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Massachusetts health care – wonky with a dose of reality

August 2, 2017

State Senate Majority Leader Harriette Chandler of Worcester, co-chair of the Massachusetts Legislature’s Oral Health Caucus, is a longtime advocate for oral health and a strong supporter of Health Care For All. Today, she published an op-ed in the Worcester Telegram and Gazette. In her article, Senator Chandler highlights the barriers currently preventing many Massachusetts residents from accessing necessary oral health care services, and encourages the state legislature to take action to address these issues. We are deeply grateful to Senator Chandler for her ongoing leadership on all health care issues, particularly her deep devotion to improved oral health. Here is her op-ed:

As I See It: Closing MassHealth gap in oral health coverage

First as a representative and later as the senator for the First Worcester District, one of my priorities has always been to make sure that people have access to the health care they need and deserve. I know that many are paying close attention to what’s happening in Washington where the future of the Affordable Care Act is on the line – and with it the access to insurance and care for hundreds of thousands of residents of the Commonwealth. We are all worried, yet access to coverage doesn’t solve all the health care problems we face in the state.

There are many other battles that we need to fight to ensure that people can get the treatments and preventive care they need. Even with more than 97 percent of the Massachusetts population covered by medical insurance, many still struggle to access oral health care – which is just as important. They struggle because our fragmented system of care separates the mouth from the rest of the body. For too many, health coverage stops short of comprehensive dental care. Quite simply for them, dental services are out of reach.

Those who are lucky have two insurance cards: one to see a medical doctor and another to see a dentist. However, even with the right card, many people cannot afford the out-of-pocket expenses that accompany much needed dental services, leading many to forego this care altogether.

I recently read an “As I See It” column published in this section written by a well-respected member of our community highlighting the challenges immigrants face when accessing oral health services. In her article, Anh Sawyer, executive director of the Southeast Asian Coalition, rightfully points out the need for increased awareness and for better integration of services, although cost remains a problem.

I agree. Educating consumers about the link between oral health and chronic conditions is critical.

Under the Affordable Care Act, Massachusetts has expanded Medicaid through the MassHealth system. The new MassHealth Accountable Care Organizations are a great opportunity to integrate dental and medical services. ACOs focus on community health, and are expected to lower prices and incentivize a healthier population. However, we must do more. I see people around Worcester every day facing high barriers to getting the care they need, especially those with limited resources. Many dentists don’t accept MassHealth due to low reimbursements. Even if they can find a dentist, many critical services are not covered because of previous state budget cuts.

MassHealth has progressively restored dental benefits, piece by piece, since they were stripped a decade ago. Yet today, 800,000 individuals – including 120,000 seniors and 180,000 people living with disabilities – still do not have coverage for the treatment of gum disease, known as periodontal treatment. They also lack coverage for specific services like root canal treatments (endodontic services), crowns and bridges (prosthodontic services), and some oral surgery procedures such as the removal of benign lesions, which are currently only available to MassHealth members under age 21 or those who are eligible for Department of Developmental Services. Unfortunately, the lack of comprehensive adult dental coverage (which would include all of the services just noted) leads to pain, tooth loss and preventable high-cost emergency department usage, to name a few.

We need to restore those benefits as soon as possible, as they are causing needless pain, suffering, and illness. The legislature has an opportunity to start the process now. I am pleased that the provision to prepare a schedule and cost estimate for restoring MassHealth adult dental care was approved as part of the final Fiscal Year 18 state budget. In addition, Representative John Scibak and I filed legislation to effectively restore all full dental benefits for adults on MassHealth. He and I also co-chair the Legislature’s Oral Health Caucus – the first such legislative caucus in the nation, focusing solely on oral health issues.

August 2, 2017

Yesterday, the D.C. Circuit Court granted the motion of Massachusetts Attorney General Maura Healey and 15 other state attorneys general to intervene in the Affordable Care Act (ACA) cost-sharing reduction (CSR) lawsuit. We truly appreciate the Massachusetts Attorney General’s work on this, and we are proud of our HCFA HelpLine Director Hannah Frigand, whose affidavit submitted to the court helped prove a dispositive issue, that states could intervene because residents would be harmed by the increase in premium costs that would flow from the termination of CSRs.

AG Healey issued a statement on the importance of this case:

The D.C. Circuit Court’s ruling is a win for states and a major hit to the Trump Administration’s efforts to sabotage the Affordable Care Act. With the court’s decision, the states won the right to defend payments that help millions of Americans access affordable health insurance. As long as the Trump Administration keeps playing politics with the health of our residents, we will be there to defend access to care in Massachusetts and across the country.

