I watched the debate Saturday evening in the House of Representatives, and wondered how elected officials could be from such different planets. Shortly after the vote was taken, news reporters such as TIME writer Jay Newton-Small tried to analyze the divide.

Republicans were fanning our worst fears last night. “Big brother” is watching and wanting to control your health. “Big brother” will make you pay a $250,000 fine and then send you to jail for five years. It didn’t matter that no one has been arrested or sent to jail under Massachusetts health reform — even after more than 3 years of implementation of reform. A lie is okay as long as they don’t have to prove it.

They are trying to frighten the public by saying that some “bureaucrat” will design your health plan, pick your drugs, or decide when you die. Like any of us really pick our plans or design them. (Don’t our employers chose what we can pick from?) Do any of us have a say in our prescriptions (doctors chose them, insurers substitute generics, or our own finances determine if we can afford them at all). And how many people die every year because they could not afford a treatment that could have prolonged their life?

The Republican substitute bill offered nothing for the uninsured. Nothing. It offered breaks for providers on malpractice coverage, but nothing that protected the quality of our care. If offered some employers the right to band together to buy coverage (hopefully at a lower rate) but left many employers out. But it provided no help for the 46 million people who have no coverage today!

Like a chapter from Orwell’s book “1984”, Republicans are frightening people in hopes of defeating healthcare reform. Access to coverage and subsidies becomes a big government take-over of your healthcare. Setting rules that mean insurance companies cannot deny you coverage because of pre-existing medical conditions becomes big government interfering in your private affairs. In the name of American freedom, they tried to shout down H3962, and leave you the freedom to remain untreated, in medical debt, or the facing the possibility of dying from lack of treatment.

The debate will now continue in the Senate. At the end of the day, Americans need good healthcare reform, despite all the hysteria Republicans are trying to stir up.

Maybe surgeon and New Yorker writer Atul Gawande was right when he raised questions about the differing costs of medical care around the country, starting with the example of McAllen, Texas. Maybe medical providers have more responsibility for costs than we think.

In Massachusetts, two instances of doctors putting costs and financial gain over patients’ needs have come to my attention.

The first was in a letter from a doctor to his patient on Cape Cod. It was a note discontinuing the patient from his practice because of the patient’s failure to use Quest laboratories (a for-profit company) for all tests. The physician “fired” the patient, stating: “As you are unable to honor my contractual obligations and requests, I am unable to serve as your physician.” The patient followed all of the doctor’s medical recommendations; he just refused to honor the doctor’s “network obligations” and was terminated from that group practice.

The second, more recent incident occurred when a physician practice changed network affiliation, leaving a network that willingly took care of the uninsured and low-income patients, to a physicians’ group with a different approach and which charged higher physician rates. Suddenly, a sign appeared on the office door, announcing the new affiliation, and with a notice that read: “XX is unable to accept the following insurance”:

MassHealth/Medicaid
BMC HealthNet
Neighborhood Health Plan
All Medicare Advantage plans except HV First Seniority
All Commonwealth Connector plans except Network Health Forward

Suddenly, patients on the South Shore were expected to scramble to find new primary care providers in a market that is already short of such providers.

Is this what the Hippocratic oath meant when it was first written? Did it ask each physician to provide measures for the benefit of the sick only when that physician agreed to take that patient’s form of insurance? When considering how to rein in health care costs, we need to remember ALL the levers providers can pull to pick and choose who they want to treat. And we need to be willing to call out those hypocrites who put their personal profit over the needs of the health-care consumers of Massachusetts.

As Boston Public Health Commissioners, we are given a a report every year on the “Health of Boston”. The 2009 version has just been released. It looks at the health of each neighborhood, rating them on the prevalence of major diseases or problems: infant mortality, Chlamydia, HIV infection, car crashes, kid’s asthma, diabetes, heart disease, and obesity. I took the ratings for eight major problems, and turned them into a map that shows the healthiest (light pink) to sickest (red) neighborhoods: Click here for an expanded view of this map.

I then used 2000 census data to break out neighborhoods based on how white/non-white the neighborhood is. This data is the most recent available data for Boston neighborhoods. Lightest green is for neighborhoods that are majority white, and the darkest green is for neighborhoods that are over 60% people of color:  Click here for an expanded map view.

Try flipping back and forth between these two maps. What you will notice is that the darkest red area (the highest level of medical problems) is nearly identical to the darkest green areas (those neighborhoods that are more than 60% communities of color).

