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Massachusetts health care – wonky with a dose of reality

January 3, 2017

Massachusetts pioneered health reform when we passed our “Chapter 58” law under Governor Mitt Romney in 2006. The result was a dramatic increase in insurance coverage and financial security, as well improvements in overall health, increases in preventive care, and dramatic reductions in racial and ethnic disparities in coverage.  These gains were most significant for the lowest income individuals.

President Obama’s Affordable Care Act (ACA) increased coverage further, and provided additional support to Massachusetts’ health care system. With the looming repeal of the ACA being proposed by President-elect Trump and the Republican Congress, it’s critical to understand how the ACA improved and strengthened Massachusetts health reform, and what the impact of repeal would be on the state.

Massachusetts Uninsurance Rates 2002 - 2015

1. What are the similarities and differences between the ACA and the 2006 Massachusetts Health Reform Law (Chapter 58)?

The success of health reform in Massachusetts provided the template for the Affordable Care Act. Both laws are built upon the same policy blueprint:

  1. Expansion of the MassHealth Medicaid program.
  2. Sliding-scale subsidies to make private coverage affordable for moderate-income people.
  3. Insurance protections that ban insurers from taking into account pre-existing conditions and from gender discrimination and that require all insurance plans to cover a list of essential health care services.
  4. Creation of an insurance exchange (here called the Health Connector) that allows people to easily compare and purchase private coverage plans.   
  5. An individual mandate that requires everyone to have coverage if an affordable plan is available.
  6. An employer responsibility requirement that requires large employers to offer coverage to their workers.

But as a federal law, the ACA in some areas went further and provided more coverage and more protections than the Massachusetts statute. Here are some of the major ways the ACA improved on our reforms:

  1. Medicaid: The federal Medicaid expansion covers more people than the Massachusetts law, allowing many to switch from Connector coverage to more comprehensive MassHealth. Currently, some 300,000 adults are covered by MassHealth due to the ACA’s Medicaid provision.
  2. Subsidies: The federal tax credits provided under the ACA go to families with incomes up to 4 times the federal poverty level, while under Chapter 58 the state provided help to those with incomes up to 3 times the poverty level. In addition the federal tax credits reduced the state cost for providing subsidies through the Connector. Over 190,000 people in Massachusetts receive federal tax credits to help them afford their insurance.
  3. Insurance Protections: The state’s insurance protections could not legally apply to most people with employer-offered coverage, which is under federal jurisdiction. In addition, the ACA includes provisions not in state law, like prohibiting copays and deductibles for preventive care, including reproductive health. These protections affect 2.5 million people with private coverage in Massachusetts.
  4. Employers: The ACA includes a tax credit to help small businesses with the cost of providing health care to their workers.
  5. Medicare: The ACA is closing the Medicare prescription drug “donut hole,” which is saving 83,000 seniors and people with disabilities an annual average of $1,039 in drug costs.

The ACA also included numerous provisions that go beyond coverage, including support for public health prevention programs, community health center grants, patient-focused medical research, workforce training, and increased transparency.

2. If the ACA is repealed, could Massachusetts just go back to the Romney-era plan established under Chapter 58?

While it depends on the precise legislative details and the timing of any repeal law, repeal of the ACA would likely result in a substantial reversal of the gains we have made due to the federal law. Moreover, it would probably be very difficult to even go back to where we were before.

First, the original Connector insurance subsidies and Medicaid expansion under Chapter 58 were substantially funded by the federal government, using special Medicaid funds authorized under a waiver negotiated with Washington. Federal policymakers encouraged Massachusetts to pilot our unique health policies, and they provided funding to test our approach. Last November, the waiver was renewed for another 5 years. But it includes provisions allowing the incoming Trump administration to alter its terms. Trump and Republican congressional leaders are planning to greatly reduce Medicaid spending in addition to repealing the ACA. With much tighter budgets, it is very doubtful that they would allow Massachusetts to continue operating its own version of Obamacare using federal Medicaid funds.

