Revisiting the Land of the Individual Mandate

[This new commentary was just published by the Milbank Quarterly.]

The years 2013 through 2016 were excruciating for the Massachusetts Health Connector. In 2013, the Connector was among the nation’s most troubled federal/state health insurance exchanges, as it endured an epic collapse of its new website to help consumers purchase individual health insurance. Since then, it has taken a step-by-step and low-key “no news is good news” approach to rebuilding trust and credibility with its 252,000 clients.

Now the silent period is ending. In 2006, Massachusetts was the first and only state to enact an individual health insurance mandate, the essential model for the federal individual mandate included in the Affordable Care Act (ACA) in 2010 and implemented in 2014. In last December’s Tax Cuts and Jobs Act, President Trump and Congress neutered the ACA mandate by reducing the financial penalty to 0. Despite widespread reports to the contrary, the mandate was not repealed, and the law, with its mandatory reporting requirements, remains on the books.

Thus, Massachusetts now returns to the spotlight as the nation prepares to examine the impact of the federal action, testing 1 state’s experience against that of the other 49. In 2015, the last year for which tax data is publicly available, only 3% of adult tax filers in Massachusetts reported not having insurance meeting state standards, corroborating other data sources indicating that it has the lowest rate of uninsurance in any state (the most recent US Census data shows Massachusetts at 97.5% coverage). Depending on an uninsured person’s household income, the monetary penalty ranges between $21 and $96 for each month without coverage. As of early February, at least 9 other Democratic-leaning states are considering adopting a similar mandate. Continue reading “Revisiting the Land of the Individual Mandate”

Mad About States

[This column was just published on the website of the Milbank Quarterly.]

A consistent theme in 2017 Republican Congressional efforts to repeal and replace the Affordable Care Act (ACA) was the intent to empower the 50 states to use federal funds to reengineer their Medicaid and individual health insurance markets as they see fit. If yet another Republican attempt at ACA repeal and replace happens in 2018, the most likely vehicle will be a reformulated Graham-Cassidy bill, the final 2017 repeal effort in the US Senate that featured far-reaching devolution to states. The idealization of states as the best makers of health policy is a myth worth busting.

States, goes the thinking, are closer to the people than those who govern from Washington, DC, more attuned to real-world preferences and values than feds. States are nimbler, better at adjusting and innovating than the plodding feds. States are, in the high-minded and oft-repeated words of late Supreme Court Justice Louis Brandeis, “the laboratories of democracy.”

As Republican Senator Bill Cassidy (R-LA) wrote in the Washington Post this past July, “Returning the decision-making power to the states is not a Republican plan or a Democratic plan, but an American plan that reflects the faith in states held by our Founding Fathers.”1

As someone who has labored for decades in the vineyards of state health policy, I reply, nonsense. I give states their due. Massachusetts, for example, provided the inspiration for both the 1997 Children’s Health Insurance Program (CHIP) and the 2010 private health insurance reforms in title 1 of the ACA. Democratic and Republican leaders there and in many other states have forged successful bipartisan approaches to some of America’s thorniest health challenges. Yet the notion that states have innate wisdom and a tighter finger on the pulse of the people always superior to the federal government is not true. One example will do. Continue reading “Mad About States”

5 Takeaways from Baker’s New Health Reform

[This commentary was published on June 24 on the Commonwealth Magazine website.]

PHASE 2 OF THE BAKER ADMINISTRATION’S ambitious health reform agenda emerged this past week.  It contains good and smart proposals – and worrisome ones needing attention.

Phase 1 is an ambitious effort to transform much of the state’s Medicaid program, known as MassHealth, into “accountable care organizations.” ACOs aim to focus hospitals, physicians, and other providers on improving population health, care integration, and efficiency.  That effort, blessed by the outgoing Obama administration last November, is well underway – unless congressional Republican efforts to repeal the Affordable Care Act throw everything into a tailspin.

Phase 2 came last week, when the Baker administration released a set of proposals to Senate and House leaders, a package of changes to MassHealth and other health programs aiming to save $314 million in fiscal year 2018, which starts July 1, and more beyond. All the proposals need state law changes (to be incorporated in the nearly finished FY 2018 state budget) and/or federal approval. Continue reading “5 Takeaways from Baker’s New Health Reform”

MassHealth Dives into Accountable Care

[I wrote this commentary for the Spring Issue of Commonwealth Magazine to profile Massachusetts’ new move into accountable care organizations, an experiment that deserves watching.  Dr. William Seligman co-wrote with me.]

