The Health Reformers’ Dilemma

[The Milbank Quarterly just published this new commentary that I wrote for their November 2018 edition.]

Ever since the US Supreme Court ruled in 2012 that the expansion of Medicaid as required by the Affordable Care Act (ACA) must be optional rather than mandatory for states, health care advocates have worked heart and soul to convince their state governments to adopt the expansion. For Virginians, the moment arrived in 2018 after years of frustration—with a catch. The only politically viable pathway to expansion included a detested provision, known as the “work requirement,” that obligates many new enrollees to work or else forfeit coverage. What to do?

I explored this dilemma with health justice advocates in Virginia, the first state to confront work requirements that had not previously expanded Medicaid. In November 2017, Virginia voters elected a respected new Democratic governor named Ralph Northam along with an eye-popping jump in the number of Democrats in the state’s House of Delegates, leaving them just 2 votes shy of majorities in the House and Senate. In May 2018, solid bipartisan majorities formed to enact Medicaid expansion after years of discouraging defeats. The wrinkle was including a work requirement and imposing cost sharing on Medicaid beneficiaries. Continue reading “The Health Reformers’ Dilemma”

Might We See a Medicaid Wave Start Next Week?

[This column appeared on the Health Affairs blog on Thursday, November 1.]

Ever since the U.S. Supreme Court ruled in 2012 that states must have an option whether or not to expand Medicaid as authorized in the Affordable Care Act, expansion has been a long, slow slog, state by state, inch by inch. While blue states had mostly lined up to expand Medicaid by 2013, nearly every purple and red state proved to be a battlefield. Today, 19 states have yet to expand, with 31 in the “yes” column (plus the District of Columbia) (see table 1). The last state to expand, #31, was Louisiana in mid-2016. But, might a mighty Medicaid wave be coming courtesy of the November 6^th elections? The answer is a definite maybe.

Right now, all that’s certain is that Virginia will become state #32 to expand Medicaid in January. The state enacted the 400,000-person expansion last May, albeit with a “work requirement” to be filed with the Centers for Medicare and Medicaid Services (CMS) sometime in 2019.

Maine is certain to become #33 early next year if Democratic Attorney General Janet Mills wins the Governor’s Chair. In November 2017, Maine voters approved expansion—59-41 percent—in a state ballot initiative. Departing Republican Governor Paul LePage refused to implement the expansion in spite of strong legislative support to do so, as well as an order from Maine’s highest court. In previous years, the Legislature failed by only a small number of votes to override LePage’s vetoes (5 times). Progressive forces expect to pick up state legislative seats on November 6^th, so it’s also possible expansion could happen with a new Republican governor, supportive or not.

State Adoption Of ACA Medicaid Expansion (By Year)

SOURCE: Advisory Board. “Where the States Stand on Medicaid Expansion.” June 8 2018. Accessed Oct. 29 2018 at: https://www.advisory.com/daily-briefing/resources/primers/medicaidmap

Medicaid On the Ballot

Activists in three states—Idaho, Nebraska, and Utah—are standing in the wings hoping to be states #34, 35, and 36 depending on the outcomes of state ballot initiatives in each of them on November 6^th. Montana has an initiative on the ballot to continue its expansion with dedicated funding.

While Idaho’s departing Governor Butch Otter fought consistently against Medicaid expansion throughout his tenure, he recently changed his position and announced his support for the Medicaid ballot initiative. Republican gubernatorial candidate Brad Little says he will respect the ballot initiative’s outcome—even though the measure does not specify how to finance the 10 percent financing match states will need to pay by 2020 (7 percent in 2019). Two organizations, Idahoans for Healthcare and Reclaim Idaho raised $594,191 by the late September reporting deadline, while the opposition Work, Not ObamaCare has raised $29,999. Idaho’s Hospital and Medical Associations contributed nearly $200,000 to the “yes” effort. Recent polling shows 66 percent support, including 77 percent from independents and 53 percent from Republicans. The yes campaign co-chair is Republican State Representative Christy Perry.

