report “Crossing the Quality Chasm.”

Because this was the first meeting of the Council, much of the time was spent reviewing cost and quality data. There was also an overview of federal and state agencies and private organizations that focus on cost and quality. One item of note is the executive order that President Bush signed on Tuesday ordering federal agencies that oversee health care programs (Medicare, VA health system, military health system, and federal employees health benefits program) to provide more cost and quality information to beneficiaries.

A proposal put before the Council from the Massachusetts participants in the National Governors Association “Policy Academy for Health Care Quality Improvement” recommended that it focus its quality improvement and cost containment efforts on the following 10 areas:

  • Misuse of services: infection, and inpatient medication errors
  • Underuse of services: diabetes, asthma, and cardiovascular/hypertension
  • Overuse of services: end of life care, imaging, ER utilization, and appropriate use of pharmaceuticals
  • Population health: obesity

The Council is also mandated to create a consumer website with quality and cost information. HHS already has such a website. DHCFP Commissioner Amy Lishko told the group that a more consumer-friendly website update is in the works.

The DHCFP staff presented a proposal for the Board to collect with more detailed price information – what insurers actually pay for each services - for the website. Harvard Pilgrim CEO Charlie Baker commented that making this information public will pressure insurers to pay more to providers getting below-average rates, but will ultimately help consumers as co-insurance becomes more prevalent. The hope is that by having quality and cost information in one location, consumers can easily compare providers to determine what will best meet their needs (and to avoid what GIC Director Dolores Mitchell referred to as the “Neiman Marcus effect” in which consumers assume that higher cost services are also higher quality). Confidentiality of data was touched on briefly and will surely be part of the ongoing discussions.

The meeting had just about ended when two extremely important points were made. Inspector General Gregory Sullivan (who called health costs a “conundrum wrapped in an enigma”) emphasized that the Council should not just be a rubber stamp giving approval to EOHHS proposals but rather is mandated to be an independent, active participant in the development of goals and steps to achieve those goals. And James Conway of the Institute for Healthcare Improvement and Dana Farber said that the Council needs to hear the consumer perspective (we agree!). The Council will establish an advisory committee that will bring a broader range of stakeholders into the process, including consumer groups.

The next meeting of the Council, which is open to the public, is Wednesday, September 20, 1-3 pm at 1 Ashburton Place.

written by HCFA's Deborah Wachenheim

August 24, 2006

Topic A in Massachusetts health reform now is affordability. Just in time, the ever excellent Blue Cross Blue Shield of Massachusetts Foundation has produced a new report: "Setting a Standard of Affordability for Health Insurance Coverage in Massachusetts." The report was written by key Urban Insitute researchers John Holahan, Jack Hadley, and Linda Blumberg. Click here for full text.

No shocking headlines, just solid analysis and perspective to understand this complex and important policy challenge. The authors helpfully explore affordability by identifying the amount people in various incomes levels and with various kinds of coverage are actually spending today on health care.

Here's the message for our friends at the Insurance Connector now grappling with this issue:

"The spending of people above 300% FPL should be the starting point for developing of an affordability standard. ... Our analysis shows that people with incomes at or below 300% FPL spend a much higher proportion of income on health coverage and out-of-pocket medical expenses than do people with higher incomes. ... For those above 300% FPL, the median (employee) contribution towards premiums represents 1.5% of income for single coverage and 3.0% for family coverage."

Check it out.

August 23, 2006

The Connector Board will be deciding on premium levels for the CCHIP program at their September 1 meeting, a week from Friday. The vote was put off at their meeting last week, after some members of the Board raised objections to the compromise proposal reached by the Affordability Committee. Several of the Romney administration members on the Board said that perhaps the proposed premiums seemed too low, particularly for the lowest-income individuals (100%-150% of poverty, or $9,800 to $14,700 annual income).

Yesterday, the Boston Herald weighed in with a muddled editorial supporting higher premiums. The straw man reason: “there is no bottomless well of taxpayer money available to finance lower premiums for the poor.” True enough, but at this stage, no one knows how the premium levels will affect the program’s ability to cover those eligible, since all of the cost factors are still unknown. Mike Widmer of the Mass Taxpayer’s Foundation also pointed out (see our blog entry from Saturday) that increased enrollment in CCHIP will mean decreased need for free care pool reimbursements, freeing up funds that can be shifted to CCHIP.

