Eligibility income levels increase tomorrow

Many programs, including HUSKY and Medicaid, base eligibility determinations on the Federal Poverty Level – an antiquated mechanism, that shortchanges CT, of determining what the basics of life cost. Anyway, those dysfunctional standards are updated every year and the new levels become effective tomorrow. Here are the new numbers, with calculations for HUSKY program eligibility categories. For more help in finding out what you may be eligible for and accessing health care in CT, go to our Consumer Health Action Network website or call 1-888-873-4585, toll-free in CT.

Notes from Massachusetts

It’s always dangerous to visit other states – you are reminded of how far Connecticut has to go. I spent yesterday in Boxborough, MA at Health Care For All’s fifth annual policy & organizing conference. The prevailing climate was of advocates, providers and state administration very comfortable working together toward a common goal – getting every MA resident affordable coverage and high quality services. There was a friendliness and mutual respect between stakeholders that was refreshing. I didn’t just rely on speakers but quizzed everyone I sat next to.

They have a great deal to be proud of – over 300,000 state residents now have insurance who didn’t before -- about the total number of CT’s uninsured. They are addressing health disparities, reining in costs, and how to fund the higher than expected demand for coverage. As one speaker put it, they are victims of their own success. They recognize the big challenges ahead and already have an ambitious agenda for cost control.

The individual mandate compromise still has an edge for many advocates, but everyone is trying to work through it and respect the final agreement. The state has hired an army of lawyers and other counselors to help people navigate the very confusing process and to hear appeals. First year penalties for consumers who do not purchase coverage are coming due with tax returns in the next few weeks. There are still no numbers on how many will have to pay 2007 penalties ($219 for individuals). For 2008 penalties will go up to 50% of the least costly health insurance available. There are plenty of details, questions and forms, including the new Schedule HC to be filed with every tax return, but there is lots of help. One big question is how much this is costing to administer.

In response to a question, Nancy Turnbull, a member of the Connector Authority Board and a lecturer at Harvard, gave this list of lessons learned to share with other states.
1 – Get as much federal money as possible
2 – Defer hard decisions to the implementation stage – you need real world experiences to make informed choices, and any decisions made earlier would have been behind closed doors, which never contributes to good policy making
3 -- Be ready for big buy-in costs – e.g. significant funding for providers, very modest employer contributions
4 – “What you can get business to agree to is not much”
5 – It was the right strategy to get coverage first and wait to control costs – one thing at a time
6 – Reform can’t happen without a broad based consumer advocacy coalition

One speaker thought the reason that reform worked in MA and other states are struggling is that others are letting the perfect be the enemy of the good – not true here in CT.
Ellen Andrews

Unnatural Causes: Is Inequality Making Us Sick airs tonight

The first of a seven part documentary on health disparities, Unnatural Causes, begins tonight at 10 pm on CPTV. Tonight’s show, In Sickness and in Wealth, focuses on overarching themes. “What are the connections between healthy bodies, healthy bank accounts and skin color?” The episode follows a CEO, a lab supervisor, a janitor and an unemployed mother to describe how class shapes opportunities for health in America. Watch the trailer here.
Thanks to the CT Assoc. of Directors of Health for the heads up.

Appropriations passes a budget

Today, the Appropriations Committee passed their version of the state budget, about $100 million below the Governor’s proposal. The Committee cut $110 million from Medicaid, HUSKY and nursing homes for cost and caseload updates – the Committee believes that the Medicaid budget has been inflated in recent years by the administration and wants to use that excess funding for other priorities. Committee Chairs voiced concerns that many of last year’s initiatives have not been implemented by the Dept. of Social Services while money sits waiting and the need grows. The Committee also did not approve the Governor’s proposal to add $5 million more to the current $11 million Charter Oak Plan budget, stating that it was premature to add to a program that hasn’t been implemented yet. The Committee added $10 million for increased nursing home staffing levels, $1.5 million to restore Medicaid podiatry and chiropractic care, and increases to various providers. The Committee rejected the Governor’s proposal to weaken Medicaid’s medical necessity definition and restored the Governor’s cut to medical interpretation services. The Committee added money to the Dept. of Public Health for more HIV/AIDS surveillance staff, more health planning staff, a nursing loan forgiveness program, more school-based health centers, and a comprehensive cancer plan. Overall, the Committee came in almost $78 million below the Governor’s proposal for Medicaid and $109 million under for DSS overall.
Ellen Andrews

