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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

May 17, 2016

What is Parity? And what does it mean for kids?

Children's Mental Health CampaignYou may have heard of Mental Health Parity, but what exactly does it mean?  When talking about parity in mental health care, we mean fairness with regard to health insurance coverage. The goal is that with fair insurance coverage of mental health and addiction services, there will be better access to treatment which will lead to improved health. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or the Federal Parity Law) requires most health plans to cover the mental health and substance use disorder benefits they offer in a comparable way to physical health benefits the plans offer.  MHPAEA does not require health plans to provide mental health or substance use disorder benefits, but if a plan does offer these benefits, it must do so in a fair way when compared to physical health benefits. Some health plans are exempt from the Federal Parity Law, including Medicare and TriCare (military health benefits).

For the 17.1 million children with behavior health needs living in the United States, Mental Health Parity is critical to ensuring kids receive the treatment they need. Limited and inequitable coverage of Mental Health services is not only a financial burden for families struggling to pay for appropriate services for their children, but it also contributes to the pervasive stigma that surrounds mental health conditions.

The Rules

The Federal Government has issued regulations which help explain how health plans must comply with the Federal Parity Law. There is one rule for private health insurance plans (such as plans offered by private employers to their employees) and another rule for the public health insurance programs Medicaid and the Children's Health Insurance Program (CHIP).  In Massachusetts, Medicaid and CHIP plans are both referred to as MassHealth. The Federal Parity Law does not apply to all  MassHealth members, but only to those in MassHealth Managed Care Organizations (MCOs), the CarePlus plan and MassHealth Family Assistance (CHIP plan). One important aspect relating to children is that for CHIP Plans, if the CHIP plan offers Early and Periodic Screening, Diagnosis and Treatment (EPSDT), the plan will be deemed in compliance the Parity Law.  While there are separate rules for private and public health plans, there is a lot of overlap between the rules. If you are interested in learning more about the details of the law, click here to read more.

The Children’s Mental Health Campaign’s goal is to help improve Massachusetts mental health care system for children.  Health Law Advocates is assisting in this effort by ensuring that Parity Law gets enforced.  If you live or work in Massachusetts and think you or someone you know has experienced a mental health parity violation or your insurance plan has denied you coverage of mental health or substance use disorder services, please contact HLA, at (617) 338- 5241 or (888) 211-6168 (toll-free number).  You can also visit the HLA's website at www.healthlawadvocates.org/.   To learn more about HLA's Children’s Mental Health Access Project, which includes our Juvenile Court Advocacy Project, click here.


May 6, 2016

Closing the SNAP Gap is a top priority for the Healthy Food, Healthy Homes, Healthy Children (HHH) Coalition and Health Care For All and we were thrilled to see Children’s HealthWatch’s letter to the editor in the Boston Globe on the importance a combined MassHealth/Supplemental Nutrition Assistance Program (SNAP) application.

What is the SNAP Gap? The difference between 1.356 million MassHealth enrollees who are likely SNAP eligible and the 785,000 MassHealth enrollees actually receiving SNAP.1 Or, to put it another way: Roughly 570,000 MassHealth enrollees who are likely eligible for, but not receiving SNAP benefits.


Common app needed for MassHealth and SNAP

MAY 06, 2016

We are glad to see the Globe acknowledge the need to better coordinate health care (“A necessary prescription for MassHealth,” April 29). Hopefully, accountable care will lead to both healthier patients and cost savings. We recommend an additional prescription.

Permitting low income families to file for both Mass-Health and the federally-funded nutrition (SNAP) benefits simultaneously is key. A common application would reduce administrative red tape for families and improve the health of young children. Children’s HealthWatch research shows that young children enrolled in MassHealth who received SNAP were more likely to be food-secure and in better health than children eligible for, but not receiving, SNAP.

Many families eligible for one public assistance benefit are often eligible for others as well. A comparison of SNAP and MassHealth data by the Mass Law Reform Institute suggests a “SNAP Gap” of roughly 600,000 very low-income MassHealth recipients eligible for SNAP but not enrolled. This is due, in part, to difficulties navigating multiple government agencies. Families often submit duplicate documentation to access a disjointed patchwork of programs. Massachusetts should seize the opportunity and offer families a common application portal.

