December 2010

December 31, 2010

Two major positive developments in Massachusetts health policy yesterday:

First, the legislature approved a supplemental appropriations bill (pdf) that includes $20 million in funds for the Commonwealth Care Bridge program. Without the funds, coverage would have ended on January 31. These funds should be sufficient to allow the program to operate through June, the end of the fiscal year.

The Bridge program covers around 22,000 legal immigrants who were cut off the regular Commonwealth Care program a year ago. The program has fewer benefits and higher copays than Commonwealth Care, as well as a more limited network of providers under the CeltiCare Health Plan. The Supreme Judicial Court is currently considering a lawsuit brought by HCFA-affiliate Health Law Advocates challenging the constitutionality of providing fewer benefits to some legal immigrants on the basis of their immigration status.

The supplemental appropriations bill also includes $258 million in additional MassHealth funds, including almost $50 million for the Children's Behavioral Health Initiative. This funding will allow the state to access an additional $157 million in federal reimbursements, which will support our economy and reduce the burden on the state budget. A number of public health programs also received additional funds, including $2.5 million for early intervention services for children with developmental delays or disabilities, and funds for domestic violence and sexual assault prevention, substance abuse, and suicide prevention.

Second, the Rate Review Board that is charged with setting the employer assessment that funds the Medical Security Program (MSP) met yesterday and agreed to increase the annual assessment by $16.80 per employee. The MSP statute requires the assessment to be increased whenever the current rate is determined to be inadequate to fund the program. The program anticipates a $95 million deficit, forcing the assessment increase.

The MSP program provides a lifeline to low-income workers who lose their job through no fault of their own and are on unemployment insurance. The deep recession has dramatically increased the number of people covered under the program:

Source: Division of Health Care Finance and Policy Quarterly Indicators


The assessment was originally set at $16.80 per worker annually in 1988, and was never increased for 20 years, until it was raised last year to $33.60. The increase to $50.40 approved yesterday means the assessment is still below what it would be had it kept up with the medical inflation since 1988 (which would equal around $56.41 in 2010). The fund also received a $30 million appropriation last year, and drastic cuts were made to the program's benefits. Much of the funding problem stems from the fact that almost $200 million was diverted from the fund in 2001 and 2003.

We are very grateful that the Administration and legislature acted to keep the Bridge and MSP programs operating. Both programs are in need of overhaul, and the advent of national reform through the Affordable Care Act in 2014 will allow for changes in both of these programs. For those who depend on the critical health benefits these program provide, New Year's 2011 just got a bit happier.
-Brian Rosman

December 31, 2010

We expect 2011 to be the year of cost control for Massachusetts health policy. Governor Patrick and both chambers' legislative leadership have made clear that this is priority one -- and we agree.

This means complicated proposals around ACOs, global payments, medical homes and more. Our Campaign For Better Care has released its 10 principles that we will be working towards in the upcoming year.

So for all the State House staffers, policy center thinkers and stakeholder meeting attendees looking for something good to read over the next week, we strongly recommend Achieving Accountable and Affordable Care: Key Health Policy Choices to Move the Health Care System Forward (pdf), written by Judy Feder and David Cutler for the Center For American Progress.

The report (the recommendations are summarized above), although focused somewhat on payment reform in the federal Medicare context, is a strong introduction to the key issues the state will need to confront in setting up ground rules for ACOs, either through legislation affecting all payers, or using the state's role as a purchaser of care. The report pays close attention to the consumer role in ACOs:

We believe that consumers should be active partners in improving the quality of their care. That means consumers should decide whether to join an ACO, and if they do, they should be able to count on rules for consumer protection and creative ways to benefit financially from seeking quality care at lower costs.