As in other cases, the court took note of “accumulating public statements” by the Trump Administration threatening to withdraw from the litigation and eliminate CSRs, and so the states were permitted to intervene to protect the public interest.

Although the ACA requires insurers to provide discounts on cost-sharing (i.e., deductibles, co-pays, co-insurance), CSRs are critical to reimburse the health plans for these discounts, keeping health insurance affordable. This is particularly important for those who are not eligible for premium assistance. Their elimination would drastically increase the price of health insurance and, as a result, the uninsured rate would climb. The states demonstrated to the court that this would present a substantial monetary burden on states. After all, state-funded hospitals must provide emergency care for individuals regardless of their coverage status or ability to pay.

So while the war to maintain the ACA and improve market stability continues, we are reassured by the tireless Massachusetts Attorney General, Maura Healey, whose work helped ensure that consumer advocates will not go down without a fight.

                                                                                                                                                                          - Ben Agatston

July 25, 2017

Oral health matters. Adequate oral health reduces emergency department utilization and enhances health equity. Knowing these benefits, Governor Baker included an amendment in the proposals he sent to the legislature in connection with his budget vetoes that authorizes dental therapists in Massachusetts, a proposal we strongly support. By allowing mid-level dental therapists (DTs) to deliver basic but critically necessary care, this amendment would increase access to dental coverage for underserved Massachusetts residents. At Tuesday's hearing on the health provisions of the budget veto amendents, we urged the legislature to support the Baker administration and approve this much-needed reform:

Oral health is integral to overall health, and poor oral health is a risk factor for diabetes, heart disease, stroke and low-birthweight children. Yet, one in ten Massachusetts residents lives in a dental shortage area. As a result, about half of our children do not get annual dental care, and some 60% of our seniors in long-term care have untreated tooth decay. Qualified, trained, professional dental therapists can fill this gap by providing basic oral care in vital locations such as in schools, in senior centers, and in community health settings, all under a dentists’ supervision. Dental therapists would increase access to oral health care, improve overall health and save money.

Although almost everyone in Massachusetts has medical coverage, many struggle to access dental care. Common obstacles include the inability to find a dentist that accepts public insurance, the prohibitive cost of dental care, or challenges in traveling to a dentist’s office. Dental Therapists can help with all of these issue. Access to good dental health is major problem for low-income people in Massachusetts. Dr. Don Berwick outlined oral health disparities in the Boston Globe:

Kids on Medicaid visited emergency departments for preventable oral health problems six times more often than commercially insured children; for MassHealth adults, the figure is seven times. Over half of the residents in Massachusetts nursing homes have untreated dental decay. In 2014, low-income seniors in Massachusetts were seven times as likely to have lost all their teeth as those with means. Nearly a third of adults with special needs are missing six or more teeth.”

EOHHS Secretary Sudders also testified in favor of the proposal, pointing out that in addition to improving care, dental therapists would provide savings to the state by reducing inappropriate use of emergency rooms for preventable oral health issues:

The Health Policy Commission (HPC) has been examining some of these cost drivers including avoidable emergency department visits.  The most recent data published by HPC indicates that 40% of all ED visits could be avoided if there was greater access to care.  In 2014, there were more than 36,000 visits for preventable oral health issues, costing the state upwards of $36 million.  MassHealth was the primary payer of these oral health emergency department visits that year, paying upwards of $17 million.  Emergency department visits for oral health complaints represents suboptimal use of a very costly setting. 

DTs would work under the general supervision of a dentist, using technology to share X-rays and patient records with the dentist and consult on complicated cases. This would allow DTs to deliver critical dental services directly to people in schools, nursing homes, and other community settings.

Moreover, DTs offer low-cost interventions that could prevent more costly illnesses. They would be reimbursed by MassHealth, which would expand access to dental care for people who have some coverage but are still unable to receive appropriate oral health care.

We urge the state legislature to follow Governor Baker’s lead and prioritize the oral and overall health of Massachusetts residents by adopting the DT amendment included in the Governor’s recommended budget amendments. 

                                                                                                                                                   -- Ben Agatston

July 25, 2017

Health Care For All testified today, Tuesday, July 25th, during the public hearing held by the Joint Committee on Ways and Means and the Joint Committee on Health Care Financing on Governor Baker's proposed package of reforms to MassHealth.