Dr. Megan Sandel

Richard Sheward

Children’s HealthWatch, Boston


Massachusetts is a national leader in health services and access to care, but staying well requires more than health insurance. SNAP significantly decreases families’ food insecurity which is an established health hazard that can lead to poor health and hoptilizations.2 Research shows that SNAP improves health outcomes and reduces health costs.3

SNAP is a 100% federally funded benefit. Over 500,000 Massachusetts residents are eligible for but not receiving SNAP. MA is leaving federal dollars on the table that could be feeding low income Massachusetts residents and improving their health.

Under the leadership of Representative Livingstone, and advocacy from the Massachusetts Law Reform Institute and HHH Coalition, the House budget included   an amendment to study the feasibility of creating this combined application. We will work through the Senate budget process to further push this important effort forward.


1 October 2015: EOHHS reported 1.8 million Masshealth enrollees, DTA reported 785K SNAP enrollees. Of the 1.8M Masshealth enrollees, 200,000 were “temporarily enrolled.”  MLRI evaluated Masshealth and SNAP participation data for October 2015. MLRI determined the “likely SNAP eligible” by counting Masshealth enrollees under 200% FPL in Masshealth Standard, CarePlus, and Commonhealth, and excluding temporarily enrolled, long term care and immigrant ineligibles.

2 Children’s Health Watch, The SNAP Vaccine: Boosting Children’s Health, February 2012, pp.1-2

3 Gunderson, Craig and Ziliak, James P., Food Insecurity and Health Outcomes, Health Affairs, 34, no. 11 (2015), pp.1830-9.

May 4, 2016

Children's Mental Health CampaignMay is Mental Health Awareness month and to celebrate, the HCFA blog in partnership with the Children’s Mental Health Campaign will be posting a series of blogs about children’s mental health throughout the month to raise awareness. 

The Children’s Mental Health Campaign (CMHC) is a coalition of families, advocates, health care providers, educators, and consumers from across Massachusetts dedicated to comprehensive reform of the children’s mental health system. The Coalition is led by five partner organizations - the Massachusetts Society for the Prevention of Cruelty to ChildrenBoston Children’s Hospital, the Parent/Professional Advocacy League, Health Care For All, and Health Law Advocates - and includes more than 140 supporting organizations across Massachusetts. 

The Campaign has received a grant from the C.F. Adams Charitable Trust for a 3-year project whose goal is to develop a better understanding of the factors which contribute to pediatric psychiatric "boarding" and ultimately, to successfully advocate for solutions. Boarding occurs when a person in the Emergency Department (ED) requires inpatient care, but there are no appropriate psychiatric placements available, leading to longer stays in hospital EDs or on non-psychiatric medical units. To learn more about the campaign’s boarding project and advocacy efforts in general, visit www.childrensmentalhealthcampaign.org or follow us on Facebook and Twitter.

Below is Linette's family’s experience with boarding:

Creating a Supportive Village for Families in Crisis

By Linette Murphy

Linette Murphy connected with PPAL (Parent-Professional Advocacy League – a leading voice in Massachusetts for children’s mental health) several years ago when her daughter had been waiting weeks for a hospital bed. She has been involved with PPAL ever since and is also a voice for Children's Mental Health Week as she runs a Facebook group called "Where's Your Ribbon?"

Having a daughter with a significant mental health diagnosis has deeply affected our family. Our daughter, and by extension, our entire family endured the traumatizing experience of being medically boarded in an emergency room for 21 days while waiting for a pediatric psychiatric placement. 