Second, Republican Congressional leaders have said that their repeal law might prohibit states from enacting the strong insurance protections required as part of the ACA. Also, their proposal would likely allow for the sale of insurance across state lines, meaning out-of-state insurance could be offered that wouldn’t have to comply with our standards.  In any case, under federal law, states cannot regulate coverage offered by self-insuring employers. Thus Massachusetts could not regulate coverage offered to workers in those employer plans.

Bottom Line: Repeal of the ACA would be very damaging to health care in Massachusetts.

December 20, 2016

Jon Kingsdale can rightfully hold the title of senior implementor of health reform in the country, As the first Executive Director of the Massachusetts Health Connector, Jon had to figure out from scratch how to set up our health care marketplace in way that would be affordable, efficient, and would rely on competition among private insurers to offer coverage.

Today, Jon published a thoughtful article that builds on the wisdom he gained from years of experience. Titled, "Republicans are about to learn just how much Americans hate health care changes, he makes the bold forecast that the best days of the ACA may still be ahead of us. He identifies the central dilemma of the repeal effort - while the ACA as a concept is not that popular, many of its features have broad support, and tens of millions of people rely on it for affordable coverage. And nobody likes changes to their health care:

While it may be unlovable, the ACA is firmly established — written into the costly software and strategic plans of hundreds of insurers, thousands of hospitals, and the 32 states that expanded Medicaid. If Republicans upend those apple carts, they’ll make a lot of Americans very nervous.

Republicans will struggle mightily over how to replace the ACA’s budget-balanced, market-oriented reforms with something far less regulated and subsidized that doesn’t throw millions of Americans off coverage. Then they must persuade at least eight Democratic senators to support their alternative. If bipartisan reform were easy, it would have happened decades ago, when the country was far less divided, or in 2009 when Senate Democrats last tried.

So, where does that leave the ACA? Pretty darn hard to repeal and replace. But doing nothing seems equally untenable: Either the Republicans fund the ACA, leading Tea Partiers to call for their heads — and everyone else to wonder how they can support a law they revile — or they preside over an insurance crisis. If they defund it, Americans will see just how much they really had to lose. And Republicans will no longer have Obama to blame.

Alongside Jon's appeal to practicality, there's also politics and policy, On the politics side, Noam Levey of the LA Times reported last week on the dwindling constiuency for repeal: 

As they race to repeal large parts of the Affordable Care Act, President-elect Donald Trump and congressional Republicans are leaving behind nearly everyone but their base voters and a handful of conservative activists.

Not a single major organization representing patients, physicians, hospitals or others who work in the nation’s healthcare system backs the GOP’s Obamacare strategy.

New polls also show far more Americans would like to expand or keep the healthcare law, rather than repeal it.

Even many conservative health policy experts caution that the emerging Republican plan, which calls for a vote in January to roll back insurance coverage followed by a lengthy period to develop a replacement, could be disastrous.

That potential disaster is explained well in Sunday's New York Times economics column by Robert Frank, "Want to Get Rid of Obamacare? Be Careful What You Wish For." Frank explains that Republican policy thinkers object most to the individual mandate, and to the sliding scale tax credit subsidies that allow moderate income people to afford coverage. But, as the Massachusetts experience shows, both are essential:

The same logic explains why private/government hybrid programs — like Obamacare, and its predecessor in Massachusetts, Romneycare — include an individual mandate. Opponents of the mandate argue that it limits individual freedom, which of course it does. But traffic lights and homicide laws also limit individual freedom; everyone celebrates liberty, but sometimes we must choose among competing freedoms. Failure to include a mandate would eliminate the freedom of citizens to purchase affordable health insurance. In such cases, we must decide which of the competing freedoms is more important.

The third feature of Obamacare (and Romneycare) is that both provide subsidies for low-income people. You simply cannot require people to buy something they cannot afford.

In short, it’s logically impossible to cobble together a private-insurer-based replacement for Obamacare that offers affordable coverage to people with pre-existing conditions without also including an individual mandate and subsidies. That’s why, despite scores of House votes to repeal it, no one has come forward with a coherent proposal to replace it. Hence the dilemma currently facing Republicans.

