Health Reform Blog

A Reporter’s Experience

With much gratitude to the Kaiser Family Foundation, I spent my time from September 2008 to May 2009 — as a Kaiser Media Fellow — researching the progress of Massachusetts’ new health reform legislation.

In 2006, Massachusetts passed landmark healthcare legislation mandating that every person in the commonwealth have health insurance. To make that possible, the state greatly expanded its subsidized health care options — such as MassHealth (Medicaid), and a new program called Commonwealth Care for people who don’t qualify for MassHealth but whose income still falls below 300 percent of the federal poverty level. It has also brokered a number of private plans for those with higher incomes, through a program called Commonwealth Choice. In concert with this mandate, the law encourages employers to provide health care subsidies — or face a fine.

My project looked at what’s working in the reform effort, and what’s not. I spoke with policy makers, physicians, patients, insurers, hospital administrators, business owners, and a variety of other stakeholders in health reform (most of us, really!) I produced (and continue to produce) radio pieces for WFCR, NPR, and other outlets — most of which appear in the health policy section of this website. This blog is meant to complement the produced stories with my observations and experiences while reporting on the topic.

I encourage community members to email me with any ideas for stories about health reform, and with YOUR OWN stories of what’s working and what’s not in Massachusetts’ experiment with universal coverage.

I should add that there are a number of established blogs on health reform that I encourage all interested observers to check out:

http://commonhealth.wbur.org
(WBUR’s blog, Common Health, administered by WBUR healthcare reporter Martha Bebinger.)

http://blog.hcfama.org
(Health Care for All’s blog)

Tip Sheet for Journalists

Friday, April 22nd, 2011

In April 2011, I took part in the Association of Health Care Journalists’ national conference in Philadelphia — where I was on a panel called “Lessons Learned from Massachusetts Health Reform.”  Here is a tip sheet that I distributed at the panel. It’s meant to help guide the local reporter who is charged with the daunting task of covering their state’s emerging health reform efforts.

SOME TIPS FOR COVERING THE IMPACT OF HEALTH REFORM ON A LOCAL LEVEL

(by Karen Brown, WFCR Public Radio, Amherst, MA)

VISIT THE ‘UNUSUAL’ SUSPECTS

State officials, insurance executives and policy experts are the obvious places to start on many issues. But to learn what’s happening in the trenches, make frequent phone calls or visits to:

– Community health centers, which are often the places that coordinate sign-ups for the new health programs. They see who’s falling through the cracks and why. They can often also put you in touch with consumers to tell their own stories.

– Primary care doctors. They can talk about waiting lists and complex insurance rules and what their patients are frustrated or happy about.

– Young invincibles. Men in their twenties remain one of the least insured group, because they just don’t think they’ll need insurance – even the subsidized kind. Find out who’s trying to circumvent the insurance mandate, and why.

– Gatherings of “middle income” earners, like artists or acupuncturists, for instance – groups that are likely to be most affected by new programs designed for people up to 3 or 4 times the poverty level. Some will be delighted because they’ve finally been given access to affordable insurance, and some will have fallen through the cracks.

– Consumer advocates can be very helpful sources, but don’t rely exclusively on those groups for examples of “real people.” They are often hand-picked to make a certain point (which may be a good one, but still….) Why not approach people in the video store…or supermarket…or local park. Everyone is affected by health insurance, and you’ll get a good cross section of experiences.

WHO’S FALLING THROUGH THE CRACKS?

You may be surprised to learn how many cracks there are in new programs, however well designed – and those cracks help inform public opinion. In Massachusetts, for instance: if your employer offers health insurance but the premium is too high for you to afford…. you’re not eligible for a state subsidy (even if your salary is otherwise low enough to qualify.) Also — there’s a fairly large population of people who make too much to qualify for a subsidy…but too little to comfortably afford private insurance. Those are the people who feel hardest hit by the insurance mandate – and many of them are quite vocal.

DEVIL IS IN THE DETAILS:

Ask people to describe their individual experiences dealing with an insurance exchange or government programs. Sometimes you’ll find trends, other times you’ll find exceptions to the rule, but either way you’ll learn a lot about what informs public opinion. For example, stories about being kept on hold for hours … and then given conflicting information from different offices… and being told you qualify for coverage only to receive a letter of denial in the mail – these are the things that define success or failure from the consumer perspective.

