Mass. single-payer advocates take on limits of state health reform

Before you write off these folks, note that a recent survey of doctors by the Massachusetts Medical Society found that a growing number of doctors support the idea of a single-payer system. More than 40 percent, up from  34 percent last year. So do a lot of folks at Occupy Boston.

Massachusetts Health Reform in Practice and The Future of National Health Reform

OVERVIEW: While the Massachusetts health reform law of 2006, widely regarded as the model for the new federal health law, reduced the uninsured population in the state, it did so at the cost of rapidly rising underinsurance, increased health care premiums, and a financial crisis among the state’s safety-net hospitals and community health centers. And the financial burden of the reform has fallen disproportionately on lower-middle-class families.

Those are some of the findings in a new, exhaustively documented report on the outcomes of the Massachusetts reform law released by Mass-Care and Massachusetts Physicians for a National Health Program. The report draws on hundreds of sources, including academic studies, government statistics and scientific surveys, in the first compilation of its kind.

EXECUTIVE SUMMARY

The Massachusetts Health Reform Law of 2006 expanded Medicaid coverage for the poor and made available publicly subsidized private health insurance for additional low-income residents of the state. It also mandated that all but the poorest uninsured residents either purchase private health insurance or pay a substantial fine (up to $1,212 in 2011). Smaller fines (up to $295 per employee) were also levied on employers who fail to offer insurance.

Four years after full implementation of the law, Massachusetts has not achieved universal coverage, although one-half to two-thirds of the previously uninsured now have some type of insurance policy. Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care. The reform did not lead to a sustained increase in employer-sponsored coverage, but did slow declining employer coverage. Instead of dropping coverage, employers in Massachusetts have increased cost sharing, shifting costs on to employees, leading to rapidly rising underinsurance after health reform. The use of high-deductible plans more than tripled for residents with private insurance, and good insurance coverage at small businesses all but disappeared over a few short years after reform.

Reform has had a positive impact on access to care in the state, but this impact has affected a modest share of residents, and for some patients has been negative. For example, some low-income patients who previously received completely free care under the state’s prior free care program faced new co-payments and premiums after becoming insured, which impeded their access to care. Reform has not reduced the burden of medical bills and medical bankruptcy on Massachusetts’ families.

The growth of residents with insurance coverage has exacerbated a primary care shortage in Massachusetts by increasing wait times for appointments and decreasing the portion of physicians accepting new patients, creating access problems even for those with coverage. Reform did not reverse growing use of the state’s emergency departments for care, despite expectations that expanding insurance coverage would reroute patients through primary care offices. There is no evidence as of yet that expanding insurance coverage has had an impact on health outcomes or disparities in health outcomes. Reform has also created a financial crisis for safety net providers that specialize in care for low-income communities and the uninsured, by shifting resources away from safety net providers while patient demand for safety net care has actually increased.

The public cost of reform has been high, exceeding $800 million in fiscal 2009 for a state with a total budget of $32.5 billion.  However, federal taxpayers paid for the bulk of the law’s public expenses. The state has made a broad range of cuts to the original law in order to its keep costs down, cutting back coverage for over 30,000 documented immigrants, curtailing some benefits, increasing cost sharing, and increasing the share of enrollees required to pay premiums. Substantial funds from the federal stimulus bill were also used to sustain the reform law, but this was a short-term fix only.

Public payments account for only a portion of the reform law’s costs. A central premise of the law was that the state, employers, and individuals would all have to sacrifice financially to approach the goal of universal coverage. This premise of “shared responsibility” for the costs of the reform was in many ways disingenuous. Although employers, individuals, state and federal government have shared the burden of increased costs roughly equally, this overlooks the fact that governments pass on their spending to taxpayers, and employers pass on their costs to employees.  The actual burden of health reform was regressive, with increased spending after health reform falling disproportionately on lower-middle income residents.

