Many of us who were — are — strong supporters of health care reform have the sensation of what it must be like for a polar bear, standing on an ice floe in the warming Arctic waters, watching pieces of its perch melt away beneath it.

I, just a year ago, firmly predicted a health care bill by year’s end, and I along with others, have watched, with growing dismay, the delays, the calculated campaigns of disinformation and distrust, and the erosion of the spirit of a community caring for those who did not fully share in access to America’s health care system. It is the loss of that spirit of caring about, and for, our fellow citizens, that I find most distressing about the events of this past year. The passion about making sure that no one in this country should have to worry about getting care for a sick child, or fail to take life-saving medications because they couldn’t pay for them, has given way to a kind of callousness from those who have, about the plight of those who have not.

I suppose that the tidal wave of concern about job losses and home foreclosures is partially to blame and of course those concerns are more than justified, but where did the compassion go? Talking about hearing the anger doesn’t quite add up to a rationale for walking away from a need that hasn’t disappeared. Indeed, the need has gotten worse as costs continue to escalate forcing more people to forego medical care or risk bankruptcy to get it. We, in the Commonwealth, despite our fiscal woes have much to be proud of for not walking away from our resolve to cover all of our citizens. Our sticking with our commitment, not the fact that we got there first, is what we should be most proud of.

I, for one, would feel much better about the need to address jobs and the economy up front and central, if I had some sense that the president and congress could lay out their commitments as to when and what they are going to do about health care, and to remind us that all of us need to participate in finding a solution for all of us, not just for some of us. Surely we can work on more than one economic issue at a time. I write this before the President’s speech tonight, hoping that these words of distress will be obsolete by the time any of you read them.

(The Group Insurance Commission of the Commonwealth of Massachusetts is the agency that provides life, health, disability and dental and vision services to over 300,000 state employees, retirees and their dependents.)

I’ve recently been reading a new biography about Justice Louis Brandeis, who, before Woodrow Wilson named him to the Supreme Court, had earned a national reputation as “The People’s Attorney.” He was given that name because over some twenty or more years, he took on the cause of advocating for the public interest in opposition to the rich and powerful — in those days they were often railroads, and, yes, big banks. He espoused competition over consolidation, and was responsible for the creation of Savings Bank Life Insurance, with its lower rates for more modest income families — (all this before Teddy Bruschi was even born!).

Some of Brandeis’s solutions are a bit dated — he didn’t like big government much more than big industries, but one thing is as needed today as it was in the first two decades of the 20th Century, (I’m only up to page 400, so his supreme court decisions are yet to come) namely, his uncompromising professional integrity. So insistent was he that if he took on a cause because he believed in its rightness, he refused to take any money for this work, and he even went so far as to compensate his law firm (still in practice today in Boston as Nutter, McClennan & Fish) for monies they might have lost as a result of his public interest work.

There were certainly paid lobbyists in those days, and some of the methods of “persuading” legislators haven’t changed all that much, but Justice Brandeis would have been appalled at the scene in Washington today, where interest groups lobbying for or against each and every section of the health reform law (to say nothing of banks, brokers, and credit card regulations) are to be found everywhere you look.

One example recently profiled in a Boston Globe editorial was the provision to protect biotech companies from generic competitors by keeping the generic off the market for 12 years. Another is the much debated Stupak Amendment – and on, and on. One almost feels pity for the legislators who have to try to make up their own minds in the midst of the cacophony of “advice” they are getting from every corner.

Interest group lobbying is of course, legal and a part of the free speech rights of Americans. But I would submit that public interest groups and the public interest are two very different things, and what I, and many others worry about, is that the voice of the former is increasingly drowning out the voices of the latter. We need more voices like that of Louis Brandeis and we need them now.

(The Group Insurance Commission of the Commonwealth of Massachusetts is the agency that provides life, health, disability and dental and vision services to over 300,000 State employees, retirees and their dependents.)

Some two months ago, the Special Commission on Payment Reform concluded its deliberations with a unanimous vote recommending a shift from a payment system based primarily on fee-for-service to one based primarily on global payments.

What was remarkable about the recommendation was that it was unanimous and that the decision to abandon fee-for-service was reached with virtually no dissenting voices.

Some skeptics have pointed out that many of the tough decisions have yet to be made, and this is certainly true. But the important point to remember and emphasize is that a group of people including physicians, hospital leaders, legislators, the administration, health plans (otherwise known as insurance companies) and economists made a public declaration that the current system in which doctors and hospitals are paid for each unit of service they provide has outlived its usefulness. This system has also become a barrier to the growing need for coordination of care, as well as acting as an accelerant to the growth of costs that are crowding out funding for other social needs.

Now that the “what” and “why” questions have been answered, the details that need addressing are the “where,” “how,” and “who” questions.

How can the various individual practicing physicians, labs, health plans, and hospitals get themselves organized into what are to be called “accountable care organizations” and who will take the lead in organizing them? How will it be determined who gets how much of the global payments, and who will determine what the global payment is? Who should sit on the board that will determine the goals and monitor the progress toward implementation, and who should select them?

When can all this get started, and how will it happen — through a legislative mandate or through administrative action? Who will do the necessary analytic work? And who will decide what services are inside the global payment tent, and which are outside? And a tough one: if patients can go outside the ACO at will, how can the group be held accountable? And cutting across all the questions is the particularly tough one in these fiscal times: where will the money come from to fund the implementation management?

These are not easy questions and the answers will not be easy, or quickly resolved. But every day of delay means that costs go up and reversing the curve of the growth in cost, or at least bending its angle, becomes harder and harder. Fortunately, the legislative Committee on Health Care Financing has already scheduled a hearing to get things rolling.

