Healthcare Reform Comes to MA . . . Again

  • Posted in Uncategorized on Thursday, June 3rd, 2010
  • Judy Vedder

I attended a wonderful forum yesterday sponsored by the Massachusetts Health Council.  The Presidents or CEOs of groups representing nearly all stakeholders were on hand to present their views on what the new healthcare reform legislation would mean to MA.  Surprisingly, the general view of these disparate stakeholders was that the legislation was welcomed, though by no means perfect. Each group expected that having had our own healthcare “revolution” in 2006 that we were already implementing many of the anticipated policy and program changes, and that the biggest difficulty might be in reconciling the differences at the detail level between the MA law and the new Federal statute.  To a person, these stakeholder representatives particularly welcomed:

  • The administrative simplification provisions
  • The funding of the CMS (Medicare) Innovation Center
  • The creation of a National Public Health and Prevention Council,
  • The creation of a prevention trust fund to the tune of $2 billion dollars a year
  • The establishment of Minimum Credible Coverage standards to guarantee that plans purchased by subscribers meet basic elements of adequate coverage.
  • The provision of home-based programs for youg children
  • Closing the donut-hole in pharmaceutical coverage
  • Tax credits for businesses with 25 or fewer employees that provide healthcare plans
  • Workplace protections for nursing mothers
  • The requirement that healthcare insurers justify rate increases
  • The individual mandate requiring every person to purchase health insurance, if they cannot present evidence of the undo hardship in doing so
  • Except for the insurance industry, of course, the assessment that will be levied against insurance companies starting in 2014.

This was not a “love-fest”, however. Stakeholders had different views about the downsides of the reform bill.  In the aggregate the most important of these were:

  • The sheer complexity of the bill and the difficulty moving to implementation over the next four years
  • The $5.3 billion dollars in cuts to Medicare that Massachusetts will see by 2014. (This is a very considerable concern when you now consider that 36% of hospital revenue in the State comes from Medicare, and that presently hospitals already lose money on 72% of Medicare admissions.)
  • The need to shore up the availability of PCPs to handle the increased volume of patients when even presently insured patients are having difficulty getting access to PCPs (The ratio in most countries of PCPs to Specialists is 75% to 25%, and many of these countries demonstrate better health and longevity outcomes than the U.S., where the ratio is the reverse with only 25% PCPs.  The point being that having insurance is not a guarantee of access to healthcare if there are not the PCPs to serve these subscribers.)
  • The penalty for not purchasing health insurance is too low,therefore, many healthy individuals not feeling the need to be insured are apt to opt out and simply pay the fine–this can result in a skewed polpulation of insureds that are heavy utilizers of service and this will push premiums higher.

Also emerging from the panel discussion was the matters of reform that were completely missing from the new bill or were insufficiently addressed, such as:

  • Reform of medical liability–currently it is estimated that only 2% of healthcare costs are the result of liability awards, however, the practice of defensive medicine to reduce liability risks is estimated to cost as much as $240 billion a year
  • The lack of sufficient guidance in developing measures of healthcare quality and outcomes to use with cost-saving estimates
  • The need to consider alternative strategies for reimbursing providers because the fee-for-service model encourages excesses in service and does not allow for the use of efficacious and less expensive therapies not enumerated in the fee-for-service coverage of insurance plans
  • The role of social factors and related public health education in determining health outcomes.

Finally, the moderator, Martha Bebinger of WBUR posed the following to each member of the panel: Since we all agree that there will be a need for a very aggressive approach to cost savings, what are each of your respective constituencies willing to bring to the table by way of concessions or innovations?  Unfortunately, this is where the discussion returned to the baser instincts of a capitalism infused healthcare system.  To a person, each stakeholder representative simply pointed to other constituents to prescribe what someone else should do–any true spirit of “we are in this together” was now no longer visible. If there is pessimism about reform it is in some significant measure rooted in a system that promotes “contests”, rather than “collaboration” among stakeholders.  Contests promote posturing, not innovation.  Contests promote incrementalism, not reform. Contests promote rhetoric and false claims, not transparency. Contests promote demonization, not partnership.  Contests promote the sabotage of change, not the facilitation of change.

Yes, the Law of the Land says we have healthcare reform, but we are probably in for some of the same internecine behavior from stakeholders that will delay and dilute implementation, just as when the Law of the Land declared that there were civil rights for all, yet 40 years later the struggle to implement that declaration continues.

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