UNINTENDED CONSEQUENCES:

There are always plenty – and each one makes for a good story. For example, in Massachusetts, the shortage of primary care doctors got worse after more people got health insurance ….And more fly-by-night insurers started to prey on confused consumers who knew they were required to buy health insurance but didn’t realize those health plans had to meet certain standards. Advocates will point out that unintended consequences do not negate all the good that comes out of reforms – and that’s a fair point – so make sure you put it all in context.

SOMETHING HAS TO GIVE:

Expanding health coverage costs a lot of money. What are state and local governments giving up to pay for that? In Massachusetts, in order to avoid limiting state-funded benefits or capping enrollment, the state has had to take money out of the outreach and education budget (which funded health outreach organizations)….out of Medicaid reimbursement rates to doctors and hospitals (affecting the bottom line of safety net institutions)….and out of the healthcare subsidy for legal immigrants (which led to a lesser health plan for one group of people.)

BE AWARE OF LANGUAGE NUANCES:

There is a difference between “access to insurance” and “access to care.” For instance, many more people in Massachusetts now have coverage….but that doesn’t mean they’re always getting the care they need, at a price they can afford, in a timely fashion. Also be aware that “reform” means different things to different people. In Mass, state-subsidized health coverage was greatly expanded, but the payment system stayed essentially the same. Explain those distinctions frequently, because even though health journalists know the jargon and the politics like the back of their hands, most consumers are still confused.

BE THICK-SKINNED AROUND POLITICAL ALLEGIANCES

Since health reform is such a politicized issue, including at the state level, it’s hard to report on the nitty gritty without having to carefully navigate political allegiances. It’s common to be accused of anti-reform bias when reporting on consumer complaints – and conversely, to be accused of acting as a government mouthpiece when reporting on people happy with the way things have changed.

Primer on Health Reform – A Conversation in Boston and Amherst

Tuesday, December 1st, 2009

WBUR health reporter Sacha Pfeiffer, and myself, teamed up for an on-air conversation about the state’s health reform programs — looking at some geographic differences between Eastern and Western Massachusetts, and highlighting some of the people we’ve each interviewed on the ground. WFCR and WBUR both aired it in two parts, on December 1-2, 2009.

Listen here for Part 1, focusing on affordability of health care in Massachusetts.

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Listen here for Part 2, looking at access to health care.

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Taking care of Business

Thursday, April 2nd, 2009

When reformers talk about “shared responsibility”, they’re usually referring to three entities who do the sharing: the individual consumer, the government, and employers. Up ’til now, I haven’t had much luck getting the employer side of the story. I have called numerous small businesses around Western Massachusetts, as well as chambers of commerce, and most have either declined to be interviewed, or failed to call me back, or left messages that say, essentially, no comment. So I decided to go up to the top — to Rick Lord, the president of Associated Industries of Massachusetts, which represents about 6,000 employers in the state. Lord was active in designing the health reform law, and now, as a member of the Connector Authority, he’s active in implementing it. He has been quite vocal about the needs of business, and he was very agreeable to being interviewed.

Not surprisingly, Lord takes issue with those — and there are many — who say business hasn’t had to pay its fair share towards health reform. He points out the state-verified statistic that Massachusetts has a 72 percent rate of employers who provide some health insurance to employees, which is higher than the 60 percent national average. And that’s up a few percentage points since before health reform. Since the individual mandate, 159,000 more employees are taking the insurance their employer offers — and he says that has cost businesses across the state about 500 million dollars.

However, he also admits — with no apology — that the business lobby in Massachusetts has been very clear that the costs of health reform should not be born disproportionately by employers. He fought, successfully, against a payroll tax to help pay for the state health programs. And with then-Governor Romney’s strong support, the employers with ten or more employees are subject to what most people believe is a fairly modest penalty when they do not offer health insurance: $295 per employee, which is considerably less than it would cost to provide health insurance to those individuals.

The burden on business has gone up slightly since the reform law passed. At first, businesses could get out of the penalty by either offering to pay 33 percent of health premiums, or getting 25 percent of employees to buy into the plan. Now, they must meet both those requirements. But Lord says he would not support any additional burden on business — and he added a reminder that one of the reasons Massachusetts passed a reform where other states did not, was because the business community supported it.

