Presentation: Health Reform in Massachusetts
-
Upload
masscare -
Category
Health & Medicine
-
view
631 -
download
0
description
Transcript of Presentation: Health Reform in Massachusetts
The Massachusetts Model of Health Reform in Practice
http://masscare.org/massachusetts-health-reform-in-practice/
And the Future of National Health Reform
Massachusetts Health Reform (“Chapter 58”) April 12, 2006
Patient Protection and Affordable Care Act March 23, 2010
Presidential Elections November, 2012
Origins of Mass. Health Reform • 2006 expiration of Massachusetts Medicaid
Waiver (Section 1115). • Bush Administration opposition to state’s ‘Free
Care Pool’ payments: culture of insurance. • Two binding ballot initiatives for ’06 election.
The ‘Free Care Pool’ • Hospital & health center reimbursement for care of
uninsured, 0 to 200% of poverty line. • 452,000 users in FY2006 (659K uninsured). • $710 million in FY2006 (Medicaid: $10 bill). • Covers all services available at hospitals, health
centers, no cost-sharing, not considered insurance.
Structure of Mass. Health Reform • Commonwealth Care: free subsidized insurance from 0
to 150% of poverty; sliding subsidies from 150% to 300% of poverty.
• Commonwealth Choice: ‘exchange’ for individual and eventually small business market (40K users currently).
• Individual Mandate: adults above 150% of poverty must demonstrate insurance coverage or pay a fine ($200 to $1,200) on tax forms.
• Employer Play-or-Pay: with 11+ employees, must cover 1/4th of employees and offer to cover 1/3rd of premium costs, or pay $295/per worker per year fine.
• No New Revenue: financed from existing free care pool funds, federal matching funds, private payments, and limited cash from state’s General Fund.
• No Cost Control: limited to access for political reasons.
Impact on the Uninsured
4.1% 4.2%
4.4%
11.3%
9.2%
10.4%
5.4%
5.5%
4.4%
5.6% 7.4%
6.4%
5.7%
2.6% 2.7%
1.9%
9.3%
10.3%
8.5%
6.2%
4.4%
5.3%
4.3%
0%
2%
4%
6%
8%
10%
12%
2004 2005 2006 2007 2008 2009 2010
Census/ACS
Census/CPS
State/CSR
State/Urban Inst
CDC/BRFSS**
Health Reform
Notes on the Uninsured • Most commonly cited estimates are
impossibly low: state survey finds less than 144,000 uninsured in fall 2008, but 150,000 report they are uninsured for whole year on tax returns.
• Most reliable surveys show uninsured population cut in half, around 4-5% of pop.
• State reports that 4/5ths of the newly insured received public subsidies – majority of these were eligible for free care prior to reform.
Impact on the Employer-Sponsored Coverage
69% 68%
70%
72%
76% 77%
67%
63%
57%
63%
60%
54% 50%
55%
60%
65%
70%
75%
80%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
% of Employers Offering Workplace Coverage
% of Employees Buying Workplace Coverage
Impact on Employer Coverage of Low-Income Residents
21.8%
26.2%
17.2% 20.9%
25.3%
46.1% 42.4%
54.2% 55.6% 59.4%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
2005 2006 2007 2008 2009
Employer-Sponsored Insurance Public Insurance
Access to Regular Source of Care Improved
85.4%
86.3%
87.8% 87.7% 88.3%
90.0%
87.0%
92.1%
89.9% 89.0%
88.0%
91.0%
82.0%
84.0%
86.0%
88.0%
90.0%
92.0%
94.0%
2005 2006 2007 2008 2009 2010
BRFSS Blue Cross/Urban Inst State/Urban Inst
Massachusetts Residents, Ages 18-64, Reporting a Regular Source of Care, Three Sources of Data
Cost Barriers to Care Declined Massachusetts Residents, Ages 18-64, Didn’t Receive Needed Care Due to Costs, Three Sources of Data
9.9% 8.6% 7.8% 6.9%
7.9% 7.6%
16.3%
11.6% 11.7%
26.0% 27.0%
29.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
2005 2006 2007 2008 2009 2010
BRFSS Blue Cross/Urban Inst State/Urban Inst
From Safety Net Care to Publicly-Subsidized Private Insurance
Co-Payments by Safety Net Plan
Free Care Pool Commonwealth Care (2011) Income Eligibility
0-200% poverty
0-100% poverty
100-200% poverty
200-300% poverty
Annual Premium (for lowest cost plans)
$0 $0 $0 - $468 $924 - $1,392
Primary Care Visit $0 $0 $10 $15
Specialist Visit $0 $0 $18 $22
Inpatient Care $0 $0 $50 $250
Outpatient Surgery $0 $0 $50 $125
Emergency Room Visit $0 $0 $50 $100
Generic Drugs $1-3 $1-3 $10 $12.50
Preferred Brand Drugs $3 $3 $20 $25
Non-Preferred Brand Drugs $3 $3 $40 $50
Maximum Prescription Co-Pays $200 $200 $500 $800
Maximum Other Co-Pays $0 $0 $750 $1,500
Patient Story on Mixed Access Impact
“Under Free Care I saw doctors at Mass General and Brigham and Women’s hospital. I had no co-payments for medications, appointments, lab tests or hospitalization; the care I received gave me a light at the end of the health care nightmare tunnel...Under my Commonwealth Care plan my routine monthly medical costs included the $110 premium, $200 for medications, a $10 appointment with my primary care doctor, and $20 for a specialist appointment. That’s $340 per month, provided I stayed well.”
