Today is the final day of the first 10 years of the State Children’s Health Insurance Program (SCHIP – though House Democrats now insist it be called CHIP). Congress and the President have yet to agree on a new authorization – it’s being extended through mid-November by a continuing resolution, so hold the panic. So a few anniversary reflections.

SCHIP was created in 1997 as part of a much larger bill, the Balanced Budget Act. In early ’97, “smart” people said there was no way a Republican Congress would create a new social program in a year of deficit reduction. They underestimated the team of Senators Kennedy and Hatch who refused to give up and got it done .

When SCHIP was created, there were about 10 million uninsured kids; today there are between 5-6 million kids in SCHIP and about 10 million uninsured kids. Huh? What’s going on? Several things. First, many employers are dropping dependent coverage just as they are dropping retiree coverage and health insurance for their workers. Would they drop as quickly if SCHIP were not around? Well, they were dropping before SCHIP. Most likely, some yes and some no. Second, the numbers of uninsured keep rising, including kids. Estimates are between a quarter and a half of kids on SCHIP had prior employer coverage.

The prevailing belief is that a large portion – as many as six million – of the 10 million still uninsured kids are eligible for their state SCHIP programs and unenrolled. Most states are reluctant to go gang-buster on enrollment because federal SCHIP dollars to states are capped, and most states are at or near their limits. Without significant new dollars, states won’t have enough money even to pay for kids currently on. The extra money in the new legislation mostly allows states to pay for enrolling kids who are eligible now under current rules.

Overwhelmingly, SCHIP kids live in families with incomes under 200% of the federal poverty line. Some states have gone up – Massachusetts up to 300%fpl – reflecting the higher cost of living that makes insurance unaffordable for families at higher income levels. The number of states over 300% is tiny, and the legislation Bush says he will veto actually would make it harder for states to expand to these higher levels.

Bush’s belligerence to SCHIP seems to reflect a growing deathwish on the part of the national Republican Party. After seven years of untold billions in waste, to draw a line in the sand on health insurance for lower income kids makes sense only from dark recesses of the political fringe. And once again, we can only shake our heads and laugh seeing Mitt Romney oppose legislation to facilitate what he happily signed (no veto pen here) in Chapter 58.

Ultimately, Bush will lose this one. He’s even done SCHIP a favor. SCHIP has gotten more publicity recently than at any point in its 10 year history. This will only enhance long term prospects for the program and give Americans one more compelling reason to vote out office those whose ideological blinders leave them unable to see uninsured kids.

By the way, click here for the New England Alliance for Children’s Health, run by our colleagues at Community Catalyst, and doing first rate work on SCHIP.
John McDonough

Today is the final day in the life of the Uncompensated Care Pool. Maybe it’s just me, but I’ve gotten no invitations to celebrations, funerals, parties or any other recognition of the sunset of a central facet of MA health care finance since its legislative creation in 1985 and its opening for business in 1986. Dense, complex, obscure, political – for better AND worse, it’s been the heart and soul of our health care safety net for 21 years.

The Pool (alternately called the Uncompensated Care Pool or the Free Care Pool) was set up during the “rate setting” era when Massachusetts regulated the growth of hospital inpatient revenues. The Pool was set up so hospitals caring for disproportionate numbers of uninsured (chiefly Boston City and Cambridge Hospitals) would not be financially disadvantaged for doing so.

Those present at the Pool’s birth (I was one) will recall it was intended as a temporary, short term fix to be replaced by a soon-to-be-enacted universal coverage system. The 1988 Universal Health Care Law (signed by then-Gov. Mike Dukakis) would have eliminated the Pool; but the law’s central mechanism – a “pay or play” employer mandate – was never implemented and repealed in 1996. Also repealed in 1991 was the rate setting system which spawned the Pool.

And yet the Pool survived, for two reasons. First, it made good policy sense to distribute the burden of paying for lower-income uninsured and underinsured. Second, hospitals found it in their self-interest to continue it. Another characteristic feature of the Pool’s life was constant infighting among hospitals over who gets how much from it.

Over the years, the Pool changed a lot and often. The biggest revisions occurred in 1988, 1991, 1997, 2002, and then, 2006 – Chapter 58 called for the demise of the existing Pool and its replacement (beginning tomorrow) by the “Health Safety Net Trust Fund.” (Click here for access to all recent UCPool reports from the Division of Health Care Finance and Policy which runs the Pool and its successor.)

Why a Pool/Fund at all given Chapter 58?

Because in spite of impressive coverage gains MA health reform is attaining and will continue to attain, at the end of the day, we will still have a lot of lower income uninsured and underinsured. A lot less, yes. A lot less expensive, yes. And still, a Pool-like mechanism is needed? Yes.

Imperfect, political, messy, maligned – for 21 years, the Pool has been the reality and symbol of a different value system in Massachusetts – less expansive than that of other civilized nation that covers everyone, and more robust and caring than can be found in just about any other US state. No cheers or tears today. Still, worth taking a moment to reflect on our abundant strengths and weaknesses, all amply on display in that damn Pool.
John McDonough

I’m in Denver for a FamiliesUSA board of directors meeting, and while here, had the chance to connect with CO public officials and activists on their health reform dreams, intentions, plans and progress. Back in 2006, a Republican Governor and Republican controlled Legislature agreed to establish a special commission to come up with plans to create universal health care and to report back no later than then end of January 2008. The group is called the Blue Ribbon Commission for Healthcare Reform, though insiders refer to is as the “208 Commission” — guess they’re as imaginative as we are when it comes to naming things (i.e.: Chapter 58).

