A Healthy Blog

Massachusetts health care – wonky with a dose of reality

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

October 31, 2016

MassHealth cardMost MassHealth members have the option of either enrolling in a health plan (a Managed Care Organization or MCO) or the Primary Care Clinician Plan (PCCP). In efforts to move more members to managed care, MassHealth proposed in its 1115 waiver proposal to cut chiropractic services, eyeglasses, hearing aids, orthotics and potentially other benefits in the PCC Plan, while maintaining these benefits for members enrolled in MCOs.

Health Care For All, along with partner organizations, such as Disability Advocates Advancing our Healthcare Rights (DAAHR), the Massachusetts Law Reform Institute, and the ACT!! Coalition, as well as several provider groups, persistently opposed the proposed benefit cuts. We argued that the benefit cuts would impose barriers to care for low-income individuals and families, and violate federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) standards for MassHealth members under age 21.

In response, MassHealth first modified their proposal to maintain the full package of benefits for children and youth under age 21, while moving forward with the benefit reductions for adult PCC Plan members. However, at their public meeting in October, MassHealth announced their decision to drop the PCC Plan benefit cuts altogether.

We commend MassHealth for making the right decision, and thank our advocacy partners for making this issue a priority.

The next hurdle is cost-sharing. MassHealth is moving forward with their request to charge higher copays to members enrolled in the PCC Plan as compared to those enrolled in MCOs or a new Accountable Care Organization (ACO) option. MassHealth also seeks to apply copays to additional services (currently MassHealth members only pay for prescription drugs), including use of the emergency room for non-emergent conditions. These cost-sharing policies are slated to go into effect in 2018, after a public process.

For low-income people using MassHealth to stay healthy, even modest copays can be barrier to getting the care they need. In the long run, this can make overall care more costly. We urge MassHealth to carefully consider the impact on health and the cost-effectiveness of adding more copays.

                                                                                                                                -- Suzanne Curry

 

October 28, 2016

Health Care For All is among more than 200 health and social service organizations and leaders who signed on to a letter yesterday requesting the reauthorization of the Prevention & Wellness Trust Fund (PWTF) before the funding expires in June of 2017. 

The PWTF was established by the legislature in 2012 as a part of Chapter 224 with the aim of reducing health care costs by investing in prevention for chronic conditions like diabetes and asthma. Services supported by this Fund are available to nearly one million Massachusetts residents in all areas of the state through nine community partnerships that help keep people safe and healthy.

The letter outlines the impact chronic illnesses have on individuals and how these conditions contribute to shorter lives, lower quality of life, reduced workplace activity, and, for children, missed school days. With rates of preventable chronic conditions skyrocketing, especially among individuals from lower-income communities, it is essential that we invest in these initiatives to ensure health care equity in Massachusetts. In fact, Representative Jeffrey Sánchez, House chair of the Joint Committee on Health Care Financing, said that "prevention at the community level is fundamental” to achieving equitable health outcomes.

HCFA believes that the integrated approach offered by the Prevention & Wellness Trust Fund is a key to addressing the underlying causes of poor health and is a complement to the ongoing transformation of the health care system. We urge  the legislature to reauthorize the funding next year so that all residents of Massachusetts have a equitable opportunities for good health.

 

--Angela Swanson

 

October 11, 2016

Policy Forum on Oral Health Integration

Last Thursday the Massachusetts Health Policy Forum hosted a forum entitled “Integrating Oral Health into ACOs.” This event brought together researchers and stakeholders to discuss the importance of oral health integration.

The context is the state’s proposal to set up ACO’s – Accountable Care Organizations – for our MassHealth program. ACOs are structured to provide more coordinated care, and the state is planning to better integrate behavioral health and long-term care services into the plans. At issue is how best to integrate oral health as well.

The morning started with a brief presentation by Dennis Heaphy, an analyst at the Disability Policy Consortium and a leader in Disability Advocates Advancing our Healthcare Rights, the leading health disability advocacy organization in Massachusetts. He spoke on the critical role good oral health and dental care has played in his own life.