Anthem not bidding on Charter Oak or HUSKY

Last week, Anthem sent a letter notifying DSS that they will not be submitting a bid for the joint HUSKY/Charter Oak Plan RFP. Initial responses are due to the state on Friday. Anthem’s concerns include inadequate funding for full-risk HUSKY and Charter Oak; advocates and other state officials have also been concerned about the programs’ financial sustainability. As of March 1st, about half (159,158) of HUSKY members were enrolled with Anthem, almost twice as many as the next largest plan. With the largest provider panel, it is hard to imagine how either HUSKY or Charter Oak could function without Anthem’s participation. However, Anthem is not walking away from HUSKY families – they are happy to continue indefinitely with the current non-risk arrangement and would consider participating in Charter Oak in a similar arrangement. They are also interested in bidding on the programs in the future if current legislative proposals restructuring the programs pass. Proposals making their way through the legislative process include HB-5618 to delay HUSKY procurement and separate it from Charter Oak, and HB-5617 which makes several improvements to Charter Oak’s design.
Ellen Andrews

Consider an internship at the CT Health Policy Project

Are you interested in making a difference for CT consumers struggling to get the health care they need? To help policymakers find solutions for complex and costly health system problems? Working with experienced professional staff and other interns from diverse fields and perspectives?
Consider an internship with the CT Health Policy Project. For almost a decade, we have been providing CT consumers and policymakers with the information they need to make the best decisions. Intern projects include consumer outreach and advocacy, policy analysis, communications, and public education. CTHPP interns have included high school, college and graduate students as well as mid-career or retired volunteers and supporters.

To learn more, go to our internships webpage.

The mortgage crisis and medical debt

I was floored when I picked up the paper the other day and read that the Federal Reserve is bailing out Bear Stearns, the fifth largest investment bank in the nation. Until the moment it teetered on the brink of failure, Bear Stearns asserted that it had avoided crisis. I wasn’t upset because of the bail out itself, but because it comes only shortly after the moralizing in Washington about not protecting individual homeowners from their own bad decisions.

Sure. Some homeowners may have taken out irresponsible loans on purpose, trying to capitalize on a housing bubble that seemed like it would never burst. But many other factors contributed to the housing crisis we now face.

Medical costs – particularly those costs that individuals bear – are rising so dramatically that folks are struggling to find ways to pay for the medical care that they need. More and more, we are relying on borrowing to cover our medical debts. A recent report confirms what we know anecdotally: even among people who have health insurance, the burden of healthcare costs is too great.

More to the point, many Americans have been forced to turn to the equity in their homes to try to cover their medical expenses. According to a 2005 Harvard study of personal bankruptcies filed in 2001:
Medical debt was also associated with mortgage problems. Among the total sample of 1,771 debtors, those with more than $1,000 in medical bills were more likely than others to have taken out a mortgage to pay medical bills (5.0 percent versus 0.8 percent). Fifteen percent of all homeowners who had taken out a second or third mortgage cited medical expenses as a reason. Follow-up phone interviews revealed that among homeowners with high-cost mortgages (interest rates greater than 12 percent, or points plus fees of at least 8 percent), 13.8 percent cited a medical reason for taking out the loan.
(The Harvard team responsible for this study is preparing an update looking at 2007 bankruptcy data.)