We provided testimony in support for some of the Baker administration's proposals, including the authorization of dental therapists and the re-instatement of employer responsibility. However, we also expressed opposition to several reforms we found concerning, particularly policies that would disqualify over 140,000 Massachusetts residents from MassHealth, shifting them onto more expensive and less comprehensive coverage.

We have created a fact sheet detailing the specific effects these proposals would have on Massachusetts residents, which can be accessed here:

HCFA Fact Sheet

July 11, 2017

HPC Chart: Oral Health ED Visits

We smiled brightly during the Health Policy Commission’s (HPC) July 5 meeting because the agency highlighted one of our top priorities, the lack of access to oral health care. In their first DataPoint analysis, HPC found 11.5% reduction in oral health-related hospital Emergency Department (ED) visits from 2013 – 2015.

But despite this overall reduction in costly and preventable care, there was a substantial increase in oral health ED visits for elementary school aged children and adults age 55 to 84. Moreover, and perhaps most concerning, is that low-income populations accounted for a disproportionate rate of oral health ED visits.

It is unclear whether the overall decrease in ED utilization is attributable to certain demographics receiving better quality preventive care or increased access to dental services. What is clear, however, is that glaring inequities exist in dental care access, causing low-income populations to over-utilize hospital EDs.

This costly outcome occurs because we neither equip EDs to treat dental conditions nor train emergency room physicians to resolve these issues. And even if EDs could provide proper dental care, these visits are preventable and burdensome on hospitals.

Ultimately, this data suggests that that access to dental care remains elusive in Massachusetts even though coverage may in fact be increasing.

This is why we agree with Governor Baker, Secretary Sudders, and the Executive Director of the HPC, David Seltz, in their support of legislation to authorize dental therapists. This common sense policy would expand quality and access to preventive oral health care to vulnerable populations.

Dental therapists, who would reach out to patients, providing care in places like schools or nursing homes, can greatly reduce oral health-related ED utilization. After all, the patients most likely to utilize ED for dental care – children and seniors – are society’s least mobile. Dental therapists meet their needs by going to them  where they are and providing the care they need at a lower cost.

Dental therapists offer low-cost interventions that can prevent more costly illnesses. They would be reimbursed by MassHealth, expanding access to people who have some coverage, but are still unable to receive appropriate oral health care.

Legislation is pending that would allow dental therapists to practice in Massachusetts. Hearings should occur this fall. This is a key HCFA priority for this fall, and we urge you to join our campaign.

                                                                                                                                                                           - Ben Agatston

July 6, 2017

The Prevention and Public Health Fund was established in 2010 as part of the Affordable Care Act. As the nation’s first mandatory fund dedicated to improving public health, this fund has played a major role in funding prevention programs throughout the country. The current proposed legislation to repeal the Affordable Care Act would eliminate this fund.

This fund provided $17 million to Massachusetts during fiscal year 2016. The programs that benefited include programs dedicated to combating racial and ethnic health disparities, providing immunizations for children, and increasing prevention and control for heart disease, strokes, and diabetes. A new study reports that If the fund is repealed, Massachusetts will lose over $88 million over the next five years.

Preventable diseases are a major health care issue. These diseases cause an estimated 70% of all deaths, and are the main cause for around 75% of health care spending. Yet only about 3 percent of health care spending goes towards preventing these same diseases.

For Massachusetts, repealing this fund along with the ACA would mean cuts in valuable programs such as

  • vaccines for children ($3.6 million);
  • diabetes and heart disease prevention programs ($5 million);
  • lead poisoning prevention and tobacco cessation ($780,000).

The funds also supports $2.3 million to combat racial and ethnic health disparities.

Prevention programs are an important and under-utilized method for addressing these diseases. Supporting prevention programs is a fiscally responsible strategy - it's cheaper to prevent illness now than treat them later. Prevention programs help improve quality of life and reduce death rates by helping individuals combat preventable diseases.

Yet another reason to oppose the plans to "repeal and replace" the Affordable Care Act.

                                                                                                                                                           - Sean Connally

June 15, 2017

Dental-medical integration is a response to decades of historic separation between two healthcare professions. The system has adapted to delivering care to people as two independent segments – one part mouth, one part everything else. But the thing is, our mouth doesn’t know it is distinct from our body and we’re the healthiest when we understand (and respect) the connection between our oral and overall health.