But some other concerns were raised by Board members that deserve serious responses.

For one, the concern was raised that the proposed premiums were so low they would disrupt the Insurance Partnership, which charges $27/month in premiums for a childless adult with incomes between 100% and 200% of the poverty line. This is more than the proposed $10/month for the 100-150% group, but less than the $29/month proposed for the 150-200% group, where most of the IP enrollees are from. Also, adults with children pay nothing if their income is below 150%, $12 per child if 150-200%. So in most cases, this problem won't occur.

In any case, the health reform law anticipated this issue and in section 20 directed the state to bring the IP subsidy into alignment with CCHIP. Once this is done, the issue will not be a concern.

A second concern was that the proposed premiums are below those in similar programs in other states. But high premiums in other states have hurt their enrollment. An Urban Institute study “examined the relationship of premium levels and program participation in three states with subsidized insurance programs (Minnesota, Tennessee, and Washington). The study found that when families were charged one percent of their income, 57 percent would join a program; when the charge was 3 percent, 35 percent would join; and when the charge was 5 percent, only 18 percent would participate.” (source: Institute of Medicine, 1998)

Also, the costs of basic living expenses of housing, food and transportation for the poor are much higher in Massachusetts than in other states. The Economic Policy Institute has a fascinating calculator that lets one compare basic budget costs for regions throughout the country. For example, the basic package that a family with 2 parents and 1 child requires costs $56,628 in Boston, but costs only $31,000 in Memphis and about $44,000 in Minneapolis. These differences more than explain why affordable premiums need to be lower for a poor family here, compared to a family in less-expensive areas with the same income.

August 19, 2006

One of the least coherent health reform strands in the past week has been the expressed concern that health reform will quickly "run out of money" and be forced to cap enrollment in the new subsidized insurance products to be released on October 1 2006 and January 1 2007. Here's Thursday's State House News Service account:

COMMONWEALTH CARE ENROLLMENT MAY HAVE TO BE CAPPED: The state may have to exclude nearly 5,000 people from its new Commonwealth Care health insurance plan next year, and more than 37,000 by 2009, depending on how many people enroll and how much they contribute, according to the agency implementing the new health care law. Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, said the numbers are speculative, and fluctuate based on the size of enrollment contributions from low-income people. The prospect of capping enrollment is addressed in statute, but the agency hasn’t begun deliberating how to do so, Kingsdale said.

We like Jon Kingsdale, and think his remarks were way premature, and sent unfortunate messages to the public. Romney HHS Sect. Tim Murphy stated at the Thursday Connector meeting his belief that such discussion is way too early for a program not yet even launched. Yesterday, Mass. Taxpayer's Foundation head Mike Widmer (with whom we have lots of agreements and lots of disagreements), put the matter in correct context (here also from SHNS):

ANALYST SAYS ‘FREE CARE POOL’ COULD FUND NEW SYSTEM: By drawing money from the very fund it is meant to diminish, the new Commonwealth Care system could avoid being forced to cap enrollment, a leading policy analyst said Friday. After officials at the Commonwealth Health Insurance Connector Authority yesterday acknowledged that the state may be forced into denying Commonwealth Care coverage to 5,000 people next year and 37,000 by 2009, Massachusetts Taxpayer Foundation President Michael Widmer said the new system could be nourished with funds from the so-called free care pool. The reform passed earlier this year was meant to drain the pool, which provides reimbursements for the hospital visits of uninsured people. State health officials yesterday downplayed the prospect of capping enrollment, but said it’s a possibility if the Commonwealth Care funding is exhausted. Widmer said that, if the $160 million budgeted for Commonwealth care runs out next year, money should be drawn from the $610 million “uncompensated care pool.” In a phone interview, he said, “The pool money’s available, you reallocate it to Commonwealth Care. Which is the whole point of the reform anyway.” Health and Human Service Secretary Timothy Murphy was unavailable for comment.

