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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

December 5, 2018

In 2016, the rate of uninsured children in the United States hit an historic low of 4.7 percent. In a report released last week, the Georgetown University Health Policy Institute’s Center for Children and Families finds that number increased to 5 percent in 2017, marking the first rise in the number of uninsured children nationally since comparable data was first collected nearly a decade ago. 

Here in Massachusetts, we boast an uninsured rate significantly lower than the national numbers. Nevertheless, this report gives us pause because it shows that the Commonwealth joined eight other states in experiencing a statistically significant increase in its rate of uninsured children, with the numbers increasing by 0.5% from 15,000 children in 2016 to 22,000 children in 2017. The reasons for this are not clear, but the findings should be a wake-up call to all of us.

Nationally, the report attributes these shifts in large part to “strong national currents” that include the ultimately unsuccessful effort to repeal the Affordable Care Act (ACA) and cap federal Medicaid funding, a Congressional delay that caused a temporary lapse in funding for the Children’s Health Insurance Program (CHIP), and efforts to undermine ACA Marketplaces which includes reducing outreach and enrollment grants as well as shortening the enrollment period. The authors caution that “…there is every reason to believe the decline in coverage is likely to continue and may get worse in 2018.” At the heart of this warning is worry about the recently proposed changes to the federal “public charge” rule which creates new tests on income and use of public benefits for lawfully present immigrants seeking to adjust their immigration status. The report cites a recent study that found that “implementation of the proposed rule could lead to a reduction in Medicaid enrollment of between 2.1 million to 4.9 people and posits the likelihood that children would “make up the majority who are disenrolled.”

At Health Care For All, we know that health insurance coverage is at the foundation of ensuring that children can access the health care services they need to grow, learn and thrive. Massachusetts is doing well, but we must remain vigilant in our efforts to enroll children and families in high-quality, affordable coverage and to protect, improve and expand the coverage that is available.
 
Our efforts must include active and vocal opposition to the proposed changes to the public charge rule during the public comment period. Join us now by learning more about the proposed changes and submitting your own comment of opposition before December 10th.

-Natalie Litton

November 5, 2018

The Department of Homeland Security (DHS) officially posted the "public charge" regulatory proposal that would significantly expand the list of public benefits that will pose barriers to immigrants' ability to obtain permanent residence via family or employment channels and prevent many from switching between non-immigrant statuses.
 
As part of the national Protecting Immigrant Families (PIF) campaign, the Massachusetts Law Reform Institute, Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA), Health Care For All and Health Law Advocates are working together to make sure that we in the Commonwealth of Massachusetts respond to these administrative actions effectively and strategically.

Since its publication in the Federal Register on October 10, 2018, a 60 day comment period has opened for the public to oppose the rule. The public comment period is open until December 10, 2018. We've launched a public comment drive, with a goal of 3,000 comments from Massachusetts. No special expertise is needed: Whether you're an immigrant yourself, a community advocate, a service provider, a business owner, an elected official or just a concerned citizen, you can help us ensure that the government is overwhelmed with opposition to the "public charge" proposal.

MIRA has put together guidance and helpful resources on their website; and they also have an easy-to-use comment submission form with questions to guide you.

For more information, please view this public charge statement on behalf of Massachusetts Protecting Immigrant Families Campaign (PIF-MA: MIRA, HCFA, HLA, MLRI).

Please also see these resources for advocates available in English, Spanish, and Portuguese.

October 24, 2018

Health Care For All and Health Law Advocates represent the needs of consumers in the health care system. As organizations focused on coverage, access, and affordability, we are concerned that Ballot Question 1 could have unintended consequences. Our goal is to ensure that consumers can make an informed decision about this question.

Meeting the proposed nurse staffing ratios could be particularly challenging for community-based hospitals, community health centers, and safety-net hospitals that disproportionately serve people of color, immigrants, and low-income families. It could put pressure on our behavioral health system, which is already experiencing significant staffing shortages, and could further reduce access to care. In addition, the Massachusetts Health Policy Commission projects an additional $676 million to $949 million annual cost to the health care system if the initiative passes. These costs may ultimately be passed on to consumers in the form of higher premiums and out-of-pocket expenses.

Health Care For All will continue to advocate for health justice in Massachusetts by promoting health equity and ensuring coverage and access for all. Health Law Advocates will continue to provide pro bono legal representation to low-income residents experiencing difficulty accessing or paying for needed medical services.