“Boarding” occurs when a patient goes to the emergency department in a mental health crisis and waits in the ED for more than 12 hours for appropriate care, in many cases for a placement in an inpatient psychiatric unit.
Our daughter was turned down by every inpatient psychiatric hospital in New England, and even some as far away as Virginia, time and again for 3 weeks.  While this was an incredibly frustrating ordeal, I have chosen to remain positive. In many ways, my family was blessed throughout this traumatic experience of childhood psychiatric boarding.  During the days, and weeks of waiting, I turned my anger at the broken system into social media posts where I wrote about our experience.  It was with my online community that I began educating others about the issues within the mental health systems as well as built compassion amongst my friends and family.  I refused to feed into the stigma, to hide, or to ashamed of what my daughter was facing.  I chose to be open and honest and have the strength to have real conversations about the issues my family was dealing with. I knew that by giving voice to our struggle, we were breaking down stigma and barriers for other families.
I was fortunate to have family support and relied on them to try to maintain a sense of normalcy for my other child. My community was also incredibly supportive as they set up a Meal Train, brought meals to the house every other day for over a month and put together gifts to bring to the hospital. Other moms who had experience with boarding with their own children visited and brought coffee, and sat with my daughter long enough for me to take a shower. One insisted I take a break from the stress and took me out for lunch.  When these parents had to return home and take care of their own families, yet more friends took turns taking care of my other child, making sure he got to school and his extracurricular activities. They had slumber parties, even on school nights, with their own children so that my son was taken care of while I lived in the hospital with my daughter. My support system helped me to keep going when I no longer had the strength to fight the system anymore.

May 3, 2016

For The People 2016

Today's Boston Globe highlighted the new look to HCFA's signature fundraising event, For The People, tonight, Tuesday, May 3 at 5:30 at 60 State Street, Boston.

Tickets are still available at FTP2016.org. Please join community members, graphic artists and thought leaders to create visions of Patient Centered Care. Celebrate Health Care For All and share your story. HCFA's annual fundraising event will include opportunities for networking while enjoying cocktails and appetizers.

Here's the Globe's take:

A conversation fit for a gala

Another gala bites the dust.

Like many other nonprofits, Boston-based Health Care for All has traditionally held a fund-raising gala each spring, replete with mass-produced food and glossy programs.

But now, fed up with the high cost and high tedium of those events, it’s joining the un-gala movement.

Tuesday night’s Health Care for All spring fund-raiser will have no sit-down dinner, no auction, no printed programs. The crowd will be smaller — 250 to 300 people, versus 550 — and only drinks and hors d’oeuvres will be served. Tickets will be cheaper, too, at $150 a seat (down from $250).

And here’s the big twist: Attendees will be encouraged to participate in small-group discussions about health care issues. They’ll be “guided conversations” led by bigwigs.

“Conversation starters” and “discussion moderators” will include notables such as Community Catalyst COO Jacquie Anderson, Blue Cross Blue Shield of Massachusetts CEO Andrew Dreyfus, Iora Health CEO Rushika Fernandopulle, Health Policy Commission executive director David Seltz, and Dr. Joel Weissman of Brigham and Women’s Hospital.

“No one will be waiting for a meal to be served or enduring a two-hour stage program,” says executive director Amy Whitcomb Slemmer.

That’s music to gala community ears.


April 18, 2016

Last week, the state House of Representatives unveiled their draft proposed budget for fiscal year 2017 (which begins this July 1). Like the Governor's proposal, the House budget proposes spending just under $40 billion, with about $15.4 billion going to MassHealth, a increase of below 5% (note that in figuring the cost to the state for MassHealth, one needs to subtract from the $15.4 million appropriation the some $7 billion in federal Medicaid revenue that we receive as a result of our MassHealth program). The budget proposes no major cuts in eligibility or benefits for MassHealth, though it also does not restore adult dental benefits eliminated a number of years ago. A major House initiative funds expanded steps to combat opiate abuse, with a 65% increase in funding for these services over the past 5 years.

Representatives have proposed over 1300 amendments to the budget, which will be voted on the week of April 25. HCFA is supporting a number of these amendments. We urge you to contact your Representative and urge support for the amendments on this fact sheet (pdf), or listed below:

Protect Health Safety Net Eligibility & Funding

The Health Safety Net (HSN) reimburses hospitals and community health centers for providing care to low-income uninsured and underinsured Massachusetts residents. Recent eligibility cuts and funding reductions impose barriers to care for individuals without access to affordable health coverage.

  • Support Rep. Barber’s amendment (#1119) to protect Health Safety Net eligibility and continue investing $30 million in the program, ensuring continued access to care for low-income uninsured and underinsured residents.

Close the SNAP Gap

Most MassHealth recipients are eligible for SNAP (food stamps), but the number of MA residents that get SNAP is just 41% of those with MassHealth.  A common application will reduce application barriers and help close the “SNAP Gap” in Massachusetts.

