Administration opposition to HB-5617, Charter Oak fix bill

Testimony from Governor Rell, DSS Commissioner Starkowski, OHCA Commissioner Vogel, OPM Secretary Genuario, and DPH Commissioner Galvin in the Human Services Committee’s public hearing Tuesday strongly opposed any changes to their plans for Charter Oak. Attorney General Blumenthal, State Health Care Advocate Lembo and fourteen consumers and advocates, including this one, testified in favor of the bill.

Calling the bill “oxymoronic”, the Governor cites several consumer emails to her office opposing provisions of HB-5617. However, she does not cite other emails received by her office, obtained through a Freedom of Information request, citing exactly the problems HB-5617 is designed to address. A few examples:

“I read, with excitement and hope about Governor Rell’s health care proposal yet have one concern. The stipulation that a person has to be uninsured for a minimum of 6 months to qualify for the Charter Oak Plan. I find that extremely unfair and risky. . . . I took on a second job because the cost of insuring myself is so unreachable I need additional income to pay the premium each month. . . . Now, to hear that people like me will be required to go without that safety net for 6 months to get the Governor’s proposed insurance coverage, seems terribly financially risky. . . . To take that chance and potentially bankrupt me and my family? Seems crazy to me.”

“I am very much in favor of the Charter Oak Health Plan for the uninsured populations of CT. I am concerned, however, over the 6-month wait period which means a person must go without insurance for 6 months before they can go into the plan. Six months is a long time to go without insurance. One could very well go bankrupt during that period if something medically detrimental happened.”

“I applaud your effort to secure low-cost health care coverage for the quarter-million uninsured Connecticut residents. However, low-cost is a pretty relative term, I’ve found! To expect a family earning $24,000 annually to pay $3,000 for health-care coverage is pretty unrealistic, as that segment (my segment!) of the population is already stretched to the very limit . . . $250 a month might seem a pittance to somebody in a higher tax bracket, but let me assure you, it might as well be $2500 a month to somebody netting less than $2,000 a month; it’s just out of reach.”

“I read your [health insurance] proposal with great interest and hope. I am concerned though, that I think you are missing some key points. . . Your plan goes a long way in addressing that problem [of the uninsured] but it leaves out those of us who have taken the responsibility of providing coverage for our families. . . . I know in my heart that I am that I am doing the right thing, being responsible and not becoming a burden to the state. I need the state to do what is responsible. . . To help the uninsured is fine, but what are we supposed to do who have maintained coverage?”
Ellen Andrews

Primary Care Access Authority Update

Adequate behavioral health services are vital to ensuring that Connecticut’s primary care infrastructure will work well for all our residents. This was the focus of yesterday’s Primary Care Access Authority meeting in Hartford. The session outlined some of the behavioral health services currently available in our state and showed the impact of healthcare staffing recruitment and retention problems on behavioral health capacity.

More striking to me, though: the barriers to designing a system of service that most effectively will address behavioral and physical health needs. Where primary care providers work closely with behavioral health clinicians, behavioral causes of physical ailments and physical causes of behavioral ailments are more likely to be diagnosed and treated. Also, having integrated services helps alleviate the stigma that is sometimes attached to seeking behavioral health services.

It is a model that has worked. But this type of integrated care has been implemented in limited cases because, as Donna Campbell from the Village for Children and Families said yesterday, the current reimbursement structure discourages this team approach. As the state considers how to make our health care system work, we have to make sure that incentives and disincentives support rather than undermine good healthcare.

Connie Razza

Charter Oak/HUSKY update and notes from the bidder’s conference

DSS has posted an advocacy-style fact sheet about Charter Oak and opposing HB-5617 which would delay implementation to allow more thoughtful planning. HB-5617 will be heard in the Human Services Committee later this morning. The flyer includes several positive quotes about Charter Oak from letters and emails to the Governor’s office. But it leaves out the critical ones, particularly those voicing concerns about the unfairness that people would have to drop health insurance for six months to qualify. Many consumers in CT struggle to afford individual coverage; $250/month premiums would offer significant relief. Why exclude them?

From Friday’s bidder’s conference -- excerpted from Jennifer Jaff’s notes, Executive Director, Advocacy for Patients with Chronic Illness. Many thanks to Jennifer for braving the storm to bring us these notes.