October 18, 2018

The Department of Homeland Security released the public charge rule for public comment. It was published in the Federal Register on Wednesday, October 10, 2018, marking the beginning of the 60-day comment period. At least 22 Senators have already opposed the rule in a letter to DHS, asking for it to be withdrawn altogether. After DHS considers public comments received on the proposed rule, DHS plans to issue a final public charge rule that will include an effective date at least 60 days after the date the final rule is published. In the meantime, and until a final rule is in effect, federal immigration officials will continue to apply the current public charge policy.

As part of the national Protecting Immigrant Families (PIF) campaign, the Massachusetts Law Reform Institute, Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA), Health Care For All and Health Law Advocates are working together to make sure that we in the Commonwealth of Massachusetts respond to these administrative actions effectively and strategically.

The public comment period is open until December 10, 2018. We've launched a public comment drive, with a goal of 2,000 comments from Massachusetts. No special expertise is needed: Whether you're an immigrant yourself, a community advocate, a service provider, a business owner, an elected official or just a concerned citizen, you can help us ensure that the government is overwhelmed with opposition to the "public charge" proposal.

MIRA has put together guidance and helpful resources on their website; and they also have an easy-to-use comment submission form with questions to guide you.

For more information, please view this public charge statement on behalf of Massachusetts Protecting Immigrant Families Campaign (PIF-MA: MIRA, HCFA, HLA, MLRI).

September 24, 2018
You may have heard about proposed policy changes that could affect immigrants’ use of public benefits (government programs that may help you pay for food, housing, health care such as MassHealth and other living expenses). New federal regulations are proposing to change the definition of who is a “Public Charge,” a person who is likely to become dependent on the government for financial and material support. This change could affect the ability to adjust status or petition for a family member. 

HCFA wants to make sure that you have the most accurate information about these changes, so that you can make the best decision for you and your family. 

  • There has been no change to the “public charge” rules at this point if you are in the US and contemplating adjusting your immigration status or sponsoring someone who is already here. These are proposed regulations that still need to go through a formal federal review process before changes are made.
  • Currently, the only benefits considered under “public charge” are cash benefits (Supplemental Security Income or Transitional Assistance for Needy Families (TANF) or payment for long-term care institutionalization).
  • Over the next several months, the proposed rule could potentially impact other benefits, including: MassHealth (except MassHealth Limited); Supplemental Nutrition Assistance Program (SNAP/food stamps); Medicare Part D Prescription Drug Subsidy; Section 8 Housing Choice Voucher Program; Section 8 Project-Based Rental Assistance; and Public Housing. There is no need to disenroll from these programs at this time. If the regulations are approved, individuals will have 60 days to withdraw from them before they impact people. After that time, the use of these benefits is dependent on other factors that should be discussed with an immigration counselor or attorney.
  • If you are sponsoring a family member who is currently living outside the country, you should check with an immigration counselor or attorney about whether receiving public benefits could affect your pending petition.
 
Health Care For All (HCFA), the Massachusetts Immigrant Refugee Advocacy Coalition (MIRA), Health Law Advocates (HLA) and many other organizations work to protect Massachusetts immigrants and ensure they have the right to access public benefits, including health care.

To learn more about changes regarding the “Public Charge” determination and how to be part of the campaign to oppose these changes, you can send an email to organizing@hcfama.org.

Attached here is a list of organizations that are trusted in the community and provide free immigration services. Some of these organizations may have limited capacity and may not accept new cases, please call first to ensure that they can help you. 

September 21, 2018

CHIA Report cover

Last week’s release of the Annual Report on the Performance of the Massachusetts Health Care System by the Center for Health Information and Analysis (CHIA) tells us that while total health care expenditures grew much more slowly, patient spending increased significantly in 2017.

In what was heralded as good news, the growth rate of Total Health Care Expenditures (THCE) in 2017 fell below the 3.6% benchmark set by the Health Policy Commission (HPC). Nevertheless, THCE did grow by 1.6% to $8,907 per resident.

While that’s unequivocally good news, not all is well. What does the report show for consumers across the Commonwealth as they try to access the care they need to live healthy lives? Digging in, the report includes the following findings:

  • Pharmacy and hospital outpatient spending remained the largest drivers of THCE growth. Prescription drugs are still skyrocketing in price, compared to other health spending. Drug costs went up 5%.
  • Annual growth in fully-insured premiums accelerated – from 2.0% in 2016 to 4.9% in 2017.
  • Between 2016 and 2017, member cost-sharing continued to grow at a faster rate (5.7%) than inflation, average wages, and premiums.
  • By 2017, 28.2% of members with private commercial insurance were enrolled in high deductible health plans.