Those neighborhoods are the ones in need of the highest level of care, and the best chronic disease management and primary care. And those neighborhoods are the ones that are predominately serviced by Boston Medical Center and its affiliated neighborhood health centers (shown as yellow dots on the map).

That means if our state is serious about solving racial health disparities, you have to wonder why they have chosen to cut more than $200M next year out of Boston Medical Center. That is 22% of BMC’s entire patient revenues.

The Governor is proposing 22% less funding for treating Boston’s sickest communities, the communities of color, at the same time that hospitals in the other neighborhoods are seeing almost no cuts.

How do we solve racial health disparities, when we are cutting the providers who serve that community? We can talk all the politically correct talk we want, but I think two pictures are worth a thousand words. Actually, two pictures are worth 200,000,000 words in this case!

Celia Wcislo is a V.P. at 1199 SEIU and a member of the Boston Public Health Commission.
Veronica Turner is a V.P. at 1199 SEIU.

Right now, we pay doctors, providers, and pharmacies predominantly on a fee-for-service basis. That is, if they see you, they get paid. If they see you a lot, they get paid a lot. If you are in the hospital, get sent home, and then have to return for the same problem, the hospital gets paid again. We pay for volume (the more a provider sees patients, the more they get paid), and we pay when you get sick. This is the problem that needs solving. To move from paying by volume for illness, to paying fairly for prevention and wellness.

We don’t now pay well for prevention. We don’t pay doctors anything special for keeping you well, and we often don’t pay for them to check up on you at all! We don’t pay for them calling you, or talking to another doctor about you. We pay providers only when you go in to see them.

As a patient, how do you know if you need that MRI for your back? Only about 25% of MRI’s give any helpful information on back problems. Many physician groups have built MRI labs, and the MRI your physician orders might give him another clue about your back (only 25% of the time), but it also might be paying for the cost of the new lab (100% of the time).

So, our US health care system pays for volume. It pays for illness. What it doesn’t pay for is keeping you healthy. It pays less for prevention and primary care. It doesn’t pay doctors to coordinate care or to provide care in the least costly appropriate setting. To solve this problem, the Special Commission is talking about “global payments”, or “bundled payments” for primary care.

Just like in the early 90’s a form of capitation is being considered to help control healthcare spending. Global payments have similar financial incentives to capitation.

There are many forms of capitation, but a more global form is the flat, monthly payment to insurers or providers, to cover the cost of your total care. Its goal can be as simple as lowering costs, or limiting the overall risk to an insurer. It can be an incentive to do more primary care and prevention, because if you are not sick, the insurer can keep the monthly payment. The less you are sick or treated the more reserves an insurer can accumulate.

Few want to go back to the capitation of the early 90s. Many policy makers consider it a failure. Consumers rejected it; businesses rejected it because their employees didn’t understand it and hated it. Doctors and providers rejected it because it sometimes transferred too much of the financial risk onto them, without the proper payments and investment in wellness, prevention and coordination of treatment between providers. It failed partly because “saving costs” took priority over adequate care. Patients worried that they were being pushed out of hospitals too quickly. People believed they were being denied services in the short run and felt their health took a back seat to cost cutting. Whether this is true or not, the collective “memory” of capitation is such that few want to reproduce it.

The Special Commission on Payment Reform is about to recommend changes that will then go to the legislature. The process has been open and transparent to many of the varied groups involved in healthcare. As recommendations are sent to the legislature, the broader public must be made aware of these potential changes. It’s important that the public be engaged now and this becomes a public conversation about the future of health care payment and delivery. Global payments, just like the capitation of the 90’s, could become a payment model that focuses primarily on cost containment, and squeezing money out of the system. What we need is a system that provides better care that keeps us well. And we need a payment system that reinforces and strengthens a healthcare system that delivers that better care.

