"Health Care For All" in lights on a bridge

A Healthy Blog

Massachusetts health care – wonky with a dose of reality

April 11, 2005

This morning about 250 persons attended a forum in downtown Boston to learn about the new Medicaid "waiver" which will establish funding rules for the program for three years beginning on July 1. The broad outlines of the agreement were announced in late January by Gov. Romney and Sen. Kennedy following their negotiations with the federal Department of Health and Human Services. The Mass. Medicaid Policy Institute, today's forum sponsor, issued a well-done report in layperson language to describe the waiver. Click here to obtain it. Some bottom lines:

* For eight years, waiver funds have been an essential source of funding to expand affordable health coverage. Under the new deal, there is less money, and it's capped.
* Unless key aspects of the agreement are renegotiated with the federal government, the state may lose significant federal revenues.
* The new waiver will require the state to develop a new plan -- albeit with limited funds -- to develop a new access plan by July 1, 2006. This plan will require approval from the feds and the state legislature to move forward.

During the Clinton years, the point of waivers was to give more money to encourage expansion. In the Bush years, the point is to reduce federal funds to states.
Check out today's Paul Krugman column in the New York Times for a health care reality check. The real crisis facing our country is not Social Security, and it's not Medicare or Medicaid, it's health care, and the answers aren't easy.

April 10, 2005

In 1993, Tennessee reinvented its Medicaid program under the name "TennCare" to cover hundreds of thousands of the state's uninsured. Because of funding pressures, Democratic Governor (and former HMO executive) Phil Bredeson (who promised in 2002 to protect TennCare) is pushing to disenroll 323,000 and to cut benefits from 400,000 more. It's looking increasingly like he will get away with this -- stay tuned and we'll know by July.

The TennCare Saves Lives Coalition has put together a booklet with personal stories of TennCare enrollees at risk. Meet two of them:

Bart Comisky from Donelson TN is 61 and has had five bypasses. His wife, Atha, (51) has had kidney cancer and has Crohn's disease. Both are uninsurable. They own a small business and, if dropped from TennCare, will not be able to obtain healthcare unless they can pay thousands per month. They will probably be forced to sell their home if Atha cannot find a job with health benefits. "We need you to solve the problem because it's not going away. Will our ER visits save taxpayers money?"

Lori Smith (39) from Nashville has multiple sclerosis (MS), lupus, and has had two abnormal pap smears. Without TennCare, she will lose her ability to work and remain self supporting, and will have to file for bankruptcy. Lori works full time and qualified for TennCare because she is "uninsurable." She pays monthly premiums and co-pays for doctor visits and prescription drugs. Her MS and Lupus require regular monitoring and continuous drug therapy, enabling her to work full-time and remain self supporting. Her doctor wants her to start a drug for her MS, but this drug costs over $1300 per month. "I want to continue to work and support myself and not become disabled, but I need insurance medical care to do it."
Last Friday, HCFA hosted our 20th anniversary celebration and awards dinner, honoring Dr. James Mongan of Partners Healthcare, Dr. Mark Doherty of the Dorchester House, and the Island Health Plan. Special thanks to all our generous sponsors and to the 600 who came to the event. Looking across the crowded hall, it's clear there's a real movement in our state to address the issue of health care access for all. Thank you!

April 8, 2005

HCFA's Bob Marra passed on the following report from a public meeting on the real problems faced by lower income consumers seeking decent dental care:

"Tears, frustration at the slow pace of change, and determination to address the dental crisis were in evidence last night at the Western Mass. Oral Health Public Forum in Holyoke (and the night before in Worcester). The Oral Health Advocacy Task Force (coordinated by HCFA's Stacey Auger) with Partners for a Healthier Community (Frank Robinson and Catherine Benoit) and State Reps John Scibak and Cheryl Rivera brought together 50 consumers along with health care and community leaders for two hours of stories of dental pain, lost teeth and oral infections resulting in expensive ER and inpatient care. A near-death experience was shared by the medical director of the Mason Square Health Center in Springfield. One of his well-controlled adult diabetic patients made many phone calls over 10 days trying to find dental care for an abscessed tooth. He finally went to the hospital ER when his infection spread to his throat. He nearly died while being intubated and was hospitalized in intensive care on a respirator for 10 days. This and other testimony was described by Rep. Scibak as the most powerful testimony he ever heard. He commended the Task Force for bringing this crisis to the attention of government leaders and the general public."

