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Massachusetts health care – wonky with a dose of reality

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

 

July 19, 2018

Oral Health = Overall Health

 

[Update - July 26 - The Governor signed the fiscal year 2019 budget into law, and did NOT veto the provision restoring periodontal care. The new benefits will start on June 1, 2019. HCFA is thankful for the Governor's support of this provision.]

Yesterday, the state legislature approved the Massachusetts state budget for fiscal year 2019, which started July 1 and runs through next June. Included in the bill was funding to restore MassHealth coverage of periodontal care - treatment of gum disease - for adults. The new coverage benefit begins in June 2019.

MassHealth is the state’s Medicaid program, and covers 1.1 million adults. While children are guaranteed full dental care under federal law, states are permitted to make their own decisions about dental benefits for adults. Massachusetts previously offered adults comprehensive dental care, but in 2010 the benefits were severely cut. Over the past years, advocacy has resulted in benefits being restored on a piecemeal basis.

Restoring periodontal care is major step forward in improving both oral health and general health.  Periodontal disease is a chronic bacterial infection of the gums and bone that surround teeth. When left untreated, this disease causes irreversible gum and bone loss, leading to tooth loss. It also directly impacts chronic disease outcomes including those of diabetes, heart disease, and stroke. Periodontal disease can also lead to low birth weight and premature birth.

Additionally, the lack of comprehensive adult dental coverage wastes millions of dollars in extensive and costly services in emergency and inpatient hospital settings and places an added burden on MassHealth and the Health Safety Net. In its report from August 2016, the Health Policy Commission found that MassHealth members disproportionately use ED visits for preventable oral health conditions, including periodontal disease, at a cost four to seven times the cost of a dental office visit. Non-elderly adults on MassHealth use the ED for preventable oral health conditions seven times more frequently than commercially-insured adults.

The decision to restore MassHealth coverage of periodontal treatment for adults is a major victory for HCFA and the Oral Health Advocacy Taskforce  which we lead. The Taskforce, a broad coalition of consumer groups, dental  providers and health organizations has been working on improving oral health in Massachusetts, including a focus on restoring adult dental benefits.

The budget also funds the DPH Office of Oral Health at just over $2 million, and includes a $300,000 grant to the Forsyth Institute for the ForsythKids program.

Now the Governor has10 days to approve or veto budget items. Any vetos can be overridden by a two-thirds vote of both branches.

 

 

 

 

July 18, 2018

Health Equity

 

[Update - July 26 - The Governor signed the Fiscal Year 2019 budget today, and did NOT veto either of the health equity provision. Both of the provisions described below are now a part of state law. We are very thankful to the Governor and the Executive Office of Health and Human Services for their support of these important steps forward.]

After weeks of delays, the conference committee reconciling the House and Senate budget bills released the final state budget proposal for this fiscal year. The budget includes two strong steps for health equity that we have been actively pushing for:

First the budget establishes an Office of Health Equity within the state’s Executive Office of Health and Human Services. While Massachusetts continues to lead nationally in health coverage, racial and ethnic minority residents continue to have lower rates of health care access and use in Massachusetts, and worse health outcomes.

The Office will coordinate resources throughout state government with the goal of eliminating racial and ethnic health disparities. The Office is directed to create a state health equity plan, collaborate with other agencies (including housing, transportation, environment, education and labor), and facilitate development of interagency initiatives. Following annual hearings, it will issue an annual report to evaluate progress and identify best practices.

The provision mirrors language we first drafted over a decade ago, and HCFA looks forward to working closely with the new office to advance health justice.

Second, the budget also included a provision requiring MassHealth to report on the impact of its ACOs on 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. These reports will allow policymakers and the public to assess the progress being made by ACOs, and strengthen their accountability.

This provision was a priority of the ACHI Coalition (Alliance for Community Health Integration) that HCFA plays a major role in.

The text of the two provisions is below.

July 16, 2018

Health Care For All, along with MassPIRG, Health Law Advocates, Community Catalyst and the Massachusetts Senior Action Council recently wrote a letter on the issue of drug transparency to the conferees meeting to work out a final health care bill. We urged the Conference Committee to include strong transparency measures to help tackle the problem of skyrocketing prescription drug prices.