So, now that – in the wake of the Bear Stearns bail out – some politicians in DC are talking seriously about how to help individuals, let’s hope they consider the full breadth of the problem.
Connie Razza

Charter Oak update

HB-5617 – the “Charter Oak fix bill – passed the Human Services Committee yesterday with substitute language along party lines. The bill that passed includes mental health parity for the program, eliminates the requirement that enrollees be uninsured for six months to be eligible, reports on services delivered and the costs of care, Charter Oak consumers will have access to outside utilization review, and independent actuarial evaluations of the bids to ensure that the program is sustainable. It does not include the original bill’s provisions to delay implementation of the program, coverage for dental and vision services, medical loss ratio standards, and reductions in consumer cost sharing.

Also, Anthem Blue Care Family Plan has notified the state in a letter that they will not be bidding on the current HUSKY/Charter Oak RRP. Their reasons are objections to Freedom of Information requirements and concerns about inadequate rates. This position is consistent with statements from Anthem over the last two years. Anthem is very interested, however, in continuing to participate in HUSKY with the current ASO, non-capitated arrangement indefinitely.
Ellen Andrews

Women’s basketball injuries similar to men’s

An article in this month’s issue of Connecticut Medicine finds that despite differences from the men’s game, women basketball players suffer similar injuries at similar rates at both the high school and college levels. ACL injuries are the exception – women are two to four times more likely to suffer these tears most commonly resulting on landing after a jump. Ankle sprains are the most common injury; others include “jumper’s knee”, shoulder dislocation, concussion, asthma, stress fractures, broken noses, finger and corneal injuries. The article covers each injury including treatment and prevention. The two authors are from UConn’s sports medicine program and a trainer for the UConn women’s team. (T. Trojian and R. Ragle, CT Medicine, 72(3):147-150, March 2008)
Ellen Andrews

Office of Health Care Advocate saved over $4 million for CT consumers in 2007

For every dollar spent on the Office of Health Care Advocate (OHA), $4.42 was returned to CT consumers in health care services last year, according to OHA’s most recent annual report. From 2001 to 2007, OHA helped consumers with almost 10,000 complaints. Additionally, OHA was able to get two pieces of consumer protection legislation passed last year – one creating a legal definition of medical necessity for health insurance policies sold in the state, and another preventing insurers from gratuitously cancelling policies for pre-existing conditions. OHA also worked with advocates from other states to ensure that proposed federal mental health parity legislation does not weaken CT’s strong state law. The annual report also includes stories of consumers who sought help from the office including getting insurers to pay for a girl’s Lyme disease medication, medically necessary services for premature twin babies, and a lift for a 12 year old girl with spastic cerebral palsy. If you have a question or feel you were unfairly denied care by your health insurance company, contact OHA toll-free at 1-866-466-4446 or healthcare.advocate@ct.gov.
Ellen Andrews

Courant column highlights UConn nursing program troubles

Too many graduates of UConn’s School of Nursing are not passing the national nursing exam according to Kevin Rennie’s column in today’s Hartford Courant. Apparently the poor performance is not new this year, but is unique to UConn. Nursing graduates of Quinnipiac University, Western CT State University and St. Joseph’s College are easily passing benchmarks. UConn was placed on probation in 2004 when less than 80% of graduates passed their exams, and again came close to that level last year. The National Council of State Boards of Nursing commented that the exam “tests what nurses need to know to be safe and competent to practice.” Rennie points out that rapid technology advances are requiring more skills and knowledge from nurses. CT, along with most states, is facing a serious and growing shortage of nurses. For more on the nursing shortage, take the March CT Health Policy Web Quiz.
Ellen Andrews

Human Services Committee passes bill delaying HUSKY HMO contracting and delinking from Charter Oak

