The next day, Thursday, I attended a rally organized by Health Care for America Now (HCAN) at the Capitol and was hyped by the overwhelming display of support for health reform from communities, organizations, and workers from across the country. I spent the day talking with legislators, staff and policymakers, including our own John McDonough who came out of a Senate committee mark up session to meet with us. Friday morning I attended the closing of the AHRQ conference in Bethesda and had an afternoon meeting with some officials in the Health Resources and Services Administration in Rockville. It was an exciting and validating few days with the positive buzz around health reform. There was but one degree of separation between me and the Senator, me and the President, and reform seemed all but assured.

A month later on Wednesday morning, July 22nd I’m in Boston on my way to work hearing on the morning news shows about the President’s press conference scheduled for that evening and how national health reform is in jeopardy of failing due to Republican opposition and some renegade Democrats. Republicans see it as the President’s Waterloo and the so called Democrats see it as too expensive. That evening President Obama made a powerful and compelling case for why we must succeed at national health reform. He articulated all the reasons. He outlined the consequences of inaction. The cost of health care is making the country less competitive in a global economy. As a nation we spend more on health care than any industrialized nation in the world that manifests in less health. Health reform is an essential strategy in the turnaround and revitalization of the economy. More and more Americans are losing their health insurance everyday, the result of job loss or unaffordable premiums. We cannot afford to wait … the time is now.

Massachusetts health reform has been at the center of the national discussion and debate and seemingly the preferred model for a national program and while it is not the model the Massachusetts experience provides valuable lessons worth learning.

Universal coverage is a valued principle and what we want in an equitable, quality health care system. However, without addressing escalating costs it is unaffordable in the short term and unsustainable over the long term. Health care costs in Massachusetts continue to rise faster than the national average and in the face of the current fiscal crisis the state cuts $115 million from Commonwealth Care, threatens the removal of 30,000 working, taxpaying, legal immigrants, and the largest safety net hospital is threatened with bankruptcy.

Cost containment and control has to be a priority in any model of reform as escalating health care costs threaten the bottom lines of businesses, the household budgets of families, and the viability of the US economy. High premiums from insurance companies result in enormous profits (surpluses in non-profit vernacular) as they pass on more to the consumer in co-pays, deductibles, and other out-of-pocket expenses. Several strategies may lead to cost containment such as price controls, strict hospital budgets, pay for performance, investments in prevention, even tort reform, and all should be tried.

A public option, yes a Government run heath plan, is essential as one other strategy for cost containment is “free market competition” and a public plan to compete with the private insurance industry is just what the people need. Despite the assertions of those that use the scare tactics about government run health care, we already have a government run plan and it must be unknown to them that Medicare consumers express the highest satisfaction rates of all consumers of health care in America.

Budget neutrality is a Washington term that requires health reform to pay for itself. The Massachusetts health reform principle of shared responsibility provides an important lesson. So a proposed tax increase on income of those more wealthy Americans after the dramatic cuts they enjoyed under the last administration seems fair. The offer of $80 billion from the pharmaceutical industry should be looked at, to see if we can get more. Increase “sin” taxes on alcohol and tobacco and impose “health risk” taxes on sugar sweetened beverages such as soda and energy drinks. Repeal deductions for medical expenses, and eliminate Medicare Advantage plans administered by insurance companies.

The American health care system is in crisis. All of the warning signs indicate its eminent collapse. They time to act is now before we find ourselves reacting like we did with the financial crisis. The time is here … Health Care for America NOW!

Elmer Freeman is Executive Director of the Center for Community Health Education Research and Service and Director of the Office of Urban Health Programs and Policy, Bouvé College of Health Sciences at Northeastern University

People of color continue to live shorter and sicker lives in Massachusetts and the United States. Even when insurance status is equal … access, treatment, and outcomes are not. As we work to ensure the success of healthcare reform in the Commonwealth and vision a nation with universal coverage, we must also increase our focus on eliminating these inequalities. These differences, inequalities and disparities in outcomes become inequities because they are “avoidable, unnecessary and unfair.”

