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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

November 13, 2016

President-Elect Trump's Health Care Site GraphicThe election of Donald Trump, running on a platform of complete repeal of the Affordable Care Act, puts at risk the coverage of some 22 million people who rely on the law for their health insurance. Patients who depend on the law for their coverage are fearing the worst. So, on the day after the election, more than 100,000 Americans rushed to sign up for coverage, the largest number ever during this year’s open enrollment.  

But what about us, in Massachusetts? Our 2006 “RomneyCare” reforms predate the ACA. Our own reform law resulted in the reduction in our uninsured rate from around 11% in 2006 to about 6% in 2010. Implementation of the ACA further expanded coverage, and today our uninsurance rate is about 3%. And our law has broad political support, including Republican Governor Baker. So now Fortune Magazine is recommending that people upset about Trump's election move to Massachusetts, rather than Canada.  

The short answer is that we can’t yet know the impact of policy changes to be enacted by Trump and the Republican Congress. Already, there are some signs of retreat, as Trump indicates support for keeping pre-existing conditions protections. The Washington Post reported that, “In the long run, waffling on repeal will probably be less painful than causing a health-care catastrophe” (see this smart analysis on The Conversation for background). For example, the President-elect’s new official government website health care page has different policies than the campaign’s. 

But our pre-ACA state reforms did not exist in vacuum. They depended on federal fiscal and policy support for their operation, provided through the MassHealth Medicaid waiver. Implementation of the ACA in Massachusetts allowed for substantial improvements in coverage, and state financial savings. Vicky Pulos, an attorney at the Massachusetts Law Reform Institute, provides some perspective and a warning about what could happen:

In MA over 300,000 adults are enrolled in MassHealth and an additional 180,000 in Connector Care under provisions of the ACA.

If the Medicaid expansion and federal tax credits and subsidies in the ACA are repealed, it won't happen overnight. We still have the bones of our 2006 state health reform law on the books, but prior to the ACA we insured far fewer people at a far greater net state cost. Retaining coverage will require all hands on deck.

Meanwhile last Friday, MassHealth received approval from CMS (the federal Medicaid agency) for amendment and extension of its 1115 demonstration (the waiver) to 2022. Approval allows MassHealth to move ahead with plans for Accountable Care Organizations that will change the way providers are organized and paid. The goals are to reduce state spending and provide more coordinated care. Approval also secures billions in additional federal funds over 5 years.

It's far too early to speculate how a new federal administration may affect the waiver. However, approval does not insulate MassHealth from future changes in federal law or policy or a new administration taking a different view of whether the waiver serves the public interest.

HCFA and our Affordable Care Today (ACT!!) Coalition will launch a broad, aggressive campaign to oppose any reduction in affordable coverage in Massachusetts. We urge you to join us, now. Sign up using this form to stay informed about Massachusetts health reform, and how you can add your voice in support of keeping good health care affordable in Massachusetts.

                                                                                                                     -- Brian Rosman 
 

November 4, 2016

Today the federal Centers for Medicare and Medicaid Services (CMS) approved Massachusetts' application for a broad restructuring of the MassHealth Medicaid program.

The "1115 waiver" allows the state to implement Accountable Care Organizations as a new choice for MassHealth members. An ACO is made up of primary care providers who team up to provide integrated, coordinated care, with the goal of both treating patients when they are sick, and keeping members healthy. They will work with community organizations to assist members with social needs that keep us healthy, like nutrition or housing. The waiver also provides the state with lots of new federal funds. It includes $1.8 billion over five years of new funding to support the move to ACOs, invest in behavioral health and long term services and supports, and promote innovative ways of addressing the social determinants of health.  It also authorizes nearly $6 billion of additional safety net care payments over five years to hospitals and the health safety net for low income uninsured and underinsured residents, and for subsidies to assist consumers in obtaining coverage through the Health Connector.

The waiver also increases opportunities for consumer involvement. ACOs are required to include a consumer representative on their boards, and each ACO must have a Patient and Family Advisory Committee.

