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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

July 30, 2015

Medicaid started in Mass in 1966

Happy Birthday, Medicaid and Medicare! Today is the 50th anniversary of the signing of Social Security Act of 1965 which created both programs. Massachusetts has had a particularly important role in influencing the evolution of Medicaid at the federal level and among the states. In honor of the day, the Blue Cross Blue Shield Foundation created a spectacular interactive timeline to showcase major milestones in Medicaid history in Massachusetts .  Notably, many of the expansions and innovations of the past 30 years are the result of the advocacy legacy of HCFA.   

Under Governor John Volpe and Lieutenant Governor Elliot Richardson, Massachusetts became the 23rd state to implement Medicaid in 1966, originally covering about 380,000 adults and children. In 1972, Massachusetts became one of 35 states to make all Supplemental Security Income (SSI) recipients eligible for Medicaid.  In the 1980’s, Massachusetts Medicaid expanded to cover many services and groups including:

  • medically necessary abortion services
  • home and community-based long-term services and supports to residents who would otherwise require institutional care
  • coverage at the maximum income level allowed under federal law for older people and people with disabilities with incomes up to the federal poverty level
  • pregnant women and children under age 8 with income below 185 percent of the federal poverty level

The timeline also highlights Chapter 203 of 1996, which expanded Medicaid to serve all children under age 19 with family incomes below 133 percent of the federal poverty level and to cover children under 12 with family incomes up to 200 percent of the federal poverty level. Our leadership led directly to Senator Kennedy conceiving of and pushing the federal CHIP program, which now covers almost 6 million kids nationally. Chapter 203 also authorized coverage expansions for adults who were not parents, and officially renamed the Massachusetts Medicaid program to MassHealth. In the 2000s, new programs for seniors ("Senior Care Options") and people with disabilities took off, and then Chapter 58 in 2006 further expanded coverage and restored benefits which had been cut. HCFA was involved in all of these policy initiatives.

Of course, our pioneering 2006 innovations combined with the earlier expansions provided the test bed for the ACA.

The most recent entries in the timeline showcase the 2013 launch of One Care, which combines Medicaid and Medicare benefits and financing for disabled adults who are eligible for both programs.  Additionally, but not the least important,  Massachusetts implemented the Affordable Care Act in 2014 which includes the creation of MassHealth CarePlus for newly eligible adults with incomes below 133 percent of the federal poverty level.  Today MassHealth covers around 1.8 million Bay Staters.

growth in Medicaid spending and enrollment

Many challenges remain. But we'd urge everyone to reflect on the inspiring history of Medicaid in Massachusetts, which can be explored on the very cool timeline on the Blue Cross Foundation website: bluecrossmafoundation.org/publications/ma-medicaid-50th.

      -Michelle Savuto

July 28, 2015

Yesterday,  the legislature's Committee on Health Care Financing approved  H. 2048 / S. 608 An Act to eliminate racial and ethnic health disparities in the Commonwealth. The bill now goes to the House Ways and Means Committee. Its lead sponsors include Representatives Jeffrey Sánchez and Byron Rushing, and Senator Jason Lewis.

Health Care For All has long supported this legislation ever since we helped draft the original bill in 2009 with a broad coalition of disparities advocates in our Disparities Action Network.

The bill creates a permanent Office of Health Equity in the Executive Office of Health and Human Services, focused on health disparities. The Office will provide a framework for a comprehensive approach to health disparities. The focus encompasses all the activities of state government, such as housing, transportation, education and economic development. It requires that the Governor's annual state budget submission identify major state initiatives that affect health and health care, and specify their impact on health disparities. It also calls for an annual report card on progress in reducing disparities.

Health Care For All is committed to working to eliminate health disparities. If your Representative is a member of the House Ways and Means Committee (look up the committee membership here, and find your legislators at WhereDoIVoteMA.com), please contact him or her in support of this important bill.

         -- Michelle Savuto

July 24, 2015

On Wednesday, the Health Policy Commission (HPC) Board met and tackled a number of issues, including updates on new Material Change Notices, planning for the 2015 Cost Trends Hearing and Cost Trends Report, developments in PCMH and ACO certification standards, new research in substance use disorders and opiate exposed newborns, and updates in the Phase 2 of the CHART investment program. You can download the slide deck with all the materials from the meeting here. And you can click on for our detailed breakdown.

July 22, 2015

Yesterday advocates, consumers, health providers, and legislators convened at the Joint Committee on Financial Services public hearing to provide testimony in support of S. 557 / H. 871, An Act to protect access to confidential health care. The bill would eliminate frighteningly common confidentiality breaches in health insurer communications by allowing patients to choose where and how they receive explanation of benefits (EOB) forms.