Nebraska previously did not have enough support to overturn a Governor’s veto against expansion. Nebraska Governor Pete Rickets maintains his opposition as he coasts toward an easy re-election. But it’s a spirited race for Nebraska Initiative 427, the Medicaid Expansion Initiative that would cover an estimated 90,000 low-income Nebraskans. The lead organization—Insure the Good Life—has raised $1.69 million as of late September to support a yes vote, versus $0 by the opposition Americans for Prosperity. The “yes” camp’s largest contributor is a national progressive political action committee called the “Fairness Project” which also backed the 2017 Maine Medicaid initiative and which has donated $1.19 million. Other key supporters include the Nebraska Hospital Association, the state health center association, Nebraska AARP and 24 other organizations.

Of the three ballot initiative campaigns, Utah’s is the most compelling. Proposition 3 would raise the state’s sale tax from 4.70 to 4.85 percent to fully finance the expansion for 150,000 low-income Utah residents. In 2021, that is projected to raise $88 million to cover the state’s projected $78 million share of the $846 million total expansion cost (the federal government pays the rest). A February 2018 poll showed 68 percent support among Utah voters. As in Nebraska, the national Fairness Project is driving the campaign, providing $2.7 of the $2.83 million raised as of late September. A wide array of health care and religious organizations are public supporters. No organization is registered with the state in public opposition to the initiative, as of late September.

To thwart the proposal, in March, Governor Gary Herbert signed House Bill 472 into law to expand Medicaid for individuals with household incomes no higher than 95 percent of the federal poverty line, as opposed to 138 percent in Proposition 3, as authorized under the ACA. HB472 would also impose work requirements on many enrollees and would cover 90,000 as opposed to the initiative’s 150,000. Earlier this year, the Trump Administration rejected a plan similar to HB472 that was advanced by Oklahoma to expand Medicaid eligibility no higher than 100 percent of the federal poverty level. So it is unclear whether the Trump Administration will allow the Utah HB472 expansion to go forward.

Montana is another state with a Medicaid expansion ballot initiative facing the voters on November 6^th, but to continue the existing expansion. The state expanded Medicaid in 2015, though only through 2019. The November 6^th ballot will present an initiative, I-185, to continue expansion past 2019 by raising tobacco taxes by $2 a pack as the state’s funding source. Healthy Montana for I-185 backers have raised $4.8 million and are battling the tobacco industry in the form of Montanans Against Tax Hikes (MATH) which has invested at least $12 million to defeat the initiative; 97 percent of the MATH’s money has come from Altria Client Services, maker of Marlboro cigarettes and other smoking products. If voters approve, the expansion will continue without restraints. If the referendum fails, the legislature still could pass a new funding law, likely with a work requirement attached.

Other Election Day Impacts

Of the 14 remaining non-expansion states, the November 6^th results may have consequential impact. If Democratic candidates win currently competitive gubernatorial races in Florida, Georgia, Kansas, and Wisconsin, and pick up legislative seats, that could alter the Medicaid expansion equation. This would be especially true in Kansas where prior expansion efforts were thwarted by a narrow inability to override gubernatorial vetoes by only three votes. In other states, notably North Carolina with Democratic Governor Roy Cooper, significant Democratic gains in the state legislature may also have a consequential impact.

Some noteworthy features of this issue are worth considering. First, in many of these remaining states with Republican control, the price of expansion is likely to include work requirements on many newly eligible enrollees—as occurred in Virginia this past year. Unless ruled illegal by the federal courts, this national experiment will more than likely run at least for the duration of Republican control of the executive branch. As is apparent from the track record in Arkansas thus far, this is about values and ideology more than dollars and sense.