  • Support Rep. Livingstone’s amendment (#1041) to create a common application portal to allow MassHealth applicants and recipients to also apply at the same time for federal SNAP nutrition assistance.

Healthy Food for Families in Motel Shelters

Even when a family is eligible for food assistance, they often do not have access to cooking devices other than the microwave, no cold storage, and no convenient way or healthy place to purchase food.

  • Support Rep. Scibak’s amendment (#943) to create a working group to find ways to provide meals to homeless families temporarily housed in hotels and motels.

Ensure Access to Oral Health Services for People with Disabilities

Individuals living with disabilities have particular oral health needs, including adaptive facilities and equipment, as well as providers with specialized training.

  • Support Rep. Garlick’s amendment (#571) to allocate an additional $500,000 for the dental program for individuals with intellectual and developmental disabilities (line item 4512-0500). 

Invest in the Office of Oral Health

Charged with preventing dental disease and improving oral health in all Massachusetts communities, the Office of Oral Health at the Department of Public Health (DPH) is an essential component of our state’s public health infrastructure.

  • Support Rep. Scibak’s amendment (#1057) to adequately fund the DPH Office of Oral Health (4512-0500).

Provide Unbiased Prescription Drug Information to Doctors

Drug company promoters market their drugs directly to doctors by providing biased information touting their most expensive drugs. To counter this, trained educators can offer objective evidence-based information to educate doctors on cost-effective uses of prescriptions, lowering the cost of health care.

  • Support Rep. Benson’s amendment (#698) to fund "Academic Detailing," the physician education program on cost-effective prescription drugs.

Ban Drug Company Marketing “Coupons”

April 12, 2016

According to the leading crowd-sourced online encyclopedia, the traditional gift for a tenth anniversary is tin. So here's a brief bulletin on how folks marked the tenth anniversary of Governor Romney's signing of Chapter 58, the Massachusetts health reform law.

WBUR's Martha Bebinger was one of the go-to reporters covering health reform in 2005 and 2006. Today, she produced a 6-minute report on people's reactions to the law, talking to ordinary people, including Madelyn Rhenisch, the first enrollee in Commonwealth Care, who calls her insurance coverage "a lifesaver."

Also from Bebinger and WBUR is a handy list of "12 Things to Know" on the law's anniversary, with source links. My favorite: "Three-hundred and twenty fewer people died in each of the first four years of mandatory health insurance in Massachusetts." Appended to the list are 13 short essays on law's birthday, from across the spectrum of views. Among those writing are Nancy Turnbull of the Harvard School of Public Health, Jon Hurst of the Retailer's who critiques the merging of small groups with the individual market, and Elizabeth Browne, of the Charles River Community Health Center, on the need for a renewed focus on primary care. And, WBUR's Radio Boston included a discussion on the legacy of the law, with HCFA Executive Director Amy Whitcomb Slemmer lined up with Jon Hurst.

10 YEARS OF IMPACT: A LITERATURE REVIEW  OF CHAPTER 58 OF THE  ACTS OF 2006For the more wonky among us, the Blue Cross Foundation released a comprehensive bibliography of dozens and dozens of studies looking at Massachusetts reform. In addition to the detailed compendium of studies, prepared by Kelly Love and Robert Seifert of the Center for Health Law and Economics at the University of Massachusetts Medical School, there's a fact sheet summarizing the findings. Some highlights:


  • Massachusetts became the state with the highest rate of insurance coverage soon after 2006 and maintains that status today.
  • The coverage gap among racial and ethnic groups narrowed post-reform.


  • Coverage expansion led to overall improvements in access, but gains were uneven across different groups.
  • Unmet need among Latino, black, and middle-income individuals and those in fair or poor health continued to be a challenge post-reform.


  • The overall use of preventive care in Massachusetts rose, but increases in the use of specific preventive care screenings varied.
  • Hospital readmission rates rose slightly in the early years post-reform; readmissions for some diagnoses, such as substance use disorder treatment, grew while readmissions for others, such as psychoses, fell.


  • Health care reform has been associated with overall improvements in health, particularly for people of lower incomes.
  • The greatest gains in health status were among racial and ethnic minorities, women, those with low incomes, and adults ages 60 to 64.


  • Chapter 58 helped reduce financial distress, most significantly among people who had limited access to credit markets pre-reform.


