June 25, 2006

For the second time in less than a year, the Romney Administration is embarking on an initiative to draw consumers into health quality and cost issues -- and leaving consumers out of the process.

Background: the National Governors Association recently invited Governors to apply to send teams to a "policy academy" to develop state plans to improve health care quality. The Massachusetts proposal includes about two dozen references to their intention to engage consumers, and lists a team of eight public and private officials that includes, you guessed it, no consumer.

Several weeks ago, the team spent a week at the posh Claremont Resort in Berkeley CA with nine other state teams. Reportedly, a major topic among everyone was: how to engage consumers. Among the ten teams, not one consumer.

The Mass. health reform law establishes a "quality and cost council" to develop state plans to improve quality and control costs (by the way, establishment of the Q&C council was first advanced by HCFA and Affordable Care Today in health reform legislation filed in December 2004). The Romney Administration now intends to use the NGA policy team to develop their plans, and use the Q&C Council for rubberstamping purposes only. (Consumers were left of the Q&C Council as well -- relegated to an advisory committee.)

This is not the first time we've seen this from the Romney Administration. Last October, they unveiled a quality and cost comparison website for consumers -- and never consulted with a single consumer about it, before or after launching, in spite of written requests to do so.

Fortunately, private groups populating the Massachusetts quality landscape have a different attitude. MA Health Quality Partners, the MA Health Date Consortium, the MA Coalition for the Prevention of Medical Errors, MassPRO, the MA e-Health Collaborative, among others, all include consumers on their boards and in their work.

Dr. Don Berwick and the Institute for Healthcare Improvement have a mantra describing their attitude about patient/consumer involvement: Nothing done to us or for us without us.

Words the Romney Administration might take to heart.

June 21, 2006

Tomorrow’s (Thursday) Insurance Connector Board Meeting will be held in the basement of 1 Ashburton Place in Boston. All the other board meetings will be held on the 21st floor of 1 Ashburton Place (much nicer view). All meetings will start at 9 am every other Thursday. Tomorrow's meeting is expected to address the benefit design of subsidized insurance plans -- also known as the C-CHIP, or Commonwealth Care Health Insurance Program, plans.

June 21, 2006

Another interesting health reform piece in the Boston Business Journal, this one an opinion piece by Boston Attorney Morris Robinson. Key quote:

"...beginning Jan. 1, 2007, Massachusetts employers must establish health care cafeteria plans for their employees under Section 125 of the U. S. Internal Revenue Code. Cafeteria plans allow employees to choose their own health plans and to pay for their own health care insurance premiums with pretax dollars through payroll deductions. Employees typically do not pay either state or federal income taxes or federal FICA taxes on their health care premiums.

Employers also benefit. No employer contribution is required, and the employees' health care premiums are deductible in computing the employers' own income taxes. Further, the employees' health care premiums are not counted in determining either the employers' state and federal payroll taxes or the employers' workers' compensation premiums.

The combined employer and employee tax savings plus the workers' comp premium savings are substantial -- roughly 37 percent to 47 percent of health care insurance premiums paid by employees through payroll deductions. These savings help make universal health care affordable for both employers and employees."

A friend at a local chamber of commerce recently scratched his head in talking with me about why more employers are not dropping health insurance coverage for their workers given the rising costs. The only explanation that made sense, he thought, were the considerable tax benefits to employers from offering coverage. Robinson, it seems, has the same insight.

June 20, 2006

As we mentioned in an earlier post, the Romney Administration is seeking a substantial number of changes to Chapter 58, the recently enacted health reform law. The Administration describes these changes as "technical." Many are, and many are not.

You can be the judge.

For the actual language submitted, click here.

For the section by section outline, click here.

June 20, 2006

Today, MassACT, a nine member statewide ballot initiative coalition, submitted over 22,000 signatures in support of comprehensive health reform to cities and towns across the Commonwealth for voter verification. MassACT collected over 112,000 signatures last fall qualifying for the ballot. This spring, the campaign mobilized volunteers to collect the additional 11,000 signatures needed for the next step towards November.