Read it - and use the comments to let us know what you think.
-Brian Rosman

December 29, 2010

The season of giving is almost over and there are only a few days left to donate to HCFA in 2010. Please help us provide health care education, enrollment services and advocacy that the people of Massachusetts deserve. In order to continue the important work we do and improve the quality and accessibility of health care for all Massachusetts residents, we depend on your generosity. We invite old and new friends to consider making a gift today. If you have not already made a donation to our annual fund and appreciate the work we do, please help out. Click here to make a fully tax deductible contribution. Thanks to you, HCFA’s good work can continue. -Melissa S. Freitas

December 21, 2010

As a followup to his column Saturday (and our blog report), Washington Post blogger Ezra Klein exposes the nation to the ease of using the Connector website to compare and purchase plans, by highlighting a Bay State reader's comment:

I'm a resident of MA, although I get insurance through my employer, where this year we were able to choose between a whopping two different insurance plans. Out of curiosity, I went to the website of the MA health connector, and I would recommend it as an enlightening exercise to you and any other interested readers.

If you click through a few options describing your situation, you'll get to a page that displays your choices for a health plan (if you lived in MA). It is nothing short of astounding. All the different plans are clearly arranged in a table according to the benefit level they offer, with out-of-pocket costs clearly indicated. For any given level of benefits, you can see all the companies offering that type of plan and the monthly premium. Not-so-surprisingly, it becomes perfectly clear that some companies offer a given plan at 50% higher cost than others. It's no small wonder then that competition is driving down premiums in the exchange. Now this is what a health care marketplace looks like!

Note that the ease of comparison was greatly enhanced last year when the Connector moved to standardize the plans within each coverage tier. Previously, the plans were grouped by "actuarial value," which confused prospective purchasers and made direct comparisons impossible. Now the standardized plans simplifies the comparison and promotes direct competition. We've been urging other states to learn from this and other lessons of Massachusetts as they set up their own exchanges.
-Brian Rosman

December 21, 2010

The latest edition of our regular feature blogging payment reform bring lots of great links and thought-provoking ideas to share for the end of the year - all free of charge.

-Brian Rosman and Georgia Maheras

December 20, 2010

Washington Post blogger and columnist Ezra Klein again masterfully explains the lessons of Massachusetts health reform - politics and substance - in the national context. From his latest column:

Declining Uninsurance Rate in MassachusettsThe health-reform bill President Obama signed into law this year was explicitly based on the Massachusetts reforms. The theory was this: A plan that a Republican governor could sign into law would be a plan that could attract Republican votes.

The theory was wrong. An approach to universal coverage that represented "health insurance for everyone without a government takeover" when it was signed by a Republican governor in Massachusetts was spun by congressional Republicans as the missing final chapter of "The Communist Manifesto" when Democrats tried to scale it nationally.

Given that the plan was enacted anyway, it's time to check in on how Massachusetts is doing. And the answer, basically, is pretty well. This week, the state's health and human services agency released the results of a new, independent survey examining coverage in Massachusetts. More than 98 percent - 98 percent! - of the state's residents now have health insurance, as do more than 99 percent of the state's children.

Remarkably, those numbers have gotten better in recent years, with the number of uninsured residents in the state falling to 1.9 percent in 2010 from 2.6 percent in 2008. That's very unusual. Normally, the ranks of the uninsured swell during recessions as people lose their jobs and states cut back on public programs to balance their budgets. Nationally, the number of Americans who are uninsured rose to 16.76 percent in 2010 from 14.8 percent in 2008, according to Gallup.

Klein acknowledges the continued cost problems in Massachusetts, and notes that the federal law provides some tools that can address costs:

All is not roses and waterlilies for Massachusetts, of course. The reforms didn't address a number of problems: The state had, on average, the highest health-care costs before reform, and it has the highest health-care costs today. (There are a variety of reasons for this, many of them having to do with the power of the state's renowned hospitals.) Waiting rooms were overcrowded before, and they're overcrowded today. And there are places where the reforms didn't work as hoped. Predictions that expensive emergency room visits would drop now that people could go to the doctor have not been borne out.

The national law is better on at least some of those counts. It has provisions to expand the medical workforce, particularly the ranks of general practitioners. It has a slew of cost-control efforts, including a tax on expensive health insurance plans, an independent board able to make cost-cutting reforms to Medicare, a vast array of changes to the health-care delivery system, changes designed to get us away from paying for volume and toward paying for quality and much more.