Insurers routinely send out EOBs detailing the type and cost of medical services received to the primary subscriber of a health insurance plan, not the individual patient who accessed services. Sensitive health information is frequently disclosed in these forms, violating the basic right to privacy for anyone enrolled as a dependent on another’s policy, such as a young adult, minor, or spouse. As we heard from bill sponsors Representative Hogan and Senator Spilka, Attorney General Maura Healy, Representative Brodeur, and four separate panels of experts, providers and consumers, the effects of this can be devastating.

The first to offer testimony in support of this bill were lead sponsors, Representative Kate Hogan and Senator Karen Spilka. They set the stage by emphasizing the moral impetus to provide confidential health care, also alluding to the negative outcomes of confidentiality breaches via EOBs such as greater likelihood to delay or forgo care, retaliatory abuse from a spouse or family members, and higher costs to publicly-funded community clinics. As Senator Spilka noted, sending member-level EOB forms as this bill proposes is a common sense solution for a shockingly simple problem -- and since some health insurers are already doing this, “clearly it should not be an issue”.

Attorney General Healey testifying at hearing for privacy protection legislation 7-21-15Following Representative Hogan and Senator Spilka was Attorney General Maura Healy (photo at left courtesy of Shira Schoenberg / The Springfield Republican). In addition to reiterating the importance of confidentiality and the negative effects of confidentiality violations, Attorney General Healy also commended the public education aspect of the bill, which would inform patients and consumers of their rights to alternative private EOB communication methods and how to go about requesting those. Her eagerness for the AG’s office to work with the committee on this legislation was palpable and we look forward to having her expertise engaged on this issue!

After hearing from public officials (including Representative Paul Brodeur who voiced his support), four separate panels spanning an array of health issues brought a human face to the bill, offering firsthand testimony about the very real effects of confidentiality breaches through EOB forms. We heard from providers at university health clinics, domestic violence and sexual assault advocacy and service organizations, behavioral and physical health providers, and patients themselves.

Advocates testifying at hearing on privacy protection legislationMany providers described the chilling effect of confidentiality concerns on their patients’ health practices, including forgoing mental health counseling and medication or sexual health services such as STI testing out of fear of reprisal from a parent or spouse. In one personal patient testimony offered on behalf of an anonymous young woman from Andover, the fear of her parents finding out she’d been to the gynecologist to treat an ovarian cyst -- fear influenced by shame, stigma, and poor communication -- was so fierce that she delayed treatment until her ovary ruptured, almost causing her to lose an entire ovary at age eighteen.

Advocates from the domestic violence and sexual assault fields also testified on the negative effects of confidentiality breaches through EOB forms. A number of service providers offered accounts of patients who had been sexually assaulted and were forced to prematurely disclose their assaults to parents or a partner when they received EOBs detailing the services received. In the case of domestic violence survivors, the consequences could be even direr. Annie Lewis-O’Connor from the C.A.R.E. Clinic at Brigham & Women’s Hospital recalled a patient who, while fortunate enough to access confidential care using a workaround, had initially lied about the cause of her injuries fearing reprisal from her husband if he learned she’d sought treatment through an EOB being sent to their home. In the patient’s own words, her husband had threatened to kill her if she went to the hospital.

July 20, 2015

On Friday afternoon, Governor Baker issued his line-tem vetoes for the Fiscal Year 2016 budget, which started on July 1.

One of the vetoes took us by surprise:

Governor Baker vetoes all Academic Detailing funds

"Academic Detailing" is the somewhat obscure name for a valuable, money-saving state program. Here's how we've explained it before

Academic detailing helps doctors stay abreast of current information while avoiding the biases of pharmaceutical-sponsored education. How does it work? Doctors, nurses, or pharmacists are trained to understand comprehensive and unbiased clinical data. They then visit physicians’ practices to pass this information on to practitioners. Academic detailers do not have a financial stake in the drugs that they are recommending, and thus serve as a counterweight to industry-sponsored information. Academic detailing has the potential to achieve two goals, both of which are good for Massachusetts:

  1. Promoting better patient outcomes. Academic detailers will present a more complete view of the available clinical data. This stands in sharp contrast to the selective marketing techniques used by pharmaceutical representatives, who focus on highlighting a drug’s strengths while glossing over its weaknesses.
  2. Reducing healthcare costs. Academic detailers recommend off-patent drugs when evidence shows that they are a safer and more effective treatment option. Pharma has no incentive to market off-patent drugs because, for them, that’s not where the money is. One study from Harvard Medical School and Brigham and Women’s Hospital found that each dollar spent on academic detailing saved two dollars in prescription drug costs. This means substantial savings on prescription drug expenditures statewide— potentially big enough for Massachusetts to recover most or all of what it spends to fund an academic detailing program.