The Commission invited anyone to submit a plan for how Colorado could get to universal coverage, and then selected four of them for rigorous review and cost analysis by the Lewin Group. The Commission also decided to put a fifth, its own, plan on the table for consideration along with the others. The ideological range travels from Health Care For All Colorado’s single payer proposal to the Colorado State Association of Health Underwriters’ market-based plan. The Committee for Colorado Health Solutions and SEIU also have proposals in the mix.

The Commission’s fifth offering includes the following elements:
1. All Coloradans required to have insurance or pay assessment through income tax filing if they do not
2. Employers not required to offer insurance
— Required to offer payroll deduction/pre-tax plans to help employees to purchase insurance themselves
3. “Connector” for employers/employees to purchase insurance
4. Reform individual insurance market
— “Healthy” people can’t be turned down
— Premiums can vary by age, geography
— Expand Cover Colorado to cover more people with chronic conditions
5. Subsidies up to 400% FPL
— Catastrophic care fund for those eligible for subsidy
6. Combine and expand Medicaid/CHP+
— Cover children up to 250% FPL
— Cover parents and childless adults up to 200% FPL
— Buy-in program for disabled
— “Medically Needy” and ‘Medically Correctable” programs
7. Optional “Continuous Coverage Portable Plan” similar to Medicare
8. 24-hour coverage option for employers

The political landscape has changed dramatically since the 208 Commission was created. For the first time in 40 years, the Governor’s office, House and Senate are controlled by Democrats, and there’s a significant public demand for addressing the needs of about 750,000 uninsured. The new Gov, Bill Ritter, is enjoying huge voter popularity at the moment. But Colorado’s constitution has a Taxpayer Bill of Rights (TABOR) embedded in it that would require almost any plan raising significant new revenues to go before the voters before it could take effect. Now there’s a roadblock. Polling shows the public wants a significant health expansion and does not want to raise taxes to pay for it.

Hmmmmm….(chin scratching).
John McDonough

From today’s State House News Service:

Secretary of Health and Human Services JudyAnn Bigby downplayed what some senators only hours earlier declared was a looming fiscal crisis for the state’s hospitals. Asked whether the state was on the verge of a crisis of hospital closures, Bigby told the News Service, “no we’re not.” Ways and Means Chairman Steven Panagiotakos earlier today said some hospitals faced “closing their doors for mental health patients” if the Legislature failed to pass immediately a $9.5 million appropriations bill, which it did just after 4 pm today. Sen. Gale Candaras warned that one distressed Western Massachusetts hospital was on the verge of shutting down. “If that hospital were to close, there would be hundreds and hundreds of jobs lost and hundreds and hundreds of patients with nowhere to go and hundreds of methadone patients out looking for heroin on the street,” she said. Asked about Panagiotakos’s statement, Bigby simply said, “I respect his opinion … some of the hospitals are less well off than others.” She noted that there was increased pressure on hospitals because they had received lesser funding than in previous years. The $9.5 million appropriation, now on the governor’s desk, would bolster the state’s Essential Community Provider Fund. The fund, which received $28 million in the fiscal year 2008 budget, was established to “enhance the ability of hospitals and community health centers to serve populations in need.” The secretary of health and human services administers the grants provided by the fund.

Get the feeling there’s more here than meets the eye?

Two posts deserving special attention over at the WBUR blog, CommonHealth:

First, Leslie Kirwan, Secretary of Administration and Finance and Chair of the Connector Board, gives an overview of the Connector’s upcoming challenges — click here. One of many money quotes:

“I was also heartened to hear “across the Board” (literally) interest in focusing on health care cost containment. The message that cost containment is essential to the success and sustainability of health reform has echoed on this blog since its creation. The Connector has a number of levers at its disposal to promote improvements in the efficiency and quality of health care, as do other parts of state government involved in the purchase and delivery of health care (for example, MassHealth and the GIC). There is great potential for collaboration between these entities (and also with non-governmental health care players) to help “bend the cost curve” in a favorable direction. Definitely more to come on this front.”

Second, Jon Hurst, President of the Retailers Association, declares war on health care costs and, in particular, the state’s insurers — click here. Big money quote:

It’s time for answers and accountability. It’s time for all payers of health care dollars (employers, consumers and taxpayers) to put big health care under the microscope and stop accepting this money grab from our pockets to theirs. We must stop putting them in positions of public policy authority and labeling them as the “experts” on health care policy, or as “important parts of the employer community.” They have taken advantage of the payers for long enough, and our future economy demands that the dollars start flowing back in the other direction.

Hurst represents the big retailers, but the bulk of his members fit into the small to tiny employer category.

Either we’re going to figure out a way to slow rising health costs collectively and collaboratively, or we’re going to end up brawling. Jon represents a class of employers on the receiving end of huge premium increases, year after year. His constituency deserves better answers and, more importantly, help.