The reform failed to “bend the cost curve” in Massachusetts because it contained no significant cost-control provisions. Health care costs in Massachusetts are higher than in any other state in the nation, and reform has been found to accelerate the rising costs of employer-sponsored health care. There is general agreement that the Massachusetts reform is itself not sustainable without effective cost control.

Massachusetts enjoyed favorable circumstances at the outset of reform, such as previously high levels of spending on health care for the poor, high personal incomes, and relatively low rates of uninsurance. Without controlling costs, national reform will run up against the same difficulties as Massachusetts: growth in public insurance coverage will prove unsustainable and will accompany the rapid erosion of private insurance benefits, while modest gains in access to care will be threatened in the short term by unsustainably high costs that are increasingly shifted on to patients.

While Massachusetts health reform has enjoyed support from a majority of residents in the state, that support has declined since national health reform instigated a broader debate over alternatives to the Massachusetts plan. Moreover, while residents support the Massachusetts reform law over no change at all, they have expressed increasing skepticism that the law is working for vulnerable communities, and more residents report that the law is hurting them than helping them.

We believe that the data in this report should give pause to those concerned with national health care reform. Although not without its successes, the Massachusetts reform has not addressed the fundamental deficiencies in the health care system – treating symptoms rather than causes – and even its modest successes are unsustainable for the state and Massachusetts residents.

Occupy Health Care: Boston protesters say Wall Street makes them sick

While health reform may not be at the top of their agenda, some of the Occupy Boston protesters down at Dewey Square had no problem linking the high cost of medical care to their complaints about Wall Street.  Some support Obama’s reforms; others called for a single payer system. But, nearly everyone interviewed had universal health care on his or her list of demands.

Even MIT professor Noam Chomsky said  the health care system is tainted by what he described as a government dominated by private corporations. Speaking on Saturday night, he told the crowd that the  federal budget deficit could be eliminated if the US had a health care system like other countries in the developed world — presumably single payer.

Medicare itself is not the problem, he said.

“It’s a problem because it goes through the privatized, unregulated system,” he said. “It is totally dysfunctional. You can’t talk about this in Washington because of the power of the financial institutions. ”

More from the rank and file below.

New Yorker: How Mitt Romney came around to Massachusetts style health reform

Watching New Yorker writer Ryan Lizza on MSNBC on Wednesday night got us thinking – is this a repeat? Since we recently watched four innings of a rain-delay repeat of a Red Sox game before realizing
we had already seen it, we were suspect.

 Lizza struggled through his explanation of Health Reform 101 — we all do — without offering much news. The same can almost be said of his story on Mitt Romney’s role in the Mass plan in this week’s New Yorker.

One angle he did nail was – the approach embraced by Mitt and Obama is a Republicans idea. And contrary to the argument that this is a government takeover of health care, it’s actually an attempt at providing universal coverage while maintaining the private health insurance industry.

For government-run health care, see the UK. For government-run insurance, aka single payer, see Medicare
or Canada or Vermont. Find support for the latter approach at Mass Care or Physicians for a National Health Plan.

So, it you need to catch up and don’t want to dish out $5.99  or subscribe to The New Yorker,  just scroll down or click on the story in last week’s Globe, the first in a series On Romney and health and not yet behind a pay wall. We recycled the headline.

Virginia ruling on health reform and Massachusetts

The Boston Business Journal quotes Columbia Law School prof on the Virgina ruling on the constitutional issues re: health reform individual mandate.

Metzger said that the argument in the ruling is that requiring individuals to buy insurance is not in the enumerated powers of Congress, and not that the mandate goes against the individual rights set out in the Constitution.

As a district court ruling, it will have no impact on other states. The case now moves to the 4th circuit Court of Appeals and legal experts expect that it will end up in the U.S. Supreme Court, whether or not the lower court ruling is reaffirmed or overturned. Even if the Supreme Court were to rule the individual mandate unconstitutional, the Massachusetts law would still stand. However, the ruling might prompt health reform opponents to launch lawsuits in Massachusetts.