More information on the waiver is here:

HCFA released the following statement following the news:

“Health Care For All (HCFA) welcomes this Medicaid waiver as an opportunity to transform MassHealth from just a program that takes care of people when they are sick to one that aims at keeping people healthy in the first place. We are particularly excited about the potential to integrate physical, behavioral health and long-term care with other social services. We hope that this overhaul expands in the future to include oral health and dental care as well, which we know are critical to overall health. HCFA will be watching closely as the state implements the innovative reforms approved today to make sure that consumer needs are the top priority.”

Six pilot ACOs will start operating this December, and the full ACO system should be up and running a year later. We congratulate the state on their approval, and pledge to closely monitor implementation of the waiver on behalf of Massachusetts consumers.

                                                                                                                                                                                     -- Brian Rosman

November 1, 2016

Open Enrollment starts nowThe Health Connector's Open Enrollment period has begun, and with it, the opportunity for people to sign up for health insurance or renew their coverage for 2017. In Massachusetts, ten insurers are offering up 62 different plans for the next year. During this year’s Open Enrollment, it is especially important for Health Connector members to review their plan and compare their options, as some changes have been enacted that may affect their coverage.

Some Connector members will be facing substantial increases in monthly premiums. About 70,000 notices from the Health Connector will be going out this month regarding a premium increase of at least 15%. For those enrolled in a Neighborhood Health Plan, the average increase is 21%.

Prior to this enrollment period, the State had been able to help subsidize the difference in premium costs between plans with a process called “smoothing,” but due to budget constraints, this process has been discontinued for 2017. This means that low-income ConnectorCare members enrolled in Neighborhood Health Plan may have to pay up to $165 a month to maintain their coverage and network of providers. Other individuals may also be subject to paying higher premiums in 2017. While the Health Connector has other less expensive insurance plans with comparable benefits, it is important for consumers to know that in some cases changing plans may mean changing providers as well.

Another change to look out for this Open Enrollment season is some members may find that they are not eligible for tax credits this year. This could be for a couple of reasons. Those who have recently become entitled to Medicare do not qualify for subsidized insurance. Members on ConnectorCare or Advanced Premium Tax Credits are also required to have filed their 2015 taxes in order to maintain benefits as data from 2015 tax returns will be used to determine eligibility for subsidies in 2017 coverage.

HCFA will be monitoring how these premium increases are impacting consumers. We are concerned that this may impact people’s decisions to re-enroll if their preferred plan has become out of reach, or if they are not able to remain with their existing medical care team. 

--Angela Swanson

October 31, 2016

MassHealth cardMost MassHealth members have the option of either enrolling in a health plan (a Managed Care Organization or MCO) or the Primary Care Clinician Plan (PCCP). In efforts to move more members to managed care, MassHealth proposed in its 1115 waiver proposal to cut chiropractic services, eyeglasses, hearing aids, orthotics and potentially other benefits in the PCC Plan, while maintaining these benefits for members enrolled in MCOs.

Health Care For All, along with partner organizations, such as Disability Advocates Advancing our Healthcare Rights (DAAHR), the Massachusetts Law Reform Institute, and the ACT!! Coalition, as well as several provider groups, persistently opposed the proposed benefit cuts. We argued that the benefit cuts would impose barriers to care for low-income individuals and families, and violate federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) standards for MassHealth members under age 21.

In response, MassHealth first modified their proposal to maintain the full package of benefits for children and youth under age 21, while moving forward with the benefit reductions for adult PCC Plan members. However, at their public meeting in October, MassHealth announced their decision to drop the PCC Plan benefit cuts altogether.

We commend MassHealth for making the right decision, and thank our advocacy partners for making this issue a priority.

The next hurdle is cost-sharing. MassHealth is moving forward with their request to charge higher copays to members enrolled in the PCC Plan as compared to those enrolled in MCOs or a new Accountable Care Organization (ACO) option. MassHealth also seeks to apply copays to additional services (currently MassHealth members only pay for prescription drugs), including use of the emergency room for non-emergent conditions. These cost-sharing policies are slated to go into effect in 2018, after a public process.

