"Health Care For All" in lights on a bridge

A Healthy Blog

Massachusetts health care – wonky with a dose of reality

July 20, 2005

This morning, Governor Romney announced the filing of his health reform plan with the Legislature. You can obtain the full legislative text from HCFA's website by clicking here. In many ways, the legislation is less revealing than the Governor's less-than-revealing Powerpoint. For example, the powerpoint shows hypothetical premiums that would be paid by lower income folks to be insured -- the legislation simply directs the new Insurance Exchange board to develop premium levels.

Bottom line? We still have our share of concerns -- the real affordability of these hypothetical products, the content of the insurance policies, the security of the safety net, the treatment of noncitizens, the appropriateness of the Commonwealth acting as collection agent for hospitals, and the fiscal soundness of the plan.

Still, this is a serious effort at devising a new way of conceptualizing health care reform and deserves study and attention. The Administration -- which admonishes the health industry to be more "transparent" -- needs more transparency itself in sharing its data, assumptions, models, and other essential components. If they do that, the health care community has an obligation to give this plan a most serious and detailed examination.

Ten years ago., Charlie Baker and Bruce Bullen (for Gov. Bill Weld) produced a health reform blueprint that had some real weaknesses. Yet the underlying framework was revolutionary and pathbreaking; the Legislature fixed the weaknesses and produced an historic health reform plan. Maybe this is the same, and maybe it isn't -- we have an obligation to find out.

So no snap judgments -- let's take a good look under the hood.

July 19, 2005

Great column yesterday by EJ Dionne on a new report by the Center for Budget and Policy Priorities documenting the value public programs play in lifting families out of poverty. More than 27 million Americans are lifted out of poverty by public benefits. More than 90 million obtain decent health coverage through Medicare, Medicaid, and the Children's Health Insurance Program. Food Stamps help 25 million poor folks obtain a healthy diet. The Women's Infants and Children's Program (WIC) helps 8 million pregnant and postpartum women obtain supplemental nurtrition.

"Does all this cost a fortune? Not by any fair reckoning. Federal spending on Medicaid and SCHIP represents 1.5 percent of gross domestic product. Federal financing for the rest of the low-income programs consumes just 2.3 percent of GDP. For a sense of comparison, consider that defense spending consumes 4 percent of GDP and interest on the national debt gobbles up 1.5 percent. President Bush's tax cuts -- which go in large part to the wealthiest Americans -- will consume roughly 2 percent of GDP."

You can obtain the full reports from the Center by clicking here.

July 18, 2005

All the pretty ads for health plans. Even puffery for Medicare. What do you never, ever see -- ads talking about how good MassHealth is. Unthinkable. So here's a public service announcement on how MassHealth gets things right for their clients, the most vulnerable and difficult population in the Commonwealth. An article in the July/August issue of Health Affairs -- T Coughlin et al -- (sorry subscribers only -- email me and I'll send it to you) looks at MassHealth compared with 12 other states and with private health plans serving low income folks in all 13 states. Interesting results:

MassHealth US Medicaid MA Private US Priv.

Doctor Visits% 84 79 85 81
Dental Visits% 63 54 67 65
Breast Exam/Pap Smear% 53 45 43 48
Unmet Surgery/Med Need% 6 8 8 7
Unmet Drug Need% 5 10 7 7
Unmet Dental Need% 17 18 12 13

With the glaring exception of dental (helllooooooo) MassHealth compares favorably on nearly every measure with other Medicaid populations and with private health plans serving low income populations -- public and private. While there's plenty of room for improvement, let's give cheers to the folks at MassHealth and to the folks throughout our health care system who serve them. If only we had money for an ad...

Meanwhile, as the nation's governors talk about the glories of copays and other cost sharing for Medicaid clients, another Health Affairs piece (Wright et al) examines the impact of cost sharing on Oregon Medicaid . Here's what they did to the poor in Oregon -- new premiums ranging from $6 to 20 per month; new copays of $5 per office visit, $50 for emergency department, and $250 for inpatient admisssion; and elimination of premium exemptions for homeless, those with zero income, and people who experienced crime, domestic violence, natural disasters, or death in the family. And finally, a six month lockout for whose who missed even one monthly payment.

The results? A 46 percent drop in covered lives, from 88,874 to 47,957 covered lives between February and December 2003. For those who left, the vast majority became uninsured, and the principal reason for leaving was the new cost sharing.