The six month waiting period is to reduce “crowd out” – people leaving private coverage to enroll in Charter Oak. (Why do we care, if they are not in the subsidized bands? If the state can save people money over private insurance, why not do it? This shouldn’t be about supporting the insurance industry but offering affordable options.) There are at least three addenda to the RFP – the latest changes were posted to DSS’ website last Thursday. The bids are due in just over two weeks, but DSS is considering an extension. The state is considering ways to get enrollment up in new plans – including giving preference in assigning members to new plans. There was a new assertion that the reason to link HUSKY and Charter Oak is to provide a “bridge” between public and private coverage. The plans have to calculate the expected costs of prescription drugs and behavioral health (which are carved out) which will be subtracted from the rates. Consumers will pay their premiums to the state. DSS is exploring getting federal matching funds for Charter Oak and expects to submit a waiver to the legislature. And if the plans can’t meet the $250/month target, DSS is willing to be creative in benefit structure. (So much for legislators’ appeals for good coverage.)
Ellen Andrews

PCCM Update

At yesterday’s Appropriations’ Human Services Subcommittee meeting, DSS reported on progress toward implementing a pilot Primary Care Case Management program for HUSKY. DSS has been busy researching other states’ PCCM programs, including a January trip to MA to hear from several states’ about best practices and collecting PCCM provider contracts. DSS generously invited this advocate and another to join their staff on the MA trip. Lessons learned included needing a critical mass of patients at Primary Care Provider (PCP) sites, the need for an adequate specialty referral network, and that reimbursement should support chronic care and prevention. The department plans to phase-in the program starting with high volume HUSKY providers; they are in the process of identifying those providers. Potential criteria for provider participation include requiring electronic medical records, minimum caseloads, and ability to handle care coordination and reporting. PCP responsibilities, performance measures, and case management reimbursement levels also need to be defined. Other next steps include DSS systems modification, developing and issuing an RFA for PCPs.
Ellen Andrews

HUSKY transition update

Also at yesterday’s Appropriations’ Human Services Subcommittee meeting, DSS reported on the HUSKY transition from four fully-capitated managed care organizations to two non-risk bearing companies and fee-for-service. The transition began Jan. 1st. Currently DSS is responsible for all decisions about medical services and MCOs are being paid only to administer the program. The transition was a policy change requiring public accountability and openness in the program; all MCOs who continue to participate in the program will be subject to Freedom of Information laws. WellCare and HealthNet’s 121,000 members will have to switch to either Anthem/Blue Care, CHN or fee-for-service by the end of March; consumer and provider notices have been sent and the HUSKY Infoline is staffed up to take calls. As of Feb. 15th, 56% of switching members chose Anthem/Blue Care, 37% chose CHN, and only 6% chose traditional fee-for-service Medicaid. The 1,524 new HUSKY enrollees have been defaulted into traditional Medicaid. In the meantime, as of Feb. 1st, all pharmacy benefits have been carved out of HUSKY; consumers now have easier access to a significantly larger list of medications than through the MCOs.

These exciting changes offer the potential to re-energize the program and greatly improve access to care for HUSKY families, however, change is never easy. At least one parent is finding the transition confusing.
Ellen Andrews

Bills we are following

HB-5617, AA Delaying Implementation of and Making Revisions to the Charter Oak Plan and HB-5618, AAC Revisions to the HUSKY Plan, have been raised by the Human Services Committee. The public hearing for both is next Tuesday, February 26th at 10am in Room 2A of the LOB.
Ellen Andrews

CMS wants to give states more Medicaid flexibility

Yesterday, CMS published proposed rules allowing state Medicaid programs more flexibility in program design, similar to SCHIP programs. The change is meant to “implement the Administration’s goals of aligning Medicaid more closely with private market insurance and giving states more control over their Medicaid benefit packages.” If approved the rules would allow states to reduce the Medicaid benefit package to the level of the standard Blue Cross/Blue Shield PPO option under FEHBP, state employee coverage (the choice CT made for HUSKY Part B, our SCHIP program), the state’s largest commercial HMO, or anything HHS approves. States would also be allowed to increase cost sharing for Medicaid consumers to SCHIP levels – no change for consumers living under the poverty level (FPL), monthly premiums can be charged over 150% FPL, but total cost sharing cannot exceed 5% of income above that amount. However 5% of annual income for a family of four living at 150% FPL ($31,800 as of this coming April) is $1,590 – a significant sum. CMS is soliciting public comment on the proposed rules.
Ellen Andrews

New Health Wonk Review

If you don’t have time to visit all the health care blogs every day, check out the Health Wonk Review. Every two weeks, health care bloggers take turns collecting the best of the blogs. Not only is it a time saver, but the different perspectives are fascinating. The latest issue is from GoozNews.com.