For low-income people using MassHealth to stay healthy, even modest copays can be barrier to getting the care they need. In the long run, this can make overall care more costly. We urge MassHealth to carefully consider the impact on health and the cost-effectiveness of adding more copays.

                                                                                                                                -- Suzanne Curry

 

October 28, 2016

Health Care For All is among more than 200 health and social service organizations and leaders who signed on to a letter yesterday requesting the reauthorization of the Prevention & Wellness Trust Fund (PWTF) before the funding expires in June of 2017. 

The PWTF was established by the legislature in 2012 as a part of Chapter 224 with the aim of reducing health care costs by investing in prevention for chronic conditions like diabetes and asthma. Services supported by this Fund are available to nearly one million Massachusetts residents in all areas of the state through nine community partnerships that help keep people safe and healthy.

The letter outlines the impact chronic illnesses have on individuals and how these conditions contribute to shorter lives, lower quality of life, reduced workplace activity, and, for children, missed school days. With rates of preventable chronic conditions skyrocketing, especially among individuals from lower-income communities, it is essential that we invest in these initiatives to ensure health care equity in Massachusetts. In fact, Representative Jeffrey Sánchez, House chair of the Joint Committee on Health Care Financing, said that "prevention at the community level is fundamental” to achieving equitable health outcomes.

HCFA believes that the integrated approach offered by the Prevention & Wellness Trust Fund is a key to addressing the underlying causes of poor health and is a complement to the ongoing transformation of the health care system. We urge  the legislature to reauthorize the funding next year so that all residents of Massachusetts have a equitable opportunities for good health.

 

--Angela Swanson

 

October 11, 2016

Policy Forum on Oral Health Integration

Last Thursday the Massachusetts Health Policy Forum hosted a forum entitled “Integrating Oral Health into ACOs.” This event brought together researchers and stakeholders to discuss the importance of oral health integration.

The context is the state’s proposal to set up ACO’s – Accountable Care Organizations – for our MassHealth program. ACOs are structured to provide more coordinated care, and the state is planning to better integrate behavioral health and long-term care services into the plans. At issue is how best to integrate oral health as well.

The morning started with a brief presentation by Dennis Heaphy, an analyst at the Disability Policy Consortium and a leader in Disability Advocates Advancing our Healthcare Rights, the leading health disability advocacy organization in Massachusetts. He spoke on the critical role good oral health and dental care has played in his own life.

The research panel presented with compelling evidence supporting coordination between oral health and overall health services and how that could fit into ACOs.  The first speaker was Yara Halasa, a dentist and PhD candidate from Brandeis’ Heller School. She provided a summary of her paper, demonstrating that including oral health care into the ACO model foster comprehensive and better quality care. She brought attention to the fact that 29% of adults in Massachusetts rated their oral health status as poor to fair. Yet, oral health is closely linked to overall health, with poor oral health leading to issues with diabetes and respiratory or cardiovascular conditions. She ended her discussion with a number of policy recommendations on how to best get to achieve integrated oral health. See her presentation here.

Chief Economist and Vice President of the Health Policy Institute and member of the American Dental Association, Marko Vujicic said that IT challenges are the top barrier for oral health integration. There are numerous benefits to oral health integration, particularly for diabetics and pregnant women. He also reported that $153 million could be saved if dentists were included in the general medical screening process.

Oregon CCOs integrate oral health

While Massachusetts prides itself on being number one in all things healthcare related, Oregon is leading the country in integrated care through ACOs. Representing the Oregon Health & Science University, Dr. Eli Schwarz discussed the successes that Oregon is having with integrating oral health in its ACO model, known as CCOs (see his presentation here). The program has reduced ED visits and hospital admissions for congestive heart failure and pulmonary disease, and increased used of effective dental sealants. It is estimated that the government will have saved $1.7 billion over the waiver period though better care.