Much more details on the program, and how it works, is here.

We call on the legislature to swiftly override this veto, which would deprive doctors of objective information on prescription drugs, and only benefits high-priced drug manufacturers who are able to market better than the competition. Join us in contacting your state legislator and asking him or her to support an override of this veto.

                 -- Brian Rosman

July 16, 2015


Globe Headline: Insurer's cost data websties lackingOur release last Tuesday of our first report card comparing the consumer cost transparency web sites of the three major insurers in Massachusetts (download and read it here) garnered lots of attention.

The Boston Globe's lead Metro story covered the report card, and HCFA ED Amy Whitcomb Slemmer was interviewed about it on Boston Neighborhood News:


The insurers cited in the report have all been upfront about the need to improve their sites. As Bill Gerlach, Blue Cross’s senior director of consumer engagement solutions, told the Globe, “It’s a work in progress.” Our report card shined a light on the numerous deficiencies we found, and we hope it will help focus their improvement efforts on the categories that matter to consumers.

It also raised a larger issue, about the role of consumer health care price comparison generally. For us, we think consumers have an absolute right to be able to find out in advance what a medical procedure will cost them. Particularly with the growth of high deductible plans, patients must have the ability to learn in advance what the out-of-pocket costs will be for a medical treatment.

Morover, some new research seems to indicate that more people want to use these tools than commonly assumed. The study by Public Agenda, How Much Will It Cost? How Americans Use Prices In Health Care (full report | summary) surveyed just over 2000 adults throughout the US last summer. Their findings went against many of the assumptions people have about consumers and health care cost comparisons:

  • 56 percent said they have tried to find out how much they would have to pay out of pocket—not including a copay—or how much their insurer would have to pay a doctor or hospital, before getting care. The proportion of those seeking out this information is higher among people with high deductibles. 67 percent of those with deductibles of $500 to $3,000 and 74 percent of those with deductibles higher than $3,000 have tried to find price information before getting care. 
  • About one in five —21 percent—say that when trying to find price information before getting care, they have compared prices across multiple providers. Among those who have compared prices across multiple providers, 62 percent believe that they have saved money, and 82 percent of those who have compared prices across multiple providers say they will do so again in the future. 

There's a lot more interesting findings in the Public Agenda study, and we encourage people interested in this issue to dig into the details. 

One issue that seems unresolved is the perceived relationship between cost and quality.  The Public Agenda survey found that 71 percent of Americans say higher prices are not typically a sign of better-quality medical care. Similarly, 63% said lower prices are not a sign of lower quality care. This apparently contradicts a 2014 survey conducted by the Associated Press-NORC Center For Public Affairs. The AP- NORC survey asked half of their survey sample if higher-quality health care usually comes at a higher cost, or if there is no real relationship between cost and quality. Nearly half (48 percent) say that higher quality comes at higher costs, 37 percent say there is no real relationship. Interestingly, the other half was asked an alternate question: whether lower-quality care comes at a lower cost. The results were not an exact mirror image of the first question. Fewer people recognized a relationship between lower-quality care and lower costs. Just about 3 in 10 (29 percent) said that lower-quality care comes at a lower cost, while the most common response was that there is no real relationship (46 percent). 

Here are the dueling graphics:

Public Agenda: 

Public Image survey finds little perceived connection between health care costs and quality

And here's the AP-NORC graphic:

AP-NORC survey finds perceived connection between health care costs and quality

Conclusion: More research is needed, but even more, more public education is needed. HCFA hopes to be a part of that process.

    - Brian Rosman

July 10, 2015

On Thursday, the Connector Board met to discuss:

  • customer service improvements;
  • Conditional Award of 2016 Seal of Approval;
  • implementing a provider search tool; and
  • the agency’s Fiscal Year 2015 and 2016 administrative budgets.

Materials from the meeting are posted here. Our full report takes a click below.

July 10, 2015

Earlier this week, two committees of the Health Policy Commission met to:

A presentation combining all the slides from the meeting is posted here.

Proposed Updates to OPP Regulations

The Joint Committee Meeting kicked off by opening the floor to hear public comments on updates to Office of Patient Protection (OPP) regulations on Health Insurance Consumer Protection and Open Enrollment Waivers. 

The consumer protection regulation has been updated to bring the OPP into compliance with amended Massachusetts law. The amended law clarifies that plan members, prospective plan members, and their health care providers may obtain medical necessity criteria, including proprietary criteria, from their health plans. The changes to this regulation will clarify the boundaries of access to proprietary and non-proprietary medical necessity criteria for market participants.