Thankfully, several efforts are now underway to help bridge the divide between medical and dental care delivery to create a healthcare system that prioritizes the patient experience. These efforts were highlighted at the Legislative Oral Health Caucus this past Tuesday where oral health advocates gathered to educate legislators about the HCFA-led Oral Health Integration Project (OHIP).  During the Caucus convening, case studies from the new HCFA policy brief were referenced to examples of oral health integration work currently underway in Massachusetts and beyond. Brief snapshots of each case study are provided below.

In Oregon, dental services are included as part of the standard Medicaid benefit package with locally-governed Accountable Care Organization (ACO)-like entities called Coordinated Care Organizations (CCOs) that are required to contract with all Dental Care Organizations (DCOs) to establish their dental provider networks. The 16 CCOs receive a global budget from Oregon’s Medicaid program to deliver medical, behavioral and oral health care for a defined population in a particular service area.

In Minnesota, Hennepin Health is a county-based Medicaid ACO made up of four different organizations, including a dental clinic, that share financial risk for over 30,000 patients. Patient care coordination and focusing on prevention are fundamental parts of the Hennepin Health care model.  For example, in well-child visits for children aged 0-3, a dental provider joins the physician to provide the first dental visit and also offers preventive parent education. The ACO also has an integrated electronic health record system to assist with care coordination.

Massachusetts also has innovative examples of oral health integration. The One Care program coordinates and integrates care for patients between the ages of 21-64 with complex needs and who are eligible for Medicare and MassHealth. Dental services are included in the One Care plan, and is cited as one of the primary reasons enrollees select the plan. At the Holyoke Health Center, medical and dental services are co-located at two comprehensive health center sites and pediatric dental residents work with primary care teams to provide oral health trainings. Lastly, the Early Childhood Caries Collaborative delivers risk-based, instead of insurance-based, oral health services to children to prevent and stop cavities that begin early in childhood.

Please click here for the full version of the policy brief titled “Case Studies in Oral Health Integration from across the care delivery spectrum: Lessons learned for Massachusetts.”

                                                                                                                                                                        Neetu Singh, DMD, MPH

June 12, 2017

Vox just published an article reporting that the U.S. Senate is getting close to enough votes to repeal the ACA, and pass a health care plan that would be devastating for Massachusetts and the rest of the country.

 

Behind closed doors, Senate Republicans have worked out a path toward Obamacare repeal. The plans under discussion would end Medicaid expansion, causing millions of low-income Americans to lose health coverage. They may allow health insurance plans to charge higher premiums to people with preexisting conditions, too.

 

In other words: The emerging bill looks a whole lot like the unpopular bill the House passed last month. It creates the same group of winners (high-income, healthier people) and the same group of losers (low-income, sicker people).

 

Read the rest of the article here.

 

This is the time to double down our efforts to stop this damaging bill from moving any further. In Massachusetts, 1.9 million people rely on MassHealth, our Medicaid program. Half of all people with disabilities, 40% of all children, two-thirds of people in low-income families, and over 60% of residents in nursing homes rely on MassHealth for their care.

 

Both MA Senators, Elizabeth Warren and Ed Markey, are on the right side of the issue, but you can reach out to your relatives and acquaintances in other states, asking them to call their Senators to show their opposition to this bill.

 

Here is how:

 

Join our Friends and Family campaign!

 

June 9, 2017

Anh Vu Sawyer, Executive Director of the Southeast Asian Coalition of Central Massachusetts and Health Care For All's supporter authored an op-ed that was published today on the Worcester Telegram and Gazette. In this piece, she shares her struggle to access dental care and her take on why oral health integration is crucial to improve access to preventive care especially for the immigrant community in the state.

As I See It: Flying to Asia to see a dentist?

As a director for the Southeast Asian Coalition of Central Massachusetts, I am quite concerned about the health care disparities my constituents have been struggling with due to their cultural and language barriers. However, a recent tooth ache that almost landed me in the ER gave me an insight into one simple step that may improve people’s overall health and make healthcare accessible and effective for many, especially the Limited English Proficient populations.

In January, right before my first vacation in four years, I ended up having to get an emergency medical appointment because of a high fever. I found out that this was due to the fact that a couple of years before, two of my teeth broke. Because there was no pain at that time, it wasn’t a big deal, so I didn’t do anything about it. But less than 24 hours before my trip to Europe, one of my broken teeth became infected and I was asked to cancel my trip. “No, my husband and I have to take this trip. Many events and appointments will be cancelled if we cancel.” That’s what I told the dentist who finally gave me very strong antibiotics so that the infection didn’t spread while on vacation. But he only did that with my solemn cross-my-heart promise that I would take care of the problem immediately once I was back in the U.S.