Second, after six years of fighting the Medicaid expansion wars, it is clear that most expansion opponents are not going to change their minds. Not much is left to say that hasn’t been said countless times before. As we saw in Virginia, a change of mind accompanies a change in occupants of legislative and gubernatorial seats. And in the four November 6^th ballot initiative states, if successful, we should anticipate that one or more of the affected Governors may imitate Maine Governor LePage in seeking to block expansion in spite of voter sentiment.

Third, in spite of all the uproar, it is significant that not one expansion state has gone back on it, or even considered doing so. The closest an expansion came to a rollback was the election of hard right conservative Matt Bevin as Kentucky’s governor in 2015. Bevin abandoned his pledge to repeal Kentucky’s ground-breaking and successful Medicaid expansion early in his gubernatorial campaign, and never returned to that stance, turning to mandatory work requirements as the next best thing.

Much like how the public’s support for banning pre-existing condition exclusions has become calcified in the public’s mind from the battles of 2017 and 2018, similarly the expansion of Medicaid has become hard-wired into public consciousness in the states that adopted it.

I have yet to read an insider’s account on how and why the U.S. Supreme Court lined up 7 votes to secure their atrocious 2012 ruling to make Medicaid expansion an option for states. It is true that their decision played a role in compelling Americans to grapple with and understand the rationale and importance for Medicaid expansion. But at what a damn price!

Continue reading “Might We See a Medicaid Wave Start Next Week?”

MassHealth’s New World of ACOs — and a Mighty Upstart

[I wrote this commentary for the spring issue of Commonwealth Magazine. I am watching the new crop of 17 Accountable Care Organizations — ACOs — with great interest. This is a nationally important demonstration that also holds risks for the medical care of many MassHealth enrollees.]

ON MARCH 1, the state’s Medicaid program—known as MassHealth—entered a new era with the launch of 17 accountable care organizations, or ACOs, aiming to provide better coordinated care at lower costs to its low-income enrollees. It’s an ambitious effort with lots of risk and big potential rewards. Within this is another compelling effort to redefine how community health centers fit into the changing health care landscape of Massachusetts and the nation.

Christina Severin, CEO of C3, the new accountable care organization formed by community health centers.

It began with a serendipitous encounter at a grocery store. Sometime in the fall of 2014, Christina Severin bumped into Lori Berry at the seafood counter of the Brighton Whole Foods market. Severin, a long-time leader in the MassHealth scene, had been mulling the creation of a community health center-based non-profit to join the cohort of ACOs being planned for as many as two-thirds of the 1.9 million Massachusetts residents who rely on the program. Continue reading “MassHealth’s New World of ACOs — and a Mighty Upstart”

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”

The State of Play Post-Trump/RyanCare

[This column is reprinted from the Commonwealth Magazine website.]

GLOBAL HEALTH EXPERT Michael Reich says that the acid test of any national health reform comes when a new national administration takes over. Only when a new president or prime minister assumes power can we judge the stability and staying power of any health system reform. In the US, that’s this moment. Since November 8, we’ve been learning what parts of the Affordable Care Act (ACA) have staying power, which do not, and what’s uncertain.

Right now, after Friday’s demise of the Republican repeal and replace plan, the American Health Care Act (AHCA), we know that Medicare, Medicaid, insurance market reforms such as guaranteed issue, and delivery system reforms such as accountable care organizations look TrumpCare3

safe. We know that the private insurance coverage reforms – insurance exchanges, premium and cost-sharing subsidies, the individual mandate – are at risk and in danger even though they dodged full repeal with the AHCA’s demise. And we don’t know the fate of the ACA’s many tax increases. Let’s view these systematically. Continue reading “The State of Play Post-Trump/RyanCare”

House Republicans Show Their Hand on ACA — and It’s Not Good

[This February 26 2017 commentary was published on the Commonwealth Magazine website.]