Scott Brown applauds the ruling in the Herald and frames it as a victory for states rights, thus serparating the Mass mandate from the federal mandate. 

This shows you the federal mandate of one size fits all is not appropriate,” Brown told the Herald. “It should be left up to the states.”

Brown added the court challenge to the federal law does not mean the Bay State’s universal health insurance plan should be panned because it is a state decision.

Blue Mass Group had this to say:

Well OK. And I don’t like mandates very much either. All things being equal … hey, just leave me alone and I’ll decide if I want insurance, all right? Step off, Big G.

Thing is, if you don’t have insurance and get hurt … someone else picks up that tab. Who? Well, maybe you, if you’re stuck with the bill and can actually sort of pay it — which may well land you in the poorhouse. And if you can’t, and you default or go bankrupt? Other ratepayers pay for it, or it gets carved out of the hospitals and doctors income, which they likely make up in charging higher rates to everyone else. There Is No Free Surgery.

 

Globe to Romney: Don’t flip-flop on Mass health plan

A staff editorial in The Globe gushes over the state health plan and asks Mitt Romney to stick up for it. Warning: The headline might stick a Tammy Wynette song in your head. 

MITT ROMNEY is coming under increasing pressure from leading conservatives to renounce his decision to sign the Massachusetts health reform law. Romney, who is widely expected to run for president in 2012, has sought to differentiate his plan from President Obama’s, but some potential Romney supporters fear that the distinctions will be lost on voters in the increasingly Tea Party-driven GOP.

 

Mass reform: Dump the MRI, bust the unions and gamble on high-deductibles

Docs, hospitals and patients – all the players are moving.  

 Carey Goldberg at WBUR’s Commonhealth mines a new report on health reform in Massachusetts for a top ten list of notable trends.  

 1.Doctors who own imaging centers are trying to sell them to hospitals, which can charge more

2.Widespread skepticism that the political will exists to rein in hospital charges

3.Hospitals blame unions and Medicaid rates for their failure to control costs

4.Electronic Medical Records as ties that bind

5.Atrius shifted from the Brigham to Beth Israel amid ‘tense relations’

6.The squeeze on small practices

7.High-deductible plans now 15% of Blue Cross commercial enrollment

8.The smaller the employer, the harder to handle reform

9.Brokers survive and thrive

10. Soaring costs of imaging: the shift toward hospitals, and new technology

New Commonhealth and Ozzy’s genes

Not in the same story

Check out the new and improved Commonhealth on WBUR.org While you’re there, check out Radio Boston’s conversation with new BC/BS CEO Andrew Dreyfus, in particular the discussion of global payments.

From Commonhealth: Massachusetts is the leading laboratory for health care reform in the nation. It is also the hub of medical innovation. But as the nation looks on, what is the reality on the ground here? We’d like CommonHealth to be your go-to source for news, conversation and analysis about these historic efforts as they unfold. Your hosts are Carey Goldberg, former Boston bureau chief of The New York Times, and Rachel Zimmerman, former health and medicine reporter for The Wall Street Journal.

With BHN and White Coat Notes at the Globe, Boston is now a three health-news-blogs town. (Not to mention a lot of niche blogs like The Health Blawg The Health Business blog and Nature Network Boston.)  In blogging, as in  journalism, competition is good. We can see who poaches someone else’s story first.

With that in mind, they did beat me on the link to Julie Rover’s NPR piece on primary care, which features a doc from Maine. But do note that none of the other blogs have this important story:

The Weekly World News — a supermarket tabloid now run as a supplement to the Sun— makes reference to Knome, the Cambridge genome sequencing company. As reported elsewhere, the company is sequencing Ozzy Osbourne’s genome.

Ozzy is interested in finding out why he has survived but the study may well produce an incidental benefit to medical science in general. For instance, it may be that some variant in his genes make this liver better than most at breaking down toxic substances. It that’s true, gene therapies based on Ozzy’s cells could provide powerful weapons in the fight against disease.

Here @ NNB, we scan the all the best medical reporting for links to local scientists.