Today the Human Services Committee passed a stripped down version of HB-5618, An Act Concerning Revisions to the HUSKY Plan. The new language would delay HUSKY contracting with HMOs until July 1, 2009, delink procurement of HUSKY from the Charter Oak Plan, and provide for a study of recent changes to HUSKY including implementation of PCCM. The Chairs promised that other provisions in the original bill, namely continuous eligibility and removing premium assistance, will be addressed by the committee in another bill and that the committee will also address needed changes to Charter Oak. Comments in favor of the bill included the need “to take a breath” after the recent “bold changes” in HUSKY, evaluate the impact, and make thoughtful decisions about the future of the program next session. Legislators also noted the unfairness to HUSKY families of asking them to make complex plan changes twice in four months. Members of the committee noted that linking HUSKY and Charter Oak was never discussed last session and “if Charter Oak is such a good plan, it should be able to stand on its own.” Comments opposing the bill centered on not allowing “the perfect to be the enemy of the good” and giving the administration a chance to implement both together. Numerous concerns about Charter Oak were raised including the lack of mental health parity, questions about sustainability, and the lack of answers to their questions raised months ago in a legislative forum. Several expressed a hope that all the parties will work together to fashion a plan that works. The Governor has threatened to veto the bill.
Ellen Andrews

Stocks up, but health insurers down

While the stock market yesterday enjoyed its biggest gain in five years, based on relief from the Federal Reserve, health insurers’ stocks dropped after Wellpoint warned that the company expects less profit than originally anticipated for the first quarter and all through 2008. After the announcement, Wellpoint shares dropped by more than 28%. The company blamed higher medical costs, lower enrollment, and the “changing economic environment in which we are operating.” Virtually all other health insurers also lost value -- Humana by 24%, UnitedHealth (the nation’s largest) by 15%, HealthNet by 20%, Cigna by 9.8% and Aetna by 8.3%. Health Care Policy and Marketplace Review blames five years of easy profit-making for insurers. “When the trend rate is steadily falling a monkey can make money. . . . Welcome to the health insurance business at a time when you can't count on windfalls!”
Ellen Andrews

Health care disparities more about where care is delivered

The latest issue of Health Affairs focusing on Disparities: Expanding the Focus includes almost two dozen articles on the subject. Two that stand out examine racial and ethnic disparities in the quality of hospital care. The first, D. Gaskin, et. al., Do Hospitals Provide Lower Quality Care to Minorities than to Whites? studied outcomes of care within hospitals across racial/ethnic lines. The short answer is no – minority patients receive the same standard of care that white patients in the same hospital receive. The authors comment, “Perhaps we are looking in the wrong place . . . we may have to follow patients out of the hospitals and look at look at other health outcomes measures – for example, rates of death within seven, thirty and ninety days or readmission due to complications.”

This research builds on previous research that suggests that the basis of disparities is more about the location of care. A second article, A. Jha, et. al., The Characteristics and Performance of Hospitals that Care for Elderly Hispanics, addresses this question. The authors, from Harvard, looked at the 5% of US hospitals (227 of them) that care for more than half of American elderly Hispanic patients. They found these hospitals were more likely to be for-profit, with higher Medicaid caseloads and low nurse-staffing levels. These hospitals provided slightly lower quality care for heart attacks/disease and pneumonia, compared to national and regional averages, and were less likely to have cardiac and medical ICUs. The good news may be that improving disparities in quality of care could involve focusing on a limited number of sites.
Ellen Andrews

Donaghue Foundation Annual Conference

Beyond Eureka!, the Donaghue Foundation’s annual meeting/conference on translating health care research into practice, will be Wednesday April 23rd at the Hilton in Hartford from 8:30am to 3pm. Atul Gawande, author of two bestsellers and a MacArthur Genius Fellow, will give the keynote address. Other speakers include Harlan Krumholz of D2B: An Alliance for Quality, Elizabeth Pivonka of the Produce for Better Health Foundation, and Veronica Nieva of AHRQ’s Health Care Innovations Exchange. The conference is free. To register, click here.

Oregon holds lottery – not for millions, but for health care coverage

From the Case Center for Reducing Health Disparities blog, for the first time in four years, there are openings in the Oregon Health Plan Standard. The state program covers the basics including medical services, medications, and limited dental and vision services. OHP Standard is offered at little or no cost to very low income residents over age 19 who are not eligible for other coverage. While the state acknowledges a great need, resources have made only a few thousand slots available. The state will randomly draw names every month until capacity is reached again. At its peak, OHP covered 132,000 Oregonians, but due to budget deficits enrollment was closed in 2004.
An LA Times story on Monday reports that 91,675 Oregonians signed up for the lottery that will offer health insurance to only a few thousand.