LATE LAST WEEK, Politico released a leaked 105-page draft bill defining the House Republican plan to repeal/replace/repair/re-whatever the Affordable Care Act/Obamacare. The draft legislation was dated February 10, so likely it’s already out of date, though it is the best indication yet of their rapidly evolving intentions and fits with many of their prior recent proposals. So a big GOP move is getting close, and it’s not good. What’s important?

First, the ACA’s generous coverage expansion (for many, not all) through Medicaid expansion and private insurance subsidies would be drastically curtailed, leaving most of the 22 million who got either form of coverage without an affordable option.

repeal-replace-720

Second, not only is the ACA Medicaid expansion repealed by 2019 (11 million people and counting), the plan would replace current Medicaid financing with a “per capita cap” by 2019, shrinking funding by hundreds of billions, perhaps more, over 10 years. Continue reading “House Republicans Show Their Hand on ACA — and It’s Not Good”

“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”

Explaining the New MassHealth 1115 Waiver Proposal

The article below — Baker’s Big Health Care Move — was published in the October 2016 issue of Commonwealth Magazine:

FOR THE THIRD time since 1996, the Massachusetts Medicaid program, called MassHealth, is preparing for transformation. After submitting a final proposal in July, state officials are anxiously awaiting a decision on the plan from the US Centers for Medicaid & Medicare Services. The goals are to: first, transform how medical services are delivered to many of MassHealth’s 1.86 million enrollees (including 40 percent of Massachusetts children); second, guarantee a five-year flow of nearly $8 billion in extra federal dollars into the state’s health care system; and third, better integrate substance abuse, mental health, and long-term services and supports into traditional medical care.

Chances are you have heard nothing about this plan that contains many worthy and some controversial changes. For state leaders, the stakes are high. Between 1997 and 2015, MassHealth’s share of the overall state budget doubled from 18 percent to 36 percent—with federal dollars accounting for more than half of the total share. At $16.4 billion in fiscal year 2017, MassHealth is the state’s biggest budget buster and most important lifeline for the state’s neediest populations. The new federal proposal represents Gov. Charlie Baker’s attempt to slow the growth rate while improving medical care and the health of enrollees.

For those who have been awaiting the Baker administration’s big health policy move, this may be it.

WHY IS THIS HAPPENING?

Since 1965, Medicaid has been a federal-state partnership that provides health coverage for low-income Americans. Originally just for poor mothers and kids on public assistance, today it is America’s largest health insurance program, covering more than 70 million people. The federal government provides most of the money, and sets tight rules governing how states run their programs. States can get flexibility from those rules by obtaining waivers from the federal government, the most pliable being the “Section 1115 research & demonstration waiver,” generally granted for 3-5 year terms. Even though federal rules require waivers to be “budget neutral,” states use creative medical and insurance redesigns to obtain substantial and desirable financial flexibility. Massachusetts Medicaid entered the 1115 game in 1997 with a major coverage expansion that transformed it into today’s MassHealth. Baker, then secretary of administration and finance under Gov. Bill Weld, was a key architect.

Since that time, Massachusetts’s 1115 waiver, now in its sixth iteration, has brought flexibility and extra dollars to support the state’s medical infrastructure for disadvantaged populations, chiefly through Boston Medical Center, Cambridge Health Alliance, and the state’s community health centers. It was the threatened loss of those extra federal dollars ($385 million in 2004) that jolted then-Gov. Mitt Romney and Sen. Ted Kennedy to formulate the plan leading to passage of the landmark 2006 Massachusetts Universal Health Care law, which in turn helped spark passage of the 2010 federal Affordable Care Act.

The state’s current 1115 funding ends in June 2017, and Baker administration officials, especially Secretary of Health and Human Services Marylou Sudders and MassHealth chief Daniel Tsai, are eager to lock in the next waiver—and the nearly $8 billion over five years—before Team Obama departs in January. Since arriving on Beacon Hill in January 2015, Team Baker has engaged in intensive planning with stakeholders, including consumer advocates, hospitals, physicians, insurers, and more. State leaders want federal approval by early fall. If federal officials like their plan—and Team Baker is hitting notes Team Obama wants to hear—they may get their wish.