August 18, 2006

HCFA has been graced this summer with the most fantastic group of interns ever assembled in one place. Unexpectedly, one has gained notoriety around town, Eric Benson, for his pithy and perceptive blog accounts of board and committee meetings of the Insurance Connector. All around town, people are appreciatively asking us: who is Eric Benson? Since this is Eric's final day at HCFA, we thought we would give him a moment in the sun, via this interview:

So Eric, who the heck are you?

I’m originally from a small town in rural Michigan. Northern Michigan is a wonderful place, but it is lacking in educational opportunities, so after high school, I came East and studied Government and Philosophy at Dartmouth. Then I moved on to law school at Harvard. I am deeply interested in politics, biotechnology and bioethics. I’m also a skier, hiker and rower. I miss skiing in the mountains of New Hampshire, but rowing on the Charles River is a nice substitute.

What's it like writing for a blog?

It’s a new experience for me. As a law student, most of my writing has been very dry and technical. It’s been fun and challenging to translate hours of technical talk and fierce debate into a short summary that uses understandable terms, is fun to read, and conveys a viewpoint without doing so too forcefully or offending anyone. I’ve found that careful editing is critical both to keeping the length and subject matter under control and to avoiding inadvertently offensive statements. It has also been wonderful to sit in on all the Connector meetings and observe such a novel, important and exciting process.

What did you learn this summer?

I’ve learned a lot about the challenge of coordinating groups with diverse interests. Observing both coalition meetings at HCFA and Connector meetings has shown me a variety of techniques for bringing divergent interests together to achieve a common goal. I’ve also learned about the immense power that a well organized group of citizens can wield and about the difficulty of developing policy in the face of great uncertainty.

What's your conclusion about Massachusetts health reform?

I’m cautiously optimistic. Overall, I think there are more reasons for celebration than alarm. I do think that there are some problems with the law and some errors in the implementation. However mistakes are to be expected with something so new, ambitious and complicated. So I think it is especially important to not get discouraged in the first couple years. The first years will be a learning experience and we’re bound to make mistakes. The important thing is to keep working, to learn from our mistakes and make gradual revisions rather than getting frustrated and scrapping the program. Also, on a personal note, I’m disappointed about the lack of improvement in student coverage.

How will this experience influence your future legal career?

Working here has rekindled my excitement about public policy. I’ve always been interested in politics, but in the woods of New Hampshire, that interest took a back seat. And the current national political climate has led me more toward frustration than fascination. But working here has brought me back to the excitement of dealing with policy and feeling like we can use policy to really make an improvement in peoples’ lives.

What is your future career anyway? Supreme Court Justice?

Well, we do need one more HLS grad on the Court to regain our majority. But I’ll leave that to one of my classmates; Justices are too far removed from the real world. I’m not entirely sure where my career is going. There are so many fields I want to explore. I’m considering academic research (especially bioethics), public policy, or directly helping those in need. I’m especially inspired by people who bridge the gaps between various professions. Specialists in law, economics, social work, medicine, etc. all bring unique perspectives to the table. Consideration of all those perspectives is essential to solving complex problems like those in the field of health care. Unfortunately, it is often hard for people with different backgrounds to see past their own perspectives and connect with people from other backgrounds. (On a side note bringing together people with various perspectives is one thing HCFA does well). To successfully resolve complex problems, we need people who can understand all those perspectives, bring them together and intertwine them effectively. I want to be one of those people who knows a bit of everything and is able to bring it all together. The specific context in which I will do so is yet to be determined.

And, lastly, lots of inquiring minds want to know -- are you attached?

Yes, I’ve been dating a lovely, pretty and fun young woman for just over a month.

Thanks and best wishes to Eric.

August 18, 2006

The Connector Affordability Committee had been rushing ahead, putting in a huge amount of effort to establish premium and cost sharing standards before upcoming deadlines, but today the full Board slammed on the brakes. Everyone expected the Board to review and vote on the Committee’s recommendations today, but instead the Board will review data and vote at its next meeting. However, taking that big issue off the table did not make for a dull meeting.

No Vote Today
Chairman Tom Trimarco said the Board should not vote on CHIP premiums until it has time to process the Committee recommendations and data. He also thought the Committee should not feel pressure to vote as a bloc. Chip Joffe-Halpern suggested the Board should pass regulations today, then revise the regulations after the September 25th hearing. Lou Malzone supported Chip, and worried that a two week delay would turn into a month. Jon Kingsdale also raised the concern that no vote today would delay contracting with MMCOs and prevent a hearing in September. Despite this, Tom and others did not feel ready to vote, so there was no vote. Instead the board will vote at its next meeting on September 1 (the meeting was moved from August 31, so Celia Wcislo can attend).