The lesson for Connecticut is to ensure we don’t make big promises we can’t keep. It is critical to make sure that Charter Oak is sustainable.
Ellen Andrews

Healthcare Partnership public hearing

HB-5536, An Act Establishing the Connecticut Healthcare Partnership is being heard in the Labor Committee as I am writing. The idea, being championed by House Majority Leader Chris Donovan, is to allow municipalities, small businesses and non-profit organizations to purchase health benefits through the state employee pool. The hope is that municipalities and others will be able to save money on health benefit spending for their employees and maintain a comprehensive package of services that is affordable for workers and towns. Twenty four other states have similar programs in place. The proposal builds on the State Comptroller’s successful MEHIP program, that allows municipalities, small businesses and non-profits who do business with the state into a pool that jointly purchases benefits with the state employee pool.
Ellen Andrews

CT Health Notes highlights

Some highlights from the latest issue of CT Health Notes -- the CT Health Policy Project’s e-newsletter:

Access to kidney disease treatment and transplants varies by race and insurance status
Hispanics’ and African-Americans’ health insurance less secure
Privately insured Americans get earlier cancer diagnoses
Geographic variation in health care spending

Click here for more on CT Health Notes
Click here to subscribe

Health First Authority update and callers to the helpline

Yesterday, I was in a meeting of the Cost, Cost Containment, and Finance sub-group of the HealthFirst Connecticut Authority. The conversation focused on cost containment strategies in three different contexts. In some cases, wellness programs were credited with playing a role – albeit a vague role – in reducing costs. These are the programs sometimes offered by employers to help workers “stay healthy” and manage chronic health risks.

But this entry is not actually about cost containment.

Another issue that came up – and will be discussed in future meetings – was so-called “Never Events.” These are the stories of medical errors, like amputating the wrong limb or leaving surgical instruments in a patient. The impact of these events on cost is unclear, but some hospital groups are now saying that they will not bill for those events and some insurers are refusing to pay for them. (Shockingly, there’s not a law that prohibits them for billing for doing the wrong thing to us!)

This entry is not about never events either.

As Bev Brakeman said in the meeting, many people face illness or injury despite their best efforts to maintain their health. Further, the impact of these events on people’s lives is as traumatic – though more mundane – as the never events we talked about.

This entry is about the urgency of changing these daily events that happen to people we each know.

My first day answering calls to our Consumer Health Action Network hotline (888.873.4585), I got a call from someone who had been diagnosed with 2 kinds of cancer and had foregone treatment because they had no insurance. In the two weeks I’ve been here, I have heard a woman say she may surrender herself to her ailment because she does not know how she can afford to fight it and there was a resident who was in the hospital for 2 days and got a bill that she said, “I could put a down payment on a house for the amount they charged me.” Several other callers simply want basic preventive care, but cannot get insurance because of “pre-existing conditions.”

We are able to offer some assistance to folks who need to navigate the health care system. But the real solution will only come from fundamental policy change and the political, financial, and social will to make our healthcare system more humane.

Connie Razza

New Haven Teen Pregnancy Council makes recommendations

New Haven has formed a new council to address the city’s teen pregnancy rate which is twice the state average. According to the New Haven Register, in 2005 almost one in four 19-year old city residents had at least one child. While the rate is dropping, the rate for Latinos is still rising. The Council is based on a city task force that completed its report last year but released recommendations yesterday. The report calls for expansion of school-based health centers, more health education, outreach to boys, supports for pregnant and parenting teens and an emphasis on parents talking with their teens about sex.

The Public Health Committee yesterday also held a public hearing on SB-461, An Act Concerning Teenage Pregnancy Prevention Programs which would provide $1 million for sex education programs in schools.
Ellen Andrews

March CT Health Web Quiz

Test your knowledge of the nursing shortage – take the March CT Health Policy Quiz