The Governors say they want to make sure their new cost sharing proposals don't lead to clients leaving the program. Whom do they think they're kidding?</s

July 16, 2005

Fed officials rolled into MA this week in shiny buses with pictures of happy seniors, to publicize the new Medicare prescription drug benefit ("Part D") going into effect 1/1/06. Mark McClellan, director of the Centers for Medicare and Medicaid Services was in Worcester. Secretary of Health and Human Services, former Utah Governor, Michael Leavitt, appeared in Boston with Mitt Romney. Both were here to increase awareness of Part D and "engage our partners" in educating communities.

Remarkable was the scarcity of information. McClellan said nothing about what CMS is doing to educate seniors or enroll difficult populations. Nothing about cost. Nothing about coverage gaps. Nothing about low income seniors or disabled residents when they are told their Medicaid card doesn't work . Nothing about what to say to thousands of MA seniors who will get less coverage than they receive under MA’s Prescription Advantage program.

Leavitt did better, explaining outreach efforts to date, giving the web site and phone number for Medicare, and acknowledging enrollment could be a "mess." Counselors worry about isolated seniors with cognitive impairments. Leavitt said "his greatest fear," is some folks will not enroll and will pay for drugs out of pocket. (They will be subject to a 1% premium hike for every month they don't enroll.) He echoed McClellan's comments that it's up to advocates and community workers to get the word out, without any $$ support to do that.

Officials are right about one thing: it's up to us. So help get the word out. Here are some key facts to get started:

  1. This program poses the greatest potential benefit for people with income under 150% of the federal poverty level ($14,355) who are ineligible for Medicaid. Those people are entitled to financial help.
  2. People who think they may be under 150% fpl should apply NOW. (All people on Medicaid, who qualify for Medicare will qualify automatically.) Fill out the application you should have received in the mail from Social Security, or click here for an online application: or call 1-800-772-1213 (TTY: 1-800-325-0778.)
  3. Enrolling in a drug plan is a separate step. (Dual eligibles will be automatically enrolled, but should look at the plans to see which best fits their needs.) Look for mail in October about plans in your area.
  4. If Medicare eligible, you must sign up for a prescription drug plan between November 15th and May 15th. If you don't enroll by May 15th, you will be charged a penalty for every month you don't enroll, unless you have other prescription drug coverage.
  5. Everyone on Prescription Advantage eligible for Medicare will have to enroll in a plan.

More Information:
Families USA
Community Partners
SHINE Counselors: 1-800-AGE-INFO

July 16, 2005

A growing movement around the nation is focussing on preventing hospital acquired infections as an important step to save lives, prevent injuries, and save big money. A new study released this past week in Pennsylvania gives the first concrete estimate of the scope of this major problem -- click here for it.

  • Infections last year accounted for 1,793 deaths and $2 billion in charges in Pennsylvania according to the PA Health Care Cost Containment Council.
  • According to the study, hospitals reported 11,668 infections in 2004, though the actual number could exceed 1115,000 based on billing date.
  • The study found 7.5 of every 1,000 hospital patients developed infections in 2004, but the actual number is likely higher.
  • Mortality among patients who developed infections was 15.4% compared with 2.4% among other patients.
  • The average cost to treat patients who developed infections was $29,000 compared with $8,300 for those who did not.
  • Infections were associated with an additional 205,000 hospital days.
    -- If these results reflect the nation, 125 hospital patients die ech day from infections, at a cost of $50 billion annually.

Organizations such as the Pittsburgh Regional Healthcare Initiative have made elimination of hospital acquired infections a major priority and have produced dramatic results. In some nations such as Denmark, infections are practially nonexistent. If Massachusetts is looking for ways to lower costs and improve quality, how about a serious, no bull---t, accountable program to eliminate infections?

July 15, 2005

U.S. District Court Judge Rya Zobel ruled today that the Massachusetts Medicaid Program violates federal law in the conduct of its dental program for 450,000 low income children in the Commonwealth.

In the case of Health Care For All v. Governor Mitt Romney, Judge Zobel concluded: "Plaintiffs have demonstrated that defendants violated sections of the Medicaid Act that require prompt provision of services, adequate notice and treatment at reasonable intervals and that these violations result, in part, from insufficient reimbursement. The parties shall attempt to develop a joint remedial program and judgment and report to the Court thereon by August 31, 2005.”

The suit was filed in 2000 in response to repeated problems faced by families in obtaining dental services for poor children. You can read Judge Zobel's decision by clicking here. Background on the case is available here. Congrats to HCFA's crack law firm, Health Law Advocates, for winning this case after five arduous years of work.

Question? Will the Commonwealth appeal the Judge's ruling or get to work fixing this embarrassment?

July 14, 2005

Back in April, Sen. Pres. Travaglini included in his health reform proposal a change in state law regarding how cities and towns can alter their health insurance plans for municipal workers -- a change favoring cities and towns and limiting the power of municipal unions. Since then, state senators have received an avalanche of mail and calls opposing "section 7" more than any other part of the President's plan. The widespread belief is that section 7 will never again see the light of day.