Prescription drug costs are currently the fastest growing healthcare expense – by far. For both public and private plans, increases in pharmacy costs far outpace every other expense. Rising drug prices are increasing health care costs, placing significant burden on consumers and putting pressure on the state budget.

A major obstacle in controlling drug price growth is a lack of transparency on pricing trends, rebates, discounts, and pharmaceutical benefit managers. Actual prices paid for drugs are hidden behind a complex veil of intermediaries, and effective transparency provisions would allow the public and policymakers to understand the causes of high prices and cost growth.

We urge the Conference Committee to adopt the Senate language, which provide for more extensive disclosures and would strengthen the ability of policymakers and the public to judge if we are getting good value for our billions spent on prescription drugs. We believe that Massachusetts should join a number of other states that have enacted strong transparency requirements to further the goals of affordable care.

If you are interested in understanding the extent of these factors, read the complete letter here.

-Louis Pratt

July 10, 2018

With both the House and Senate having passed ambitious health care bills this session, now a joint House-Senate conference committee is hammering out the differences to reconcile the two bills for final passage. Health Care For All recently provided comments to the legislature on our recommendations for provisions  to reduce health care costs, protect consumers, and strengthen our state’s health care system.

While Massachusetts has the highest insurance coverage rate in the country, there is still progress to be made to improve the quality and affordability of health care in the Commonwealth. Some of the reforms that HCFA believes are important which were included in both the House and Senate bills are:

  • establishing an academic detailing program to provide independent evidence-based education that focuses on the therapeutic and cost-effective utilization of prescription drugs;
  • requiring the Center for Health Information and Analysis (CHIA) to develop and adopt a uniform methodology to communicate information on how health care providers are assigned to tiers;
  • requiring pharmacies to charge consumers the off-the-shelf price (the price people would pay with no insurance) if it is lower than their copay;
  • requiring insurers to continue coverage past age 26 for dependents with substantial disabilities.

For our full letter to the Conference Committee with detailed explanations of our positions, please click here. Here are summaries of HCFA’s recommendations regarding the legislation:

June 6, 2018

The Massachusetts Senate recently approved their version of the Fiscal Year 2019 (FY19) state budget. The Senate version and the House version must now be reconciled through negotiation between the two chambers. Health Care For All (HCFA) has a number of budget priorities related to health care that have made it this far and should continue on to the final budget.

To find HCFA’s full FY19 Conference Committee letter with detailed explanations of our positions, please click here. You can find summaries of each budget priority that HCFA supports below:

  1. Restore Coverage for Periodontal Care For Adults on MassHealth

We urge the Conference Committee to direct MassHealth to reinstate coverage for periodontic services for adult MassHealth enrollees so that they are able to get the appropriate care that they need to maintain good oral, and overall, health.

  1. Establish a strong Office of Health Equity within EOHHS, and provide funds for the Office’s operation

We urge the Conference Committee to include Section 7 and line item 4000-0009 of the House budget, which would establish and fund an Office of Health Equity to reduce the serious racial and ethnic health disparities that exist in Massachusetts.

  1. Provide expanded authority to MassHealth to negotiate for fair prescription drug prices

We urge the Conference Committee to include authority for MassHealth to seek supplemental prescription drug rebates, and require pharmaceutical pricing information from manufacturers if reasonable rebates are not provided to MassHealth. The provision should also allow EOHHS to assess penalties on manufacturers who refuse to provide the required information, or who do not offer fair rebate amounts to MassHealth.

  1. Direct MassHealth to provide information on ACO outcomes and activities addressing social determinants of health

We urge the Conference Committee to include language in the MassHealth line item (4000-0500) directing MassHealth to provide information on ACO outcomes and performance, particularly data on ACO activities addressing the social determinants of health.

  1. Fund critical children’s mental health programs

We urge the Conference Committee to fund the MHAP for Kids program at $50,000 (within line item 4800-0200).

We urge the Conference Committee provide level-funding for Return to School “Bridge” Programs at $250,000 (within the School Health Services line item 4590-0250).

  1. Preserve Sunset on Prescription Drug Marketing Coupons on Rebates

We urge the Conference Committee to maintain the state’s prohibition on drug industry marketing “coupons” by 2019 and direct the Health Policy Commission to engage in a substantive study of the long-term costs and benefits of drug coupons on the Massachusetts health care market.