“We did it again! The legislature wrote significant health care expansions, subsidies and restorations into Chapter 58 because of our ballot initiative and our successful fall campaign.” explained Reverend Hurmon Hamilton, of Roxbury Presbyterian Church and President of the Greater Boston Interfaith Organization. “This next 22,000 signatures shows our continued resolve to see this law through to fair and just implementation.” “The public supports comprehensive health reform that is fairly funded with employer responsibility as a key component” said John McDonough, Executive Director of Health care for All. “Our signatures prove this loud and clear.”

The campaign will announce our intentions regarding the November Ballot at a press conference at 12 noon, Wednesday, July 5th, at 30 Winter St. 9th Floor, Boston.

June 20, 2006

For about two months now, word has been that the Romney Administration would propose a legislative set of "technical corrections" to Chapter 58, the new MA health reform law. Then word spread they would not file corrective legislation -- and would informally submit suggested changes to key legislators to slip into a budget or other vehicle to avoid a public hearing and public process.

Administration officials gave their list to legislators about two weeks ago and legislators are waiting for full text.

In our never-ending effort to help the Romney Adminstration live up to their goal of "transparency," we are making the list of technical corrections available by clicking here.

As with any complex bill, technical corrections are often passed to fix errors and clarify imprecise wording. Of course, one person's technical correction is another's policy change. The legislature has the final word.

We have no idea if this is the Administration's final list. We hope they make their final submission public so everyone can comment and weigh in. And we hope the Legislature gives the public an opportunity to weigh in on these changes -- many of which are by no means "technical."

Looking at the list, it's hard to understand some cryptic references. Some stick out and deserve full public discussion:

1. Board membership - Under the "purely technical" category is adding the Secretary of EOHHS to the Connector Board. The current language in the Connector statute declares the Board shall have 11 members, and then lists just 10 people for the Board: 4 government officials, 3 administration appointees, and 3 AG appointees. Adding another Administration official would not bring more expertise to the board. It would stack the deck in the administration's favor in case of a close vote. And already there are questions about how open the Connector's process will be.

2. Mandating kids - Also in the "purely technical" category is amending the individual mandate to include children. We think the legislature was deliberate that the mandate only apply to adults. We support universal coverage for children, but the framework is not there to support this change. Mandating children's coverage will complicate the affordability determiniation for the individual mandate. Many employers do not offer family coverage, and coverage through the Children's Medical Security Plan, which is available to all parents, is not comprehensive coverage. It would be unfair to penalize parents for not providing coverage to their children when employers are under no obligation to provide family plans.

3. Unfreezing the Pool. The legislature wisely decided to lock in place the current Free Care Pool regulations until October, 2007. This keeps the safety net in place for the poorest residents during the transisiton to an untested system that will have glitches and errors. As Medicare Part D demonstrates, new programs frequently don't work as planned, and people get hurt if promised coverage is not available. The Romney Adminstration's list proposes to unfreeze Pool regs and allow them to make unspecified changes. We support the original intent of the legislature and urge this proposal to go into the deep freeze.

Lots more here. Let us and the Legislature know what you notice and think.

June 18, 2006

If you don't know Helen Osborne, then you don't know one of the most practical and smart experts on Health Literacy around. Helen runs her own health literacy consulting practice in Natick and is the founding director of health literacy month (October), an international campaign to raise awareness about the important of understandable health information.

Just got hold of Helen's new book -- Health Literacy from A to Z -- and it's first rate, with loads of useful information and insight, an indispensible resource for anyone who wants to understand and work on this issue.

The Institute of Medicine estimates there are at least 90 million adult Americans with low health literacy, meaning they can't understand a prescription label or an appointment slip, or can't understand instructions from the medical professional. More than race, ethnicity, or income, a person's health literacy skill is the most important predictor of health status. And the financial consequences are huge. It also intersects with the important issue of racial and ethnic health disparities.

Rep. Liz Malia has filed state legislation to set up a special state commission to study and report on ways to improve health literacy in Massachusetts.

What do you know and think about this issue?

June 15, 2006

From Brian Rosman:

The Administration filed its first health reform implementation update with the legislature today. You can download and read it here.