All three of these recent articles reach related, overlapping conclusions to some extent, and all are worth looking at. Massachusetts has a unique role in the upcoming debate. Because our 2.8% uninsurance rate is the best in the country, we are the prime example of how good implementation of health reform can work. And, because of that, in some sense we have the most to lose under repeal. We need you to join the effort to protect our care. Sign up here to join the campaign.

                                                                                                                                        -- Brian Rosman

 

December 8, 2016

White House Cabinet Room

The day after his inauguration, President Trump convenes his first cabinet meeting at the White House.

“As you all know, just an hour after yesterday’s swearing-in ceremony, I signed the bill to repeal Obamacare,” the President says with a broad smile. The cabinet explodes in applause, with hoots and hollers. “The American people will no longer be subject to that sad law, with its heavy-handed government mandates and taxes.”

“Now comes the hard part,” he explains. “We must come up with our replacement proposal. And I’ve said, I want our plan to meet just a few simple principles. It should not result in people losing their health coverage. We can’t afford millions of newly uninsured people angry at us. We also of course should not increase the growth rate of health care premiums. Oh, and we can’t increase the federal deficit with our plan.”

The President looks over at his new Secretary of Health and Human Services, Dr. Tom Price.

“So Tom, what’s your thinking? Is there a plan we can propose that meets these goals?”

“We’re beginning the process, Mr. President,” Price replies. We’re looking at options that meet your conditions. We also want to find a plan that is consistent with long-standing Republican principles. Our plan should promote individual responsibility, like the plan from the conservative Heritage Foundation. We should learn from states, so ideally we should forward a plan that was successful in some state. And as a doctor, I believe it’s critical that the plan not just provide coverage, but also improve the overall health of the people. And it would be good if the plan also improved people’s economic well-being, too.

“But so far, sir, we have not come up with the right plan.”

The President looks displeased, and makes a face. Everyone sits in silence.

Then, a hand is slowly raised from the far side of the table. It's the new Secretary of State.

“Gosh, Mr. President,” he says, “I have a swell plan that I think would work just fine.”

                                                                                                           -- Brian Rosman

December 8, 2016

It would be a disaster if the ACA were repealed, almost 370,000 Massachusetts residents would lose health coverage in 2019.

Chart from CBPP factsheetThat’s the stark conclusion of an analysis just released by the Urban Institute and the Center on Budget and Policy Priorities (CBPP). The report details the implications of a partial repeal of the Affordable Care Act through “reconciliation” – the process that allows the US Senate to approve budget-related bills with just 51 votes, avoiding a filibuster.  The report concludes that, “This scenario does not just move the country back to the situation before the ACA. It moves the country to a situation with higher uninsurance rates than was the case before the ACA’s reform.”

Here are some highlights from the report:

On the national level:

  • 29.8 million people nationwide would lose health insurance coverage. Of these 29.8 million, a majority of them would be working-class families and minorities.
  • Of the 29.8 million people newly uninsured, 22.5 million would become uninsured because they would no longer be eligible financial assistance.
  • Many, if not most, insurers are unlikely to participate in Marketplaces in 2018—even with tax credits and cost-sharing reductions still in place—if the individual mandate is not enforced starting in 2017.

But what about in Massachusetts? The CBPP looked specifically at the impact here.

  • The number of uninsured people would increase by 273%, to over half a million uninsured.
  • The health care system would be forced to absorb immense cuts, with hospitals and doctors facing huge increases in demand for uncompensated care.
  • Massachusetts would lose $1.4 billion in federal Medicaid funds for 2019, and $491 million in support for Health Connector plans.

Even if the ACA is replaced after reconciliation with programs designed to increase the insurance rate, the government would still need to raise taxes, cut spending, or increase the deficit. Reconciliation would also directly affect the most vulnerable populations in the US and across the Commonwealth, which is why it is so vital that we work to keep our health reforms in place.

Please add your voice to support affordable health care in Massachusetts and get involved today. 