WHAT’S THE PLAN?

The state’s application outlines five goals for the new five-year waiver that would begin in 2017:

Enact payment and delivery system reforms that promote integrated, coordinated care and hold providers accountable for the quality and total cost of care.
Improve integration of physical health, behavioral health, long-term services and supports, and health-related social services.
Maintain near-universal coverage.
Sustainably support safety net providers to ensure continued access to care for Medicaid and low-income uninsured individuals.
Address the opioid addiction crisis by expanding access to a broad spectrum of recovery-focused substance abuse disorder services.

The most controversial goal is the first: inducing Mass-Health medical providers (hospitals, physician groups, home health agencies, community providers, and post-acute providers such as rehabilitation hospitals and nursing homes) to form or expand “accountable care organizations” (ACOs) to assume responsibility for the total cost of care for their MassHealth members.

ACOs were invented in the Affordable Care Act to push providers away from fee-for-service payments that tend to reward volume over quality and efficiency. Since 2010, more than 800 ACOs have formed across the nation in Medicare, private coverage, and, increasingly, Medicaid, with 17 states now using ACOs or looking to do so. In 2012, in that year’s health care cost control law signed by then-Gov. Deval Patrick, the Legislature directed MassHealth to move quickly to adopt “alternative payment models” such as ACOs. So the new waiver will enable MassHealth to meet both federal objectives as well as its legislative mandate.

Currently, about 840,000 of MassHealth’s 1.86 million enrollees obtain care through one of the state’s Medicaid managed care organizations such as Neighborhood Health Plan or Boston Medical Center’s Health Net. About 383,000 others participate in the loosely managed Primary Care Clinician (PCC) program. The rest, especially seniors and persons with disabilities, are in fee-for-service. MassHealth officials want to push as many PCC enrollees as possible into managed care organizations or ACOs by curbing benefits such as eyeglasses, hearing aids, and chiropractic or orthotic care and imposing new out-of-pocket costs on unwilling enrollees who choose to stay with the PCC program.

This aspect concerns patients, advocates, and medical groups. Though ACOs have grown rapidly since 2010, their track record in reducing costs and in improving quality has been modest, and their future is a topic of urgent debate among health policy experts. Some data suggest that PCC enrollees are no more expensive than managed care enrollees. Many PCC enrollees have serious, complex medical needs that can be poorly served by Medicaid managed care organizations with exclusive provider networks.

On the other side, encouraging states to jump into ACO-style “value-based payment”—and away from uncoordinated and unmanaged fee-for-service care—is among the highest priorities of federal officials such as US Health and Human Services Secretary Sylvia Burwell. If Massachusetts wants any hope of keeping the $8 billion in extra federal dollars flowing, they need to excite federal officials with ambitious designs of this variety.

The second goal—integrating physical health, behavioral health (the combined term for mental health and substance abuse treatment), long-term services and supports (the new term of art for long-term care), and health-related social services—is a major health system improvement goal advocated nationally and in Massachusetts by many, especially Sudders, a former clinical social worker and state mental health commissioner who has long fought to demolish medical care siloes.

Under the new waiver, new MassHealth ACOs will be required to build partnerships with certified “community partner” organizations that provide behavioral health plus long-term services and supports while managing the total cost of care of their enrollees. Providers will operate with per-person capitated payments that require improving the health and well-being of enrollee populations rather than just treating sick patients, a paradigm-shift for providers trained to care—and bill—for one patient at a time.

In response to health care providers worried about adapting to this new system, state officials emphasize the five-year transition to an ACO-centered MassHealth set to launch October 1, 2017. They also note that the $8 billion in federal waiver money will include $1.8 billion in additional federal payments (called Delivery System Reform Incentive Payments) specifically to help providers undertake the transition.