The report includes a good summary of the provisions of Chapter 58, the health reform statute. The chart on pages 27-28 lists 90 separate implementation projects being tracked by the administration’s inter-agency management committee. An early task of this committee is to develop a list of “technical corrections” to the statute to submit to the legislature. The report lists a number of these proposed changes, and we understand some have already been shared with legislative leadership.

Overall, it’s clear the administration is working aggressively to implement health reform. All of the myriad of Medicaid expansions and benefit restorations are on track to be implemented on July 1. EOHHS officials are talking daily with federal CMS authorities, and the report is cautiously optimistic that CMS will approve the plan on time with only minor modifications.

Looking over the report, a few items did jump out:

Connector Board membership – the report states that the administration proposes to add the EOHHS secretary as an 11th voting member of the Connector Board. We’re doubtful the legislature will accede to adding yet another administration vote.

Pool Continuation? – the report states that CMS is concerned about the provision that continues Free Care Pool eligibility for people below 200% of poverty. The concern is that people eligible for subsidized Commonwealth Care plans will opt out of coverage and use Pool services instead. They also worry that the insurance plans’ benefit restrictions could be circumvented if the Pool wrapped around and covered medically necessary care not included in the plan, as it does now for eligible insured people. The administration will be proposing a technical amendment on this point, too.

This issue could be a flash point, as the legislature was explicit in keeping the safety net in place for the transition period. Hospitals and health centers will also weigh in on this issue, as they could be stuck with no source of payment for services provided to people who don’t sign up for coverage plans.

Rate increases for all – Chapter 58 calls for replacing the lost federal funds now going to the Medicaid health plans operated by Boston Medical Center and Cambridge Health Alliance. The report states that the Administration will also raise rates paid to the other two Medicaid managed care plans “to avoid market distortion and unfair competitive disadvantage.” As a result, rather than costing $87 million, some $111 million will go for increased Medicaid managed care payments.

Implementation push-backs – the administration proposes to delay until July 1, 2007, implementation of a number of the provisions of the bill now scheduled to take effect earlier, including the changes to the small group market (scheduled for 1/1/07), start-up for Connector-sold affordable coverage (4/1/07), young adult plans (now), and the requirement for “section 125 cafeteria plans” that facilitate pre-tax purchase of coverage (1/107). Coordinating these dates may make sense, since the pieces all go together in a package.

Regulation speed-ups – while proposing to delay some provisions, the administration is in a hurry to get regulations done before it goes out of business this December. The regulation timetable calls for completing the Uncompensated Care regulations by September 2006, even though the statute prohibits any changes until October, 2007.

June 7, 2006

By HCFA's Melissa Shannon:

The Romney Folks Tried to Own the Day, but the Consumer and Labor Reps Weren’t Giving it Away.

There was a lot of process, and not much substance in today’s three hour meeting of the Commonwealth Health Insurance Connector Board. It was worth the trip in the rain to get a feeling for how things started. Some interesting things about the setting:

  • The meeting was held in a sparsely furnished, windowless basement room. There weren’t chairs for most people who came. It wasn’t until the EOHHS General Counsel explained the open meeting law, and suggested chairs for the public might be an appropriate part of that “openness,” that chairs were provided There never were enough chairs for everyone despite plenty of space.
  • Seats in the front row closest to board members were reserved for staff of ex-officio members. No seats were reserved for people to staff other members.
  • Board members were arranged in a horseshoe with their backs to the public.
  • Secretary Tom Trimarco, Board Chair, Secretary Tim Murphy, Connector CEO Jon Kingsdale and guest speakers were the only people formally introduced. If you haven’t been in this business for 20 years or didn’t Google everyone ahead of time, too bad for you.
  • 100 people endured the rain, a long security line and a long wait for a chair. There were faces from across our health care “system”: providers, insurers, Medicaid MCO’s, GBIO, the House Health Care Finance staff, the legislature (Rep. Marzilli), the ACT Coalition, advocates, and reporters.