Posted by Ellen Andrews

Health First Authority meeting update

At today’s meeting of the Health First Authority, their fifth, members expressed frustration with the group’s slow progress. The group was to hear presentations by representatives from other states working on health care reform, but that was postponed. The proposed facilitator, whose services are being donated by Academy Health, has changed. They are now considering Randall Bovbjerg and Barbara Ormond from the Urban Institute. The group has created two committees – one to address costs and cost containment, the other to work on quality issues. Each committee has over 40 members and has met once. Members repeatedly expressed concerns about meeting the December final report deadline in statute. A motion was made to vote on five consensus goals including e-health and data systems, focus on prevention – tobacco, obesity and behavioral health, chronic care, increasing access for children, and simplifying claims and procedures. There was widespread resistance to the motion both because it was premature and for lack of detail; the motion was withdrawn. The next meeting will be March 27th.

Posted by Ellen Andrews

AG refuses DSS lawsuit against advocates, supports free speech rights

In a very strongly worded letter, Attorney General Richard Blumenthal rejected DSS Commissioner Mike Starkowski’s request to hire outside attorneys to sue three legal aid lawyers, Sheldon Toubman of New Haven Legal Assistance, Jamey Bell of Greater Hartford Legal Aid, and Randi Mezzy of CT Legal Services. The lawyers sent a letter to each of the six registered potential bidders for the combined HUSKY and Charter Oak programs describing their responsibilities to consumers under the law. The lawyers also sent a copy of the letter to DSS. The Commissioner asked the AG to hire outside lawyers to sue the lawyers for “tortious interference” with the bidding process. The AG’s response denying DSS’ request was unequivocal. He said that not only would DSS’ suit likely fail, but that it could open the state and state officials to costly lawsuits for constitutional free speech violations. He notes that “leveraging the power and resources of state government to sue public interest lawyers, based on their advocacy on behalf of economically disadvantaged Medicaid recipients, could be regarded as chilling free speech rights. Your lawsuit could reasonably be perceived as an attempt to prevent public discourse concerning the proper administration of a vital and expensive public program affecting hundreds of thousands of our neediest residents, in violation of constitutional rights to free speech.” He continues, “These countervailing concerns, touching on core democratic liberties that all public officials must seek to preserve, counsel the greatest restraint when considering legal action potentially chilling or discouraging these Legal Services Attorneys, or anyone else.” Advocates’ civil liberties are secure.

Posted by Ellen Andrews

DSS comes to Appropriations

Last week the Appropriations Committee met with state agencies on the Governor’s budget adjustments. Friday was DSS Commissioner Mike Starkowski’s turn. Beyond the “lovefest” over the agency’s performance in meeting pre-set goals, there were several tense exchanges. Legislators expressed concern that the dept. has chosen not to implement several programs the legislature negotiated into last year’s budget but has chosen to fast-track some of the agency’s priorities. Rep. Gail Hamm expressed deep concern that the dept.’s Charter Oak Plan to cover the uninsured does not comply with mental health parity, which is required of private health plans under state law. She also asked if DSS had checked with the Attorney General to see if this is legal. The answer was no. Rep. Peter Tercyak asked under what authority DSS plans to sue advocates for poor people. He also wanted to know in which line item is the funding to hire outside counsel for that suit. Given that this was a budget hearing, might we expect a cut to that funding?

Posted by Ellen Andrews

Geographic Variation in Health Care Spending

In a recent report, the Congressional Budget Office found that Medicare spending varies significantly by geographic region, even after controlling for differences in demographics, treatment preferences, and regional prices of medical services. The authors cite three possible reasons for the residual geographic variation in Medicare spending: (1) disagreement among medical professionals regarding the appropriateness of some treatments, (2) differences in the providers’ financial incentives, and (3) geographic variation in the supply of physicians. Whatever the reason, this geographical variation in Medicare spending implies that there are substantial inefficiencies in our healthcare system, raising concerns that federal taxpayer money may not be equitably distributed through Medicare's current reimbursement scheme.

Posted by Wilbur Hu, CTHPP Policy Fellow

Governor’s proposal to cut interpreters faces opposition

An article on ctnewsjunkie.com reports on Friday’s press conference by legislators opposing Governor Rell’s proposal to cut $4.7 million for medical interpreters in Medicaid. At last week’s Medicaid Managed Care Council, CT Voices for Children presented on the very high and growing rate of costly emergency room visits by Medicaid Managed Care/HUSKY patients. 38% of HUSKY children under age 21 visited an ER at least once in 2006; that rate has increased from 33% in 2003. Spanish-speaking children were at special risk of needing to access care at an ER. Comments at the Council meeting suggested that many doctor’s offices do not have medical interpretation resources and that patients who do not speak English well may be forced to get care at the ER, costing taxpayers far more than an office visit. The legislators made the point that the federal government reimburses states for half the cost of Medicaid translation services.