The antibiotic had unpleasant side effects and helped me to promptly keep my promise. I went to the dentist and was told I needed two root canals among other treatments and that would cost me around $5,000. I had dental insurance, but it would only cover 10 percent of the cost. I understood then that my dental insurance wasn’t really insurance; it worked more like a discount card. This preventable infection had been not only painful for my mouth, but also for my pocket, and almost ruined my sanity (I very much needed a vacation).

I was born and raised in Vietnam but I have been in this country for over 40 years. I am an educated and accomplished woman. I lead a wonderful community-based organization in Worcester that handles almost 10,000 visits a year and helps hundreds of refugees, immigrants and low-income residents to rebuild their lives and strengthen their communities. And I am a US citizen. What a gift! I might be Americanized in many ways. But not in every way. In my culture, at least where I grew up, oral health is not a priority and you don’t go to see a dental professional unless you really have to (i.e. life or death). For many years, because of my busy schedule, being frugal, and the lack of understanding the importance of healthy teeth, I didn’t visit a dentist. And for many years, I didn’t get a regular cleaning or a checkup - “It’s OK, because I brush and floss my teeth daily,” I reasoned with myself. I had to learn my mistake the hard way.

Many of us in the immigrant community experience language, cultural and financial barriers accessing this type of preventive care. Many of my fellow immigrants forego oral health care altogether. Some go as far as traveling to their home countries to get any dental procedure because it is cheaper to travel overseas and see a dentist than crossing the street to the dental office in their neighborhood. In one of our surveys, quite a few folks mentioned the money they saved from not seeing an American dentist covered the round trip airfares that they happily used to visit families. This doesn’t make any sense.

Read the whole article here

June 1, 2017

Andrew Dreyfus, the President and CEO of Blue Cross Blue Shield of Massachusetts, just published an op-ed in The Hill, a key source of news for Capitol Hill and people following federal legislation. Dreyfus argues strongly that the Senate should reject the provision in the House-passed ACA repeal bill that penalizes people with pre-existing conditions. While economics is an important consideration, he roots his arguments in the core American values of fairness and equality. This adds a new, and important dimension to the debate in Washington:

Our nation is already struggling with enough division — economic, racial, geographic, and political. It would be both tragic and unnecessary to create a new divide between those who are seriously ill and those who are healthy. Rather than trying to fix the pre-existing condition provisions in the House bill, the Senate should take them off the table, permanently. ...

Since 2010, the ACA has guaranteed that individuals with pre-existing conditions are eligible for the same coverage as everyone else, at the same cost. My state, Massachusetts, is one of seven that had pre-existing condition protections in place even before the ACA became law. It’s arguably one of the ACA’s most popular provisions, and it has maintained broad, bipartisan support. Unfortunately, a last-minute addition to the House-passed American Health Care Act (AHCA) reopens the issue by giving states the option of once again allowing insurers to charge higher premiums for individuals with pre-existing medical conditions. The CBO found that, in states choosing this option, “less healthy people would face extremely high premiums.” The Senate should settle the matter by rejecting this provision as unnecessary and divisive.  ...

A return to charging higher premiums for people with pre-existing conditions would also reinforce the mistaken notion that serious illness stems largely from personal choice. Most illness and disability is due not to choice but to bad luck and bad circumstances — the accidents of birth and life, including genes, economic and social factors, workplace conditions, and exposure to infection and toxins. 

Dreyfus also critiques other parts of the proposal, including the deep cuts to Medicaid (our MassHealth program), and the reductions in assistance for people buying coverage through health insurance marketplaces like our Health Connector.

But he concludes that our national comittment to impartiality and equal opportunity should guide our policy:

The net effect of these provisions would be to make health insurance unaffordable for many of the older and poorer Americans who are currently insured under the ACA. Bipartisan solutions to these problems should be within reach and may emerge in the Senate. But before we tackle these problems, we should agree that, whether we are healthy or sick, we are all created equal, and our health insurance system should reflect this American principle.  

We appreciate's his forthright voice in support of fair health policy, that provides not just the healthy and well-off, but to everyone in need.

                                                                                                                                                             Brian Rosman

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