We have not written much recently on the SCHIP battle between a bipartisan Congressional majority on one side and President Bush and his dwindling band of true believers on the other. Not much because there’s no controversy over SCHIP renewal in this part of the nation at all. Every single member of the US House from New England voted in favor of the reauthorization bill. Every Senator — save Judd Gregg from New Hampshire — will vote for it tomorrow.

So, what to do? How about sending a thank you note to your member of Congress to thank him or her for the House action on SCHIP? Could not be easier. Click here for a contact list. And click here to send an immediate email message courtesy of FamiliesUSA.

Thanks!

The Massachusetts Quality and Cost Council, the statewide body established under health reform to set quality improvement and cost containment goals for Massachusetts, has restructured its committees and has issued a new schedule for meetings. All meetings are open to the public. If you have a particular interest in any of the committees, or in attending the full Council meetings, please show up!

Full Council meetings will generally be held at One Ashburton Place, 21st floor. Committee meetings may be held in another room in the building tbd (look for updates on the Council’s website.

For more information about the Council, contact Deb Wachenheim (dwachenheim@hcfama.org or 617-275-2902).

Meeting Schedule:
1st Wednesdays of every month – beginning October 3
11:00 – 12:30 End of Life Care Committee
1:00- 3:00 Full Council meeting
3:15 – 4:45 Communications/Transparency Committee

3rd Wednesdays of every month – beginning October 17
11:00 – 12:30 Chronic Disease Prevention Committee
1:00 – 3:00 Full Council meeting
3:15 – 4:45 Patient Safety Committee

Yesterday, HCFA and the MA Coalition for the Prevention of Medical Errors cosponsored an event focusing on the potential to use hospital mortality data in general – and the Hospital Standardized Mortality Ratio in particular – for internal hospital quality improvement and for public consumer information.

80+ people listened to presentations, including an HSMR overview from Sir Brian Jarman, developer of the measure which is used by the Institute for Healthcare Improvement (www.ihi.org) to help hospitals improve quality. See Sir Brian’s slides by clicking here. The UK – and soon Canada – publish hospital HSMRs.

Sir Brian was followed by four speakers (Paul Levy, Beth Israel Deaconess CEO, Dr. Gregg Meyer of MGH, HCFA’s John McDonough and Ken Sands of BIDMC). Beth Israel is the only MA hospital that publicly posts its HSMR (on Paul’s blog, among other places), a move that triggered a negative response from other hospital CEOs. He argues nonprofit hospitals, as tax-exempt institutions, have a moral obligation to be open and transparent. He suggests hospitals should publish their HSMRs through IHI’s website. He said: with IHI posting the info, and HCFA and BIDMC linking to the IHI webpage, “To quote Arlo Guthrie…We’ve got three of us. It’s a movement!”

Gregg Meyer (click here his slides) and Ken Sands (click here) said this measure can be useful for internal improvement, and should not be publicly available because of its complexity and because it is not useful for consumer decision-making. Ken said individual hospitals should disclose their own numbers if they wish.

John McDonough talked about seeing a scatter plot of HSMR numbers for all MA hospitals (without names) and noted that some hospitals had rates way above than the average. He said consumers should know about this and hospitals should know their own HSMRs (which many of them don’t) so they know if there is a problem that needs to be corrected. John also wondered, who’s paying attention to hospitals with mortality rates way above the state average?” He also noted, on average, Massachusetts hospitals perform worse than all US hospitals.

The event was cut short by a fire alarm. We look forward to continuing the conversation with interested parties, including the MA Coalition and IHI and all of those in attendance at today’s event.

Since yesterday’s event, Paul Levy has added more thoughts on his blog, Running a Hospital. And Charley Blandy from Blue Mass Group added an informed lay person’s perspective.

The burning question is this: why should consumers not have access to numbers which tell us how how well or poorly a hospital does in keeping patients alive?
Deb Wachenheim

Last spring, State Representative Marty Walz wrote a guide on health reform for her legal colleagues. She’s just published an “Updated Guidance for Employers About the Massachusetts Health Care Reform Law,” another comprehensive look at Chapter 58. Click here to get. This one focuses on employer responsibility through health reform. Thank you, Representative!

Attention Consumers: You May be Able to Join a Class Action Lawsuit on Prescription Drug Prices

The Prescription Access Litigation (PAL) Project (a project of HCFA’s national partner, Community Catalyst and a coalition of which HCFA is a proud member) continues working to make prescription drug prices more affordable for consumers. In June 2005 and February 2006, members of the PAL Coalition filed class action lawsuits against First Databank, Inc. and McKesson Corp, alleging that the companies conspired to raise drug prices by inflating the “Average Wholesale Price” (AWP) of hundreds of drugs. AWP is used to set the retail price of prescription drugs. The case seeks to get reimbursement for consumers and health plans, and to end this type of scheme.

You may be eligible to join this lawsuit if you:
• Had no insurance at any time between 2001 and 2004, and
• Paid for brand-name prescription drugs (not generics) yourself
Or if you paid for brand-name prescription drugs yourself that were not covered by insurance.

To find out if you qualify, please call 617-275-2931 or 866-208-9800 ext. 2931 by October 4th.