-- Angela Swanson

November 30, 2016

Tom Price tears a page from the health care bill during a press conference. (Win McNamee/Getty Images)

The announcement by President-Elect Trump to nominate Rep. Tom Price as federal Secretary of Health and Human Services is chilling. As the Vox headline put it, "By picking Tom Price to lead HHS, Trump shows he’s absolutely serious about dismantling Obamacare." Price introduced a draconian version of an ACA replacement plan, even much less generous than the stingy plan sponsored by Speaker Paul Ryan. The centerpiece is the elimination of income-based help for the purchase of insurance. In an ironic flip of priorities, the Price plan provides more help to younger, healthier and richer people, at the expense of older, sicker and poorer Americans, who would get much less assistance. The plan also sets up deep cuts in Medicaid funding (explained here), which would necessitate slashing coverage and benefits for the 1.9 million low-income Bay Staters who depend on MassHealth for their medical care.  

But here in Massachusetts, there's a broad consensus in opposition to cuts which would hurt our best-in-the-nation record of expanding coverage and virtually eliminating uninsurance. Today's Globe included statements from the heads of the Biotechnology Council (“I’d hate to see us go back to a day where so many people are uninsured or can’t get insurance because of preexisting conditions”) and the state Health and Hospital Association ("Fundamentally, it’s like a sweater with threads, if you pull a few out, you gotta repair that somehow") opposing any changes to the ACA.

Governor Charlie Baker is with us, too. He was very clear about his approach

"Massachusetts had a universal plan in place before the Affordable Care Act. It's important to the people of Massachusetts that we can continue to be committed to that," Baker told reporters Nov. 16 after returning from a Republican Governors Association meetings in Florida.

"I think it's going to be incumbent on all of us that the people of Massachusetts continue to be covered," Baker said.

We will be looking to Governor Baker to rally other Republican Governors, as 15 other of his Republican colleagues have also implemented the Medicaid expansion authorized by the ACA.

Health Care For All is committed to once again bringing together a broad coalition to resist any efforts to reduce access to affordable coverage in Massachusetts. In 2006, under Governor Romney, we organized the health care, business, labor, senior, children's, religious and citizen activist communities to support our health reform campaign, which showed the way for the rest of the country. Our bi-partisan effort was focused on results, not politics. We are determined to continue that fight. Please join with us. Use this link to add your name to our effort.

                                                                                                                                                          -- Brian Rosman

November 18, 2016

While deciphering exactly where the Trump administration wants to go with the Affordable Care Act is difficult, reports have suggested that the new administration will seek to repeal almost all, but not every single provision all of the Obamacare law. The parts he would keep are the most politically attractive components - allowing adult children to stay on their parents' family coverage to age 26, and the core insurance protections - excluding coverage or charging higher premiums for people with pre-existing conditions.

Would it work to keep the insurance protections, but repeal the individual mandate - the requirement to purchase coverage, and to repeal the sliding scale premium assistance subsidies?

The lesson from Massachusetts is a clear no. We tried that here during the late 1990s and early 200s, and the result was premiums going up and up. The policy results in adverse selection, when healthier people avoid getting coverage, since they can sign up when they get sick. This increases premiums as the pool of those buying insurance are relatively sicker and costlier. This leads more healthy people to drop more expensive coverage, causing what's called a death spiral in the insurance market.

This dynamic led then-Governor Romney to propose his plan, combining insurance protections, the mandate, and subsidies.

It's all explained well in a court brief. As part of court case challenging ObamaCare, a bipartisan group of 49 distinguished economists submitted a brief in support of the ACA. The brief defends the ACA as relying on all three components. They explain how the pre-Romney Massachusetts experience with insurance protections failed:

The tumultuous experience in Massachusetts documents why all three legs are necessary to make broad coverage affordable and stable. The state first tried to reform the health insurance market in 1996. The legislature passed guaranteed issue and community rating laws that prohibited insurers from discriminating in the issuance of insurance on the basis of health status or other factors, prohibited insurers from varying premium rates based on health status, and restricted the amount by which insurers might vary rates based on characteristics such as age or sex. Following these reforms, average  premiums for individual coverage reached $8,537 per year, the most expensive in the nation by a wide margin. Those premiums fell only after Massachusetts implemented a second wave of reforms that included both an individual mandate and premium subsidies for low-income individuals. With the combination of those reforms, premiums for individual coverage in Massachusetts dropped by 35% compared to the national average between 2006 and 2009.