  • Immediately following 2006, increased coverage contributed to fewer reported problems paying medical bills, particularly for low-income adults.
  • Chapter 58’s individual mandate made insurance more affordable for those purchasing it individually, by bringing healthier people into the pool across which costs are spread.
  • Overall, however, Massachusetts has not escaped the long-term national trends in health care costs, and affordability challenges remain. A significant percentage of insured Massachusetts residents continue to report that health care spending causes them financial problems, that they go without needed care because of health care costs, and that they are worried about their ability to pay medical bills in the future.

Finally, former HCFA ED John McDonough blogged today with his take on the anniversary. John marveled at the strange evolution of conservative opinion on health reform, reminding us first, that the conservative Heritage Foundation spoke warmly of the policies embodied in our bill at the signing ceremony 10 years ago; and second, that this all changed with the advent of Obama and the ACA. He concludes,

April 11, 2016

Ten years ago today, April 12, 2006, we all made history in health care. Just look (and you can click on the picture for the video):

Romney signing the health care law - Click to see the signing ceremony video

Since 2003. HCFA had been working on assembling a broad coalition in support of what was originally known as just Chapter 58, and later “RomneyCare.” Looking ahead then, we figured that 2006 was going to be the year of opportunity. We built the ACT! (Affordable Care Today) coalition of religious activists, the health care industry (hospitals, doctors, community health centers, insurers, nurses and more), labor unions, citizen activists and political leaders that really did make history. What’s more, the coalition stayed together after the reform law passed (becoming ACT!! – or, Act 2), and continues to be a force for effective implementation of access programs.

RomneyCare and Obamacare as identical twins?This cartoon overstates it – RomneyCare and ObamaCare are not identical twins (contra an exuberant Jon Gruber, and more on this below). But there’s no question that our achievement became the template for the ACA, and we would not have over 20 million more people nationally with insurance, and additional millions with more affordable coverage, without our law's success.

Another Anniversary

Today also marks another important anniversary. Exactly nine years ago, on April 12, 2007, the Connector Board approved its premium schedule for subsidized people in Commonwealth Care (now called ConnectorCare). The fight over the level of premiums was the first major implementation battle. We worked closely with the Greater Boston Interfaith Organization to bring real family budgets to the discussion, demonstrating the tight finances of low-income people struggling with the high cost of living in Massachusetts. We were pleased that, in the end, on 4/12/2007, the Connector board ended up agreeing with us. As we said then, “We have achieved affordiosity.” These affordable premiums, along with no deductibles and modest copays in the subsidized plans, led to a surge of enrollment, bringing the coverage rate here up to around 97%.

But when the ACA was being designed, they deviated from the Massachusetts experience. Subsidized Obamacare plans have much higher premiums, and included deductibles and larger copays. In large part, this was due to the need for Congress to meet overall federal spending targets. The result is a stark difference in affordability:

Higher premiums under the ACA

We think this explains in part why Massachusetts enrollment has been better than the rest of the country - even states that have expanded Medicaid. The next frontier for Obamacare after Obama is more affordable coverage for low income people.

Still More To Do

We’re not done, though. This call from the Blue Cross Foundation points to continued challenges for all of us:

Health Reform at 10: Still must address access and affordability gaps

March 25, 2016

Safety Net

Yesterday, the legislature began a process to extend a temporary reprieve to low-income residents concerned about planned cuts to their access to health care.

Last month, the Executive Office of Health and Human Services (EOHHS) proposed changes to regulations governing the Health Safety Net (HSN) program. The HSN provides payments to hospitals and community health centers (CHCs) for providing care to low-income uninsured and underinsured Massachusetts residents. The program is primarily funded by an assessment on hospitals and insurers.

The proposed changes would significantly impact both the Commonwealth’s residents who rely on the program and providers who care for these residents by:

  • Reducing overall eligibility from 400% of the federal poverty level (FPL) to 300% FPL;
  • Charging deductibles for HSN users at or above 150% FPL (instead of 200% FPL); and
  • Limiting retroactive coverage to 10 days prior to application (instead of 6 months).

These cuts were scheduled to take effect on April 1, but are now being delayed until June 1 thanks to advocacy efforts. Also, the Governor’s proposed FY2017 state budget also does not include the customary $30 million investment in the HSN program.