Today’s New York Times editorial does the best job we’ve seen assessing all the health positions of the Democratic and Republican candidates and putting them in a useful perspective. There’s reason to be hopeful, and there’s reason for concern. Money graphs:

All of the plans, both Republican and Democratic, fail to provide a plausible solution to the problem that has driven health care reform to the fore as a political issue: the inexorably rising costs that drive up insurance rates and force employers to cut back on coverage or charge higher premiums. All of the plans acknowledge the need to restrain costs, but most of the remedies they offer are not likely to do much.

Electronic medical records to eliminate errors and increase efficiency, more preventive care to head off serious diseases, and better coordination of patients suffering multiple, chronic illnesses are all worthy proposals, but there is scant evidence they will reduce costs. Proposals to import drugs from abroad, allow Medicare to negotiate drug prices, restrain malpractice expenses, increase competition among health plans, and empower consumers to shop more wisely for medical care might help a bit. But many experts doubt that any of this will truly put the brakes on escalating health care costs.

No top candidate in either party has broached more drastic remedies, like limiting the use of expensive new technologies, cutting reimbursements to doctors and hospitals, or forcing people to use health maintenance organizations. And no one has suggested imposing higher taxes on everyone, not just the wealthy, to finance universal coverage. These solutions are not even discussed on the campaign trail lest they alienate voters and interest groups.

At this stage, the various plans should be considered as broad outlines of where the candidates want to go, with details to be worked out later. Voters who put a high priority on covering all or most of the uninsured will prefer the Democrats’ approach, as we do. The chief danger is that the Democrats have a tendency to imply that everyone can be covered with good benefit packages without inconveniencing anyone but the wealthy. Their cost and savings assumptions will need thorough analysis when more detailed plans emerge.

Stephen Schroeder, former head of the Robert Wood Johnson Foundation, makes a powerful case for a renewed and stepped up commitment to improve population health in this week’s New England Journal of Medicine – click here.

“Improving population health would be more than a statistical accomplishment. It could enhance the productivity of the workforce and boost the national economy, reduce health care expenditures, and most important, improve people’s lives. But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health. This sense of purpose resonates with our deepest professional values and is the reason why many chose medicine as a profession. It is also one of the most productive expressions of patriotism. Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. Why don’t we try to become number one in health?”

Check out the illuminating chart on the parallels between tobacco and obesity as public health issues.

Earlier this week, the Division of Health Care Finance and Policy (DHCFP) heard testimony regarding their proposals to adjust reimbursement rates paid to dental providers who treat MassHealth patients.

In Massachusetts we face a crisis of access to dental care for the poor. Over half our cities and towns have no dental provider and the misdistribution of those who will see MassHealth patients leaves those living in areas like Western Massachusetts with few options. Having good oral health is essential to having good overall health. Associations between dental disease and adverse outcomes such as increased risk for heart disease, diabetes, lung disease and the delivery of pre-term low-birth weight babies are found regularly. It is important that those with compromised health and immune systems have consistent access to oral care.

In recent years, we have seen increases in reimbursement rates paid for children’s dental services. This is because dental benefits for children are mandated by the federal government’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program, which is the child health component of Medicaid. DHCFP has proposed raising the reimbursement rates for children about 1% for this year. As the costs of providing care continue to rise annually, this proposal is essentially a non-increase.

Adults have not fared as well in dental services. MA eliminated dental services for adults on MassHealth from 2002-2006. These benefits were reinstated in MassHealth last year, but reimbursement rates for dental services to MassHealth adults are shamefully low. Dentists cite low reimbursement as one of the most significant barriers to participation in MassHealth. Those who do participate are paid a fraction of the costs of services- current reimbursement rates for MassHealth services fall in the lowest 10th percentile of rates billed by dentists.

These rates are so poor and the process for reimbursement so complicated, many providers have stopped treating MassHealth patients altogether. DHCFP, in their annual review, has proposed raising reimbursement rates for adult services by 8% for this year. While this is a nice effort, the starting base is so low, 8% does little to address the barriers to participation. Like children’s rates, these rates do not even keep pace with the increasing costs of providing care in Massachusetts.

Safety Net providers feel the impact of these rates the most. Health centers and Tufts Dental Facilities for Persons with Special Needs treat patients regardless of ability to pay. The majority of the client base at these facilities are adults with no other option for care outside of expensive emergency room treatment. Low reimbursement rates coupled with overall changes to the Safety Net force safety net providers to choose between cutting essential services or accumulating debt.

We must stop the erosion of our safety net dental providers and encourage the growth of a network of MassHealth dental providers. Raising dental reimbursement levels to a rate that encourages provider participation and allows for financial stability is essential to retain providers and maintain the safety net.

For more information about these rates or about the Oral Health Advocacy Taskforce, please contact Kate Vaughan at 617-275-2919 or vaughan@hcfama.org

A who’s who of quality improvement in MA gathered by the bay on Friday for the first annual meeting of the Massachusetts Health Care Quality & Cost Council.

Secretary Judy Ann Bigby kicked off the event at the JFK Library and Museum with an overview. The Council was formed under Chapter 58, and as Stuart Altman suggested, it may prove the most critical piece to maintain and expand health reform’s gains. The Council is charged with containing health care cost growth while improving quality and eliminating racial and ethnic health disparities. The Council established a set of goals to this end available here.

