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)

Young, invincible, and still uninsured

Monday, February 2nd, 2009

Lucas Wyant doesn’t worry much about worst-case scenarios,

Lucas Wyant

Lucas Wyant

and that’s why he hasn’t gotten around to buying health insurance — despite the state mandate. He’s a friendly, relaxed 20-something guy from Indiana, who’s never gotten seriously ill or injured. He works as a house painter for a small company that doesn’t provide insurance. He lives modestly in a Northampton walk-up apartment. When the painting work is coming in, he makes just too much money to qualify for Commonwealth Care, but he doesn’t see the point in buying private health insurance — despite pleas from his girlfriend and his parents.

Health reformers know Lucas’ type well. The Division of Health and Finance — in a December survey — actually found that healthy males in their twenties were making up the lion share of mandate-snubbers. And it’s a problem for the system, because insurance companies say without the healthy subscribers in the mix, the overall cost of insuring everyone will just go up.

But that’s not Lucas’ problem. He’s got to worry about paying his bills. He says the one factor that IS likely to force his hand is the state’s tax penalty. The first year, when the penalty was only $219, he never saw a bill — somehow, he managed to get under the radar. So that’s why he decided not to worry about this year’s penalty, which could be up to $900. Maybe they’ll forget about him again, he’s hoping. But if they don’t and he DOES find himself with a $900 bill, he’ll probably break down and try to find some health insurance. (Next year the penalty is even higher.) He also admits to getting a bit of reality check when his father, who is insured, recently had a bad car accident and needed a lot of expensive care.

In fact, Lucas has a few options for health insurance — and is only now starting to look into them. His painting company recently laid him off while the work is slow, so he’s collecting unemployment — and has applied for health insurance though the Medical Security Plan. If that doesn’t work, or after that runs out, he’s going to see if he can qualify for Commonwealth Care. But if he starts working again, he’s pretty sure that will tip his salary out of the pool.

He says some of his fellow painters already tried to get Commonwealth Care while they WERE working, but there was a glitch. The owner of the company thought his employees were eligible to sign up for his health insurance, but in fact, they weren’t……still, the Connector Board believed they had an employer-option and turned them down for Comm Care. Lucas says that level of hassle was enough to stop most of them from advocating further.

It’s worth noting that Commonwealth Choice (which brokers the private, non-subsidized plans) has a cheaper option for young, healthy people like Lucas. That very fact has been controversial, because older folks think it’s unfair. But reform supporters say that may be the only way to get them into the pool. Lucas, however, hadn’t heard about this plan.

A Physician for Social Responsibility

Wednesday, January 21st, 2009

Dr. Ira Helfand is well-known locally, and nationally, as a co-founder of Physicians for Social Responsibility.

Ira Helfand

Ira Helfand

It’s an organization that primarily works against nuclear war and proliferation, from a medical and social perspective. But I thought Helfand might also have some interesting perspectives on health reform.

Helfand runs an urgent-care practice (and smaller primary care practice) in Springfield, MA. He used to run the Emergency Department at Cooley Dickinson hospital (full disclosure: he treated my son for midnight croupe, about ten years ago. He didn’t remember us, of course…)

Helfand’s clinic is an interesting response to the primary care crisis I’ve been reporting on. It’s a cross between an emergency room, and a primary care private practice. It’s partly a walk-in clinic that will treat any one off the street — so people who have urgent, but non-”emergency”, problems, such as minor injuries, acute illnesses, back pain, etc., can come in without an appointment and get care within an hour or so. Helfand says that frees up emergency rooms for the bigger emergencies, and it’s also much less of a hassle for the patient. Moreover, he offers more continuity of care than ER’s.

In fact, he says he actually started to take on some of the walk-in patients AS primary care patients, because so many of them didn’t have primary care doctors already. (And he was very articulate about the primary care shortage, citing the same reasons as my other sources: inequitable pay, huge paperwork and overhead loads, shrinking job satisfaction.) But he says he had to stop taking new primary care patients because that was threatening to eat up all his time, and leave little extra for the walk-in service.

