Pervasive uncertainty affects CT Health Reform Dashboard

July’s CT Health Reform Dashboard reflects growing uncertainty at the state and federal levels. If passed, Congressional proposals to replace the ACA will shift massive costs onto CT and result in a sharp drop in coverage. State budget cuts threaten current services and coverage. Nevertheless, DSS is doggedly forging ahead with a questionable payment experiment without waiting for data; we’ve seen this before and it doesn’t end well. Insurers seek double digit rate increases and physicians are building a health information exchange, because the state can’t seem to get it done.

Sen. Blumenthal holds third hearing on Senate ACA repeal bill

In response to public concerns, Sen. Richard Blumenthal will hold a third emergency field hearing on the Senate’s Better Care Reconciliation Act tomorrow, June 30^th 10:00 to 11:30 am at the Hartford Public Library, 500 Main St. Earlier this week, CBO reported that the bill would make 22 million more Americans uninsured and cost state Medicaid programs $772 billion by 2026. A new analysis from Governor Malloy predicts that the Senate’s bill would raise insurance premiums in CT by 10 to 15% and cost CT’s state budget up to $2.9 billion annually when fully implemented.

Advocates document concerns with PCMH+ implementation

The Medicaid Study Group, a coalition of independent consumer advocates, have published an update on CT Medicaid’s new payment reform experiment, PCMH+,  fact sheet and report. The program started January 1^st with 137,037 members. Under the new shared saving payment model, large health systems (called ACOs in other states and programs), get half the health care savings they are able to generate on their assigned patients. Advocates are concerned that DSS intends to rush forward with a massive expansion of the experiment to another 200,000 people without data on outcomes, possible harm to people, and overspending. UConn reportedly has the ability to give policymakers timely performance information, but cannot get access to DSS's data. In response to concerns, DSS did survey members who opted out of the program, but only spoke to 7 of the 1,808 people who refused the program. There is no mechanism to detect ACOs shifting patients between practices to generate false “savings” payments, as happened in other states. Advocates are concerned that, despite the label “shared savings”, PCMH+ could end up costing the state more as has happened in other states and programs, which CT cannot afford. The biggest problem is that trust has been eroded by broken promises and a lack of transparency. Mistrust makes it very hard to move forward.

One hopeful note from the Governor’s otherwise dismal executive order budget proposal is to save $700,000 by delaying the expansion of PCMH+ planned for next year.

CBO estimates that 22 million more Americans will become uninsured by 2026 under the Senate’s ACA replacement proposal

Thursday morning Senate leaders published their plan to replace the Affordable Care Act and modified it earlier today. The Senate proposal closely follows the bill that passed the House in May. According to today’s Congressional Budget Office’s report, the Senate bill would increase the number of uninsured Americans by 15 million next year and 22 million by 2026, including 15 million losing Medicaid. Increases in the uninsured rate would cross income and age categories, but would fall hardest on low-income and older Americans. The Senate bill would reduce Medicaid funding to states more than the House bill but spreads those cuts out over three years. Under the Senate bill, Medicaid funding to states would drop by $772 billion by 2026. According to the CBO, “With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services.” CBO also estimates that the Senate bill would increase private insurance premiums by 20% on average next year but lower them beginning in 2020 when plans could be less generous. By 2026 premiums would be 20% lower than under current law, but because of less generous plans, consumer out-of-pocket costs would be higher. CBO predicts that some people will “experience substantial increases in what they would spend on health care” depending, in part, on whether states choose to waive Essential Health Benefit standards in current law.

(Update added 6/30/17) A subsequent extended CBO analysis finds that under the Senate bill federal Medicaid spending would decrease even farther in the future. Analysts estimate that under the Senate’s bill, federal spending on Medicaid would decrease by 26% by 2026 and 35% by 2036.

The Kaiser Family Foundation has published a side-by-side comparison of ACA repeal and replacement proposals.

New to the Book Club -- Economic Ideas You Should Forget

The title alone pulls you in – Economic Ideas You Should Forget. Ideas and theories that everyone believes but aren’t true. 71 eminent economists and social scientists from around the world each contributed an economic theory that should be forgotten. Myths debunked include more choice is better, that economic growth increases well-being, and that CEO pay reflects talent and hard work. This book, and the underlying message, should be required reading for all healthcare payment reformers. For more summer reading books, visit the CT Health Policy Project Book Club.

Blumenthal holding second emergency field hearing on ACA repeal proposals

Senator Blumenthal has scheduled an emergency field hearing in New Haven Friday to hear the public’s thoughts on federal proposals to repeal and replace the Affordable Care Act. Monday’s hearing in Hartford drew over 200 people with standing room only who wanted to share their concerns. Senate leaders will not allow any official public hearings or committee review of their bill. Senator Blumenthal is scheduling these hearings to give CT residents a voice in this important legislation that will touch every American’s life and one fifth of our economy. A draft of Senate leadership’s bill is expected tomorrow morning.

