I am surprised to see the abundance of support in this community for a specific Public Option when the debate should be focused in a much larger context within Health Care reform. The tremendous opportunity at hand presents long time universal access advocates with an opening to engrave into the debate once and for all that health care is a human right and not a privilege for only those who are working and not only for those who are citizens. Also to focus energy on a public option within a paradigm where the profit motive still dictates the delivery of health care services does nothing to forward the goal to universal access. In my view supporting a public option as merely a mode of paying for private services is akin to being satisfied with table scraps. We must expand the debate to include the complete trifecta of a not only a public payer, but public points of access and a stringent public regulatory framework that ensures patients are treated fairly.
Now I understand that such lofty idealism can seem grandiose without a clear and concise strategies and specific policy proposals to implement these values. First allow me to begin with the Massachusetts “experiment” and the consequences of the universal access law that has now been in effect for some time. Although no clear conclusions have been reached as to its efficacy, that law has some very serious problems further compounded with the current fiscal crisis facing the Commonwealth. Specifically the Massachusetts Universal Health Care law created the The Commonwealth Connector which is the portal for those who do not have access to insurance by other means to purchase insurance through a public/private partnership. The Connector is then split into two distinct categories; Commonwealth Choice which offers access to private plans; Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, Harvard Pilgrim Health Care, Health New England, Neighborhood Health Plan, and Tufts Health Plan. Then Commonwealth Care which is access to the same plans but for folks who have either limited or no income. After that each of the private plans offer different plans according to coverage needs which several levels of premiums which reflect these needs.
Plain and simple these plans are terrible, coverage is limited, access to specialist are almost non-existent and members of these plans are finding that visits to doctor’s offices are filled with limited access creating a even more complicated two-tier system of health care delivery. Granted this view is mostly anecdotal, but I do spend quite of bit of time trying to get folks of Commonwealth Care and onto Masshealth, the state Medicaid program because the Connector programs are not meeting people’s basic medical needs. Yet the implementation of the Connector has created a significant strain on the state’s budget and compounded with the current fiscal crisis, it has left policy makers few choices but to increase premiums for sub-standard care and re-examine the payment structure on how the state reimburses private providers across all state health care programs.
In an article on May 7, the Globe reported that the State Special Commission on Health Care Payment System is seeking to revamp the manner in which hospitals and other providers are reimbursed from a fee-for-service system to a set payment for each patient that covers each patient for the entire year. Their rational for looking to change the payment structure;
The commission's work partly grows out of the state's near-universal health insurance mandate, which is being closely watched as President Obama and Congress draft a similar national health insurance program. The escalating cost of caring for newly insured patients could threaten the future of the program, making state subsidies for lower-income residents and their out-of-pocket payments too expensive. Employers and workers in the private market also are struggling with soaring costs.
One set payment per patient has been tried before under the auspices of manager care, “capitation” as it is generally referred was absolutely disastrous on every level of service delivery. It devastated preventative care and allowed absurd cost containment policies to be instituted so private health plans could make a profit on each patient by keeping the cost of care per patient intentionally bellow the lump sum payment.
One incredibly positive and unexpected development from the implementation of the universal health care law in Massachusetts however, is the dramatic rise in patients seen at Community Health Centers. Community Health Centers is a Unique, Community-Based Care Model home grown in Massachusetts; In 1965, the nation’s first community health center opened in Boston. Prior to this, health care for the inner-city residents was virtually non-existent therefore community members joined together to bring direct access to health care to their neighborhoods. The boards of directors that included a majority of health center patients was incorporated into the model and today health center consumers continue to develop the policy of community health centers service delivery across the Commonwealth.
Contrary to popular belief community health centers in Massachusetts care for patients of all ages, income levels and racial and ethnic backgrounds, and represent a major source of health care for low-income women and children. Prior to the health care law, about a third of patients served at these centers were uninsured, a third covered by Medicaid and a third covered by private health insurance or Medicare.
The Keiser Family Foundation did a fantastic study on the effects of the Massachusetts health care law on the state’s community health centers. Its findings were undeniable,
• Community health centers continue to play a critical role in caring for newly-insured patients while simultaneously serving as the primary care safety net for uninsured residents
• Many of the newly insured patients at health centers had previously been their uninsured patients, but health centers also gained new patients.
• The reform did not alter the overall financial status of health centers.
• Health center revenue mix changed, with state grants declining and insurance revenue increasing.
The study also developed “lessons for national health care reform”;
• Insurance expansions can lead to a surge in the demand for primary health care, especially in medically underserved low-income communities.
• In addition to expanding insurance coverage, investments to expand the capacity of the primary care system that will care for the newly insured, as well as for those who remain uninsured will be important.
• Even post-reform, there will be a continuing need for sources of care for the uninsured.
There are some very important lessons here, principally that the creation of an available payer/plan will not completely solve the problem of the uninsured. Capacity in organizations that traditionally have served the uninsured needs to be increased tenfold, therefore significant government investment must be directed at services delivery models that have demonstrated success in providing much needed care to underserved and uninsured populations.
We know that Community Health Centers provide care that is cost effective and the quality of care provided at health centers exceeds national averages (according to the Massachusetts League of Community Health Centers);
• Medical expenses for patients who receive most of their care at a health center are 41% lower ($1,810 per person annually) compared to patients seen elsewhere. The National Association of Community Health Centers estimates that health centers save the health care system $9.9 billion to $17.6 billion a year.
• Health center Medicaid patients are 22 percent less likely to be hospitalized for potentially avoidable conditions than Medicaid patients who receive care elsewhere.
• The cost of treating health center Medicaid recipients is 30-34 percent less than the cost for beneficiaries receiving care elsewhere.
• The cost of providing prescription drugs to Medicaid recipients is 26-40 percent lower through health centers.
• Health centers have lowered overall emergency room use, and reduced inpatient admission rates between 22 and 67 percent
Now, one of the problematic issues confronting Community Health Centers is that the primary funding sources of these centers differ. Some have created more structured public and private partnerships, others have become affiliated with some of the larger private hospitals, others have large endowments and yet others rely solely on community support. All these models have created incredible institutions, for example Fenway Community Health, which is the principal HIV/AIDS research facility in Massachusetts and providing exceptional care to thousands of residents in that community.
The primary point of this diary is that with upcoming health care reform, we should demand public service delivery access points based on this community health model. Consolidate and streamline funding for these centers free of political influences and fund what works. There are numerous ways in which these Community Health Centers can be publicly financed; either through direct government control with professional staff being retained through loan remission/waiver programs, dedicated funding streams through HHS or even long term public grants. The specifics can be worked out, the main point however is that simply advocating giving public money to private providers will do nothing to ensure that health care truly becomes equitable. Community health centers present a tremendous opportunity to reshape preventative care that includes wellness programs, nutritional check-ups, sort of a one-stop health center for all our wellness needs.
I would encourage everyone to go and begin using these health centers are there primary source of care. I myself have excellent private health insurance but still go to my local community health center for my health care needs (they take my insurance of course), immediately upon entering the focus is on my well being from physical, mental and emotional as they take a holistic approach to my health. It does take a village, so lets as village members demand that we take control how our health care is provided instead of just how it’s paid for.