There is some good news for Massachusetts. Several efforts are in progress to achieve health equity and improve community health for everyone. Institutions, legislators, administrative officials and advocates are pushing forward some significant initiatives to get to the roots of disparities … the social determinants of health.

Hospitals have begun collecting race and ethnicity data. This critical effort to understand the hospital patient population will help us know what access and quality patterns exist between populations, and where interventions are needed.

The Massachusetts Health Disparities Council is active. With the legislative leadership of Senator Susan Fargo and Representative Rushing, the Council is actively working and identifying post health reform disparities priorities and strategies.

The Executive Office of Health Equity is underway. EOHHS Secretary JudyAnn Bigby is developing the EOHHS Office of Health Equity. Passed in the FY09 budget, the Office works across both health and non health state agencies to develop collaborative efforts that address health inequality. In partnership with the state Disparities Council, the Office is also developing an annual state health disparities report card to track the state’s progress.

Advocates are pushing policy change. Advocates like the state’s Disparities Action Network (DAN) continue to make the case for legislative and budget proposals to support health equity. Working with Senator Susan Fargo and Representative Rushing the (DAN) is currently working to protect the Executive level Office of Health Equity in the state budget as well as public health programs that address disparities in local communities.

These are all important steps forward for Massachusetts, but we must not grow complacent. All of these initiatives need leadership, support and resources to continue advancing a comprehensive health equity agenda. As we mark National Minority Health Month, I challenge us all to reaffirm a commitment to health equity. We all benefit from a healthier and more vital population, and everyone deserves an equal chance to be healthy.

Elmer R. Freeman
Executive Director, Center for Community Health Education Research and Service, Inc.
Co Chair, Disparities Action Network

Adding to these realities are reports in the Boston Sunday Globe of significant increases in the number of unemployed Massachusetts residents applying to the state’s Medical Security Program. A remnant of universal coverage from the Dukakis era, the Medical Security Program, provides assistance to middle and low income residents who are collecting unemployment by paying up to 80% of their health insurance premium. The unemployment rate has increased from 4.1 to 5.9% over the past eight months and over the past year the number of participants in the program is up 73%. While some companies offer COBRA, many find it too expensive to purchase and applications to the Medical Security Program have increased substantially. The total number of the unemployed and their dependents was 13,000 at the end of November as compared with 7,700 last year. The program is also faced with the challenge of having been tapped by the Governor for $35 million earlier this year to help finance health reform.

The challenges are many … the national economic crisis, increasing unemployment, demise of major corporations, and the squeeze on the middle class. Health reform, i.e. a major (transformative even)shift in the way the “business” of health care is conducted, should be, in fact, has to be at the forefront of the economic and public policy agendas for President Obama’s administration. As the Federal government readies an economic stimulus package for the states, Governor Patrick is seeking several hundred million of dollars through an enhanced Federal Medical Assistance Percentage (FMAP) as part of a package for Massachusetts. The question here is whether he will reinvest FMAP funds in restoring the 9C cuts to MassHealth, and other health programs or use it to address the myriad other fiscal challenges of the state.

Many make the simple argument that health money ought to go to support health needs and health reform and I agree. The calls for restoring the 9C cuts to MassHealth this fall; protecting Boston Medical Center and Cambridge Health Alliance, and increasing provider reimbursement rates with FMAP are understandable. The belief that pouring this money into the current system, for the same ole reasons will help sustain health reform is wrong. It’s pouring more money into a broken system.