I sat in (with microphone) on one of Dr. Helfand’s visits with a walk-in patient. She was a middle-aged woman named Denise who had been suffering from a very unpleasant stomach bug and was worried she was dehydrated. She actually has a primary care doctor, but his office was so overbooked, they sent her intead to the urgent care practice. Dr. Helfand told her she was probably at the end of the virus; he checked her for dehydration, gave her advice on what to eat and how to care for herself.

Dr. Helfand says urgent-care clinics like his are not all that common in Massachusetts, but they do fill an important gap in community care. He’s adamant, however, that they are not the same as “retail clinics” — sometimes called “minute clinics” — which the state recently approved. Retail clinics are generally urgent care centers set up at CVS or Walmart, staffed by nurses or other para-professionals, for minor health issues. He is very much concerned about retail clinics for several reasons: the staff nurses are not always supervised by doctors and therefore less qualified than his practice; they are subject to fewer regulations than regular doctor’s offices or ERs; there is no continuity of care for patients; and he believes there is a clear conflict of interest when a pharmacy that makes its money off medications is paying the salary of medical staff. He says it’s reasonable to wonder if the nursing staff is under some pressure to prescribe medication….. whether or not that medication is necessary.

So far, no retail clinics have opened up in Western Massachusetts, but Helfand has heard of a nearby CVS that is considering starting one up….

On the broader issue of health reform, Dr. Helfand didn’t pull any punches. “First, kill all the insurance companies.” That’s an actual quote. He is very much a supporter of a single-payer, government run system, and while he acknowledges there could be pitfalls with putting all the power in one payer, he believes the advantages of eliminating the profit-seeking role of insurance companies would far outweigh any negatives. Having said that, he does think that Massachusetts should be commended with working within the current system to get more people covered by health insurance. He sees many of those people in his own medical practicem, and believes health reform probably has benefitted a number of individuals. But as far as system-wide change, the Mass efforts don’t go nearly far enough.

The Community Hospital Perspective

Friday, January 16th, 2009

Craig Melin, the CEO of Cooley Dickinson Hospital in Northampton, says, in principle, the state’s universal health care law is very much in line with the hospital’s values. But in practice, the reform is often problematic.

CEO Craig Melin

CEO Craig Melin

Unlike Holyoke Hospital, which serves a mostly low-income population,  Cooley Dickinson serves a greater mix of people — both privately-insured and insured by the state’s new and old programs — so the health reform law has not been as large a financial burden on Cooley Dickinson as on hospitals considered more of a “social safety net.” (See my blog entry,  A day at the Holyoke Health Center .)

What does put a burden on his hospital, Melin says, is the increasing number of Medicaid patients — those with the lowest incomes. Medicaid has always paid less for care than hospitals say it should, and now, with recent state budget cuts, it’s paying out even lower rates. At the same time, the state’s economy is leading to more unemployment and higher rates of poverty….so more people are getting Medicaid (known in this state as Mass Health.) Why is this related to health reform? Because the state decided to make the latest rate cuts in order to preserve the larger Commonwealth Care program.

Melin also says the explosion in the number of people getting either Medicaid or Commonwealth Care has created a backlog at the state level. So payments are getting held up significantly — and that puts another burden on community hospitals. Moreover, the different programs and administrators don’t always talk to each other….or know the other one’s rules … creating even greater havoc for hospital accountants and consumers.

Another way a bad economy puts strain on a hospital like Cooley Dickinson is through the shrinking “voluntary” patient population. Fewer people are getting elective surgeries or non-essential tests and procedures, because of the costs involved. But Cooley Dickinson was counting on that population to grow, because when rates for individual procedures go down, you need volume to go up! And he says it is this phenomenon — rather than the health reform law — that led Cooley Dickinson to lay off staff in recent months.

Meanwhile, Melin was quite frank about the need for a different kind of health reform — mostly around the way payments are doled out. He is very much in favor of an arrangement that would reward hospitals, primary care doctors, and community clinics who keep patients HEALTHY.  That way, hospitals like his wouldn’t be under pressure to use so many high-tech procedures to keep the higher reimbursements coming in. Instead, they could look at community health more holistically, and with a much more preventative approach. (He says Cooley Dickinson has already been doing this by supporting community health and education programs — with virtually no financial return.)