The session ended with a panel of stakeholders, who discussed the importance of oral health integration, perceived barriers to integration and how to tackle those challenges. Members of this panel included the moderator Michael Monopoli of the DentaQuest Foundation, State Senator Harriette Chandler, MassHealth dental director Dr. Donna Jones, HCFA’s Brian Rosman, Dr. Hugh Silk, a primary care physician and instructor at UMass Medical School, and Dr. Raymond Martin, president of the Massachusetts Dental Society.

Senator Chandler, who co-chairs the legislature’s oral health caucus, passionately remarked that the state of Massachusetts is a “long way” from providing what we do for oral health than what we do for physical insurance, and pledged to continue working for full integration.

-- Chelsea Canedy and Angela Swanson

September 15, 2016

Our friend Vicky Pulos, attorney and advocate at the Massachusetts Law Reform Institute, has a blistering letter in today's Boston Globe, objecting to the reasoning used by the Connector in suddenly raising subsidized ConnectorCare premiums (see our post for background).

Here it is:

A safety net frays as Mass. health plan premiums spike

THE MASSACHUSETTS Health Connector’s decision to raise most premiums for subsidized insurance in 2017 represents a change in its longstanding policy of protecting the poorest of the poor from the full effects of premium increases (“Subsidized health plan raises rates 21%,” Page A1, Sept. 9). For the lowest-income ConnectorCare enrollees, including the destitute and the homeless, the cost of remaining with their current plan may increase by as much as $165 per month.

Massachusetts’ 2006 health reform law prohibited premium contributions for those living below the poverty level. Until last week’s board meeting, the Connector had honored the spirit of state health reform by fully subsidizing all plan choices for the very poor.

Several board members objected to this practice of what they called “cross-subsidization.” However, the Connector is not a private insurance company. It has no profitable or unprofitable product lines. It’s a public authority, and ConnectorCare is a public program. The fiscal constraints driving the Connector have more to do with declining state tax revenue, and the need to transfer funds back to the general fund to support other state spending, than with any other cause. Now that’s cross-subsidization.

Victoria Pulos
Senior health law attorney
Massachusetts Law Reform Institute
Boston

We agree. The Connector is a public entity, tasked with administering a public insurance program, for the benefit of the low-income people in the Commonwealth. We urge the Connector to re-examine its decision.

Thanks, Vicky, for a great letter.

                                                                                                                     -- Brian Rosman

September 13, 2016

We're number oneToday the federal Census Bureau released its annual statiscal report on “Income, Poverty and Health Insurance Coverage in the United States: 2015” (link). This is their annual survey based on the Current Population Survey and the American Community Survey.

And so, it's time for our annual blog post (e.g, 2014, 2010, and 2009) on the continuing progress Massachusetts in making in expanding health coverage.

First, the encouraging national headlines:

  • Fewer uninsured: The percentage of people without health insurance coverage for the entire 2015 calendar year was 9.1 percent, down from 10.4 percent in 2014. The number of people without health insurance declined to 29.0 million from 33.0 million over the period.
  • Both private and public coverage: Between 2014 and 2015, the increase in the percentage of the population covered by health insurance was due to an increase in the rates of both private and government coverage. The rate of private coverage increased by 1.2 percentage points to 67.2 percent in 2015, and the government coverage rate increased by 0.6 percentage points to 37.1 percent.
  • Kids better, too: In 2015, the uninsured rate for children younger than age 19 was 5.3 percent, down from 6.2 percent in 2014.

The Massachusetts headlines: (based on this state table)

  • We’re number one: The 2015 uninsurance rate in Massachusetts went down to 2.8% - again, the best in the country. (second best is a tie between DC and VT, each at 3.8%). So our coverage rate is 97.2%
  • Continuing Improvement: The uninsurance rate continues to decline - it was 3.3% in 2014, and 3.7% in 2013, and 3.9% in 2012

More analysis (including great charts) are available from the Mass Budget and Policy Center.