The Proceedings:

  • Romney started by swearing in the members and telling his version of how we got to this point, quoting US HH&S Secretary Leavitt’s opinion that Medicaid, “is not a good insurance product, because it doesn’t include deductibles, co-pays and other forms of cost sharing.” He didn’t say this to start debate, but as something he thought we all agreed on. (We don’t, but the show goes on.)
  • The jaw dropping moment came when Sect. Trimarco said the legislature’s failure to name 11 people to the board (they named 10) was an accidental omission of Sect. Murphy, whom he invited to join the table, noting that the administration would request Murphy's inclusion as a technical amendment to Chapter 58.
  • The first challenge to the Administration came when Chip Joffe-Halpern (the Consumer rep, Exec. Dir. of EcuHealth Care in North Adams and HCFA’s Board President) made opening remarks. Chip said he wanted full opportunity for public input, particularly around affordability standards and subsidies. He reminded the group of the key purpose of health insurance: “to reduce barriers to care and protect people from financial hardship in the event of an illness.”
  • Celia Wcislo, from SEIU Local 1199 and the labor rep, followed stressing the need to ensure health care access for individuals and employers, both small and not-so small.
  • Rick Lord, the business rep from Associated Industries of Mass., made a pitch for cost savings for small businesses and then it was back to the administration’s show.
  • No other board members introduced themselves or shared their vision of the Connector’s role.
  • Things remained smooth and boring through technical presentations until Jon Kingsdale described his vision for the Connector’s role. He showed a slide listing the Connector’s responsibilities, with a date and description for the Board to approve, review or oversee each item.
  • Dolores Mitchell, Exec. Dir. of the Group Insurance Commission, interrupted with the first “hold on a minute, partner” moment of the day. She asked if they were statutorily required to approve something, shouldn’t they actually approve it and not just review it?
  • Celia and Chip jumped in to voice their desire for substantive discussion on these topics, not just a reviewing role. No one used the word “rubber stamp,” but it was clear at least 2 to 3 board members have no intention to delegate their duties to the Connector staff.
  • The Chair and other members got the message, vowed to heed it, and realized that meeting monthly wouldn't fly either.
  • A plan was made to meet every other week on Thursday mornings, starting on June 21st, with a promise that notice on the agenda would be made at least 48 hours in advance in keeping with the open meeting law.

We all headed back into the rain.

May 31, 2006

An engaging and provocative forum, hosted last week by the libertarian Cato Institute in Washington DC, is well worth a listen or a read. Click here to obtain either. Speakers included:

Len Nichols, director, Health Policy Program, New America Foundation
Ron Pollack, executive director, Families USA
Arnold Kling, adjunct scholar, Cato Institute
Michael Tanner, director, Health and Welfare Studies, Cato Institute

Interesting to read the Cato take on MA health reform. Most thought provoking by far is Len Nichols, a fascinating cat. For years, Len worked as a super-smart health economist for middle of the road places such as the Urban Institute and the Center for Studying Health System Change. Several years ago he got religion, literally, and became the resident health expert at the New America Foundation where he's pounding pavement to make the moral, ethical, and -- yes -- biblical case for national health reform. He speaks with passion, power, and persuasion. He makes this session a must read/view. A few choice quotes:

"...a couple of things about [insurance] mandates. I'll say it's kind of interesting how here's a state -- one of the reasons why Massachusetts is so unique is because they only has 10.7 percent uninsured, whereas the nation as a whole is about 16 percent. If their mandates were so onerous, how is that possible?"

"This is the fun time of the presidential sweepstakes. I've been approached by four candidates, just to come in and talk ... What's interesting is, the similarity of the questions the Rs have asked, and this is all before Massachusetts. The first was: 'You know, my aide has heard you talk about the moral case for health care. What is that?' And I go through that ... but I'll just say they care because they're devout, and they really want to know what that's about..."

"But the second question for today's talk is more interesting. 'How can I make universal coverage consistent with Republican principles?' It turns out the answer's quite simple. It's Massachusetts: individual mandate, individual responsibility. We just went through the moral case. You've got to have a community to make it possible for each individual to try help themselves. You've got to have subsidies and some kind of mechanism to buy it efficiently. ... If you want to seriously run in 2008, you've got to be prepared to answer this question. You've got to be prepared to address the sense of urgency the American people feel for being unable to afford health care. And we can do it with Republican principles. We can do it with Democratic principles. We can do it."

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