Initially, the state hoped that penalties on businesses not offering insurance would bring in about 47 million dollars; instead, during the first year, the amount was closer to 6 or 7 million dollars. Lord says that’s because the state overestimated the benefit. He acknowledged that, in some cases, businesses have wiggled out of the penalty by breaking up into smaller entities or relying on temporary and part time staff that don’t need to be offered insurance. But he does not believe that’s a widespread practice.

Nor does he believe that businesses have left Massachusetts — or chosen not to locate here — as a result of health reform.

I asked what he thought the rest of the country could learn from the Massachusetts example. He believes the coalition model — bringing business into the fold, getting employer support — is key. He also thinks other states should probably work on the cost issue at the same time as access, unlike Massachusetts, which dealt with access first and is now grappling with cost.

I was also curious what he would think of a single payer system — since presumably employers would benefit by not having to spend money on employee health insurance if the government was taking care of that. He is NOT, however, a fan of single payer, because he expects single payer would be paid for with higher taxes, including taxes on business.

It’s also worth noting the many businesses that are involved in the health insurance industry … would of course be put OUT of business with single payer.

TV roundtable on Mass Health Reform — WGBY/PBS

Thursday, March 26th, 2009

My WFCR colleague Susan Kaplan hosts a weekly public affairs show called “Watercooler” on the local PBS station, WGBY. This week, the topic was Massachusetts Health Reform. I was a guest, along with Jay Brienes of the Holyoke Health Center, and Meg Kroeplin of Community Partners of Amherst. Aired on March 25, 2009.

Click Here to Play video

An Industry Perspective — Andrew Dreyfus

Monday, February 16th, 2009
Andrew Dreyfus

Andrew Dreyfus

Many people I’ve talked to about health reform consider the insurance industry to be the evil empire — the stakeholder clinging onto the status quo for its own lucrative benefit.  But nothing is black and white, and I didn’t want put off getting the insurance industry’s side of things any longer.  Since I’ve always had a good relationship with Andrew Dreyfus — VP of Health Services for Blue Cross Blue Shield of Massachusetts — I thought I’d start with him.

Dreyfus is very personable and smart, with a long history in various parts of the health care system, and frankly, he just doesn’t come off as an evil emperor. (He used to be spokesman for the Mass Hospital Association, and later, president of the Blue Cross Foundation, which once sponsored me on a week-long journalism fellowship.)

But obviously these issues go beyond personality — so here’s how he sees health reform in Massachusetts so far, and how his insurance company (a nonprofit, he points out) fits in.

He believes the state has done a great job expanding coverage, but — like most observers — he’s less upbeat about the part where it controls costs.  Massachusetts made a conscious decision to give lots more people coverage without figuring out how it would pay for this coverage in the long run, and frankly, Dreyfus says that’s the only way this would’ve gone ahead. (He worked in the Dukakis administration during a previous attempt at health reform.)

But now the rubber meets the road, since the economy is only creating more need, and it’s certainly not slowing costs (currently increasing by double-digits for health care). Why, I asked him, do health costs go up so much faster than inflation? Because more and more people are relying on higher-tech medical care that is expensive, without necessarily leading to better results. Because in order to keep making money, hospitals and providers HAVE to order more expensive tests and procedures, since that’s how the payment system works. And Massachusetts frankly has more expensive care than most other places in the country, because it’s such a medical/technical mecca.

Dreyfus is on the state “payment reform” commission to look into changing the way insurance/Medicaid payments are made, but that’s a very slow process. But what he’s most excited by is what Blue Cross is doing on its own to control costs and, he says, improve health care quality.

He is one of the creators of what’s called an Alternative Quality Contract, or AQC. Currently, most insurers and government programs use a traditional “fee for service” model that rewards specialist care, hospitalizations, high tech procedures and medical tests — at the expense of basic primary care and preventative care. As a result, providers (doctors, hospitals, clinics) have an incentive to order more costly services, and they DON’T have an incentive to talk to patients about longterm health habits, to create relationships with patients, and to promote illness or injury preventation. This incentive system both drives costs up, and drives health indicators down. So what Blue Cross is doing with a select group of doctor’s groups (including Hampden Physicians Group in WMass) is entering a payment contract that provides a set amount of money to keep patients healthy — the doctors can choose how to spread the money around — and bonuses at the end of the year if in fact patients DO stay healthy. That way, he says, the emphasis is on health, not sickness; on prevention, not intervention.

