Deborah Chollet & Amy Lischko: Partners in Research

Deborah Chollet, Ph.D., is a Senior Fellow at Mathematica Policy Research in Washington, D.C. She is a health economist whose research interests include state health insurance markets, public/private-sector health care reforms, the effects of state high-risk insurance pools on coverage and cost, and the economic feasibility of major state reforms. Amy Lischko, D.Sc., is an Assistant Professor at Tufts University School of Medicine. Her interests include health insurance expansions, access to health insurance, delivery of health care services, quality improvement, and health policy.

We talked to Deborah and Amy about their SHARE project examining risk selection in state programs that offer private coverage. They talked about different types of risk selection, media coverage of health policy issues, and a mascot for Mathematica.

Why does your research focus on Maine, Massachusetts, and New York?

CHOLLET: We are interested in evaluating programs that operate within a market context. The programs in Maine, Massachusetts, and New York compete with private carriers and we wanted to assess the impact of this. Specifically, there is the potential for these state programs to attract much more risk than the average in the market, making them unsustainable. To explore whether and why they do, we are evaluating the programs in the context of their markets.

What can you tell us about risk selection in these state programs?

CHOLLET: With some exceptions, we know these programs tend to have better risk selection than they anticipated.

LISCHKO: This is the opposite of what people tend to think. People tend to think you are going to get sicker populations in these programs because of their generous benefits and low premiums.

CHOLLET: But they have all done something around benefits and eligibility to try to deal with the issue of risk selection up front.

Why have states been experiencing favorable risk selection despite the potential for attracting a sicker population?

CHOLLET: That’s what we are hoping to find out. First, we need to show whether there is favorable risk selection—more conclusively than has been done so far. Then we can then examine why this occurs. For example, some have argued that New York has experienced favorable risk because the program offers very limited mental health benefits. Others look at New York and note that individual guaranteed issue and full community rating mean that most of the sick have already found coverage.

What can programs do to mitigate the effects of risk selection?

CHOLLET: The programs in these states have already tried some strategies, such as encouraging group enrollment or limiting coverage for certain high-cost conditions, like mental illness.

LISCHKO: Another approach is to mandate health insurance.

Seems like opposite approaches – either limiting benefits or mandating coverage.

CHOLLET: Yes. Massachusetts defined a very broad benefit package. To avoid risk selection they mandated insurance. New York wanted to keep premiums affordable, so they narrowed the benefits and may have excluded people who are really sick. Maine offers high deductible products to small businesses, the self-employed, and those without access to employer-sponsored insurance, but appears to have run into trouble when they eliminated individuals’ waiting period for pre-existing conditions. Every state approaches it differently, which makes it interesting to compare and contrast.

What goals do these states share?

CHOLLET: All three of these states have tried to organize programs for a block of people who are otherwise not eligible for public programs.

LISCHKO: They are focused on the people who are falling through the cracks.

Why not put it all in the hands of the consumers and let them sort it out?

CHOLLET: Most people are happy with private insurance because they do not have a direct relationship to it. They have an employer that buffers the relationship. Individual insurance is complicated, expensive, and in most states you’re locked in – not only for the period of one contract but for subsequent contracts, as long as you stay in the market. I have yet to find a person among my personal acquaintances who, when confronted with buying individual coverage, found it to be a satisfying experience.

Once you have some results, there is the task of translating them for the public. The press plays an important role in that process, how have you worked with the press in your career as a health services researcher?

CHOLLET: The New York Times is developing quite a squad of capable researchers. I am really impressed with Kevin Sack – he gets it. Another media outlet that recently has been doing a great job is National Public Radio. They’ve been doing stories on health care in other countries like the Netherlands. They are really interesting stories, particularly when you consider the subtext of who gets covered and how people get services.

Amy, how did your get your start in health services research?

LISCHKO: After undergrad, I joined the Peace Corps and went to Liberia, West Africa. It was before their civil war and I worked on nutrition and pre-natal counseling in a small village. This was before there were Internet connections there, even before motor scooters. There weren’t any nearby markets and the diet consisted mainly of palm oil and bush meat. In the face of limited resources, I tried to teach them to as eat as balanced as possible. I even started a garden in my backyard which I had to hand-water with a bucket each day. It was a life-changing experience. I also realized that I could have more of an impact in my own culture with my own language. It was my wake up call.

After you returned, you found yourself at schools with interesting mascots, from the
UMass Minutemen to Boston University’s Rhett the Boston Terrier to Tufts’ Jumbo the elephant. Which one is your favorite?

LISCHKO: I would like my kids to be Jumbos, so I’d have to say that is the most fun. I don’t know if I can identify completely with the elephant. But it certainly is a mascot that people talk about. Mathematica needs a mascot.

Would Mathematica’s mascot be a calculator?

CHOLLET: It’s got to be more fun than that! We would be hard-pressed to find a good mascot. We are earnest to a fault. Even our mouse pads have our mission on them.

What is Mathematica’s mission?

CHOLLET: According to my mouse pad, it is “To improve public well-being by bringing the highest standards of quality, objectivity, and excellence to bear on the provision of information collection and analysis.” It’s very hard to imagine a mascot for that.