In short, while total expenditure growth is down, patients are spending more – to pay for prescription drugs at the pharmacy, to pay their monthly premiums, and to cover co-pays for care before they meet their deductibles.

Health Care For All (HCFA) is deeply concerned about the implications this increased spending has on the ability of individuals and families to access the comprehensive, high-quality care they need when they need it. HCFA’s Director of Policy and Government Relations Brian Rosman told the Boston Globe, "We know that people with high cost sharing, high co-pays, high deductibles end up delaying care that they need and that leads to worsening of their conditions and higher costs later on.”

We need to take more aggressive action to control the growth of drug prices and to contain out-of-pocket costs so that access to equitable, affordable, and comprehensive health care is a reality for ALL Massachusetts residents. Stay tuned to learn more about HCFA’s priorities for the upcoming legislative session and how you can get involved.

                                                                                                                                                                                          -Natalie Litton

September 6, 2018

Massachusetts Health Connector

It’s hard to believe, but true. Massachusetts has among the highest costs for medical care in the country. Yet, paradoxically, for people who obtain their insurance through the Health Connector, we have the lowest average premium costs in the country. Our “benchmark plan” (explained below) is the second lowest nationally. And these findings apply to the unsubsidized cost of the plans, before the federal tax credits and state ConnectorCare subsidies.  As one expert analyst put it, “Which state has the least-expensive ACA policies? Take a guess. No, guess again.” (link)

A number of senior Connector staff members explore this in a blog post in Health Affairs. They point out that what makes this even more remarkable is that Massachusetts requires insurers to cover more benefits than national standards due to our extensive state benefit mandates. In addition, plans here must limit out-of-pocket costs as part of state health reform’s “minimum creditable coverage” requirements. Yet, our premiums are still the lowest. Robust consumer protections need not come at the expense of affordability.

Average state exchange premium levels are calculated based on premiums paid by all individuals purchasing coverage, at every metallic tier and for every carrier. For 2018, the Massachusetts average monthly premium was $385, compared to a national average of $600 a month, making us the lowest in the country. We were the lowest in 2017 as well.    

The benchmark premium is the premium for the second-lowest cost silver plan offered in a state’s exchange. The federal government uses that amount as the basis for setting federal tax credits offered to people eligible for subsidized coverage under the ACA. For this measure, we are the second lowest, at $316 per month for 2018. Rhode Island is a smidge less, with a $311 monthly premium (see this chart). Offering a low benchmark plan saves federal taxpayers money because it leads to lower tax credits APTC subsidies. Unsubsidized shoppers also save money, because they can choose from low-cost silver plans.

The blog authors emphasize that Massachusetts’ success in keeping premiums more affordable can provides lessons to other states. A number of factors contribute to our broad enrollment, which keeps premiums low. One of the Health Connector’s most unique features is the ConnectorCare program for individuals earning up to three times the poverty level. The program provides additional state subsidies to lower-cost silver tier plans by providing both premium and cost-sharing subsidies “on top” of Affordable Care Act subsidies. Enrollees have access to zero or low-dollar premium plans, zero or low-dollar co-pays, with no deductibles or co-insurance. Massachusetts’ extensive network of enrollment assisters reach out and help people enroll in coverage. ConnectorCare covers approximately 190,000 individuals, constituting about three-quarters of total individual enrollment in the Health Connector. This extensive membership rewards ConnectorCare plans that offer low premiums, encouraging them to keep administrative costs low and take advantage of their MassHealth managed care plan networks.

Massachusetts’ lower premiums are also a function of the competition in our marketplace, with multiple carriers offering plans and a structure that encourages comparison shopping. The Health Connector’s standardized plan requirement lets consumers make apples-to-apples comparisons among plans, rather than face a jumble of different deductibles, copays and benefit levels.  Affordability of health coverage is also helped by the large risk pool that includes plans offered by small employers as well as individual coverage. In addition, because Massachusetts has retained its state-level individual mandate, fewer healthy individuals are tempted to go without coverage.

The Massachusetts health care policy community should be proud of our collective work together, reflected in the success that the Health Connector has achieved in controlling premium growth over the past few years. Yet challenges will persist. In 2019, the continued withholding by the Trump administration of federal Cost Sharing Reduction payments to insurers will again force carriers to increase premiums, raising costs for unsubsidized individuals.