The research panel presented with compelling evidence supporting coordination between oral health and overall health services and how that could fit into ACOs.  The first speaker was Yara Halasa, a dentist and PhD candidate from Brandeis’ Heller School. She provided a summary of her paper, demonstrating that including oral health care into the ACO model foster comprehensive and better quality care. She brought attention to the fact that 29% of adults in Massachusetts rated their oral health status as poor to fair. Yet, oral health is closely linked to overall health, with poor oral health leading to issues with diabetes and respiratory or cardiovascular conditions. She ended her discussion with a number of policy recommendations on how to best get to achieve integrated oral health. See her presentation here.

Chief Economist and Vice President of the Health Policy Institute and member of the American Dental Association, Marko Vujicic said that IT challenges are the top barrier for oral health integration. There are numerous benefits to oral health integration, particularly for diabetics and pregnant women. He also reported that $153 million could be saved if dentists were included in the general medical screening process.

Oregon CCOs integrate oral health

While Massachusetts prides itself on being number one in all things healthcare related, Oregon is leading the country in integrated care through ACOs. Representing the Oregon Health & Science University, Dr. Eli Schwarz discussed the successes that Oregon is having with integrating oral health in its ACO model, known as CCOs (see his presentation here). The program has reduced ED visits and hospital admissions for congestive heart failure and pulmonary disease, and increased used of effective dental sealants. It is estimated that the government will have saved $1.7 billion over the waiver period though better care.

The session ended with a panel of stakeholders, who discussed the importance of oral health integration, perceived barriers to integration and how to tackle those challenges. Members of this panel included the moderator Michael Monopoli of the DentaQuest Foundation, State Senator Harriette Chandler, MassHealth dental director Dr. Donna Jones, HCFA’s Brian Rosman, Dr. Hugh Silk, a primary care physician and instructor at UMass Medical School, and Dr. Raymond Martin, president of the Massachusetts Dental Society.

Senator Chandler, who co-chairs the legislature’s oral health caucus, passionately remarked that the state of Massachusetts is a “long way” from providing what we do for oral health than what we do for physical insurance, and pledged to continue working for full integration.

-- Chelsea Canedy and Angela Swanson

September 15, 2016

Our friend Vicky Pulos, attorney and advocate at the Massachusetts Law Reform Institute, has a blistering letter in today's Boston Globe, objecting to the reasoning used by the Connector in suddenly raising subsidized ConnectorCare premiums (see our post for background).

Here it is:

A safety net frays as Mass. health plan premiums spike

THE MASSACHUSETTS Health Connector’s decision to raise most premiums for subsidized insurance in 2017 represents a change in its longstanding policy of protecting the poorest of the poor from the full effects of premium increases (“Subsidized health plan raises rates 21%,” Page A1, Sept. 9). For the lowest-income ConnectorCare enrollees, including the destitute and the homeless, the cost of remaining with their current plan may increase by as much as $165 per month.

Massachusetts’ 2006 health reform law prohibited premium contributions for those living below the poverty level. Until last week’s board meeting, the Connector had honored the spirit of state health reform by fully subsidizing all plan choices for the very poor.

Several board members objected to this practice of what they called “cross-subsidization.” However, the Connector is not a private insurance company. It has no profitable or unprofitable product lines. It’s a public authority, and ConnectorCare is a public program. The fiscal constraints driving the Connector have more to do with declining state tax revenue, and the need to transfer funds back to the general fund to support other state spending, than with any other cause. Now that’s cross-subsidization.

Victoria Pulos
Senior health law attorney
Massachusetts Law Reform Institute
Boston

We agree. The Connector is a public entity, tasked with administering a public insurance program, for the benefit of the low-income people in the Commonwealth. We urge the Connector to re-examine its decision.

Thanks, Vicky, for a great letter.

                                                                                                                     -- Brian Rosman

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