It is imperative to keep the momentum going and not to let the defenders of the status quo gain momentum in the interest of keeping things as they are. We’ve all been watching that happening in Washington with a fair amount of trepidation. The difference here is that while the Commission’s recommendation is not yet embedded in law and contract, it carries with it a rational solution to two enormous problems — improving health care quality, and lowering costs so that the access issue we so bravely addressed three years ago in Ch. 58, can survive and continue to be a source of pride and satisfaction to the Commonwealth

(The Group Insurance Commission of the Commonwealth of Massachusetts is the agency that provides life, health, disability, dental and vision services to 300,000 state employees, retirees and their dependents.)

The current system has had 15 years or more since the early 90’s, when rates actually went down, to prove that a less managed system could provide quality care to all Americans at affordable costs. Perhaps it is time to try a different approach.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 300,000 State employees, retirees and their dependents.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 300,000 State employees, retirees and their dependents.

Dolores L. Mitchell
Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 300,000 State employees, retirees and their dependents.

Although we can see the future only dimly, the one thing we know is that things will be different in Washington — and in Boston. So, with absolutely no inside knowledge to guide me — my predictions are the following:

- There will be a stimulus package, and it will pass quickly.
- There will be a health reform bill and it will pass during the first year of the new Congress.
- There will be a tax increase for some, and tax relief for others, as promised by then Candidate Obama.
- The pressure on Massachusetts health care providers to lower their costs will gain momentum, but it will be an uphill struggle. Redistribution of income is always the highest hurdle of all, but it will have to come.
- The excruciatingly slow adoption of Information Technology in medicine will accelerate as it becomes an expected standard of care.
- We won’t equal the Japanese, but the gap between the CEO pay and hourly workers pay will begin to narrow — ever so slightly — and it’s about time.
- Health plans and purchasers will continue to push providers to do better by measuring their performance and reporting the outcomes, as the most effective way to improve the quality of medical care.

Does this sound Pollyannaish? Well, maybe, but despite the grim economic news there is a breath of fresh air as we change administrations in Washington. With change, there is hope. With hope anything is possible. Tune in a year from now and see how many of my predictions come true.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 300,000 State employees, retirees and their dependents.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 285,000 State employees, retirees and their dependents.

All of this, of course, makes life more difficult for our sector, health care, particularly in Massachusetts where health care is a cost driver and simultaneously an economic generator and a job creator. Growth, in economic discourse, is usually viewed as a good thing, but it is also a matter of concern to payers, purchasers, and budget-watchers, since we all know that if you build it, people will come, and there goes the budget.

So what does all this have to do with health reform? As Jon Kingsdale noted in his recent monthly report, the Connector’s need for additional revenue this year has come as a consequence of its success in enrolling more uninsureds than planned for. My agency has had its budget problems too, as utilization climbs. So volume counts, and so does price — and supply does drive demand. We know all this, but what we don’t know or don’t have agreement on, is what to do about it. All of us who work in state government are on notice that our FY09 budgets are subject to change, — down, not up, so health care costs are of concern to all of us — public and private sectors alike.

A lot of good people are working very hard on a number of fronts to deal with aspects of reform — encouraging transparency, funding disease management and wellness initiatives, looking for ways to simplify administrative procedures — every one of them useful contributions to reform. But the basic values, structures, and delivery systems of health care in this country are basically pretty much as they have been for decades. We used to be able to afford its inefficiencies, but those days are over.

Basic reform in this country has almost always occurred as a result of cataclysmic events — depression or war — or when the middle class itself is threatened. We are perhaps closer to the latter scenario than we would like. The Massachusetts Health Reform Acts of 2006 and 2008 called for shared responsibility. It may be that 2009 will call upon all sectors — hospitals, doctors, medical schools, businesses, and patients to dig deeper and accept the necessity of systemic change. We may not have time for gradualism.

So summertime is almost over and “the livin hasn’t been easy”. Maybe the cool, crisp days of fall will bring more clarity and the energy we need to deal with “insolvable” problems. In the meantime, my recommendation to all is to prepare yourselves for some rough weather in the months ahead.

P.S. I promise never to use a weather metaphor again!

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 285,000 State employees, retirees and their dependents.

I’ve been giving this matter a lot of thought and it seems to me to present even larger policy issues. The distribution of state tax dollars across state sponsored programs, as we know, has changed over the years of health care inflation coupled with health insurance coverage expansion, be it Medicaid, state employees, or the creation of CommCare itself. And, while it is a matter of justifiable pride that we have covered so many of our fellow citizens with insurance that they didn’t have before, we need to keep our eyes on the other state needs that are competing for those dollars. The Governor’s new and exciting education program is just one example. As the administrator of one of the Commonwealth’s health care agencies — the GIC — and as a board member of another — the Connector Authority — I know I can support and feel very good about the health services that we can provide with every additional dollar we are given. But as a citizen of this Commonwealth, standing back and looking at all of the needs of our Commonwealth and its people, it is the obligation of every one of us to look long and hard at every expansion proposal that comes before us to make sure that it is well thought out, carefully costed out, and every alternative to saving dollars seriously considered.

State government is supposed to serve all the people and balancing their needs is a very tough job. I have worked on a governor’s staff, and I know how tough that balancing act is. Those of us who serve in one sector and those whose advocacy efforts are about one sector must not forget that they are also part of the whole. It’s hard to do, but it must be done, especially in times of economic uncertainty. Ever-increasing dollars spent on health care will not be available for other program needs. We need to keep those other needs in mind as we move into a new fiscal year.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 285,000 State employees, retirees and their dependents.