Kathryn, Boston MA (2008)
Primary Care Wait Times Rise With Increased Demand
Average Wait Time for New Patient Appointment
47
33
52 50
44
53
48
25
30
35
40
45
50
55
2005 2006 2007 2008 2009 2010 2011
Days
Internal Medicine Trendline
Decline in Primary Care Practices Accepting New Patients
Percentage of Practices Accepting New Patients
66%
64%
51%
58%
44%
51%
49%
40%
45%
50%
55%
60%
65%
70%
2005 2006 2007 2008 2009 2010 2011
Internal Medicine Trendline
Underinsurance Rises: Primarily at Small Employers
Private Insurance Plans with High-Deductibles ($1,000+)
3.4%
6.1%
11.3%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
2006 2007 2008
5%
50%
16%
28%
46%
15% 34%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
≤ 70% 70.1% - 80% 80.1% - 90% 90.1% - 100%
Share of Medical Costs Covered by Small Business Employees’ Insurance, 2007-2009
Out-of-Pocket Barriers Decline Change in % of Families with High Out-of-Pocket Spending
21.8%
18.4% 18.0%
9.4%
7.3% 6.7%
0%
5%
10%
15%
20%
25%
2006 2007 2008 2009
Out-of-pocket costs 5% of income or more Out-of-pocket costs 10% of income or more
Impact on Total Household Spending on Health Care
Change in Percentage of Families with High Total Health Spending
14.2%
3.6%
20.2%
5.2%
0%
5%
10%
15%
20%
25%
Spent 10%+ of income on health care Spent 25%+ of income on health care
2000 2009
Impact on Medical Debt and Medical Bankruptcies
19.1% 19.5%
59.3%
19.1% 20.3%
52.9%
0%
10%
20%
30%
40%
50%
60%
70%
Problems paying medical bills Paying medical bills over time Bankruptcies related toillness/medical bills*
2006/07 2009
Emergency Department Use
102
107
111
113
100
101
104
107
109
95
97
99
101
103
105
107
109
111
113
115
2004 2005 2006 2007 2008
Preventable/Avoidable ED visits Total ED visits
Trends in Emergency Department Use (Indexed to 2004)
Financial Crisis for Safety Net • Contrary to expectations, patient volume at safety net
providers has gone up since health reform: – 31% growth in patients receiving care at community health
centers – Ambulatory visits to safety net hospital clinics grew at 2X the
rate of visits to non-safety net hospital clinics • Reimbursement rates at safety net hospitals are down.
Promised Medicaid rate increases reversed through budget cuts and health safety net funds falling short, creating a serious financial crisis. – Unsuccessful lawsuit by Boston Medical Center and six
community hospitals for Medicaid underpayments in 2009. – “Soft landing” funds for two largest safety net hospitals run out
in 2010. – Cambridge Health Alliance forced to close six clinics and shut
down all inpatient services at one of its hospitals, seeking a buyer or a merger.
Rise in Premiums Has Accelerated, Growth in Provider Administration
• Employer premium growth accelerated in Massachusetts after health reform compared to other states: – For single coverage: premium growth was 5.9% higher in three
years after reform for all employers, 6.8% higher for small employers
– For family coverage: average annual premium growth was premium growth was 1.5% higher in three years after reform for all employers, 14.4% higher for small employers
• Small employer premiums due in part to merger of individual and small group markets in Mass.
• Job growth in Mass. health care industry almost double that of nation after reform, slower than nation prior to reform. Almost all of difference accounted for by growth in administrative occupations in Massachusetts, which grew by 18.4% over three years (compared to 8.0% nationally).
Concept of “Shared Responsibility”
“Massachusetts mandated shared responsibility… The costs of expanding coverage to all are considerable… the only way to ensure the sustainability of that expense over the long term is through universal responsibility, spreading the cost broadly among all sectors of society: individuals, government, and employers.”