This process is also clearly explained in a charming set of cartoons, in the online news site, Vox. Click below to check it out:

                                                                                        -- Brian Rosman

November 17, 2016

The election puts at risk the coverage of some 22 million people nationally who depend on the Affordable Care Act for their health insurance.

What about us here in Massachusetts?

Our reforms predated the ACA. Yet repealing the ACA would be devastating. It substantially strengthened our ability to provide affordable coverage. Over 300,000 adults are enrolled in MassHealth and an additional 180,000 in Connector Care directly under provisions of the ACA. 480,000 of us and our neighbors.

Because of the ACA, we’ve been able to provide premium assistance for more people, allow children to remain on their parents’ health coverage longer, eliminate limits on benefits, provide free preventive care (including contraception) in insurance plans, and improve drug coverage for seniors on Medicare. The ACA has improved care quality, and funded community health centers, workforce development, and community-based prevention.

Massachusetts is unique proof that the ACA can reduce uninsurance to very low levels – under 3%. That’s why we must spearhead the fight to protect health reform.

We urge you to add your voice to support affordable health care in MassachusettsJoin our campaign here and donate now to help us continue our work to protect your access to healthcare.

Check out this blog to learn more about the importance of protecting the ACA. 

November 13, 2016

President-Elect Trump's Health Care Site GraphicThe election of Donald Trump, running on a platform of complete repeal of the Affordable Care Act, puts at risk the coverage of some 22 million people who rely on the law for their health insurance. Patients who depend on the law for their coverage are fearing the worst. So, on the day after the election, more than 100,000 Americans rushed to sign up for coverage, the largest number ever during this year’s open enrollment.  

But what about us, in Massachusetts? Our 2006 “RomneyCare” reforms predate the ACA. Our own reform law resulted in the reduction in our uninsured rate from around 11% in 2006 to about 6% in 2010. Implementation of the ACA further expanded coverage, and today our uninsurance rate is about 3%. And our law has broad political support, including Republican Governor Baker. So now Fortune Magazine is recommending that people upset about Trump's election move to Massachusetts, rather than Canada.  

The short answer is that we can’t yet know the impact of policy changes to be enacted by Trump and the Republican Congress. Already, there are some signs of retreat, as Trump indicates support for keeping pre-existing conditions protections. The Washington Post reported that, “In the long run, waffling on repeal will probably be less painful than causing a health-care catastrophe” (see this smart analysis on The Conversation for background). For example, the President-elect’s new official government website health care page has different policies than the campaign’s. 

But our pre-ACA state reforms did not exist in vacuum. They depended on federal fiscal and policy support for their operation, provided through the MassHealth Medicaid waiver. Implementation of the ACA in Massachusetts allowed for substantial improvements in coverage, and state financial savings. Vicky Pulos, an attorney at the Massachusetts Law Reform Institute, provides some perspective and a warning about what could happen:

In MA over 300,000 adults are enrolled in MassHealth and an additional 180,000 in Connector Care under provisions of the ACA.

If the Medicaid expansion and federal tax credits and subsidies in the ACA are repealed, it won't happen overnight. We still have the bones of our 2006 state health reform law on the books, but prior to the ACA we insured far fewer people at a far greater net state cost. Retaining coverage will require all hands on deck.

Meanwhile last Friday, MassHealth received approval from CMS (the federal Medicaid agency) for amendment and extension of its 1115 demonstration (the waiver) to 2022. Approval allows MassHealth to move ahead with plans for Accountable Care Organizations that will change the way providers are organized and paid. The goals are to reduce state spending and provide more coordinated care. Approval also secures billions in additional federal funds over 5 years.