Cost control took center stage Altman’s keynote. He recalled being charged by the Nixon administration in 1971 to contain national health expenditures. This speech was atonement. Take homes: Massachusetts spending is not as far out of line with the nation as raw spending data suggests, but we may be nearing a national meltdown if we can’t control costs. Costs have risen 2% above GDP growth over the long term, with slower growth during times of regulation and faster growth during deregulation. Reforms that would have the greatest impact are the most difficult politically, i.e. price regulation.

Experts came from far away lands of England and New Hampshire to talk about public reporting of cost and quality data. A collective gasp of “they get away with that?” went through the room as Leslie Ludtke spoke about NH Health Cost. Through this website, NH residents can compare median costs of most common procedures. Prices are reported at the insurance carrier and hospital level, and will soon extend to physicians. Sir Brian Jarman spoke about the Hospital Standardized Mortality Ratio (HSMR). We blogged on HSMR’s potential – a bottom-line, risk-adjusted measure of how likely a patient is to die at a given hospital – in December. Hear more from Jarman on the topic at a forum sponsored by HCFA and the MA Coalition for the Prevention of Medical Errors: Monday, 9/24, 9:30-11:30am, 5th floor, China Trade Center, 2 Boylston Street, Boston.

IHI’s Jim Conway introduced a panel on preventing hospital acquired infections (HAI) with kudos to HCFA’s Consumer Health Quality Council members’ testimony before the Public Health committee last week. He said they sent a message of “enough! Focus on when and how to eliminate infections.” DPH Commissioner John Auerbach spoke of the Department’s work. DPH is beginning work on public reporting, oversight, and assisting providers. CMS’ William Kassler described feds’ plan to stop paying for preventable inpatient complications. Maureen Spencer, infection control manager at New England Baptist, described Baptist’s work to eliminate staph infections prior to orthopedic surgery. She underscored the importance of “working towards zero.” It is possible to eliminate most HAIs; it requires a top-to-bottom commitment. Benchmarking gets in the way. Their experience shows a great return on investment. Their program cost $400,000 to achieve savings of $25,000 per patient infection.

The last panel focused on racial and ethnic health disparities. The first Q&A comment called out the elephant in the room. Call it post-lunch blues, but only a third of the crowd remained. The commenter called on everyone to place disparities at the center of our work, not an aside. Moderator Robert Seifert turned the axiom, “I rob banks because that’s where the money is” into “Quality improvement should focus on disparities because that’s where the greatest problem is.” The panel featured details about MassHealth’s disparities work through pay-for-performance and in-the-trenches research from Harvard Vanguard’s experiences fighting disparities in diabetes care.
James Madden

This afternoon, the State Division of Healthcare Financing and Policy issued its final regulations governing the new Health Safety Net Trust Fund taking effect on October 1. The Fund replaces the Uncompensated Care Pool, which turns into a pumpkin on 9/30/07, after 21 years of reimbursing hospitals for care provided to income eligible uninsured and underinsured patients.

Click here for the press release issued by the state’s Executive Office of Health and Human Services.

Click here for the final regulations regarding eligible services.

And click here for the final regulations regarding payments and funding.

Replacement of the Pool with the Fund was included in the Health Reform Law, Chapter 58, back in April 2006. Since then, many who care about the future of the MA health care safety net have paid close attention to the development of this new mechanism. HCFA and the ACT!! Coalition raised many concerns about the draft regulations released last July, subject to a public hearing last August.

We appreciate that EOHHS Secretary Judy Ann Bigby and DHCFP Commissioner Sarah Iselin listened carefully to many concerns raised. While the final regs do not address all our concerns, they clearly made a good faith effort to fix many of the most serious matters, including the unrealistic deductibles, persons with unaffordable employer sponsored coverage, persons transitioning from one form of coverage to another, and much more. The new “Fund/Pool” represents an important change for many folks who relied on care funded by the former Pool. We will all be monitoring this new structure closely. We are grateful to the Patrick Administration for their serious and good faith efforts to meet this important health reform milestone.

Here’s a bit from the EOHHS release:

“Massachusetts has been a national leader in ensuring access to care for the uninsured and in supporting providers who care for them,” said DHCFP Commissioner Sarah Iselin. “These regulations represent an important step in health care reform implementation and demonstrate the state’s commitment to aligning incentives to get as many people as possible enrolled in affordable health insurance plans.”

In developing these final regulations, DHCFP carefully considered testimony offered during hearings on proposed regulations on August 22.

“We value the thoughtful testimony offered by providers, payers, consumers and others who will be affected by the transition of the Uncompensated Care Pool to the Health Safety Net Trust Fund,” said Health and Human Services Secretary Dr. JudyAnn Bigby. “The final regulations reflect the feedback we received and we look forward to continuing our work together to accomplish our health reform goals.”

The regulations include changes that will decrease out of pocket expenses; promote access to community health centers and community hospitals; and facilitate a gradual transition of eligibility criteria. Overall, the proposed regulations define eligibility criteria for reimbursable services; the scope of services eligible for reimbursement; standards for medical hardship; and standards for reasonable efforts to collect payments for emergency care costs.