Sen. Blumenthal’s hearing will be this Friday, June 23^rd at 1:30pm in the Aldermanic Chambers, New Haven City Hall, 165 Church St. Street parking is limited. Click here for a map of local parking.

Report estimates AHCA would cut $5.9 billion in Medicaid funds to CT

Connecticut would lose $5.9 billion in Medicaid funding from 2019 to 2028 under the American Health Care Act passed by the House last month, according to a new report from the Urban Institute and the Robert Wood Johnson Foundation. Connecticut would likely not be in a position to fill that funding gap with state funds. The authors note that provider rate and benefit cuts are unlikely to generate much in savings. If the AHCA passes, Connecticut would have to decide whether to fill some or all of the gap with state funds and/or cut eligibility to ease state funding. If Connecticut chooses to cut only the 168,300 people estimated to have gained coverage under the Affordable Care Act by 2022, the state funding gap drops to $900 million over those ten years. If Connecticut chooses to cut eligibility enough to keep state Medicaid spending level, 179,600 more people would be uninsured by 2022. The report’s authors point out that their estimates are very sensitive to changes in Medicaid spending growth and per capita cap growth rates.

New data finds CT leads nation in lowering Medicaid costs

New data from CMS actuaries finds that Medicaid per capita health care spending dropped 5.7% from 2010 to 2014, better than any other state. Of note, in 2012 CT Medicaid shifted away from capitated managed care organizations to run Medicaid. Unfortunately, the rest of the CT’s market is not performing as well as Medicaid – Medicare per person costs rose 1.6% and private insurance by 2.5% over those same years. Despite the progress, at $8,058 per person in 2014, CT was still twelfth among states in per capita Medicaid spending. But for total per capita spending across all populations, CT ranked fifth among states at $9,859 in 2014. Our average annual rate of increase from 1991 to 2014 was 4.9% for total per person spending, equal to the US average. It appears the rest of CT’s market and other US states should be copying CT Medicaid’s success.

Medicaid update – administrative conversion drives up call wait times

Friday’s Medicaid oversight council meeting focused on DSS’s conversion to ImpactCT, a new IT system to handle eligibility and enrollment. The hope is that moving more administrative functions online will streamline the process and reduce errors. Unfortunately, implementing the system is pulling staff away from their desks for 9 days of training, causing a sharp increase in average call wait times up to 54 minutes last month. Also disturbing is the very large volume of calls – 134,903 monthly on average -- which has been pretty steady over the last two years. If those were unique callers (which they probably aren’t) that would mean that one in five members was calling for help every month. The phone tree is only serving half of the callers -- 76,021 average ask to be connected to a real person, and 30% of those callers give up – not surprising as they will lively wait an hour to talk to that real person. In good news, by all reports, when callers do reach a person they are getting what they need and have a very good experience with the call. But in more bad news, shifting members to apply and manage their eligibility online is not working. DSS receives an average of 355,118 separate paper envelopes of applications, renewals and changes each month while only a few thousand are using the online system. An average 33,761 members (4% of the population, if unique) trek to a walk-in service center monthly but that rate is going down. DSS acknowledged the problems, said they’ve learned from past administrative shifts, are working to improve service, and promised to remain transparent, sharing public updates regularly. Committee members noted the large reductions in staff over the years and expressed concern that tight state finances not make the problem worse. DSS asked all of us to help them guide people to the online system, but they never addressed whether the system is user-friendly and working. In good news, DSS noted that timelines for SNAP applications and error rates have improved with the administrative updates so far. The shift to ImpactCT should be completed by this Fall.

CT insurers’ 2018 rate requests as much as 52% increase -- public hearing, comment

As part of the health insurance rate review process, CT’s Insurance Department will hold a public hearing June 14^th in Hartford on insurers’ double-digit rate requests for next year. In the morning, the hearing will address Anthem’s requests averaging 33.8% increases and affecting 35,000 policyholders. In the afternoon, the hearing will consider ConnectiCare’s average 17.5% increase request affecting 50,907 policyholders. The hearing will be at 153 Market St. in Hartford in the 7^th floor hearing room. Info on the hearings, including parking validation and public comment, and the full rate filings are online. Residents can also submit written comment online by July 1^st by clicking “Select” next to the filing you want to address. Commenters can also mail comments to CT Insurance Department, P.O. Box 816, Hartford CT 06142.

June CT Health Reform Dashboard – concerns remain but some hope for drug costs

CT’s June Health Reform Dashboard remains unsettled. Mistrust remains at the core of problems in CT. The new state HIT environmental scan mentions the need for trust a dozen times.  Medicaid policy development and implementation remains mired in mistrust, rushing ahead without data, and a lack of transparency. The state budget remains dreary and signals around Medicaid from the US Senate are mixed. In good news, CT’s Senate unanimously passed a bill to remove gag clauses so pharmacists can tell us the full truth about our medications, their costs and effectiveness. The Health Care Cabinet is continuing our work to control drug costs in CT with new workgroups to develop options.