We must have a reform that has incentives built which will:

• Make a priority of prevention, wellness, and primary care services, even if that means we pay more for those services.
• Increase equity in payment by the major providers. The state, Medicaid and Medicare need to pay their fair share of the costs of coverage, and the current cost shifting to employer provided health insurance must be reduced. Currently, Medicaid payments are the lowest, and providers turn to other payers to make up the difference. More equity in payer contributions must be part of any reform.
• Any payment system must adjustment for patients’ health status and the socio-economic needs of different populations. We most consider the needs of our teaching programs and guarantee the financial health of our hospitals and physician groups. It should support the important and cost-effective role of our safety net, community hospitals and health centers, and provide adequate access to primary care services. It must be thoughtfully designed, implemented gradually, and evaluated along the way to stop any unintended consequences.
• We must work on administrative simplicity, both for the providers, and the consumers of health care. As we make this change, it must be transparent, simple, clear, and consistent across as much of the system as possible.
• If we can design a system that restrains costs while increasing wellness, then some of the savings that insurance companies will see should go back directly to the consumers and businesses that pay these premiums. As we did with healthcare reform, we need to make sure there is shared responsibility and shared savings.
• Finally, we must include doctors, providers and consumers in the process, as we evaluate how, and what, we pay for. If we do not include consumers and those who are on the front line of healthcare delivery, we will repeat the mistakes made in the capitation movement of the early 90’s. The goal is not simply squeezing money out of the system. The goal must be to improve our Commonwealth’s health.

Celia Wcislo is a board member of the Massachusetts Connector Authority, Assistant Division Director for 1199SEIU United Healthcare Workers East, and an Executive Board member of the Service Employees International Union.

The Administration’s FY 2010 budget tried to protect eligibility and benefits for low-income residents. They proposed some expansion of Medicaid and CommCare with the assumption that more residents will be in economic trouble this year.

Unfortunately, they also made dramatic cuts in payments to hospitals that serve the poor, freezing rates for most other healthcare institutions and nursing homes, and cutting public health and behavioral health programs.

The rest of FY 09’s health budget was balanced by using $533M (for three quarters) of financial assistance from the Recovery Act. This week, Massachusetts will be eligible for $594M for just two of the three FY09 quarters. In fact, the amount Massachusetts will receive before July 2009 is closer to $900M. This could mean some restoration of the $330M in Medicaid 9C cuts that have already been made.

For next year, the Administration’s budget anticipated using $711M from the Recovery Act. Yet most assessments of the bill have indicated that Massachusetts will receive twice as much – closer to $1.4 billion in increased Medicaid funds. This money could, and should be used to do the following:

· Increase rates of Medicaid payments to the two largest providers of care to the poor, Boston Medical Center and Cambridge Health Alliance. Ensuring residents have access to care requires paying the true cost of that care.

· Keep some money available to provide health insurance coverage for more people in case the recession grows worse.

· Restore many of the public health programs cut this year and in next year’s budget.

· Provide more rate relief to nursing homes, to at least make up for the $75M more in taxes they will be asked to pay in 2010.

· To honor Chapter 58’s commitment that Medicaid should pay better and closer to the true cost of caring for the poor, restore some rate relief to hospitals that treat Medicaid patients. Also, restore the cuts to Graduate Medical Education to primary care teaching programs.

· Restore the 2010 cuts to outreach and enrollment grants for groups helping people find health coverage.

The Recovery Act and Medicaid relief was meant to provide protection to state programs that help residents. Our Governor has attempted to honor the commitment to health care reform by keeping most programs intact. However, by cutting back on payments to hospitals, nursing homes, and health care centers for that same care, the Administration’s currently policy takes one step forward and one step back. The good news is there is an opportunity to change that now. With Federal relief in sight, the Governor and legislature should restore cuts to our health care system immediately, particularly the cuts to patient services at Boston Medical Center and Cambridge Health Alliance. It is those cuts that currently pose the largest threat to the integrity of health care reform and require the most urgent attention.

Celia Wcislo is a board member of the Massachusetts Connector Authority, Assistant Division Director for 1199SEIU United Healthcare Workers East, and an Executive Board member of the Service Employees International Union.

These cuts have local and national implications. With cuts looming, and with no apparent plan in place to ensure access and care, patients and caregivers in the communities where minority and low-income neighbors are served by BMC and CHA are feeling increasingly alarmed by a proposal which would be devastating for their community hospitals. Community, labor, and religious groups are taking measure of the impact the proposed cuts would have to essential care for minority and low-income neighborhoods. And advocates, safety net providers, and policymakers across the country are watching to see if Massachusetts can develop a plan to ensure the continued viability of its safety net system in the face of the dramatic changes wrought by health reform and the current economic and budget crisis.

A plan is essential because Massachusetts cannot afford to lose the vital services provided by BMC and CHA.