Posted by Ellen Andrews

Two studies question cost effectiveness of prevention and treatment

A recent article in the New England Journal of Medicine challenges the dogma that prevention always pays. This is especially important within the current presidential political environment with candidates promoting prevention as a way to stop skyrocketing health care costs. The authors note that many preventive measures do save money such as flu vaccines for seniors and fortifying cereal with folic acid. However, many others don’t save as much as they cost, for example some disease screening tests for people who are not at risk or for very rare conditions. In fact, the large majority of preventive measures that have been tested have not been found cost effective. The authors state that prevention is very valuable, but that it may not be enough to fix our health care cost problems.

In another study Dutch researchers using computer modeling of lifetime health costs, found that while obese individuals and smokers have higher average annual health costs, they consume less in health care services over their lifespan. Healthy people live 84 years on average, while obese individuals average 80 years and smokers only 77. Over their lifetime, healthy people will consume $410,000 in health care costs compared to $365,000 for obese individuals and $321,000 for smokers. While successful treatment of obese patients and smokers increases life expectancy, those years gained are not lived in full health; there is substitution of less deadly but more costly disease. The authors do not advocate that governments and other payers discontinue policies to prevent and treat smoking and obesity, but that the goal should be to improve lives, not to save money.

Posted by Ellen Andrews

Free prescription drug samples less likely to go to poor or uninsured patients

$16.4 billion in free drug samples were distributed to US patients in 2004, up from $4.9 billion in 1996. Samples have been criticized for influencing physicians’ prescribing patterns among other concerns, but drug manufacturers have defended the practice by asserting that many of those drugs go to low-income and uninsured patients who might not otherwise have access to prescriptions. However, a new study found that in 2003, less than one in three sample recipients had incomes below 200% of the Federal Poverty Level and only one in five was uninsured. Hispanics, non-English speakers, and patients born outside the US were also less likely to receive samples. Office-based patients were more likely to receive samples and there is evidence that office-based physicians are targeting their samples to uninsured patients but, as the uninsured are more likely to access care from clinics or not have a usual source of care at all, they are missing out. S. Cutrona, et. al., Am J of Public Health, Feb ’08.

Posted by Ellen Andrews

Policymaker Issue Brief No. 43 – 2008 Upcoming Health Issues for Connecticut

CT will face some important health policy issues this year including HUSKY, Medicaid, Charter Oak and Covering the Uninsured. For a summary, go to the CT Health Policy Project's Issue Brief -- 2008 Upcoming Health Issues for CT

Posted by Ellen Andrews

Vote for your favorite among three current proposals to cover CT’s uninsured

Three proposals have been made by the Governor and legislative leadership to cover CT’s uninsured. Currently, the Governor’s charter Oak plan is ahead in on-line voting. For more information on the options, go to http://www.cthealthpolicy.org/briefs/issue_brief_41.pdf. Go to our on-line poll to vote for your favorite or suggest your own idea http://www.cthealthpolicy.org/surveys/200712/.

Over 40 million Americans missed needed health care services due to cost

18.6% of American adults did not receive needed medical care in 2005 because they could not afford it, according to a new report by the CDC. 25 million did not get needed dental care, over 18 million missed needed prescriptions and over 15 million did not get medical care they needed because of cost. 6% of American adults living in poverty did not get needed medical care due to a lack of transportation. Among adults with no chronic conditions, Hispanics were twice as likely not to have a usual source of care as whites. 30% of young adults age 18 to 24 had no usual source of care. One in three children living in poverty did not receive dental care in 2005 compared to less than one in five higher income children.

Posted by Ellen Andrews

Policymaker Issue BriefNo. 42 -- Connecticut hospitals had access to over $128 million in free bed funds in 2006

Free bed funds at Connecticut hospitals were up $5.3 million in 2006 over the year before. Yale-New Haven and Hartford Hospitals control over two thirds of the total private free bed funds in the state to cover the costs of caring for needy uninsured and underinsured patients. On average, hospitals spent 11% of their fund balance in 2006, up from 9% in 2005. Eleven Connecticut hospitals have no free bed funds. In addition to private free bed funds, all Connecticut hospitals had access to state DSH funds to cover unpaid bills of uninsured patients and Medicaid/SAGA underpayments totaling almost $165 million in 2006.

Posted by Ellen Andrews