-Brian Rosman

December 15, 2010

Our health care system is complicated. Several new legislators and their staffers came to understand that even more today as they participated in HCFA’s incoming legislator briefing here at 30 Winter Street. Representatives Geoff Diehl, Russell Holmes, and Paul Brodeur, as well as staffers representing Senator Dan Wolf, Representative Chris Walsh, and Representative Jim Lyons took part in a two hour overview of the Massachusetts’ health care system.

Running the gamut from private insurance and public programs to care for children and seniors, these newly-elected legislators and their aides asked HCFA staff questions regarding coverage options available to individuals and families of various income levels, how different policy proposals could impact our state budget, and about ways to assist their constituents navigate our health care system to ensure they have affordable access to care.

Following the briefing, legislators and staff engaged in informal conversations with HCFA coalition leaders in order to drill deeper into areas including prescription drugs, mental health, and payment reform.

Over the next two years, health care will likely to dominate the policy agenda at the State House. Legislators will have to make difficult and important decisions that will have long-term consequences for many in the Commonwealth. Today’s briefing was hopefully just the first step in establishing relationships between HCFA and these new legislators and their staffs as we work together to improve our health care system and make it work well for all our residents.
-Matt Noyes

December 15, 2010

Two of our close partners, Linda Landry of the Disability Law Center and Sarah Anderson at Greater Boston Legal Services wrote this response to the Boston Globe series on SSI. Here's their guest post:

When did providing health insurance to kids with disabilities become a bad thing?

After all, the state is just celebrating the recent news that in 2010, 99.8% of Massachusetts children had health insurance coverage. This includes kids with disabilities who receive SSI. This insurance is provided on sliding scale, starting with free coverage for the poorest children and families. Providing access to health care for children makes good public policy sense. Massachusetts has worked for decades to achieve this goal of insuring all children. Access to appropriate health screenings and treatment may prevent the development or worsening of conditions that will later prevent a child from becoming a tax paying adult citizen of the state. It's easy to discount invisible disabilities like mental health conditions, but these deserve identification and treatment as well. Thanks to advances in medicine, it is increasingly possible to identify and treat some mental health conditions earlier in life, This can help children maximize their potential and mitigate the effect of potentially lifelong disabling conditions in adulthood. The goal is not to label children as disabled, but rather to identify potential barriers to functioning and provide access to appropriate means of addressing the condition. In some cases, this means medication. Indeed, some conditions, like speech problems must be treated early for the best effect to avoid the formation of less effective neurological pathways that may be more difficult and more expensive to treat later.

This week’s Globe series on SSI leaves the impression that it is easy to qualify children for SSI disability benefits and that parents must medicate their children to qualify. Neither of these is true. The SSI program for children requires medical evidence of a diagnosis, but to get benefits a child must show that she is functioning at least 50 - 70% below what is expected of same age children without disabilities in two areas of childhood functioning.

The SSI program does not require children to take medication in order to qualify for benefits. However, the Social Security Administration, SSA, does want to see that children are involved in treatment that is appropriate for the condition and the individual circumstances. This is one way SSA works to prevent applicants from receiving benefits for conditions that, when treated, are not disabling. The Globe series leaves the impression that there is something wrong with providing benefits to children with invisible disabilities like mental health conditions or DHD. But, no diagnosis in and of itself, qualifies as a disability for SSI, without an investigation how the condition affects the child’s ability to function - at home, at school, or with their friends. It’s time to celebrate health care for all kids, not bash the program that makes it possible for kids with disabilities to get the care they need.

Linda Landry, Disability Law Center and
Sarah Anderson, Greater Boston Legal Services

December 14, 2010

The QCC is meeting this Wednesday, December 15, 1-3pm, 1 Ashburton Place, 21st floor.

The agenda (pdf) includes reports from the committees (cost containment, quality and safety, communications and transparency, and payment reform), an update from the administrative director on the annual report, a preview of a report on the MOLST (Medical Orders for Life Sustaining Treatment) project and the recommendation for statewide implementation, a report from the Advisory Committee regarding payment reform recommendations, and a discussion about forming an expert panel on communications relating to the website.

There will be a closed session at the end of the meeting to review and approve updated cost and quality data for the website.