After an August hiatus, the Connector Board met this morning for the first time since July 12th (see all the handouts here). Secretary Kirwan opened the meeting with some personnel housekeeping. Nancy Schwartz attended the meeting for Insurance Commissioner Nonnie Burnes; Medicaid Director Tom Dehner is now a permanent board member; and there will be a new face at the table next meeting – the Governor’s actuarial appointee. In a touching gift-exchange, outgoing Board member Chip Joffe-Halpern welcomed incoming Board member Nancy Turnbull with a symbolic red bowtie, and she congratulated him on his service with a “Health Reform Rock Star” T-shirt, complete with Bruce Springsteen hair and guitar. Board Chair Secretary Kirwan and Executive Director Jon Kingsdale thanked Joffe-Halpern for his presence and contribution with a Connector-engraved clock.

Chip, we will miss you greatly. And Nancy, we are so thrilled you are joining the Board.

Kingsdale began with his Executive Director report. At the July Board meeting, the staff presented their proposal for the MCC alternative minimum drug benefit. The staff continues research and consideration of external input; they will bring a final proposal to the Board in October for a November vote. Also upcoming next meeting is a Commonwealth Care presentation, with a focus on enrollment—not claims—data. Bob Carey detailed the type of data they are looking for, including: information by carrier, plan type, age, geography, who’s enrolling, why they choose their plan, differences in utilization for the auto-enrolled, identifying gaps, and what demographics are lagging in enrollment. We look forward to that presentation! And finally, Kingsdale reported on last Saturday’s successful Connector day at Fenway Park.

Rosemarie Day presented the operations report. Click here for the CommCare and CommChoice progress reports. Some details to note – As of September 1st, there are over 115,000 Commonwealth Care members, about 20% of whom are premium paying. Nancy Turnbull asked about churn, and Melissa Boudreault responded that between 2,500 and 4,000 individuals drop or switch coverage each month. The Customer Service Center continues to experience heavy volume with the significant growth in membership. Estimated call volume a year ago was 3,000 weekly; they’re now averaging over than 10,000 per week. While the Connector is thinking about ways to reduce call volume, perhaps by moving people to the internet, they expect numbers to stay high through the Fall. Jon Gruber asked if use of the Pool (Health Safety Net) is decreasing. Tom Dehner responded that it is and use will change radically with the new regulations. Kirwan suggested a later talk about Pool use and its relationship to CommCare.

Commonwealth Choice plans now have over 7,000 members, 30% of whom are on Young Adult Plans and 40% of whom are on Bronze Plans, suggesting that plan cost continues to be primary in choosing a plan. 71% of enrollees have chosen plans that include drug coverage. Enrollment spans the six plans, with BCBS carrying over a third of the total.

Kingsdale then walked the Board through draft objectives and goals for FY’08, which were agreed upon after discussion and suggested amendments. For the Commonwealth Care goal, “cover virtually all qualified uninsured people,” Celia Wcislo asked for an explication of who that included. Dolores Mitchell likewise asked for clarification on controlling “costs of contracting with MMCOs.” The third goal in this category included allowing CommCare enrollees to pay for their premiums with pre-tax dollars. Under Commonwealth Choice, Kingsdale highlighted the website as an important and popular transparency tool for both businesses and consumers. Turnbull questioned the goal of so much choice in plans, regardless of cost; Kirwan responded with a request to include a goal related to cost control. Wcislo asked how the Connector was tracking changes in CommChoice premiums, and Kingsdale said the Board would get data on pricing. In the discussion of goals for “Health Care Reform” more broadly, the group spent more time on cost (see the State House News story below) as well as the benefit of continuing partnerships with other government arms and agencies to address some cost containment strategies, both narrow and macro.

The Board then reviewed their calendar for the remainder of the fiscal year. A few issues—such as reviewing the MCC requirements and addressing the population of low-income individuals who are not eligible for CommCare because they have an offer of employer coverage—were noted as not on the calendar. Kingsdale promised he’d give ample warning of when they would be addressed. Returning to the question of rising CommChoice premiums, Turnbull asked if there was a framework for evaluating plans that have the Connector’s Seal of Approval; are there monitoring factors moving forward the Board can use to judge plans? (Another interesting note - the only referenced item on Public Information Campaign is “Review penalty schedule with Board.” When can we learn more about the continuing campaign?)

The only formal vote of the morning was approving a continuing line of credit for the Connector. Patrick Holland presented it as an important safeguard that they don’t expect to use in ’08 or ’09.

The final agenda item was a walk-through of the website for employers. Small group Commonwealth Choice isn’t expected to be launched until Feb, 2008, but employers can now offer their part-time and other employees who aren’t eligible for employer-sponsored coverage tax-free access to CommChoice plans through Section 125 plans. This can translate to significant savings for those employees. So far, 2,830 employers have set up these plans, with 50,399 employees eligible—382 of which have signed up.
Lindsey Tucker

For a meeting where not a heck of a lot happened, a heck of a lot happened at today’s Connector Board Meeting. Our report is above; here’s some excerpts from State House News’ report:

BOSTON, SEPT. 20, 2007…..State officials implementing the new law that requires most adults to have health insurance sped through their agenda of goals and objectives today, but stopped short on a topic that wasn’t on the docket yet is demanding more and more attention: cost control.