Consider:

CHA provides 150,000 visits annually for patients with behavioral or substance abuse problems. CHA provides 10% of all the state’s mental health inpatient stays, and 14% of all Medicaid mental health and substance abuse care. With the cuts proposed to CHA this year alone, it is possible that 10% of all the acute care psychiatric beds in Massachusetts could be closed. Where would 10% more beds be found in the surrounding areas for this patient population? If the proposed cuts are not rescinded, it is reasonable to expect that many of these patients will not be able to find accessible beds at all, creating unthinkable circumstances for the patients, their families, and the community at-large.

BMC serves over 150,000 low-income patients every year, 70% of who are ethnic and racial minorities. 93% of low-income children served by BMC are minorities. 88% of maternity patients served by BMC are also minorities. At a time when Massachusetts is a leader in efforts to reduce racial and ethnic health disparities, the impact of the cuts at BMC will fall mainly on minorities.

Between them, BMC and CHA staff five emergency rooms and the major Trauma center in the state. At a time when many hospitals are on daily “hospital diversions” because their emergency departments are closed because of lack of capacity, what is the plan to provide emergency entry points if any of the ERS in the CHA or BMC systems are closed?

BMC and CHA are affiliated with, and help finance, more than thirty community health centers. Any loss of primary care capacity will diminish health care access and increase demands on other, more expensive parts of the health care system. Many of the 442,000 state residents insured through the state’s health reform law will find that they still have their insurance cards but they might not be able to go see the doctor who has been treating them, or perhaps find any doctor at all.

Cuts are not a plan. What is the state’s plan for caring for the patients who will no longer be able to be served by BMC and CHA? Most of the expensive Boston teaching hospitals are already filled to capacity. Is the expectation simply that the poorest and neediest among us will have to travel further into the suburbs for the health care they need? Or just go without?

What is the state’s long-term vision for the role of BMC and CHA in our health care system? What type of safety net system do we need in the face of the changes brought by health reform? How can we get there in a measured and thoughtful way?

The consequences of the proposed cuts to BMC and CHA are becoming clearer to a growing and diverse group of people, and we are coalescing to deliver a clear message to the state that it is time to work in partnership with CHA and BMC to develop a plan that preserves needed services for low-income patients and communities. As of today, there is no plan from the State about what will happen to patients if BMC and CHA close vital services.

We need lower costs and greater efficiency and quality throughout our health care system. BMC and CHA cannot be exempt from these imperatives. But developing thoughtful plans to transition to a more cost-effective care and delivery systems is not the same as forcing change through the blunt instrument of budget cuts. It requires thoughtful leadership, a clear vision, agreement on the facts, skillful politics, and close collaboration. I am confident that we have all of these abilities among the people who need to participate in such a process, and all would be willing to participate.

If Massachusetts doesn’t navigate skillfully and thoughtfully the tricky waters of how to finance and preserve the vital services provided by its two major safety net providers, its failure will have devastating effects on the public health, and on the national conversation about health reform.

Celia Wcislo is a board member of the Massachusetts Connector Authority, Assistant Division Director for 1199SEIU United Healthcare Workers East, and an Executive Board member of the Service Employees International Union.

Previously, the regulation in place said that to avoid a penalty, employers must offer to pay 33% of the premium or 25% of full-time employees must buy the insurance their employer offers. That meant employers could avoid responsibility and the penalty, even if employees pay up to 67% of the premiums, or if their workforce is mostly part-time.

Employers meeting either of these two tests faced no penalty under the law. This arrangement was negotiated between business representatives and the Romney administration, with the understanding that many employers would not have to pay the penalty.

Everyone is being asked to pay more for the cost of successfully insuring more than 170,000 Massachusetts residents. If you buy cigarettes, you will pay $1 more per pack in state taxes. If you are on CommCare, you could pay 10% higher in premiums, and higher co-pays for doctor visits. Providers will pay $20M more to cover health costs, and insurers will pay $33M more.

Consumers and advocates have consistently asked that everyone share in the cost of reform. The Patrick Administration has listened to and honored that request. Reform has worked so far because all of us, including businesses, have come to the table to make it work.

Having listened carefully to all sides, DHCFP is releasing new, final regulations today. The new DHCFP rules are aimed at those businesses who have failed to insure their workforce and have chosen to pay almost nothing towards the reform by requiring they meet both the 33% premium payment, and the 25% enrollment standards, with some important exceptions..

