Massachusetts Health Reform from the Perspective of the SORH

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Massachusetts Health Reform from the Perspective
of the SORH
Cathleen McElligott, MS, RD Director, Mass. State
Office of Rural HealthMassachusetts Department
of Public Health Cathleen.mcelligott_at_state.ma.us

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MA Healthcare Reform

• HCR Overview
• Phase I
• Phase II
• Successes
• Challenges
• SORH Lessons Learned

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The Status Quo is Unsustainable (Mass
Legislature, 2006)

• Double-digit, annual increases in premiums
• 550,000 Mass. uninsured (higher in rural areas),
  40 million nationwide
• Businesses dropping insurance benefits due to
  costs
• Mandate on hospitals to provide care (EMTALA)
• 1.2 billion spent by state to reimburse free
  care
• No consequences for those who choose free-ride
  they get care
• Limited consumer information available for
  informed cost and quality decisions
• Significant barriers for individuals who want to
  buy coverage
• Part-timers, contractors, workers with more than
  one job,
• sole-proprietors

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Chapter 58 of the Acts of 2006

• April 12, 2006
• Gov. Mitt Romney signs Massachusetts Universal
  Health Care law, as Sen. Ted Kennedy, standing
  behind him, gives his approval and support.
•  

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Cornerstones of MassHealth Reform

• Accessibility for all individuals to affordable,
  portable, private insurance coverage
• Level the playing field by giving small
  businesses access to a range of affordable
  insurance products
• Reallocate federal and state money previously
  paid to compensate providers for free care for
  the uninsured to assist low-income individuals
  purchasing private insurance
• End cost-shifting by holding individuals (and
  families) responsible for their own health care
• Patient Right-to-Know Health care quality and
  costs transparent to consumers
• Leverage technology with E-Health Records
• Goal All Massachusetts residents insured by 2009

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How Did It Happen? Key Players

• Blue Cross Blue Shield Access Foundation
• Roadmap to Coverage Initiative/Urban Institute
• Gov. Mitt Romney
• Advocacy Community
• Patients/Consumers, Providers, Labor, Business
  Leaders
• Affordable Care Today Coalition (ACT!)
  legislative coalition
• Ballot Initiative Committee (MassACT!) 120,000
  citizen signatures
• Senate President Robert Travaglini Senate
• House Speaker Sal DiMasi House
• Federal Government 1115 Medicaid Waiver
• 385M supplemental payments at risk
• Breaking the Altman Rule Status Quo was not
  an option
• Business Groups

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To Get To Near Universal Coverage

• Subsidize insurance for low and moderate income
• Medicaid expansions, restoration, and
  enhancements
• Commonwealth Care (for people up to 300 FPL)
• Reform the non-group/individual market
• Merger of individual and small group markets
• Health Insurance Connector
• Young Adult Products
• Require individuals age 18 to have health
  insurance
• Completely overhauled the Uncompensated Care Pool
  to become the Health Safety Net
• Require employers w/11 FTE-employees to
• Make a Fair Share contribution
• Offer a pre-tax, payroll deduction plan

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The Power of Incrementalism
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Chapter 58 MassHealth Expansions and Restorations

• Kids coverage from 200 to 300 FPL (63K family
  of 4)
• MassHealth enrollment caps lifted
• Essential, CommonHealth, HIV
• Optional benefits restored dental, dentures,
  eyeglasses
• New smoking cessation and wellness benefits

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Commonwealth Health Insurance Connector Authority

• 10 member board
• Three principal responsibilities
• Commonwealth Care (subsidized lt300FPL)
• Subsidized coverage for uninsured with no other
  options
• No premium lt150FPL sliding scale 150-300 FPL
  Co-pays
• Commonwealth Choice (non-subsidized gt300FPL)
• Private plans for uninsured gt300 FPL and small
  employers
• Through the Connector Travelocity of health
  insurance
• One stop shopping for cost effective plans at
  different levels certified by the Authority
  www,mahealthconnector.org
• Define affordability for individual mandate and
  minimum creditable coverage

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Small/Nongroup Insurance Market Reforms

• Individual market (60K lives) merged with small
  group market (750K lives) on 7/1/07 dramatic
  premium reductions
• Young adults (19-25) can stay on parents plans
  for two years
• Young adult plans for 19-26 year olds

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Individual Responsibility

• Beginning 7/1/07, all 18 must obtain health
  insurance
• Penalties if affordable coverage available
• 2007 loss of personal tax exemption if no
  coverage (219)
• 2008 tax penalty up to 76 per month or 912
  per year based on family size and income
• 2009 and Beyond to be determined
• Minimum acceptable benefit package (Minimum
  Creditable Coverage) set by Connector
• Standard of affordability set by the Connector
  (based on income and family size)
• Enforced through state tax system