As individuals, businesses and the government shell out more for insurance than they can afford, growing health care costs are being viewed more acutely as a major threat to the near-universal coverage law, which is in the early stages of its implementation. Its fate is being monitored nationally by policy makers and presidential candidates. The Commonwealth Health Insurance Connector Authority, during its first year of operation, has worked to control rates at managed care organizations that provide subsidized coverage to low-income individuals and with insurers pitching a new menu of plans to those who aren’t eligible for subsidies and don’t have employer-based coverage.

Jon Kingsdale, the Connector’s executive director, told board members today at their first meeting since July that controlling rising costs of private health insurance is the “number one anxiety for me.” Board member Dolores Mitchell, director of the state Group Insurance Commission, the large insurer of public employees and retirees, said draft objectives calling for the board to “begin to develop” cost containment strategies to ensure health care reform’s long-term success are “a little on the weak side.” She called for tougher wording. “Some sense of urgency in that I think is very important,” said Mitchell, adding that writing checks that match the growing costs of health care will make cost control a pressing matter. Mitchell also sits on the state’s Health Care Quality and Cost Council, which is finalizing rules for bringing provider cost and quality data to the public online.

Leslie Kirwan, who chairs the Connector board and is Gov. Deval Patrick’s top budget aide, said the administration is formalizing cost control plans among at least six state agencies and emphasized bulk purchasing power as an antidote to rising costs. “There will be more stress on collaborating,” Kirwan told the board today. After the meeting, she said she wasn’t prepared to discuss the administration’s plans, but pointed to growing costs tied to the insurance expansion law, Medicaid, insurance for public employees and inmate care in the corrections system. “It’s a trend that we really have to keep our eye on,” she said. During the meeting, Kirwan described herself as “very worried” that health care costs appear to be consuming nearly half of the $26.8 billion budget and crowding out state government’s ability to afford other priorities. “There are a lot of other things that the state has to be in the business of,” she said. …

Kirwan, apparently referencing the stirring talk about health reform at the presidential campaign level, mentioned to board members at the outset of the meeting that many are already watching implementation of the health law here. “That will be doubled or tripled given what’s going on nationally,” she said. …

EOHHS Secretary Judy Ann Bigby will conduct two public hearings to hear the views of community members regarding the agencies under her purview.

Wednesday, October 3, 2007 — 10 a.m. – 2 p.m.
Reggie Lewis Center, 1350 Tremont St, Roxbury, MA —

Wednesday, October 3, 2007 – 10 a.m. – 2 p.m.Western New England College School of Law
Wilbraham Road, Springfield, MA — Rivers Memorial Hall

Thursday, October 4, 2007 — 10 a.m. – 2 p.m.
University of Massachusetts Medical School, Worcester

The hearings will tentatively be divided as follows:
10:00 to 11:00 Veterans, Elder Affairs, Soldiers’ Homes
11:00 to 12:00 Disabilities & Community Services – MCDHH, MCB, MRC, DMR
12:00 to 1:00 Health Services - DMH, DPH, MassHealth
1:00 to 2:00 Children, Youth and Families - DSS, DYS, ORI, DTA

OK, we categorize this as “health care humor.” Just count the number of times you break out laughing and you’ll get it. But this is no joke — this is Mitt Romney’s column in today’s Wall Street Journal. Priceless.

Where HillaryCare Goes Wrong
By MITT ROMNEY — September 20, 2007

Some of the details have changed, but at the heart of Sen. Hillary Clinton’s new health-care proposal are the same flaws that sunk her first version. They flow from her distrust of markets, from her distaste for profit-motivated private enterprise, and from her consequent faith that Washington knows best. The truth is that the American people know best, and when a sector of the economy is not working as well as it might, you should look to give the people more influence, to unleash competitive forces, and to welcome private ingenuity. The last thing you should do is apply more government. But that’s just what HillaryCare Version 2.0 does.

As governor of Massachusetts, I led the fight for reforms that used free markets and innovation, rather than big-government control, to lower health-care costs and cover the uninsured. I recently proposed a federalist reform plan that will use these principles to improve America’s health-care system. Sen. Clinton has a very different view about the changes we need to make. Her plan has several weaknesses and should be distinguished from the reforms I led in Massachusetts and the reform plan I have proposed. So let’s take a closer look at what her new proposal would really do:

• Raise taxes. The new plan is slated to cost $110 billion a year. And to pay for the new entitlement — a tax hike. That in turn will slow down the economy and make the cost of her system grow even higher. By contrast, both the reforms I led in Massachusetts and the federalist reform plan I recently proposed do not raise taxes or increase spending. In fact, in the new plan that I have proposed, funds currently sent to states to care for the uninsured are made flexible so that the states may use them to help the poor acquire their own private insurance.

• Expand government insurance. People who don’t obtain insurance through their employer are invited to buy a government-run, Medicare-like plan or enroll in the Federal Employees Health Benefits Program (FEHBP). And so, more Americans will end up in government-run insurance. It’s the gentle slope to a single payer, socialized medicine model. My plan in Massachusetts instead allowed the uninsured to choose a private insurance product from one of the many private insurance companies.