Check out more about HCFA's Oral Health Task Force by clicking here.
The ever fabulous Mass. Medicaid Policy Institute has produced another gem of a report at just the right time. "Eligible but Uninsured: Challenges to Getting and Keeping MassHealth" describes current enrollment initiatives and examines barriers state residents face to getting and retaining MassHealth benefits. Margaret Oakes, the author, interviewed representatives of organizations that work directly with people enrolled in or applying for MassHealth. The brief reports on their views of how recent changes in the administration of MassHealth have resulted in problems with enrollment and retention.

The issue brief concludes that the State's current efforts, while effective, are not sufficient to enroll all those who are eligible for MassHealth. It calls for the creation of an Outreach, Enrollment, and Retention Workgroup to develop information about specific populations most likely to be eligible but unenrolled, and to craft strategies for reaching out and bringing them into the program. Get the report by clicking here.

April 7, 2005

Everyone hears lots of criticism about the state of local television news, much of it well deserved. So it's worth noting when a local TV station goes above and beyond the call of duty in digging into a complex and difficult public policy issue such as health coverage for the working uninsured. So it's only right to issue a strong and sincere compliment to WCVBTV Channel Five for an indepth and serious look at the problems of real Massachusetts residents struggling for affordable coverage, as well as a serious look at various policy solutions.

Dr. Tim Johnson and Natalie Jacobsen put in lots of time and effort into making this a serious and worthy series and they succeeded admirably, topped off by a town meeting on Wednesday evening, attended by Gov. Mitt Romney and many members of the Mass. Health Reform Coalition, including a large contingent from the Greater Boston Interfaith Organization.

For access to transcripts of the weeklong series, please click here.

For information on Gov. Romney and Sen. Travaglini's plans, please check out HCFA's Health Reform home page. I'll have more comments on both plans over the next few days.

April 6, 2005

Today, the pace of health reform picks up. Sen. Pres. Travaglini outlines his reform themes before the Greater Boston Chamber of Commerce this morning, with a press conference and plan release tomorrow (Thursday). Gov. Romney releases his plan this afternoon at a 1:30pm press conference, and will appear live at a Channel Five health care town meeting tonight between 7 and 8pm.

While both plans will contain new and interesting ideas, neither will go as far as the Moore/Blumer Health Access and Affordability Act, supported by the Mass. Health Reform Coalition. There will now be three major proposals before the Legislature's Health Care Financing Committee, whose job will be to report out their own plan drawn from elements of all three. A public hearing may occur within the next month.

What does all this mean? The stakes for reform are increasing, raising the likelihood something major will happen this year or next. The various ideas and details can be mind numbing -- the overall direction is positive.
On Monday, Elliot Stone, the executive director of the Massachusetts Health Data Consortium since its founding in 1978, died of cancer. I know, what could sound more boring than "Health Data Consortium"? But Elliot brought passion and purpose to his work, seeing technology as a means to improve the quality of care and the efficiency of our badly messed up health system. The organization that is his legacy is a rich source of innovation and inspiration. He was a gentle, earnest, and terrific human being who will be missed by all who knew him.

April 5, 2005

Chip Joffe Halpern runs the Ecu-Care program in North Adams that helps uninsured persons get medical care. He's also President of HCFA's Board of Directors. He writes a twice-monthly column for the North Adams Transcript. His column last week was a great summary of our oral health disgrace in Massachusetts.

"Thursday, March 31, 2005 - This past year, the Massachusetts Society for the Prevention of Cruelty to Children released a disturbing report revealing that dental decay is now the most widespread chronic childhood disease -- five times more common than asthma and seven times more common than hay fever. The prevalence of dental disease falls disproportionately on children covered by MassHealth, the state's health insurance program that covers one out of every four children in Massachusetts.

The seriousness of this critical problem cannot be overstated. Consider these findings from a survey of third graders in Massachusetts: 65 percent of children on MassHealth had a history of dental disease, 40 percent had untreated decay and 16 percent of these children had urgent needs requiring immediate care.