LET THE GAMES BEGIN – OR NOT

Opaque is a word often applied to 1115 waivers, one the Obama administration has attempted to replace with “transparent.” States must now conduct open public hearings on new waiver applications and make public all sorts of information relating to 1115 applications. MassHealth’s information, including the application, is here.

Noteworthy are 94 stakeholder letters submitted in July, 400 pages of praise and criticism from organizations large (Massachusetts Hospital Association, Massachusetts Medical Society) and small (Home Care Aide Council, Autism Housing Pathways). One letter from Leann DiDomenico, the mother of a 12-year-old adopted foster child, caught my eye:

“My son…spent the first three years of his life in an abusive birth home followed by 18 months in three different foster homes leaving him with a number of behavioral health issues, including PTSD and reactive attachment disorder (RAD). Over the past seven years my husband and I have worked hard alongside [his] primary care provider and various therapists to help [him] to heal and develop the tools he needs to live a full, productive life in spite of his mental health issues. If/when [he] is transitioned to an ACO, I have no confidence that we will be able to keep the professionals we currently have in place that are working well for [him].”

Leann’s letter gives voice to the concerns advocates have raised about the waiver plan. In 2013, MassHealth launched another ambitious demonstration to move their disabled enrollees into a new managed care program called One Care. Though One Care has made substantial improvements in quality, only about 13,000 of 115,000 MassHealth eligible enrollees have signed up after a rocky implementation (see “No time to go wobbly on One Care,” CW, Fall 2015). The new 1115 waiver is even more ambitious and dicey. Many PCC enrollees and their families have painstakingly built personal provider networks to address their serious and unique needs. ACO implementation risks serious disruption for them. MassHealth should offer these individuals and families a no-penalty “opt-out” until this experiment proves itself.

Baker’s 1115 waiver plan includes major steps forward for Massachusetts health care that may pay important dividends well into the future. Until they have demonstrated the capacity to implement this without harming any of their enrollees, they should proceed with more caution.

Back to the Future with Speaker Paul Ryan

This past week at Georgetown University, House Speaker Paul Ryan proposed scrapping an essential component of the Affordable Care Act (ACA) that bans health insurance companies from imposing pre-existing condition exclusions on consumers and prohibits the practice of “medical underwriting” to discriminate against anyone with a current or prior medical condition. Instead, he proposed, states could re-establish “high risk pools” from which those with pre-existing conditions could obtain coverage, leaving standard health insurance only for the “healthy.”

Paul Ryan 2 Christopher Lloyd

Wow. Ryan may or may not realize it – but his speech just changed the stakes regarding the ACA and the November 8 federal elections.

Prior to Ryan’s speech, conventional wisdom, as evidenced in Republican Congressional and conservative think tank proposals, was to preserve the ACA’s ban on pre-existing conditions, albeit only for those who maintain “continuous coverage.” This stance enabled Republican office-holders to affirm their support for the pre-ex ban, even as their proposals’ fine print would reintroduce medical underwriting. Continue reading “Back to the Future with Speaker Paul Ryan”

Behind the Bipartisan Kumbaya on Substance Abuse

[This op-ed was posted yesterday on the website of the Milbank Quarterly.]

For several years, Republicans and Democrats alike have been concerned about the crisis of opioid and heroin addiction in the United States. It is hard to find anyone who rejects the notion of a serious problem that demands at least a partial governmental response. Across the nation, governors and legislatures are hard at work seeking solutions and avoiding partisan bickering. Numerous current and former presidential candidates in the 2016 campaign cycle got favorable attention explaining how the crisis has affected their families and friends in personal ways.

Behavioral health

The question is whether there is any meaningful difference between Republicans and Democrats when it comes to substance abuse (and, for that matter, behavioral health—the merger of substance abuse and mental health).

The answer is yes, and the difference comes down to the Affordable Care Act (ACA). Continue reading “Behind the Bipartisan Kumbaya on Substance Abuse”