Interestingly, the next day, the local media announced a deal between Blue Cross and a Western Mass medical practice to do just what Melin suggested. It’s called the Alternative Quality Contract. I’ll have to follow up on that….

Near the end of our conversation, I got the distinct impression that Melin is quite frustrated with the status quo (re: fee-for-service from private and public insurers) and the incredible administrative burdens placed on hospitals to survive in the current health care system — with or without Chapter 58.  I asked him if he would instead prefer a single-payer system. Yes, he would. That’s not to say that he believes it’s an easy political path to take, but I find his take on it — from a community hospital perspective — to be telling.

Interview with my host station, WFCR

Tuesday, January 13th, 2009

WFCR’s Morning Edition host Bob Paquette interviewed me about where things stand — based on my reporting — in Mass health reform. This interview aired on January 13, 2009.

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Bob Paquette

Bob Paquette

Host introduction: WFCR’s Karen Brown has been spending the last few months examining Massachusetts health care reform law. Her work, funded by the Kaiser Family Foundation, has included interviews with people who have health coverage for the first time — and those having trouble navigating the new system. She’s also talked to doctors, hospital personnel, state officials and health care advocates. The economy has soured since Brown started this project, but she says, so far, state officials have been able to largely insulate health reform from the downturn.

Yin and Yang in Boston

Wednesday, January 7th, 2009

I spent 24 hours on a “policy” junket in Boston — talking to some of the policy makers/advocates/rabble rousers who are involved in the state’s health reform. They each seem to come from very different perspectives, all of which made complete sense to me at the time. Maybe that’s what makes a good journalist….but a rotten debate team member.

I started with Dr. Nancy Turnbull, a well-regarded academic at the Harvard School of Public Health (former head of the Blue Cross Foundation) who is also a member of the Connector Board. She is charged with representing the consumer’s point of view on the Board. She conceded that there are gaps in the law, but on the whole, she believes it’s the best the state can hope for right now. Her main focus is on controlling the costs of health care, and — unlike some of her colleagues on the board — she’d like to see a stronger hand of government reigning in expenses. In that way, she’s on the progressive side of things. In another way, she’s also a pragmatist, and while she may at heart favor more government involvement, she believes it is folly to hold out for a complete overhaul, such as a single payer system.

The next day, I spent several hours at Health Care for All (HCFA). This is a consumer organization that is very vested in the health reform law. Leaders from the organization played a key role in getting the law passed (including former Executive Director John McDonough, whom I interviewed in September. He’s now an advisor to Sen. Kennedy.) Staff at HCFA, which has long worked towards universal health care, are unwavering in their position that health reform in Massachusetts has been a success.  HCFA points to the 440,000 people who are newly insured under the law, and highlights anecdotes of people who say they owe their health, and in some cases lives, to the health insurance now provided by the state.(It’s worth noting that Health Care for All does get some funding from the private insurance industry, as well as state funding.)

One of HCFA’s tasks is to run a HelpLine . In the last year, five HelpLine counselors took

HelpLine counselor Hannah Frigand

HelpLine counselor Hannah Frigand

35,000 calls from consumers trying to navigate the new state health system. (Only about 1300 callers were from Western Mass.) The volume has apparently increased significantly in the last month, which the counselors attribute to the lousy economy and the numbers of newly unemployed.

During the hours I was shadowing the phone counselors, people called wondering where their applications were in the system…..asking for help proving their eligibility for Commonwealth Care …..and getting pointed in other directions. (HCFA gets $127,000 in state funding to provide this service.) While the counselors were certainly upbeat about their work, they admitted that there are glitches in the system — the delays in getting people approved, for instance, and the cumbersome paperwork involved — as well as holes in eligibility, such as people who make just above the income cut-off for Commonwealth Care but can’t afford private insurance.  On some occasions, the HelpLine ends up on the receiving end of some pretty angry callers — but there are also many notes tacked up on bulletin boards from grateful consumers who now have health insurance.