IN A WILDLY uncertain national health care environment, something new, audacious, and risky is happening in MassHealth, the Medicaid program that provides health coverage to 1.9 million people who are poor, elderly, and persons with disabilities in Massachusetts. Gov. Charlie Baker’s administration is betting that an emerging health care delivery and payment model, called “accountable care organizations,” can restrain rising costs by keeping enrollees healthy and out of expensive settings, especially hospitals. Positive results will have big consequences for the state, for medical providers, and for hundreds of thousands of MassHealth enrollees who will become part of ACOs this year and into the future.

The ACO scheme is the major part of a massive new federal Medicaid waiver that Team Baker won from the outgoing Obama administration days before the November 8

MassHealth spending 17

election that put Donald Trump in the White House. The Obama administration liked the Baker plan because it fit with their mission to move US health care away from expensive fee-for-service payment and toward value-based financing that rewards quality and efficiency. Though no one knows for sure which way the Trump administration will move, right now it’s full speed ahead at MassHealth on the ACO agenda. Continue reading “MassHealth Dives into Accountable Care”

“It has saved my life.” Voices from Ohio on Medicaid Expansion

[This commentary was first published on February 15 on the Commonwealth Magazine website:]

OHIO IS ONE of 31 states that expanded Medicaid as permitted by the Affordable Care Act/Obamacare for nearly all low-income citizens. The state’s Republican governor, former presidential candidate John Kasich, has been among the most vocal proponents of the expansion on the Republican side and has taken a lot of grief for it from ACA opponents.

In early January, the state released an evaluation of the impact of the expansion, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly“. (Group VIII is the legal name for the ACA Medicaid expansion population.)

ohio-medicaid

The report has a host of quotes from interviews with individuals who benefited from the expansion, and I include a selection of these quotes below, along with a section from the report’s overall summary. This is what Medicaid expansion has meant to real Americans:

“It gives me peace of mind knowing that I don’t have to pay for the medical insurance, and it saves me money being able to afford food and utilities and everyday things you need in life.”

“It’s been a blessing and I thank God that I have Medicaid because I no longer have large payments and I can get my Medicaid medicines.”

“More freedom. Less worries. I was an addict for 3 years before getting Medicaid. Because of Medicaid I’m not an addict.” Continue reading ““It has saved my life.” Voices from Ohio on Medicaid Expansion”

Obama, Clinton and the New Public Option

The era of Democratic silence on strengthening and improving the Affordable Care Act is officially over.  President Barack Obama’s tour de force review of the ACA’s successes in the new Journal of the American Medical Association is also important for his identification of key ACA improvements needed on insurance affordability, Medicaid, prescription drug prices and more. I note his call for a “public option” health plan to spur competition in states with low numbers of health insurers participating in state ACA exchanges/marketplaces:

“…(I)n the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. … Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

Serendipitously, Sect. Hillary Clinton is now actively promoting the public option in her White House run, partially to woo backers of her Democratic opponent, Sen. Bernie Sanders (D-VT), and also because she has supported this idea since 2008:

“To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.”

What does the “public option” mean and why now? Continue reading “Obama, Clinton and the New Public Option”

Behind the Turnaround at the MA Health Connector

(This article was just published in the Spring Issue of Commonwealth magazine.)

It’s 11:59 PM on October 31, 2015, about 20 nervous state officials and contractors hunched around computer terminals in a non-descript office in the Charles F. Hurley Building near Beacon Hill. Among them was Louis Gutierrez, executive director of the Massachusetts Health Connector, appointed the previous February by newly inaugurated Gov. Charlie Baker. The launch of the third open enrollment since the 2013 implementation of the federal Affordable Care Act (ACA) was less than a minute away with lots on the line. Would months of hard preparation avoid another website calamity that could jeopardize health insurance for hundreds of thousands of Massachusetts residents.

As the website opened at midnight and kept humming without a hitch throughout the night and following days, sighs of relief were heard across the Commonwealth as a major governmental embarrassment was averted. By early February 2016, 201,000 state

Guttierez
Louis Gutierrez

residents had successfully enrolled in plans for 2016, including 36,000 new members. Today, the Connector is a marquee success for the still-youngish Baker administration — an ironic twist for a Republican governor who was never a fan of the ACA, Barack Obama’s marquee presidential achievement. Continue reading “Behind the Turnaround at the MA Health Connector”