Consumer advocates, hospitals and CHCs testified at the public hearing on February 26th in opposition to these changes. You can read the ACT!! Coalition’s comments here.

Dozens of legislators have also taken up the fight to preserve current HSN rules and funding. Yesterday, the Senate unanimously voted to approve an amendment to a FY2016 supplemental budget bill to preserve current HSN eligibility rules through June 30, 2016. The bill now must be reconciled with a House version that does not include the HSN provision, before enactment in both chambers.

We urge the Legislature to include this amendment in the final version of the FY2016 supplemental budget and the Administration to accept the budget language, and reconsider the proposed changes to the HSN program.

              -- Suzanne Curry

March 24, 2016

Boston Globe headline: Drug bill calls for student screening

Last week Health Care for All stood with policymakers, law enforcement, families, and advocates to watch Governor Baker sign Massachusetts' comprehensive opioid bill into law. It was an emotional yet hopeful moment as the Governor said “May today’s bill passage signal to you that the Commonwealth is listening and we will keep fighting for all of you.”

The new law has several key provisions aimed addressing the opioid epidemic including:

  • Limits on first-time prescriptions for opioid drugs to a seven-day supply, with exceptions for treating cancer or chronic pain.
  • Requiring doctors to check a state Prescription Monitoring Program (PMP) each time they prescribe an addictive opioid
  • Establishes civil liability for anyone administering the anti-overdose drug naloxone
  • Allows patients to fill a lesser amount of an opioid prescription.
  • Establishes a drug stewardship program to dispose of unneeded drugs and allows patients to fill a lesser amount of an opioid prescription.
  • Requires that a mental health professional provide a substance abuse evaluation to anyone who enters the emergency room suffering from an opioid overdose within 24 hours

The Children’s Mental Health Campaign, which HCFA helps lead, is proud to have worked hard to make sure prevention is central to the conversation around substance abuse. The campaign worked with Massachusetts State Senator Jennifer Flanagan to include a provision within the legislation that establishes a process for schools to verbally screen students to identify those at risk of drug addiction. This set of tools, called Screening, Brief Intervention, and Referral to Treatment (SBIRT), helps identify alcohol or drug use and guides follow-up counseling and treatment if a problem exists. With adolescents, SBIRT is an effective prevention and early intervention strategy.

HCFA and the Children's Mental Health Campaign will be closely following the implementation of this important strategy to improve the health of children in Massachusetts.

       -- Jamie Gaynes

March 23, 2016

This. The headline above topped the Blue Cross Blue Shield Foundation's annoucement of the latest results from the Massachusetts Health Reform Survey. The sobering report has some good news - overall, coverage is still very strong in Massachusetts, with 95.7 percent of nonelderly adults reporting having insurance.

But the report is newsworthy for the challenges it lays bare. Just having an insurance card is not nearly enough.

Almost half of insured adults (46.9 percent) reported a major access challenge: 1) difficulty finding a provider that would accept their insurance; 2) difficulty finding a provider that was accepting new patients; or 3) difficulty getting an appointment with a provider in a timely manner. Of these, 37% did not get needed health care in the past year.

Also, more Bay Staters reported going without care due to costs than in previous years. While this figure is 12.6% for those making more than 4 times the poverty level, it's 28% for those earning below 138% of the poverty level (around $16,200 annual income for an individual). We suspect many of these people are not in the MassHealth program, which has virtually no cost sharing, but are in employer plans with co-pays and deductibles that put a strain on low and moderate income people.

The situation is worse for those with a health limitation or a chronic health condition:

Health status and income affect ability to get care

HCFA is supporting the "No Copay" bill that would eliminate cost sharing for high-value preventive care treatments for chronic disease, like asthma inhalers or insulin for diabetics. This would go a long way in helping people with chronic conditions afford their care and prevent expensive acute episodes.

The survey also asked about dental coverage for the first time. Around 69% percent of us have dental insurance that includes coverage for routine dental care, leaving almost a third of the state without good dental coverage. We know that oral health care is integral to overall health, and we are working to make sure that the next generation of coverage and care coordination systems fully integrate oral health along with medical care. 

     -- Brian Rosman