The MSPCC report emphasizes how critical this problem is for all children: "The implications of untreated dental illnesses are serious and can be permanent. Significant tooth decay, pain, or infection can inhibit learning, speech, and eating, leading to problems in school, negative self-image, and poor nutrition. More than 51 million hours nationwide are lost each year due to dental-related illnesses."

A U.S. Department of Health and Human Service study adds: "Oral infections and disease in childhood have been linked to increased risk for future decay, and chronic oral infections are associated with an array of other health problems later in life such as heart disease, diabetes, and unfavorable pregnancy outcomes."

The reasons for the children's oral health crisis in Massachusetts have been well documented by a statewide Oral Health Advocacy Task Force of dental and healthcare leaders, and academicians. The Task Force notes that while over 450,000 children are eligible for MassHealth dental benefits, fewer than 15 percent of Massachusetts' dentists accept MassHealth members. The result is that an appalling 70 percent of enrolled children do not have access to care.

Dentists from North Berkshire tell me that they see children whose parents drive over two hours for an appointment, because no MassHealth dentist in their area is available to treat them.

Dentists give a number of reasons for not participating in the MassHealth program. This includes cumbersome administrative procedures and inadequate reimbursement rates that have been far lower than private rates. In addition, because of current regulations, they cannot limit the number of MassHealth patients they see, thus putting them at risk of becoming overwhelmed with new MassHealth patients seeking services.

Recently, important first steps have been taken to address this urgent problem:

* Gov. Romney has proposed allowing dentists to cap the number of MassHealth patients that they would have to accept. But, now the Legislature must also agree to approve this.
* The state recently increased reimbursement rates for dentists participating in MassHealth. But the rate is still lower than the median rates of the private market and there is real concern that these rates will not attract a meaningful number of new dentists into the program.
* Based on a review of upcoming reports, the Legislature must decide whether or not to allocate the funds necessary to put into place a third-party administrator to run the MassHealth dental program. This would remedy the current administrative struggles that dentists experience. Implementing a third-party administrator is considered crucial if we are to be successful in recruiting more dentists into the program.

Addressing the children's dental crisis will require a long-term commitment involving expanding access to preventative care and treatment, oral health education, nutrition, and expanding fluoridation initiatives. But the next 12 months will be critical in determining whether or not we will be making real progress toward addressing this long overlooked children's health struggle.

A state legislative staff member once shared with me that, as a child, her family relied on MassHealth as their source of insurance. Fortunate enough to have access to a dentist, she shuddered to think what may have happened if she wasn't able to receive this necessary care during her childhood.

A fourth of all children in Massachusetts will now depend on the Legislature to strengthen the MassHealth dental program, so they too can have access to basic dental care.

Charles Joffe-Halpern is the executive director of Ecu-Heath Care and the president of the Board of Directors of Health Care for All in Boston. He can be contacted at cjoffehalpern@nbhealth.org.

April 4, 2005

From the business section of yesterday's New York Times, required reading for anyone who thinks tax cuts spur economic growth:

"Despite the widespread notion the taxes harm the economy, no one has actually been able to back that up. ... over all, there is surprisingly little evidence that tax rates are an important factor in determining the nation's economic prosperity. ... Over the last 30 years, economists have undertaken hundreds of studies to determine whether taxes hurt the economy. So far, they've turned up little to convict taxes of the charge. After reviewing the literature on the topic in 1993, two economists, William Easterly of New York University and Sergio Rebelo of Northwestern, concluded in a joint paper that "the evidence that tax rates matter for growth is disturbingly fragile." A leading tax specialist today, Joel B. Slemrod of the University of Michigan, would agree. He notes that in the 20th century, a rising tax burden in the United States and other developed countries went hand in hand with rising prosperity. ... Looking at the data from 1950 to 2002, the authors found that periods of strong productivity growth actually occurred when the top tax rates were the highest. And they showed that, on average, high-tax countries are the most affuent countries. ... After study of the tax cuts of the Reagan years, most economists agree that taxes don't play a big part in how hard Americans work. While the study of savings is less precise, large effects from tax incentives haven't been measured. ... reform based on the notion that taxes are bad for the economy is just that: a notion not backed by strong evidence. And the costs of ignoring experience in favor of hope can be high: mounting deficits, decaying infrastructure, inadequate investment in public education and research."
-- Anna Bernasek, Economic View, New York Times, 4/3/05

Not to mention, a government that watches the numbers of uninsured rise year after year and takes no action to address it. In Washington, President Bush pushes huge tax cuts for the wealthy while seeking to cut Medicaid by $16 billion. In Massachusetts, Governor Romney pushes income tax cuts and refuses to restore dental services for more than 550,000 poor adults. All in the name of "economic growth." In health care, there's a big, legitimate cry for "evidence based medicine." Seems we could use some "evidence based policy" as well.