First, the new changes recognize the difficulties that small businesses are facing. The amended regulations apply only to those firms with over 50 full-time employees, rather than the initial standard, which applied them to any business with over 11 full time equivalent (FTE) workers. This means smaller businesses will not be impacted by the regulatory changes.

Secondly, any employer that has 75% of their full-time employees buying insurance, will also be allowed to live by the current rules. This changes acknowledges that these businesses are already doing their fair share.

Finally, DHCFP has postponed the start date of this regulation from October 1, until January 1, saving businesses three months of penalties, and allowing time for larger employers to adjust to the new regulations.

The new regulations are both responsive and fair. They correctly target those larger employers who have chosen not to insure their employees, while ensuring that shared responsibility remains the bedrock of Massachusetts health care reform.

Celia Wcislo
Assistant Division Director, 1199 SEIU
Connector board member

I would predict that a large number of these folks are people who are offered employer-sponsored insurance, but at rates that are unaffordable to them. Over a year ago, the Connector predicted that there could be 60,000 people who would not be penalized because insurance was unaffordable.

At the last Connector Board meeting, the Connector set up policy workgroups to begin tackling hard issues, including how to help workers who are low income, but can’t afford the insurance they are offered at work. We want to help them obtain coverage, but we also want their employer’s money to help fund that insurance.

The Massachusetts Health Reform law was built to maintain employer-sponsored insurance, so that costs would not be shifted from employers onto state taxpayers. This is called “crowd-out”, and we have been worrying about crowd- out since the Commonwealth Care program started. The recently released studies of the Urban Institute and the Division of Healthcare Finance and Policy all find no indications of crowd-out. In fact, it appears that more residents are covered by insurance at work than were several years ago. Since 2005, the rate of employer-sponsored health coverage has grown from 70% to 72%, bucking the national decline of workplace coverage.

For Massachusetts’ reform to be truly universal, we must find more ways to cover individuals who have employer-sponsored coverage, but can’t afford it. It is the right and fair thing to do. “Universal” does mean we cover everyone.

As the original legislation recognized, we need to develop plans to help insure this particular population. Over the summer, the Connector will study this problem, and try to develop some options, which could include pilot programs. As the possibility of national health reform grows, Massachusetts has an obligation to work harder and push further to make sure our program is as universal as possible.

What we learn here may be of help to the national debate on coverage after the November elections. The 62,000 in Massachusetts translates into millions across America. It’s time health insurance is available and affordable for every American!

Celia Wcislo
Assistant Division Director, 1199 SEIU
Connector board member

In a nutshell, they have done well, very well indeed. 2007 data shows hefty profits for the state’s “non-profit” health insurance companies. More importantly, the data shows these companies are well positioned to contribute more towards the rising costs of healthcare reform. Over the last five years, the major health insurers in the state have earned more than $2 billion in profits, and at year-end 2007 had combined reserves of nearly $3 billion. The majority of profits and surplus have been accrued by BCBS, the state’s largest health plan, but most other carriers have done well also.

Since 2006, close to 100,000 people have privately bought health plans (which based on an average annual premium of $3,000-$4.000 a year means an estimated $ $300-$400 million in new revenue). In addition to revenues from those who have purchased private coverage, the state’s four Medicaid Managed Care Organizations will be paid $869 million to over a billion dollars next year for the coverage of 225,000 Commonwealth Care enrollees. In total that is $1-$1.5 billion dollars in new revenues flowing to insurance companies.

Meanwhile, health insurance companies are not contributing a penny more to the “free care” assessment that they pay. Those payments have been capped for the last three years at $160 million per year – a small sum compared to the dollars reform efforts have produced for insurers. In truth, this assessment is borne by the insured, not the health plans. Additionally, most of the larger Massachusetts insurers are “non-profits”, they pay less in taxes than most companies do.

Everyone has been calling for health care cost controls and shared responsibility from all the stakeholders to help fund reform. While consumers and taxpayers have begun to pay more through higher premiums and a new tobacco tax, no other stakeholder has come to the table.

In light of this new data on the financial performance of insurers, here is a fresh idea. The “assessment” for the Safety Net Trust Fund (formerly the free care pool) on all insurers doing business in Massachusetts should be increased. Let’s put the assessment on all of insurers’ income, including income from interest earned on their reserves. We could then use that new source of revenue to fund subsidized coverage through CommCare, while also setting some of this revenue aside to fund cost containment measures such as electronic medical records. As one insurance representative explained to me, financing cost containment measures makes sense since cost savings, in the end, go back to insurers and their members.

