Today marks the 20th birthday of the Colorado Department of Health Care Policy and Financing. The story of its creation provides an important reminder of how our thinking about health care has evolved over the past few decades – and how it continues to evolve today.
Back in the bad old days, Medicaid was just another social service. Housed within a broader social services agency, Colorado Medicaid – as was the case in most states – grew up with a typical welfare mentality. Program enrollees were beneficiaries. If they did not enroll, we assumed it meant they did not need or want our services. Eligibility was a cumbersome, rule-bound process with inscrutable results and unintelligible notices to applicants of what was missing from their file.
Equally important was our thinking about services. Medicaid, containing the same DNA as Medicare, was a payer of claims. Effective care delivery meant open access to as broad a network of providers as possible. Payment was fee-for-service reimbursement for care provided by individual doctors, hospitals, and other clinicians.
Colorado was one of the early states to realize that effective health policy required a different way of thinking. HCPF (lovingly pronounced Hick-Puff) pulled health programs out of the social services agency (although eligibility, as in most states, remained with social services, since that department oversaw the county agencies that had the personnel and computer systems to determine eligibility). HCPF’s primary job was to act like a purchaser, not just a payer of claims. In the 1990s this meant contracting with managed care companies, and, under state legislative mandate, that is precisely what we did.
Much has happened over the past twenty years, but I can’t help but notice that our current health discourse reveals that the thinking that created HCPF is showing its age. Today we are talking about population health and social determinants. We are acting upon what we have known for some time—that attending to social needs is an essential component of achieving our health goals. Yes, we need health agencies to act as purchasers, but we also need them to integrate their work with those that provide food, housing, employment, family support services, and the like.
We need them to be part of social services—not separate from them. Organizational structure doesn’t determine whether or not these systems work together, but it does send a strong signal to people inside and outside of government about how we approach addressing peoples’ needs.
Yes, I was there at the birth. On July 1, 1994, I became the first executive director of the Colorado Department of Health Care Policy and Financing, serving as a member of Governor Roy Romer’s cabinet. Twenty years later I wish my former colleagues a happy birthday and a little perspective on what has changed over the years.