We cannot be complacent about the continuing progress. Our state's success relies on the aggressive outreach and enrollment efforts, which should not be curtailed. We do hear frequent reports of considerable churn in enrollment, as people shift between various programs and private coverage. And there is a big challenge coming in next year, as MassHealth (which covers 1.8 million in the state), begins rolling out ACO options for most of its members.

                                                                                                                                                                         -- Brian Rosman

 

 

September 12, 2016

On Thursday, the Health Connector Board met to award the final Seal of Approval (SoA) for plans to be sold through the Health Connector in 2017. This included a review of premium changes in the ConnectorCare program and plans for member communication and outreach for open enrollment. The meeting sparked big headlines, including the lead story in the Boston Globe (see below). Materials from the meeting can be found here.

Boston Globe: Subsidized Health Plan raises rates 21%

Due to an increase in rates offered by some health plans, the Health Connector reported that many members will have higher premiums upon their 2017 plan renewal. This will particularly impact individuals enrolled in Harvard Pilgrim HealthCare, Neighborhood Health Plan, and Health New England. Members receiving only premium tax credits or no subsidies will see a 19% premium increase.

That’s going to have a big impact on people. There’s going to be a lot of shifting and a lot of disruption.’Until now, the Health Connector “smoothed” the difference in premiums between the lowest and highest cost plans in the ConnectorCare program. After considering budget constraints and alternative solutions, the Health Connector has decided to discontinue most premium smoothing in the ConnectorCare program beginning in plan year 2017. However, the Connector will continue to “smooth” plans offering premium rates less than $35 different from the lowest cost plan for 2017 only.   Continuing smoothing as it has been implemented would cost $51 million ($35 million after federal reimbursement). The significantly reduced premium smoothing in 2017 will cost $4.2 million ($2.1 million net).  

The impact this decision has on the most vulnerable members of the Commonwealth is apparent. The starkest change if for “Plan Type I” ConnectorCare members, whose incomes put them below the poverty level (about $11,800/year in income for an individual). In previous years, these members could choose any ConnectorCare plan and not pay a premium. Starting in 2017, they will pay anywhere from $0 to $165 in premiums, depending on their choice of plans.  

While the Connector has other insurance plans that are less expensive and have comparable benefits, the individuals who choose to switch their plans will likely need to switch physicians and providers. The Connector Board stated that these changes are necessary in order to adhere to their goal of giving individuals options in light of their heavy budget restrictions.

The next Connector Board meeting is scheduled for Thursday, October 13th, 9am, at 1 Ashburton Place, 21st floor, Boston.

                                                                                                                                        -- Chelsea Canedy

September 4, 2016

MassHealth has pending before CMS - the federal Centers for Medicare & Medicaid Services - its proposal for a major redesign of its care delivery system. MassHealth is the state's Medicaid program, and covers nearly 1.9 million Bay Staters. 

The proposal (read the submission and supporting materials here) calls for creating Accountable Care Organizations (ACOs) as a new choice for MassHealth members. An ACO is made up of primary care providers who team up to provide integrated, coordinated care, with the goal of both treating patients when they are sick, and keeping members healthy. They will work with community organizations to assist members with social needs that keep us healthy, like nutrition or housing.

MassHealth is asking CMS for a $1.8 billion up-front investment over five years to support transition toward ACO models, including direct funding for community-based providers of behavioral health and long-term services, as well as funding for safety net programs.

HCFA coordinated the submission of 5 sets of comments to CMS on the proposal, from various coalitions that we coordinate. All together, 96 different organziations signed on to one or more of the comments that we coordinated. The comments reflect each coalition's particular concerns. The final set of comments below is from over 30 consumer groups, such as the Greater Boston Food Bank, Alliance of Massachusetts YMCAs, Easter Seals Massachusetts and the Massachusetts Association of Community Health Workers. Click the links below to see the submitted comments.

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