More broadly, there’s still much to do to make health care affordable for everyone in the state. Many people struggle with high deductibles and copays. Drug costs in particular continue to go up unabated and the state needs to take aggressive steps to rein in pharmacy costs. Lots of good ideas are being tossed around for states to consider.

States should look to Massachusetts as a laboratory for good policy ideas. Already, New Jersey, Vermont and DC have followed our lead and passed their own individual mandates. Other states are looking at this option as well. Ultimately, it will take a federal government supportive of increased insurance coverage and affordability to continue the progressive path interrupted by the 2016 election.

August 23, 2018

Much of the increased attention on immigration has been fueled by the belief that immigrants are a financial drain on the American economy, particularly on the health care system. A recently published study finds this claim to be false. 

The meta-analysis, Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review, written by Boston researchers Lila Flavin, Leah Zallman, Danny McCormick, and J. Wesley Boyd, focused on 16 peer-reviewed studies looking at medical expenditures of immigrant populations in the US. 

They found, contrary to popular belief, that immigrants consume less health care system resources compared to US-born individuals. Foreign-born persons make up 12% of the population, but only contribute to 8.6% of overall expenditures. Among immigrants with insurance, healthcare costs were 52% lower than American-born individuals.  They concluded that,  “Overall, immigrants almost certainly paid more toward medical expenses than they withdrew, providing a low-risk pool that subsidized the public and private health insurance markets.”

The study found that especially for Medicare, immigrants contribute more to the health care system financially than they use. This is particularly true for younger immigrants, found Cato Institute’s immigrant policy analyst, Alex Nowrasteh. Statistically, younger immigrants “pay more into the system than they take out over the course of their lives.” 

“Our review of the literature overwhelmingly showed that immigrants spend less on healthcare, including publicly funded health care, compared to their U.S.-born counterparts,” the authors of the study wrote. “Moreover, immigrants contributed more towards Medicare than they withdrew; they are net contributors to Medicare’s trust fund.”

Consensus seems to have been struck in the public health community: denying immigrants green cards will not fix America’s welfare system, and will increase burden for the federal government. These researchers concluded that government should remove nonfinancial barriers to enrolling in health insurance. In fact, they argue that the US should provide insurance to foreign-born individuals, particularly to newly arrived immigrants, since it would be financially sound to enroll those who (on average) contribute more than they withdraw from the health care system.

The Cato Institute recently conducted a cost-benefit analysis of the proposed regulation that would deny immigrants green cards and thus access to health care coverage, and found that it would cost $1.46 for every dollar saved. The research also showed that this proposed regulation will not protect taxpayer’s money, but will instead backfire and increase spending while negatively impact the health of individuals and communities. The current administration rejects any fiscal connection between immigration and public benefits, citing a lack of research, which is not accurate based on the already available data. Consumers and advocates alike need to continue to work to protect health care access as well as fact-based approaches to health care policy.

-Leah Dreyfus

 

 

August 17, 2018

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All of us at Health Care For All were saddened to hear of the loss of Kate Nordahl this week. Kate was a longtime friend of HCFA who lost her battle to cancer. Kate was a passionate champion of the cause of expanding health coverage, and she devoted herself to advocating on behalf of those most in need.

At the Blue Cross Blue Shield of Massachusetts Foundation, Kate was the Senior Director of Coverage and oversaw the Massachusetts Medicaid Policy Institute, which promotes a thoughtful understanding of the Massachusetts Medicaid program (MassHealth) through policy research and analysis. She also directed the Foundation's Massachusetts Health Reform Survey (MHRS), which tracks trends in access and affordability of health care and health insurance. Since 2006 the MHRS has highlighted health reform’s successes and areas that still need improvement to meet the goal of accessible, affordable health coverage for all.

Prior to her time at the Foundation, Kate served as assistant commissioner for the Massachusetts Division of Health Care Finance and Policy, where she led the agency's work monitoring the impact of the state's health reform law and analyzing health care cost trends in the Commonwealth. Prior to her role at the Division, Kate was director of policy and research at the Blue Cross Foundation where she developed the Foundation's research agenda to assess the impact of health reform.

Kate also spent 12 years in leadership positions with MassHealth in roles ranging from directing the MassHealth managed care program to designing the Senior Care Options (SCO) program for seniors dually eligible for Medicare and Medicaid. SCO has served as a national model for integrating payment and care delivery for seniors on Medicaid and Medicare. While at MassHealth she was also in charge of the state’s Medicaid managed care contracts, which served about a third of the under-65 Medicaid population.