It’s past time to take a closer look at the financials of health insurance companies in Massachusetts and to make those companies pay a more reasonable assessment. The health insurance industry is doing well, very well. Who else can say that right now?

The data shows there is no excuse for cost-shifting to employers and consumers at this. Clearly, the insurers can afford at least a $100 million from their ample and ever-increasing reserves. It’s important to note that these “reserves” are essentially premiums that have already been generated from the premiums that have already been paid. There is no need to pass this on in our premiums so we pay it again!

Assessment? Tax? Surcharge? Payment in Lieu of Taxes? Whatever you call it, it’s time we asked for more “shared responsibility” from those who have benefited most from healthcare reform.

Celia Wcislo
Assistant Division Director, 1199SEIU
and Connector Board member

Locally and nationally, rough fiscal waters are ahead for healthcare. Threats by the federal government to further decimate funding for children’s healthcare and Medicaid loom like a black cloud over our state’s noble first-in-the-country healthcare experiment.

The time is now for new, big ideas about how Massachusetts keeps healthcare reform on course. Consumers, taxpayers, and the state are doing their share of the rowing. It’s time for businesses, insurers, and hospitals to grab an oar.

A recent Boston Globe editorial asked, “If people on limited incomes must pay more, why not employers?” It’s an important question at the right time. It should also be applied to insurers and hospitals. The $295 fee employers who fail to offer affordable insurance must pay is a paltry sum, in light of what is now being asked of Connector insurance enrollees, the state, and taxpayers. If consumer rates go up, so should assessments for negligent businesses. The state should also revise the anemic regulations that determine which employers are obligated to pay assessments.

Right now, only 33% of employees at a business must purchase the employer-provided healthcare for that business to avoid paying special assessments fees to the Connector program. It’s time to raise that bar, so there is a real incentive for employers to offer affordable plans which at least half of their staff will choose to purchase. The Romney administration predicted $55 million in revenue would be generated from negligent employer assessments to offset healthcare costs for consumers and taxpayers. Due to the weak 33% standard, only $6.2 million has been collected through these employer assessments to date. That’s a big hole in an even bigger bucket – one that no amount of cost-shifting to consumer or individual taxpayers will ever fill.

In contrast to proposed co-pay and premium increases for consumers, hospital and insurer contributions to state-subsidized healthcare have remained flat since 2005. In fact, large hospital systems and insurers continue to reap financial gains from the system. Over three years, healthcare reform will bring in over $540 million in new taxpayer-funded reimbursements for hospitals. Meanwhile, the amount of charity care hospitals provide the community is declining rapidly, because more of their patients are coming through the doors with insurance. It’s evidence that healthcare reform is working, but it’s also evidence that the powerful Boston teaching hospitals are in a position to contribute more towards the future success of reform.

In 2007, major Boston teaching hospitals held nearly $9 billion in unrestricted net assets, an increase of $2 billion, or 30%, from the previous year. Major Boston teaching hospitals hold $16 billion total in assets. If hospital assessments were simply increased at the rate of healthcare inflation, it would be a significant step towards filling the current fiscal gap facing reform, while alleviating mounting pressure on consumers and taxpayers.

There’s plenty of opportunity for insurers to row harder, too. According to recent reports, Blue-Cross and Blue Shield chairman William C. Van Faasen was paid $16.4 million in retirement benefits in January 2006. That’s more than double what the proposed premium increases for thousands of Massachusetts consumers would yield the state this year, if the proposed Connector insurance fee hikes are accepted in their current form.

The proposed course of dramatic cost-shifting to consumers, the state, and taxpayers is neither a short-term nor a long-term solution for funding healthcare reform. Why must working families and taxpayers shoulder the burden alone? Clearly, new revenue sources from hospitals, insurers, and from businesses who fail to provide affordable coverage to their employees, must be considered.

A sense of shared responsibility is what has made reform a success thus far. That sense of shared responsibility must not be allowed to erode. With rough waters ahead, simply asking consumers, the state, and taxpayers to row harder won’t cut it. Hospitals, insurers, and businesses must embrace an “all hands on deck” approach and pay their fair share to keep this honorable first-in-the-nation experiment on course.

Celia Wcislo
Assistant Division Director, 1199SEIU
and Connector Board member