December 14, 2010

2010 Uninsurance Rates by Age

For us at HCFA, the report of the continued increase in insurance coverage cheered us yet again. The 2010 Massachusetts Health Insurance Survey from DHCFP reported the extraordinary finding that 98.1% of all Massachusetts residents have coverage, a statistically significant increase from last year's level of 97.3% (full report (pdf); 1-page summary (pdf); press release).

Just 120,000 Bay Staters are uninsured. The study found higher uninsurance rates among those under age 25, people with low income, and Hispanic residents.

But for us, the finding that 99.8% of all children had coverage took our breath away. Children have always been a special concern of HCFA. HCFA fought in 1991 for expanding coverage to all kids under 6, and then started the Children's Health Access Coalition in 1995, in response to the closing of kid's eligibility for coverage. In 1996 and 1997 we were central in expanding coverage for all kids up to age 18, and our law became the model for the federal CHIP law. In 2002 we were one of few non-profits nationally to host the Covering Kids and Families project, and last year we received a federal grant to help enroll every uninsured child in the Commonwealth.

So today's historic news of virtually universal coverage for children in Massachusetts rewarded all of our hard work over the past 2½ decades. As we mark the end of HCFA's 25th anniversary year, we could not ask for a better present.
-Brian Rosman

December 11, 2010

The long-delayed quarterly "Key Indicators" report, dated August 2010, was just released by the Division of Health Care Finance and Policy. The report provides a statistical snapshot as of March 31 for insurance coverage, premiums, hospital and health plan performance and other health care data.

Among the highlights is renewed growth in overall insurance coverage. The total number of newly insured residents since implementation of health care reform in June 2006 was 410,000 as of March 31, 2010. About 16,000 more people were covered on that date than were covered on December 31, 2009. As one would expect during a recession, most of the growth was in MassHealth coverage, although employer coverage increased by approximately 2,000 during the quarter. This contrasts with the previous quarter, which saw a decline in employer coverage. The Medical Security Program, which covers low-income people receiving unemployment benefits, continued its steep rise. Enrollment over the three months grew by almost 5,000 people, a 14% increase.

The first quarter of calendar year 2010 data also show large improvements in health plan "medical loss ratios," meaning a higher percentage of health plan spending is going towards medical services. This was matched by a decline in health plan profit margins, with the median plan losing money. However, quarterly results are not fully indicative of full-year performance. More hospitals showed a loss than the same quarter last year as well.

Apparently this report was prepared 4 months ago, and was awaiting release since then. We urge the administration to push out all data without delay. The November report, which would cover data up through June 30, is already late. We hope it is released by the end of the year, so that the researchers, analysts, advocates, the press, policymakers and the public can better evaluate our health care system performance and guide efforts to improve health care in Massachusetts. It would be helpful if the Division could publish an advance schedule of the expected release dates of its various reports and publications.
-Brian Rosman

December 10, 2010

Today’s Connector Board meeting (materials here) included updates on the provider search tool, student health plans and the Commonwealth Care Bridge program for legal immigrants.

The meeting started off with a quick update on the CommChoice seal of approval process. The Connector has reached agreement with all seven carriers on the terms and conditions for the first six months of 2011.

The Commonwealth Care Bridge program will continue through January 2011. Secretary Gonzalez indicated that the Administration has identified resources that could be used for funding the program after January and they are working with the Legislature to get an appropriation to extend the program beyond January.

Much of the meeting was spent discussing the new provider search tool for the CommChoice website. The goal of this tool is to make it easier for shoppers to evaluate whether their providers are within carrier networks. The tool will allow people to search for hospitals and physicians (other providers should be coming on line in the future). The provider search tool launches in March 2011.

The meeting ended with an update about Student Health Plans (check out the HCFA blog post for background on the 2009 Report on these plans). For the 2010-2011 Academic Year, the Connector worked to improve the benefits while maintaining a modest price increase (15% benefits increase for 5% price increase). There are two tiers: one for Community Colleges and one for State Universities. The Community College plan does not include prescription drugs, but the State University program does- this is because the plans were improvements on the existing student plans in those systems. There was some discussion about how to improve the Community College plan because it still seemed inadequate to some. For the renewal, the contract will include the UMass campuses, which will double the number of students in these plans and hopefully continue to continue the benefit improvement, including enhanced wellness programs.
-Georgia J. Maheras