Benefits/Cost Sharing
Jon K. started by explaining the Committee’s original thoughts and their consensus proposal on benefits and cost sharing (you can read the documents here). The consensus gives one option for people in the 100%-200% fpl federal poverty level) range, while people in the 200%-300% range can choose the plan available to people in the 100%-200% range or a lower premium option with higher co-pays. There was some discussion of overall caps and Bruce Butler noted that the cost to the program of a cap is small while the effect of a cap on an individual is huge. The Board took a straw vote and got unanimous support for the Committee’s proposal, thereby allowing the Connector to begin its contracting process with the four MMCOs.

Premiums
Jon K. started with a discussion of the Connector’s projected budget and the impact of premium levels on exceeding the budget and necessitating enrollment caps. EOHHS Secretary Tim Murphy (who was sitting in for Beth Waldman) noted that the success-based funding formula will allow the program to use Free Care Pool funds as CCHIP enrollment reduces Pool demand. And Celia noted that unaffordable premiums keep people out of the plan as effectively as enrollment caps.

Jon K. talked the Board through data about premiums in other states’ health programs. Jon G. made the good point that other states are different because they lack an individual mandate and are not trying to cover everybody. Jon K. discussed the original committee proposals and consensus proposal (see yesterday’s blog). He noted that the considerations affecting premiums are affordability to enrollees, affordability to the state, and usage levels/crowd out.

Chip argued that premiums have to stay low to convince people to come off the free care pool, but Tim and Julianne Bowler suggested that it would be better to just change the free care pool regulations (as Romney requested in the technical corrections bill).

Tom said he understands, but disagrees with the goal of enticing people out of the free care pool. Instead he thinks the individual mandate will force free care pool users to change and thinks the minimum wage increase will make insurance affordable to them. He wants premiums above 2% of income at 100% fpl and above 6% at 300% fpl. The Committee had recommended premiums ranging from 1% ($10/month) to about 4.5% ($100/month) of income.

Many in the audience were taken aback when Tom said, “One percent is setting the bar far too low. I'd like to know the number of people in that group who have cell phones. The cost of that is far more than $10 a month.” (last week it was tobacco and lottery tickets—see this blog entry on Tom’s comments after last week’s hearing). Both cost of living research and GBIO’s affordability workshops have shown that many low income families don’t have any money for discretionary items; instead they pile up crushing debt just to survive. As Jon G. wisely said, what counts as essential depends on your definition.

Tim had two other concerns, first that the proposed premiums were much lower than those for the Insurance Partnership (IP), which charges $27 per person. He was concerned that lower rates for Commonwealth Care would harm the IP. Celia raised the point that the IP’s uptake has been terribly low and suggested that it may have been because premiums were unaffordable. Tim admitted that uptake had been only 15,000 instead of the projected 70,000 (the actual initial projection was some 250,000), but argued that it was due to employer reluctance, poor marketing and no individual mandate. We’re not convinced. Also, section 20 of the health reform law requires the IP subsidy to match the CCHIP subsidy, aligning both programs, so the concern will be dealt with in any case.

Tim’s second concern was that the proposed premiums would make Massachusetts an outlier compared to other state programs, especially Minnesota. Lou gracefully reminded Tim that Minnesota doesn’t have an individual mandate that will punish those who decide to not purchase unaffordable plans. Tim also failed to realize that cost of living—especially housing—in Minnesota is only a fraction of the cost in Massachusetts.

August 17, 2006

Wonder if MA health reform has influenced other states? Exhibit A: a Colorado gubernatorial debate on health care. Democrat Bill Ritter and Republican Bob Beauprez show the influence Massachusetts has had. Click here for the full account in the Rocky Mountain News. Some excerpts below:

About 770,000 Coloradans are uninsured - 17% of the population. Health insurance premiums are rising at three times the rate of inflation. And Medicaid is the fastest- growing part of the state budget. With the stage set, the Rocky Mountain News asked gubernatorial candidates Bill Ritter and Bob Beauprez how they would reform health care if elected governor. ...