The open enrollment waiver regulation describes the waiver process for consumers who are seeking to buy non-group insurance outside of the open enrollment periods. It has been revised to bring the OPP regulation into compliance with certain eligibility rules that have been changed in the Affordable Care Act and related Massachusetts law.  

Health Care For All and Health Law Advocates weighed in and provided recommendations.

Health Law Advocates staff attorney Laura Goodman proposed that a direct telephone line be established to address the needs of patients seeking medical necessity criteria from insurance companies because currently the staff on call are untrained in collecting or releasing this information in a timely way. In addition, Goodman stated that the regulations could be used as another tool to monitor plan compliance with federal and state mental health parity laws. She suggested that the OPP regulations clarify that when a health plan member, prospective member or provider requests medical necessity criteria or other protocols relevant to a behavioral health service, that individual is entitled, upon request, to a copy of the medical necessity criteria and other protocols that are relevant to comparable medical or surgical services. 

Health Care For All’s Senior Health Policy Manager Suzanne Curry built upon Laura’s testimony to include the recommendation that there should be online components for patients to search for medical necessary criteria through their health plan’s website.  Additionally, HCFA recommends that the deadline for health plans to meet requests for medically necessary criteria be shortened to two business days instead of the current standard of 30 days. Last, HCFA provided supportive comments on the changes made to the insurance open enrollment waiver regulations.

Attorney General’s Report: “Examination of Health Care Cost Trends and Cost Drivers”

Current  approaches separate  “behavioral health ” and  “medical ”  care, resulting in a ripple effect that  impacts the integration of behavioral  health and medical care

Two representatives from the Attorney General’s Office gave a presentation on their most recent AG Cost Trends Report, with its focus on behavioral health. The report’s principal findings were:

July 5, 2015

Report Cover: Comparing Public Coverage in Massachusetts with Employer-Sponsored Insurance Coverage The Blue Cross Blue Shield Foundation released a report authored by Sharon K. Long and Thomas H. Dimmock of the Urban Institute that analyzes the 2013 Massachusetts Reform Survey by comparing the experience of adults with employer-sponsored insurance coverage (ESI) to adults with public coverage, mostly MassHealth, but some with Connector-sponsored coverage.

The conclusions of the report  remind us that gaps in access to care persist between those covered by public and private insurance, despite current rates of near-universal health insurance coverage. These disparities persist even after controlling for variations in health care needs and socioeconomic status between the two groups.

The report highlights ongoing problems of cost and access depending on whether a person has ESI or public coverage:

Comparing unmet need among Massachusetts residents with public and private ESI coverage

  1. When you adjust for health status and socioeconomic status, affordability of health care was less of an issue for full-year insured adults with public coverage than it was for adults with ESI coverage. If you look at the raw data, about half of full-year insured adults with other non-ESI coverage reported that health care costs were a problem over the past year, as compared with 33.5 percent of those with ESI coverage. But controlling for differences in health status and socio-economic status reverses the picture. Adjusted, adults with public coverage are doing better than similar adults with ESI when it comes to affordability of health care
  2. Those with lower incomes and those with public coverage were more likely to report not getting needed care in the past 12 months because of cost, with 20.3% percent of lower-income adults and 22.6% of those with public coverage reporting such problems. The most common types of care that were not received due to cost were dental services and prescription drugs.
  3. Among the insured adults, adults with ESI coverage were more likely than adults with public coverage, 78.4 versus 43.6 percent, to know how to obtain information about providers in tiered networks.
  4. Adults with public coverage are more likely than adults with ESI coverage to have had problems with a doctor’s office not accepting their insurance type, with more than 25% of those with public coverage reporting such access problems.
  5. Unmet need for health care was significantly higher for full-year insured adults with public coverage as compared with adults with ESI coverage. For example, 44.5% of insured adults with other non-ESI coverage reported unmet need, as compared with 23% of insured adults with ESI coverage. Similarly, 22.6% of the adults with other non-ESI coverage reported unmet need due to the cost of care, which was more than double the 9.8% for adults with ESI.

Overall, the report concludes that simply reducing the number of uninsured people in Massachusetts is not sufficient to claim that the goals of health care reform have been achieved. Many people continue to be burdened by health care costs and lower-income adults and adults with non-ESI coverage are most at risk for access and financial issues.  The hardest work is still to come - bringing affordable, quality care to all Massachusetts residents regardless of their income or insurance type.

       - Michelle Savuto

[update: edited point above to clarify that after adjusting factors to make a direct comparison, people with public coverage have fewer affordability problems than those with employer coverage]


June 29, 2015

Two consecutive Supreme Court decisions take an idea that was first implemented in Massachusetts and make it national law. So it's official: The Spirit of Massachusetts is the Spirit of America:

Mass license plate with "The Spirit of America" slogan




(Context 2:)