Bruce Bodaken President and CEO, Blue Shield of California
Measuring Shared Responsibility
21% 22% 25%
28%
0%5%
10%15%20%25%30%
Employers and UnionPlans
Individuals State Government Federal Government
Change in Health Care Spending by Payer, Before and After Reform, 2005-2007
Measuring Shared Responsibility
21% 22% 25%
28%
0%5%
10%15%20%25%30%
Employers and UnionPlans
Individuals State Government Federal Government
Change in Health Care Spending by Payer, Before and After Reform, 2005-2007
Increase in Health Care Spending After Reform as a Percentage of Family Income, by Income Quintiles, 2005-2007
-1.5%
4.6%
1.7% 1.4% 0.4%
-2%
-1%
0%
1%
2%
3%
4%
5%
Bottom 20%($0 - $20k)
Second 20%($20k - $41k)
Middle 20%($41k - $66k)
Fourth 20%($66k - $111k)
Top 20%($111k+)In
cear
se in
Hea
lth S
pend
ing
as P
erce
ntag
e of
Hou
seho
ld
Inco
me
Income Quintiles: Bottom to Top 20% of Income Earners
Mass. Health Reform Has Had Positive Impacts, But Is
Unsustainable “If we have double-digit increases (annually in
costs), health reform is not sustainable.” Jon Kingsdale
Executive Director, Commonwealth Connector “If we do not constrain healthcare costs, the
system we worked so hard to create and implement will collapse..”
Therese Murray Senate President, Massachusetts Legislature
State Has Been Gradually Rolling Back Coverage to Control Costs Share of Commonwealth Care Enrollees Paying Premiums
0% 8%
25% 20% 23% 28% 29% 33% 32% 31% 31%
43% 42% 42% 42% 50% 49%
0%
20%
40%
60%
Q2
'07
Q3
'07
Q4
'07
Q1
'08
Q2
'08
Q3
'08
Q4
'08
Q1
'09
Q2
'09
Q3
'09
Q4
'09
Q1
'10
Q2
'10
Q3
'10
Q4
'10
Q1
'11
Q2
'11
3,654
177,136 178,686
152,571 5% 5%
9%
0%1%2%3%4%5%6%7%8%9%10%
020000400006000080000
100000120000140000160000180000200000
Nov
'06
Dec
'06
Jan
'07
Feb
'07
Mar
'07
Apr '
07M
ay '0
7Ju
n '0
7Ju
l '07
Aug
'07
Sep
'07
Oct
'07
Nov
'07
Dec
'07
Jan
'08
Feb
'08
Mar
'08
Apr '
08M
ay '0
8Ju
n '0
8Ju
l '08
Aug
'08
Sep
'08
Oct
'08
Nov
'08
Dec
'08
Jan
'09
Feb
'09
Mar
'09
Apr '
09M
ay '0
9Ju
n '0
9Ju
l '09
Aug
'09
Sep
'09
Oct
'09
Nov
'09
Dec
'09
Jan
'10
Feb
'10
Mar
'10
Mas
sach
uset
ts
Une
mpl
oym
ent
Com
mCa
re E
nrol
lmen
t
Commonwealth Care Enrollment % Unemployed
Commonwealth Care Enrollment and Mass. Unemployment Rate
Individual Mandate Also Unsustainable, Mass. Has Raised
Affordability Thresholds Percent of Income Deemed Affordable for Health Premiums (Families of Three, 2007-2011)
3.3%
4.9%
5.9%
7.5%
5.6%
7.0%
3.4%
5.0%
6.0%
8.0%
9.5%
11.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
151% ofPoverty
201% ofPoverty
251% ofPoverty
301% ofPoverty
401% ofPoverty
500% ofPoverty
2007
2011
Takeaway Points for National Health Reform (PPACA)
1. Mass. reform affected the insurance status of about 4-5% of the population (half the previously uninsured), and improved access for about half of those. The impact in other states will vary depending on their existing safety net programs, but focus on access outcomes – not insurance coverage!
2. National reform is unlikely to have a significant impact on outcomes that predominantly afflict the insured population, including emergency department visits, medical debt, and health-related bankruptcy.
3. While safety net providers handle most of the increased demand for care that results from reform, Massachusetts and national reform rely on cuts to public health care programs that can threaten the viability of those providers. This increased demand will also increase strain on primary care provider networks.
4. Most of the population will be relatively unaffected by health reform, but will continue to experience the health care crisis of unaffordable premiums and high barriers to care. (They also vote!)
5. This model of reform defers serious action on cost control. Without addressing the systemic causes of our high costs – which has thus far proven politically impossible – access gains will face retrenchment, or will force us to sacrifice spending on other basic social goods.