In 2016, Kate was honored with the Boston Center for Independent Living's Marie Feltin Award for her work advancing innovative Medicaid policy and programs in Massachusetts. She also held a master's degree in health policy and management from the Harvard School of Public Health.

As we mourn Kate, our thoughts are with her family, her husband Erik and two children. The family suggests that donations in her memory may be made to the Kate Willrich Nordahl Fellowship Fund at the Harvard T.H. Chan School of Public Health,  P.O. Box 419209, Boston, MA 02241 by check or online at hsph.harvard.edu/give (please specifically note the Kate Willrich Nordahl Fellowship Fund). The fellowship will support a graduate student who has demonstrated passion and commitment to social justice and health equity.

We will remember Kate for her lifelong commitment to making people’s lives better by working passionately to improve health care in Massachusetts.

                                                                                                                                                                  -- Louis Pratt

July 26, 2018

health care budget

Governor Baker signed the state budget for Fiscal Year 2019 today. The budget funds state programs and also includes numerous policy changes. Massachusetts budget procedures allow the Governor to veto specific provisions of the budget However, for the most part, the Governor did not veto our key health care priorities.

We are very pleased that the budget does not call for cuts in MassHealth or other state-funded health programs, and adds a new periodontal (gum care) dental benefit for adults in MassHealth.

Here are some of the issues that we have been working on that were included in the budget signed today:

  • Restore coverage for periodontal care for adults on MassHealth – the budget provides for periodontal (gum care) benefits to be provided to adults in the MassHealth program effective June 1 of 2019. Coverage for the treatment of periodontal disease is critical to improving the oral and general health of the adult population.  
  • Establish an Office of Health Equity within EOHHS – the budget includes a long-standing HCFA priority by funding a permanent, codified Office of Health Equity that would work to improve the health of racial and ethnic minority populations in the Commonwealth by establishing statewide goals and a plan to meet those goals. The Office would coordinate resources throughout state government, as well as evaluate the effectiveness of statewide and regional programs.
  • Direct MassHealth to provide information on ACO outcomes and activities addressing social determinants of health – MassHealth ACOs will be responsible for screening their 800,000 members for health-related social needs, such as housing insecurity, food insecurity, transportation needs, and exposure to violence – issues directly related to poor health outcomes, health inequities and high health care costs. This provision directs MassHealth to report on the impact of the ACO program, including data concerning screening and interventions related to the social determinants of health.
  • Fund critical children’s mental health programs, including the Mental Health Advocacy Program for Kids (MHAP for Kids) and Return to School “Bridge” programs – the MHAP for Kids program improves the mental health of vulnerable youth who have been diverted from juvenile court or are already court-involved and have unmet mental health needs by providing these children with a legal advocate trained in removing barriers to treatment. Return to School “Bridge” programs ensure that youth who have been out of school for psychiatric or other hospitalizations can successfully transition back to school.
  • Fund pediatric palliative care programs – these programs provide invaluable services to over 344 ill children and their families, including consultation for pain and symptom management, nursing care, case management, social services, counseling, volunteer support, respite, complimentary therapies and bereavement services for families.

In signing the budget, the Governor vetoed several provisions that we prioritized. The vetoes included funding for the “academic detailing” program, which is an evidence-based prescriber education program on the therapeutic and cost-effective utilization of prescription drugs. The program helps doctors make decisions based on balanced research data rather than biased promotional information.

The Governor also proposed to cut in half the the $300,000 allocated to the ForsythKids program. This program provides preventive oral health services for kids in 51 schools to provide school-based oral health care.

We will be calling on the legislature to override both of these vetoes.

The Governor also returned a section of the bill with a request that the legislature amend the provision. The issue is prescription drug discount “coupons.” Drug companies use these to entice consumers into purchasing more expensive brand-name drugs, often when cheaper and equally-effective alternatives are available. When the coupons run out, patients are left with high copays. Massachusetts originally banned these coupons, then temporarily authorized them several years ago. The budget provision, which HCFA opposed, would have extended permission for these coupons until 2021. The Governor’s requested amendment would limit the extension just to 2020, and set up a study to make recommendations on the issue. HCFA supports the Governor’s request.

With the budget completed, eyes now turn to the big health care package still pending before a House-Senate conference committee. The legislature adjourns at midnight (more or less) on July 31, so there's not much time left to complete work on the bill.

                                                                                                           -- Brian Rosman

 

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