April 3, 2005

I just spent a few days in Chiould increase to pay for the plan (about 13% combo new income and payroll) got leaked ancago at a conference for state legislators new to health policy. Many fascinating developments in states, none more so than in Vermont where enactment of a single payer (tax financed) health care system is a front burner issue supported by many members of the Democratic House and Senate majorities.

A little history: back in 1992 when Howard Dean was governor, Vermont decided to create a universal health care system, setting up a commission to figure out financing. In 1994, the Commission’s estimate of how much taxes wd plastered on the front page of the Burlington Free Press. That day, the reform process died.

They’re trying again, this time learning from episode one’s collapse. The bill would set up a governing structure and leave the treacherous chore of defining a benefit package and tax rates (to replace insurance premiums) to two commissions with the Legislature ratifying next year in an up or down vote. The new system would start in 2007. Benefits would be structured similar to those in Oregon’s now-defunct Health Plan, ranking services in order of priority, and linking the budget to the number of services that could be provided. A key obstacle is Republican Governor Jim Douglas who criticizes the plan and estimates the combo of new income and payroll taxes now needed at 20 percent. The Legislature wraps its session in late April, so this will play out quickly.

Back in the early ‘90s, many folks said Vermont was a good place to try such a huge experiment because of its size and compactness. They’re traveling down a difficult and controversial road and deserve our attention and respect for tackling this issue.

April 1, 2005

Welcome to HCFA's blog. We'll do this 3-5 times weekly, touching on anything related to MA health policy. For starters, let's see where health reform in Massachusetts is at right now.

Last November, health care access hit the front pages big time with announcements by Sen. Pres. Bob Travaglini and Gov. Mitt Romney that they want to eliminate or reduce substantially the number of MA uninsured, estimated between 460,000 and 650,000 residents. In December, the MA Health Reform Coalition -- with HCFA in the lead -- filed reform (the Health Access and Affordability Act-- lead sponsors: Sen. Dick Moore and Rep. Debbie Blumer) legislation. Since then, the issue dropped off the media radar screen.

The issue is ready to re-emerge. Next week, we expect Pres. Travaglini to release a plan, and we hear Gov. Romney's staff is working furiously on their own. So, most likely by late April, there will be three major proposals -- all of which will be referred to the new Joint Committee on Health Care Financing, chaired by Sen. Moore and Rep. Patricia Walrath. Among the three, there will be similarities and striking differences. Gov. Romney's will be a "market based" approach offering a scaled down insurance plan he hopes the uninsured will voluntarily purchase. The MHRC approach includes expansion of MassHealth for lower income and a "health care minimum wage" to help all working uninsured persons get coverage. Sen. Travaglini's plan, we believe, will be in the middle.

Also at play:

In January, the state and federal governments agreed on a plan to continue a "waiver" under which Massachusetts operates our Medicaid program, preserving $600 million in vital extra payments. Key details are unresolved, and the state may yet lose a big chunk of the money, with drastic consequences for health access reform . The new waiver takes effect, for better or worse, on July 1, 2005.

Also, the Blue Cross Access Foundationcontinues work with the Urban Institute on its "roadmap" plan for universal coverage due for a final release in the fall.

And the MHRC this summer will file a ballot petition for placement on the November 2006 state ballot with the requirement to collect more than 65,000 signatures between early September and mid-November 2005 to give voters a chance to weigh in.

What's it all add to? A thick policy and political stew with much left to do. Will reform happen in 2005? Maybe, and there's a chance to achieve real progress in the FY06 budget process this spring, making downpayments on access, provider rates, and more. Experience teaches us that it will take the House and Senate a lot of time to get their arms and minds around this complex area, and we expect major legislative action to occur between January and July 2006. That's how it looks to us right now.

Please use the form at the bottom to add your own thoughts and ideas. We'll use some of the best comments in a future column. And let us know how to make this blog better.

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