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Minimum Creditable Coverage

• Benefits
• Broad range of medical services
• preventive and primary care (at least 3 visits
  prior to deductible)
• emergency services, hospitalization benefits,
  ambulatory patient services, mental health
  services, prescription drug coverage
• Cost-sharing
• Deductible capped at 2,000 for individual
  coverage and 4,000 for family coverage
• Separate drug deductible may not exceed 250/500
• Maximum out-of-pocket spending capped at
  5,000/10,000
• MCC will be phased in until 2010

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Employer Responsibility

• Fair Share Employer Contribution
• Employers (11 FTE workers) must pay 295
  annually per uncovered worker
• Employers 11 must create Section 125 cafeteria
  plans
• Free Rider Surcharge
• Non-offering Employers (11 workers) with
  frequent Uncompensated Care Pool users may be
  charged up to 55 of costs over 50K
• No charge on non-offering firms with 125 plans

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Not Just Coverage

• Health insurance does not equal access to
  quality, affordable care.
• Change to health care system is needed.
• Rural is ready. Rural cannot be left out of that
  change.

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Provisions Related to Racial and Ethnic Health
Disparities

• Study to develop a sustainable Community Health
  Outreach Worker Program
• Created Health Disparities Council to continue
  the work of the Special Commission on Racial and
  Ethnic
• Health Disparities
• Requires hospitals to report health
• care data related to race, ethnicity,
• and language

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Patient Right-To-Know Provisions Transparency in
Cost and Quality

• State website providing cost and quality
  information on hospitals and physicians
• Creates Health Care Quality and Cost Council to
  set quality improvement and cost containment
  goals
• Council has authority to collect cost and quality
  data from health care providers, pharmacies,
  payers and insurers
• Council required to analyze data and publish on
  website
• First set of goals
• Reduce the annual rise in costs to no more than
  unadjusted growth in GDP by 2012
• Promote quality improvement through transparency
• Establish a chronic disease blueprint

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Additional Provisions

• 5 million for Mass Technology Collaboratives
  CPOE Initiative and E-Health Pilot Communities
• Promise of increased payments for providers,
  hospitals, CHCs
• Pay-for-performance mandated in Medicaid
• Essential Community Provider grants for targeted
  support to safety net hospitals and CHCs

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Additional Provisions

• Funding for public health programs at DPH focus
  on vaccination, chronic disease control and
  prevention, womens health, tobacco use reduction
  and more
• Insurers may offer discounted premiums to
  non-smokers
• Disability standards for MassHealth not more
  restrictive than for Social Security

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By Second Year Anniversary

• More than 340,000 residents are newly insured
  health care coverage by April 10, 2008
• Gov Deval Patrick, Sen Pres Therese Murray,
  Speaker Sal
• DiMasi, Sen Richard Moore, and Rep Patricia
  Walrath

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Health Care Reform Part II

• Chapter 305 of the Acts of 2008
• Requires hospitals to report data on hospital
  acquired infections, serious reportable events,
  and serious adverse drug reactions as a condition
  of licensure
• Pilot program for use of Physician Order for
  Life-Sustaining Treatment
• Medical home demonstration project

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Health Care Reform Part II

• Chapter 305 of the Acts of 2008
• Health Care Workforce
• Creates DPH Health Care Workforce Center - MD and
  APN shortages
• Creates loan repayment program for MDs and nurses
  who commit to practicing primary care in
  underserved areas
• Allows patients to choose NP as their provider.
  Requires insurers to recognize and reimburse NPs
  as primary care providers
• Creates affordable housing model for health
  professionals committed to providing care in
  underserved areas
• Expands the number of PAs that MD may supervise
  from 2 to 4 in medically underserved areas

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Health Care Reform Part II

• Chapter 305 of the Acts of 2008
• Encourage HIT adoption by creating E-Health
  Institute to provide oversight and plans for
  mandated statewide interoperable EMR system
• Hospitals and CHCs mandated CPOE by 2012, EMR
  by 2015
• Pharmaceutical reforms including an academic
  detailing program an evidence-based education
  about therapeutic and cost-effective use of
  prescription drugs for physicians, pharmacists,
  and other health professionals. and a pharm.
  manufacturers Code of Conduct (Gifts Ban)

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Health Care Reform Part II

• Chapter 305 of the Acts of 2008
• Payment reform, including recommendations for a
  common health care payment methodology for use by
  all payers
• Enhances transparency and efficiency through
  annual hearings for providers and insurers to
  testify on cost drivers and standardizing coding
  claim sets
• Mandates licensure and DON review for
  physician-based ambulatory surgery centers
• Mandates DON application and review for
  outpatient capital projects exceeding 25 million

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How Is It Going? (3rd Year Anniversary, April
2009)

• Health care security provides invaluable comfort
  for individuals and their families. This is a
  wonderful experiment, and it's showing fantastic
  results. 
• - Governor Deval Patrick

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Uninsurance
Uninsurance Ratefor All Massachusetts Residents

• Uninsurance was low among Massachusetts
  residents, with less than 3 (167,300 people)
  uninsured at the time of the survey.