• Impose a national model on everyone. Sen. Clinton fundamentally distrusts state governments. But the states are closer to the people, and more responsive to them. They are also the laboratories of democracy — the best ideas can come from 50 states each doing their best work. The senator’s plan is a one-size-fits-all approach. It ignores significant differences between people and the needs of the 50 different states. Federalism is the right approach. The national reforms I have proposed give states financial flexibility to craft their own program to cover the uninsured, a program tailored to the specific needs of their citizens.

• Significantly increase the role of the federal government at the expense of free markets. For example, Sen. Clinton proposes the creation of an entirely new government-run Medicare-like program for the uninsured. Inevitably, lobbyists will go to town adding coverage mandates, setting rates and re-shaping plans to fit the wants of their clients. The better path is the market path. Let the multitude of private companies compete for the consumer’s dollar — the quality and the cost will be much better than what government could ever cobble together.

• Leave the mandate problem unsolved. Before you can impose a mandate on employers or individuals to purchase insurance, you need to reform state health insurance markets. Otherwise, policies can be so beefed-up with state mandated coverage and regulation that they are simply unaffordable. Then a mandate is unfair.

Moreover, her employer mandate doesn’t solve the problem of the uninsured — that’s why I vetoed a similar measure when I was governor of Massachusetts. I chose an individual mandate only after we had done our best to reform state insurance regulations — lowering premiums by as much as 50%. Let’s be clear here: My plan in Massachusetts worked very differently than Sen. Clinton’s plan would. First, we worked to reduce the burdens of regulation. The legislature insisted on more coverage mandates and regulation than I would have liked, but even so, less regulation has resulted in much lower premiums.

Second, we used the money we were already getting from the federal government to help the poor purchase their own private insurance — without new taxes or spending. And even the poor paid their fair share of their premiums. Third, with the help of the Heritage Foundation, we found a path for most individuals to purchase insurance with pre-tax dollars, just like people who get their coverage through their employers. And finally, once premiums had been lowered and the poor were able to afford private insurance, my plan called for people to either purchase insurance or pay their own way — no more free riders.

I like the plan I put forward in Massachusetts. But even so, I wouldn’t do what Sen. Clinton does — impose my way on every other state. Other states may borrow from what we did. Some will surely improve on it. But let’s keep faith in federalism, in private markets and in individual responsibility.

I have announced my health-care plan for the nation. It follows the principles I pursued in Massachusetts. Reform state insurance markets first, to lower the cost of policies. Give states financial flexibility with Medicaid funds and with existing “free care” payments so that states can craft their own programs to expand private insurance. End the tax discrimination against individual purchasers of health insurance who currently must buy their coverage with post-tax dollars.

These, among other features of my plan, will lower the cost of health insurance, get all of our citizens insured, remove the threat of losing insurance when you lose or change jobs, improve the health of our citizens, and reduce the growth in health-care spending. It’s the free market way, the private sector way, the individual responsibility way — the American way.”

It’s not news that MA has the highest per capita health spending in the nation, but the new Health Affairs study offers some helpful insights in understanding the nature of our dubious distinction.

The numbers: 2004 — $6683 vs. $5283 for the nation. Average growth 1998-2004, 6.2% in MA vs. 6.3% in US. In 1998, MA was 127% of the US rate; in 2004, we were 126%. Some interesting comments:

“In 2004, the ten states with the highest per capita personal health care spending were Massachusetts, Maine, New York, Alaska, Connecticut, Delaware, Rhode Island, Vermont, West Virginia, and Pennsylvania. These ten states consumed an average of $6,345 per person in 2004–nearly 20 percent higher than the U.S. average of $5,283. …

“…within the top ten states, Massachusetts, New York, Connecticut, and Delaware ranked among the highest in the nation in per capita personal income. In addition, Massachusetts, New York, Connecticut, Rhode Island, Vermont, and Pennsylvania ranked among the highest in concentration of physicians to population. Also, the uninsured share of the population was among the lowest in the nation for some of the top ten per capita health spending states. This suggests that residents in these states may receive more services through more comprehensive employer-based health insurance benefit packages, or that the states are in a stronger financial position to provide expanded benefits through Medicaid or other state-initiated programs. …

“Massachusetts, for example, had the highest per capita health care spending in 2004 ($6,683)–nearly 27 percent above the U.S. average. It ranked near the top for per capita hospital, nursing home, and home health spending as well as for total per enrollee Medicare and Medicaid spending. Hospital spending in Massachusetts may be driven by higher-than-average use of services, such as diagnostic treatments and more intensive services commonly used in teaching hospitals. Furthermore, Massachusetts offers an expansive Medicaid program that may contribute to its higher-than-average Medicaid and overall health spending. …”

John Holahan from the Urban Institute offers comments on the link between higher per capita spending and state health reform efforts:

“Ironically, the recent interest in state health reform is likely to make current inequities worse. Massachusetts has enacted a plan to achieve (close to) universal coverage. Other relatively progressive states including New York, Connecticut, Vermont, Pennsylvania, and Illinois have enacted or are seriously considering major proposals to extend coverage to all. In American politics today, it is likely that only these more progressive states can achieve the political consensus necessary to substantially extend coverage.”

So we spend a lot, some due to higher levels of coverage, some due to higher per capita income, some due to higher provider spending (hospitals, nursing homes, home health), and some due to higher utilization by non-state residents. Let’s put a nice spin on it — we have lots of opportunity for improvement.