I also had a conversation with Lindsey Tucker, who oversees a coalition of diverse stakeholders in health reform. (The ACT coalition, for “Affordable Health Care Now.”) The coalition members come from very different perspectives — hospitals, labor unions, activists, employers — and as a result, the coalition tends to shy away from the most controversial issues (such as payment reform and employer contributions). But Tucker says that’s simply the trade-off to having a diverse group working together towards tweaking the law for the better.

David Himmelstein and Steffie Woolhandler

David Himmelstein and Steffie Woolhandler

My last stop of the day was the Cambridge home of David Himmelstein, who, it’s fair to say, is not on the Christmas card list of Health Care for All, nor are they on his. He is a national activist for a single payer system; he and his wife, Steffie Woolhandler, are both doctors who helped found the group Physicians for a National Health Program.  To Himmelstein, Massachusetts health reform has been a virtual disaster. He says many of the low-income patients he sees at Cambridge Hospital, where he’s a primary care physician, are actually doing worse than before, because they now have co-pays under the law, whereas they used to get free care. He also points out that the law has led to severe budget cuts to safety net institutions like his, which care for mostly poor populations.

Himmelstein scoffs at the idea that the federal govermnent would model health reform on Massachusetts, because he believes it’s simply magnifying problems without fixing them. To him, healthcare in America is going to be out of reach for almost everyone unless costs are seriously moderated, and the best way that can be done is by reducing overhead costs — i.e. creating a government-run, single-payer system. He does concede that there could be SOME ways to reduce costs in the current system, but not the ways that most people think. He does not believe that chronic disease management or even prevention reduce costs (although he thinks they’re a good idea!), but rather, he wants to see major change in how payment is doled out (stop paying specialists three times more than family doctors! stop providing financial incentives for unnecessary procedures!). Simply mandating health insurance for everyone, as Massachusetts has done, is not real health reform, he says.

He was willing to credit Massachusetts health reform for providing health insurance to some populations who wouldn’t have had it otherwise — by expanding Medicaid and creating Commonwealth Care for low to moderate income people — but he considers that a drop in the bucket of what needs to be done.

I should add that the folks at Health Care for All, as well as Nancy Turnbull, tell me privately that, sure, they’d be delighted with a single payer system; it’s simply not feasible in this political climate. And given that reality, incremental changes, such as Massachusetts’ health reform, is the best we can hope for.  Himmelstein’s response to that pragmatism is a fairly disgusted shrug. Given the signficant popular support in polls for single payer, and the strong record it has had in other countries, it’s clear to him that the only reason politicians aren’t willing to put it into effect is the influence of the corporate and insurance lobbies. What would need to happen to make single payer a reality here, I asked him? Hard to say, he says. Nobody could have predicted the impact of Rosa Parks when she refused to give up her seat on the bus, and look what happened there. Maybe someone will take a similar stand, he says, that could lead to a true overhaul of the health care system.

Skittishness

Tuesday, December 30th, 2008

I am finding more and more people with strong opinions about health reform, and but fewer willing to talk on tape. My kind chiropractor, who can’t afford to buy insurance and is among those not willing to go on the record, nevertheless talked to many of her self-employed friends who are in the same bind. She asked if THEY’d be willing to be interviewed, and they all said….. No. The reason? They are worried they’ll get in bigger trouble than they already expect to be in (i.e. getting penalized at tax time.) I pointed out to her that, unless people explain what’s not working, the policy makers will assume it IS all working. And she agreed, but added (and I can understand this) that these days, very few people are willing to sacrifice their own security for the greater good. (We actually got so caught up in this argument….that I was too tense for her to crack to my neck.)

Meanwhile, three people I have interviewed who ARE getting the state’s health insurance…..have refused to have their photo taken. Granted, this is a tangential issue, but I still think it’s interesting. One person didn’t think she looked very pretty these days. Another two people said they simply don’t like the idea of their photos being on the web (even though their voices are fair game.)  I have a feeling that this comes down to how personal people consider their health…..and how exposed they feel in general, especially when, to some extent, their care is being paid for by the government for the first time in their lives.