Source Urban Institute tabulations on the 2008
Massachusetts HIS
Massachusetts Division of Health Care Finance and
Policy
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Access to Health Care Has Improved

• From Fall 2006 to Fall 2007, uninsurance rates
  for working-age adults decreased from 13 to 7
• The number of low-income adults with
  Employer-Sponsored Insurance has increased from
  38 to 42
• Low-income adults are more likely to have access
  to a primary care physician
• The number of low-income adults able to see a
  doctor for preventive care increased from 65 to
  70
• 59 of low-income adults were able to see a
  dental provider,as compared to 49 in 2006
• Source On the Road to Universal Coverage
  Impacts Of Reform In Massachusetts At One Year,
  Author Sharon K. Long of the Urban Institute,
  published in Health Affairs on June 3,2008,
  http//content.healthaffairs.org/cgi/content/full/
  hlthaff.27.4.w270/DC1

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Access to Health Care Has Improved

• As of June 30, 2008, 442,000 people have gained
  health insurance since health reform implemented
• 187,000 additional by private insurance
• 80,000 more on MassHealth,
• 176,000 with Commonwealth Care
• In the first six months of 2008, 68,000 more
  people became insured
• In the second quarter of 2008, employer coverage
  dropped by 12,000, but enrollment in MassHealth
  and individual purchase both increased by about
  8,000.

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Health Care is More Affordable

• The number of low-income adults who did not seek
  medical care because of costs decreased from 27
  in 2006 to 17 in 2007
• Low-income MA residents reported a drop in
  out-of-pocket health care costs and medical debt.
• The number of low-income adults having problems
  paying medical bills dropped from 32 in 2006 to
  24 in 2007.
• Source On the Road to Universal Coverage
  Impacts Of Reform In Massachusetts At One Year,
  Author Sharon K. Long of the Urban Institute,
  published in Health Affairs on June 3,2008,
  http//content.healthaffairs.org/cgi/content/full/
  hlthaff.27.4.w270/DC1

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Support for Reform
MA Residents Continue to Support Health Reform
Three out of every four Massachusetts households
supported health reform at the time of the
survey. Only 14 of households did not support
reform. 68 in 2006 71 in 2007 75 in 2008
Information based on household respondents
awareness of the individual mandate. Source
Urban Institute tabulations on the 2008
Massachusetts HIS
Massachusetts Division of Health Care Finance and
Policy
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Individual Mandate

• DOR Data From 2007
• 95 of tax-filing adults have health insurance
• 2.5 of adults did not have insurance coverage
  and were required to pay the penalty

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Challenges
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Challenges

• Continuing to finance in difficult economic times
• Cost containment very difficult
• Maintaining affordability
• Need more time and experience with the new lower
  cost plans
• Quality work still to do...just beginning
• Need more monitoring in rural areas
• Need more rural input

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SORH Lessons Learned

• Health care reform must be a work in progress
• Think broadly about rural health needs and
  possible ways to address under health reform
• Monitor the accessibility and affordability of
  new plans or expansions in rural areas
• Outreach and enrollment assistance very, very
  important in rural communities
• Check on how state is handling safety net
  providersonly CHCs? How will CAHs and other
  rural providers be handled?

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SORH Lessons Learned

• Health insurance does not equal access and
  improved health
• Incrementalism and individual mandates can work
• Health promotion and disease prevention programs
  still needed in addition to healthcare insurance
  and medical care
• Healthcare workforce programs needed !!!!!!
• Capacity building and infrastructure funds needed
  for rural healthcare system
• Need rural components to cost, quality, HIT, and
  other initiatives -- or may be urban models and
  ideas and implementation with less rural impact

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SORH Lessons Learned

• Very hard to be in the right place at the right
  time behind closed doors with what is being
  negotiated at a very high level
• Look for your partners
• Leverage relationships
• Look for opportunities and pounce on them
• (e.g. CHWs, R/E health disparities, etc.)
• Figure out SORH internal and external roles and
  how you can use both to impact
• Try to get impact and implementation analyses
  done specifically for rural areas

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Role of the SORH
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• "Few will have the greatness to bend history
  itself but each of us can work to change a small
  portion of events, and in the total of all those
  acts will be written the history of this
  generation."
• Robert Kennedy