Q: Who are your health care gurus?

Ritter: Joan Henneberry and Sue Williamson at the Denver think tank Policy Studies Inc. Barbara Yondorf, senior program officer at the Rose Community Foundation, has helped talk me through this. I have talked to former Oregon Gov. Dr. John Kitzhaber. I met with John McDonough, executive director of Health Care For All, the group that helped craft the Massachusetts Health Plan legislation. I've also met with CEOs of health insurance companies, hospitals, doctors and members of the Colorado Medical Society.

Beauprez: I consider Dr. Patty Gabow, CEO of Denver Health, one of my very good gurus. I've grown rapidly fond of Dr. Michael Salem, CEO of National Jewish. I have an exceptionally good staffer in Jake Allen in my congressional office. A number of doctors, including a radiologist, Dr. Steve Brown, and Dr. Jack Kletcher, who heads the Colorado Medical Society's political action committee. As a member of the House Ways and Means Committee, on a regular basis we've had Secretary Leavitt in front of us. I have a personal relationship with Dr. Mark McClellan, head administrator for the Centers for Medicare and Medicaid.

Q: How would you take on Medicaid?

Ritter: Certainly the rate of increase in Medicaid spending has outstripped every other category. So it is a big budgetary pressure. There are things you can do to address Medicaid spending, to address prescription drug purchasing that Owens decided not to do. But you can't do it piecemeal. Look at what Massachusetts did: They went to the federal government, received a waiver, then they combined all their state dollar spending - Medicaid, state employees and money for businesses, and they said, we're going to have a statewide health plan. They didn't do it piece by piece by piece.

Beauprez: We need to make Medicaid consumer-driven. And South Carolina and Florida provide some great models. It's what most of us, who have an employer- based system, use: a defined contribution. They tell patients, "Here's your contribution based on your needs." Then, suppose your defined contribution is $1,000. You can use it to buy health insurance. But if you adopt a wellness program, a preventive care program, or get into job training, that's worth some more. And if you end up with some change in your pocket, we'll split it with you. Now we're really changing the paradigm.

Q: What can we learn from Massachusetts?

Ritter: Colorado should be looking to create its own universal coverage plan. The genius of the Massachusetts plan is shared responsibility. I've committed to a planning process that brings everybody with an interest in trying to solve this to the table. People say that sounds vague because we can't offer a specific answer. But even the architect of the Massachusetts plan said, "Don't think you can take our plan and transfer it to Colorado. Commit to a process that has transparency in it, and that's ultimately how you get to a Colorado plan." And if you have to take on interest groups to get there, that's part of being a leader.

Beauprez: We'll know in hopefully a little while. You want to see some results. The effort is noble if the effort is to give everyone you can insurance coverage. Gov. Mitt Romney himself has told me he has a problem with the mandatory employer contribution. I understand the argument: Like auto insurance, you ought to have to have health care. We ought to have that debate. I'm usually a mandate-light sort of a guy. But I also recognize when you've got in excess of 17 percent of our state's population uninsured - some of them by choice, some by necessity - that you've got a problem.

Q: Is there the political will to take on the uninsured?

Ritter: The problem with the uninsured is they are not people who exercise their political voice, who show up at political gatherings and meet-and-greets. But I don't talk to anybody who doesn't think the health care system is broken. The conversation this year shows that businesses really believe it is in need of fixing. CEOs and large-business people talk about it, as do small businesses. It's really fascinating the number of businesses around the state that are making business decisions around health care costs.

Beauprez: It's a must-do. We're on an unsustainable path, and health care is rapidly getting more and more expensive.The solution is to make health care and health insurance less expensive. It's a free-market approach. If cars are too expensive, somebody comes in with a more affordable product to get the job done. The other option is to say we'll tax somebody. Who? The health care fairy who is going to pay for somebody's health insurance tomorrow? If we are going to become the caretaker of all people, maybe we ought to do that with the autos you buy, the house you live in, the food you eat. I look at solutions I think are consumer-driven. If people are in charge of their own decisions and their own money, we'll all get along a lot better.

Q: What's your take on mandating that employers provide health care coverage?

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