The Price of Compromise: The Massachusetts Health Care Reform
Kemble, Sarah, King, Susanne L., Fleck, Leonard M., The Hastings Center Report
To the Editor: Six months into its implementation, four key aspects of Chapter 58, the Massachusetts health care reform recently discussed in the Hastings Center Report (September-October 2006), are clear.
First, the Uncompensated Care Pool--a unique, progressive Massachusetts financing mechanism to pay safety net providers directly to care for the uninsured--has been diverted to the private insurance industry. Second, the most costly and dysfunctional feature of our current health care financing--namely, linking health care resources to employment and thereby channeling vast resources through the private insurance industry--has been explicitly reinforced as a social good. Third, the excess cost for obtaining commercial insurance for the poor will be shifted, in theory, to those individuals themselves. And finally, the public debate on cost has overemphasized insurance premiums, rather than what services they will buy in the "affordable products" required under the individual mandate. The regulatory mandates on the insurance industry are inadequate to assure our low-income population's continuity of and access to care.
The implementation of Chapter 58 is still only in the Medicaid expansion phase, with the poorest residents now enrolling in four state-designated managed care organizations. The more draconian individual mandate is still in the future, yet many systemic flaws are evident. Since October, our poorest uninsured patients (adults at or below 100 percent of federal poverty, amounting to around 25 percent of our practice [at a community health center in Turner Falls, Massachusetts]) have been receiving difficult-to-understand letters--sometimes on letterhead with only a Web site address and no telephone number--informing them that they have fourteen days to choose a health plan and a provider. If they do not, they are automatically assigned to a health plan.
The four official MCOs have carved up the state map in a gentlemen's agreement with the Connector, the new state bureaucracy that establishes the regulations, headed by former Tufts Health Plan executive John Kingsdale. At a talk I heard him give, Kingsdale said, "This is all about choice." Yet in our rural service area in the western part of the state, only one of the four MCOs has a contract with one of our local community hospitals, and a different one has a contract with the other.
The Connector has allowed (or perhaps encouraged) the MCOs to create restrictive networks, an old managed care cost saving strategy. Therefore, for instance, if a patient of our health center now seeks emergency care at the "wrong" hospital, either the MCO covering that patient will pay the full charge for that visit, or payment will be denied and the patient will receive a large bill. Previously, with the Uncompensated Care Pool, hospitals were prohibited from billing anyone at or below 200 percent of federal poverty.
Worse from my standpoint as a primary care physician is that automatic assignments of my patients to an MCO whose network excludes my health care center disrupts many longstanding primary care relationships and funnels some of the poorest of the low-income uninsured population away from their medical homes in safety net facilities. The adverse health effects caused by interrupting primary care, particularly for people with chronic conditions, are well known, yet Chapter 58 does it anyway in the name of providing insurance to all.
In designing the new system, policymakers assumed that uninsured patients have not had any access to care in the past. This is not true. Over fifty community health centers in our state already care for approximately one in nine Massachusetts residents, including thousands of uninsured. By failing to require all MCOs to contract with all safety net primary care providers, the Connector has created an absurd situation for many practices and patients. The maintenance and continuity of longstanding primary care relationships now requires an active and costly process. …