  1. Provide Unbiased Information about the Cost and Efficacy of Prescription Drugs

We urge the Conference Committee to provide funding for Health Policy Commission to operate the Academic Detailing program (line item 1450-1266 of the Senate budget) at $150,000.

  1. Require data collection on pediatric continuous skilled nursing services

We urge the Conference Committee to include Section 16 of the Senate budget, which directs the Center for Health Information and Analysis and MassHealth to regularly report data about pediatric patients requiring Continuous Skilled Nursing services.

  1. Fund pediatric palliative care programs

We urge the Conference Committee to fund Pediatric Palliative Care Programs (4590-1503) at $3,816,053, to ensure that all children and families who need these services can get them.

  1. Adequately fund DPH’s Office of Oral Health and the successful ForsythKids Program

We urge the Conference Committee adequately fund the general operations of DPH’s Office of Oral Health, and continue to earmark $300,000 for the ForsythKids program (line item 4512-0500).

Each of these provisions serve important purposes in supporting health care in Massachusetts. As always, HCFA is committed to advocating for affordable and quality health care coverage. All ten of these proposals do just that.

-Brian Rosman and Davis Jackson

May 23, 2018
In the worlds of health care policy and delivery, there is increasing recognition that addressing the social determinants of health (SDOH) –access to nutritious foods, affordable housing, safe neighborhoods, dependable transportation, well-paying jobs and safety from violence—is essential to improving health outcomes, containing health care costs and addressing health inequities across race and income. In other words, health care is about even more than having insurance coverage and receiving traditional medical care. 
 
The Massachusetts Budget and Policy Center (MassBudget) recently released issue briefs on the health effects of the Earned Income Tax Credit (EITC) and Paid Family & Medical Leave (PFML). MassBudget presents research showing that both policies improve the health of individuals, families and communities by addressing economic hardship and promoting the family and social support that contribute to better health. 
 
These are live issues now. The Senate budget being debated this week includes an increase in the state EITC, as did the House budget and Governor’s Baker’s budget proposal. In addition, PFML is a proposed initiative to be before state voters this fall.
 
Each year over 400,000 Massachusetts tax filers claim the EITC, a refundable tax credit that goes to families and individuals, primarily workers with children, who have income from paid work. The Massachusetts EITC partially matches the EITC at the federal level which “keeps administrative costs and complexity to a minimum, while rewarding and encouraging work.” MassBudget found that increases in EITC payments are associated with:
 
Reduction in occurrences of low birthweight
Increased gestation time for pregnant women
Increased educational attainment for children – which is linked to better health outcomes
Improvements in children’s behavioral index scores which measure behaviors such as peer conflict, anxiousness and depression
Avoidance of the early onset of disabilities and other illnesses associated with low family income
Increased in the self-reported health of mothers  and improved blood pressure, heart rate, cholesterol and inflammation levels for these mothers
Increased prenatal care
Increased spending on healthy foods such as fruits and vegetables
Increased economic  activity in neighborhoods with a high concentration of households receiving the credit
 
A policy that allows workers to take paid time off from work to care for themselves, a new child, or a family member with a serious illness or injury, PFML influences the ability of individuals and families to live healthy lives. The MassBudget report shows that access to PFML can have both short-term and longer term health benefits across the lifespan, including:
 
A decline in infant mortality
Increased rate and duration of breastfeeding
Improved physical, cognitive and behavioral outcomes for children – including higher rates of vaccination
Decreased likelihood of behavioral and adjustment problems for adolescents and adults
Faster recovery from both inpatient and outpatient procedures for children
Fewer depressive symptoms for new mothers in the short-term and the long-term
Reduced  nursing home utilization by elders
 
Tackling the complexities of social determinants of health is essential to realizing our vision of a Massachusetts in which everyone has the equitable, affordable, and comprehensive care they need to be healthy. While we must always stand firm in protecting and expanding coverage and care, we must also identify and champion policy solutions that extend beyond this classic framework to address the multitude of factors that so powerfully affect the health of the Commonwealth.
 
-Natalie Litton

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