Yesterday, Gov. Romney's new Health & Human Services Secretary, Tim Murphy, told municipal officials that the pending Romney health reform bill (now expected to be filed next week) will include new proposals to remove municipal health insurance from collective bargaining rules. Let's skip the disputable merits of the proposal and focus on the politics. Every member of the House and Senate knows both proposals will never move. Indeed, they will all reap political gain by killing it -- and its inclusion only guarantees an extended sideshow and distraction from the real issues related to health reform.

Smart -- canny -- keeping an eye on the ball? Or tin eared -- clueless -- not half as smart as they think they are? Jury's out.

July 13, 2005

The new issue of the policy journal, Health Affairs, presents data on health spending in industrialized nations, especially the US. (Sorry, it's a subscription journal -- so I'll give you some key findings.) In 2002, the US spent $5,267 per capita on health care, $1,821 more than Switzerland, the second highest spender. Even after adjusting for higher US incomes and cost of living, we spend $2,037 more than median spending in 30 developed nations of $2,193. You may wonder, how come?

Maybe it's because we have so much more of everything in the good old USA? Except for MRI scanners, the answer is "nope."
US 30 Nation Median
Hospital Beds per 1,000 persons 2.9 3.7
Physicians per 1,000 2.4 3.1
Nurses per 1,000 7.9 8.9
MRIs per 1,000 8.2 5.5
CT Scanners per 1,000 13.3 12.8

OK then, it must be malpractice -- those greedy lawyers, as Pres. Bush reminds us. Nope. Total malpractice awards per capita in 4 nations: US -- $16 (out of $5,267), United Kingdom -- $12, Australia -- $10, Canada -- $4. "In all four countries, however, malpractice payments represent less than 0.5% of health spending ... The cost of defending US malpractice claims, including awards, legal costs, and underwriting costs, was an estimated $6.5 billion in 2001 -- 0.46% of total health spending."

Dammit then, what's the cause? -- "...the prices of care, not the amount of care delivered, are the primary differences between the United States and other countries. These higher prices are increasingly making health care unaffordable for many Americans. Equally troubling, the more-costly U.S. health care has not resulted in demonstrably better technical quality of care or better patient satisfaction with care. Future U.S. policies should focus on the prices paid for health services and on improving the quality of those services."

July 12, 2005

HCFA's policy director, Brian Rosman, just returned from a short trip to Israel. Although his trip didn't focus on health policy issues, he couldn't help but notice it when health issues were in the news:

"Israel moved to a universal coverage 'managed competition' system in the mid-1990s. Everyone must join one of 4 health plans, of which each has a network of clinics and hospitals. The government pays plans using funds that come from a payroll tax and from general revenue. The government sets a uniform benefits package for all plans.

"Last week, the news focused on the services available from the health plans. There is a constant tug-of-war in Israel between the Health Ministry, which seeks to add more benefits, and the Treasury, which tries to limit expenditure growth. Patients who could be helped by expensive new therapies often go to the press, aided by promoters of new therapies. The media pressure often succeeds in getting the new treatment added to the package. There is less public pressure on behalf cheaper preventive therapies, even though they may be more cost effective. Last week, a conference presented charges that drug companies withhold unfavorable information to get new drugs approved."

Another Israel connection: HCFA board member Dr. Norbert Goldfield heads a program called "Healing Across the Divides," which organizes cooperation between Israeli and Palestinian health professionals. The program works with Physicians for Human Rights and other groups to promote peace and improve health for Palestinians in Israel and in the West Bank.

July 9, 2005

More on the new Medicare Drug Law. FamiliesUSA has a new report showing how a number of states are eliminating eligibility for senior citizens to get Medicaid coverage in addition to Medicare (the so-called "dual eligibles.") Federal law requires states to enroll all seniors below 73% of the federal poverty line, though 21 states -- including Massachusetts -- go as high as 100%fpl. Three states have already cut back: Florida (77,000 seniors), Mississippi (65,000) , and Missouri (8660), and North Carolina is planning to do so.

Now the disagreement. FamiliesUSA says states are doing this so they will owe the federal government less money once the dreaded Medicare Prescription Drug Law "clawback" takes effect in January 2006 (under this, states will have to write a fat check to the federal government to pay for 90% of drug costs for seniors assumed by feds). An anonymous US Senate Finance Committee aide disagreed, and said states would be cutting back any way without the new drug benefit.

The timing is way too suspicious here. Families has the more convincing argument . Chalk another one up for the law of unintended consequences.