This sounds like a very innovative approach, but it also raises a number of questions. How do you make sure doctors don’t only select patients they know are healthy, as a way to make sure they keep the lion share of the contract money? Well, he says — by offering more money in the initial contract for patients that come with high risk factors or existing illness. But how do you make sure doctors don’t fail to order NECESSARY tests or hospitalizations, because now they have an incentive to keep care to a minimum. Well, he says, because they will be measuring how healthy patients are at the end of the year, and if in fact they are getting sicker, then clearly they have not been getting the care they need, and the doctors won’t get their bonuses. But he did say that this approach will require a certain patience on the part of consumers, who may not get the same convenience, or the same degree of care, that they’re used to, or that they want. But if the system works, they will still get the care they need. (Isn’t that a Rolling Stones song?)

For doctors that enter this AQC, the insurer would promise a slower rate in premium increase from year to year (lower than the current 10 percent). Over time, the hope is that Blue Cross can keep premiums lower and thereby attract more business from employers and individuals. The AQC is still in a pilot stage, Dreyfus says, but he believes it’s an approach that could slow the rate of health care costs (and he was careful not to promise much more than that.) Why should other insurers follow BC’s example? Because this may be the only way to forestall a drastic government intervention.

That, of course, begs the question — would that be so bad? Perhaps government should play a stronger regulatory role in health insurance? To which Dreyfus replied that, certainly, whatever happens on the national stage, government is likely to play a stronger role, but he says even government needs to look at these sorts of innovative payment reforms.

We also talked about the prospect of a single-payer system — a system that many of the aforementioned skeptics believe would be the best way to cut costs, primarily by cutting OUT the insurance companies. To this, Dreyfus insists that insurance companies actually only add a small amount to the overall costs of health care. Perhaps 10 percent in administrative overhead, he says. And for that reason, he believes the real cost-cutting has to occur on the medical side of things, not the administrative side.

It’s worth noting that the week before our interview, Blue Cross announced it was enacting major cuts in its executive and employee pay, in anticipation of a loss of revenue from declining membership and investment income.  We ran out of time for me to get into this issue.

Holyoke community health, Revisited

Monday, February 16th, 2009

I spent another day last week at the Holyoke Health Center — roaming the hallways looking for personified illustrations of health reform. I was accompanied by a very kind administrator from the center, Marisol, who served as my translator when the Spanish went too fast.

A number of people said they had long been on MassHealth (low-income, disabled or parents of young children), and that hasn’t changed. They were mostly unaware of the changes under health reform.

But there were a few notable exceptions. One family had moved from Puerto Rico to Holyoke because they are raising a child with autism, and they heard that Massachusetts had the best medical care in the country, and, after doing some internet research, they realized they would qualify for either Commonwealth Care or MassHealth. They chose Holyoke because the cost of living is affordable, and now they are coming regularly for care for their child.

Another woman had been a housecleaner for many years, and for some of that time, she had health coverage from her employer, but she lost that coverage several years earlier. She is a few years too young for MediCare, and wasn’t getting any health care. But now she qualifies for CommonWealth Care, and is getting treated for chronic conditions she had been ignoring.

And one other man, in his 50s, was in the urgent care clinic for a stomach ailment. He is a part-time janitor — quite overweight — who has never had health insurance before. Now he has Commonwealth Care — and while he says he hasn’t used it much (he had no plans to get a physical), he is darn happy that he can get care from the walk-in clinic at the health center. (Although it’s likely he could have gotten urgent care before Commonwealth Care through the Free Care Pool.)

After spending a few hours at the Health Center, I stopped by Holyoke Community College. I wanted to meet

Holyoke Community College

Holyoke Community College

students to find out if they knew about the health reform and if they were affected. Most of the young people I talked to, to be honest, hadn’t heard about the mandate or the new Connector programs. They were mostly either on their parents’ health plans, or getting the school plan. (A bare-bones plan — I’m not sure how that qualifies under state law.) One young man told me he had heard of the mandate, but planned to move out of Massachusetts after graduation to avoid it. He was unaware of Commonwealth Care — didn’t know he could apply for subsidized insurance.