It's far too early to speculate how a new federal administration may affect the waiver. However, approval does not insulate MassHealth from future changes in federal law or policy or a new administration taking a different view of whether the waiver serves the public interest.

HCFA and our Affordable Care Today (ACT!!) Coalition will launch a broad, aggressive campaign to oppose any reduction in affordable coverage in Massachusetts. We urge you to join us, now. Sign up using this form to stay informed about Massachusetts health reform, and how you can add your voice in support of keeping good health care affordable in Massachusetts.

                                                                                                                     -- Brian Rosman 
 

November 4, 2016

Today the federal Centers for Medicare and Medicaid Services (CMS) approved Massachusetts' application for a broad restructuring of the MassHealth Medicaid program.

The "1115 waiver" allows the state to implement Accountable Care Organizations as a new choice for MassHealth members. An ACO is made up of primary care providers who team up to provide integrated, coordinated care, with the goal of both treating patients when they are sick, and keeping members healthy. They will work with community organizations to assist members with social needs that keep us healthy, like nutrition or housing. The waiver also provides the state with lots of new federal funds. It includes $1.8 billion over five years of new funding to support the move to ACOs, invest in behavioral health and long term services and supports, and promote innovative ways of addressing the social determinants of health.  It also authorizes nearly $6 billion of additional safety net care payments over five years to hospitals and the health safety net for low income uninsured and underinsured residents, and for subsidies to assist consumers in obtaining coverage through the Health Connector.

The waiver also increases opportunities for consumer involvement. ACOs are required to include a consumer representative on their boards, and each ACO must have a Patient and Family Advisory Committee.

More information on the waiver is here:

HCFA released the following statement following the news:

“Health Care For All (HCFA) welcomes this Medicaid waiver as an opportunity to transform MassHealth from just a program that takes care of people when they are sick to one that aims at keeping people healthy in the first place. We are particularly excited about the potential to integrate physical, behavioral health and long-term care with other social services. We hope that this overhaul expands in the future to include oral health and dental care as well, which we know are critical to overall health. HCFA will be watching closely as the state implements the innovative reforms approved today to make sure that consumer needs are the top priority.”

Six pilot ACOs will start operating this December, and the full ACO system should be up and running a year later. We congratulate the state on their approval, and pledge to closely monitor implementation of the waiver on behalf of Massachusetts consumers.

                                                                                                                                                                                     -- Brian Rosman

November 1, 2016

Open Enrollment starts nowThe Health Connector's Open Enrollment period has begun, and with it, the opportunity for people to sign up for health insurance or renew their coverage for 2017. In Massachusetts, ten insurers are offering up 62 different plans for the next year. During this year’s Open Enrollment, it is especially important for Health Connector members to review their plan and compare their options, as some changes have been enacted that may affect their coverage.

Some Connector members will be facing substantial increases in monthly premiums. About 70,000 notices from the Health Connector will be going out this month regarding a premium increase of at least 15%. For those enrolled in a Neighborhood Health Plan, the average increase is 21%.

Prior to this enrollment period, the State had been able to help subsidize the difference in premium costs between plans with a process called “smoothing,” but due to budget constraints, this process has been discontinued for 2017. This means that low-income ConnectorCare members enrolled in Neighborhood Health Plan may have to pay up to $165 a month to maintain their coverage and network of providers. Other individuals may also be subject to paying higher premiums in 2017. While the Health Connector has other less expensive insurance plans with comparable benefits, it is important for consumers to know that in some cases changing plans may mean changing providers as well.

Another change to look out for this Open Enrollment season is some members may find that they are not eligible for tax credits this year. This could be for a couple of reasons. Those who have recently become entitled to Medicare do not qualify for subsidized insurance. Members on ConnectorCare or Advanced Premium Tax Credits are also required to have filed their 2015 taxes in order to maintain benefits as data from 2015 tax returns will be used to determine eligibility for subsidies in 2017 coverage.

HCFA will be monitoring how these premium increases are impacting consumers. We are concerned that this may impact people’s decisions to re-enroll if their preferred plan has become out of reach, or if they are not able to remain with their existing medical care team. 

--Angela Swanson

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