Our investment should be done in a very deliberative and strategic way that supports the kind of “reform” we need in the system, such as: (1) increased support for and expansion of primary care; (2) support for the most vulnerable populations; (3) improved quality and increased accountability; and (4) elimination of health disparities and promotion of health equity. Universal coverage did not bring universal access as we experience a critical shortage of primary care physicians and providers as the door to the system and a medical home for the newly insured. The tight fiscal times have had its greatest impact on those most vulnerable in society, the poor, children, elderly, and infirmed and now challenge the health and well-being of the middle class as well. The Globe Spotlight Series on the power of Partners Healthcare makes the case for creating greater transparency and increased public accountability given the amount of public money and the public’s money that goes into financing our health care system. The great and growing diversity of the country makes the persistence of disparities in health and health care of racial and ethnic minorities unacceptable and warrants a more equitable system.

We must recognize and develop health policy within the broad framework of social policy and take into account the social, political and economic determinants of health and quality of life of individuals in their communities of residence. At the local, state and national level, education policy, employment policy, housing policy, transportation policy, tax policy, energy policy, legal policy, and all policy must be seen as health policy and weigh the implications and consequences of policy promulgation on the health of the population. Now is the time for strong visionary leadership for the implementation of real health reform in Massachusetts. We certainly have that in Secretary Bigby and we should support her in her efforts.

Elmer Freeman is Executive Director of the Center for Community Health Education Research and Service, Inc. and Co-Chair of the Disparities Action Network of Critical MASS and Health Care for All

On September 16, 2008, Charles Kenney, former journalist at The Boston Globe, introduced his new book, The Best Practice: How the New Quality Movement is Transforming Medicine, to the health care establishment of Boston, touting such ideas and concepts as the introduction of the principles of quality in the Toyota Production System being employed at the Allegheny General Hospital. The forum was sponsored by Blue Cross Blue Shield of Massachusetts and hosted by its Chairman and CEO, Cleve Killingsworth, writer of the foreword to the book, who issued a “call to action” for transformation of the system to improve quality, and promote affordable patient centered health care.

A quick scan of the room and of the table full of name badges, I determined that the forum drew 350+ people from the major teaching hospitals, medical schools, networks and health plans all interested in identifying ways of improving quality and increasing productivity while also keeping health care affordable. The Best Practice Quality Forum featured a keynote presentation by Donald Berwick, President and CEO of the Institute for Healthcare Improvement who campaigns for saving 100,000 lives and protecting 5 million from harm through quality improvement initiatives. Sorrel King who lost her daughter due to medical error and champions efforts to give greater involvement and control to parents and other responsible relatives in the care of their family members, gave a passionate presentation. Charles Kenney’s presentation preceded the panel discussion among three of the leaders in the healthcare quality movement written about in his book, with each one providing valuable lessons from their experiences in the healthcare quality imperative. Kenney’s book documents the challenges faced by these three, as well as other leaders in the quality improvement arena in health care. It provides the inspiration necessary for taking on the complicated compounded complexities of quality improvement.

Studies have demonstrated and the evidence is clear of the relationship between quality measures and potential for cost savings. Dr. Berwick made the case for cost savings to be realized by decreasing hospital infections and medical errors and investing in quality improvement strategies and techniques. Single payer advocates have long made the case for cost savings on the administrative operations of the system. There seems to be equal or greater savings to be realized on the clinical operations as well. Health reform as we know it in Massachusetts is very much tied to what we can achieve in quality improvement and cost containment.

Under Chapter 58, the Health Care Quality and Cost Council is charged with “establishing health care quality improvement and cost containment goals to promote high-quality, safe, timely, efficient, equitable and patient centered health care” in Massachusetts and the Council released a progress report on patient safety efforts two days after the Forum. Kenney’s book of stories of these visionary leaders should be required reading for the members of the Council and everyone in Massachusetts concerned about the sustainability of universal coverage for all of the citizens of the Commonwealth.

Elmer Freeman is Executive Director of the Center for Community Health Education Research and Service, Inc. and Co-Chair of the Disparities Action Network.

One step toward achieving that goal was realized when the Massachusetts State Legislature passed legislation that authorized the creation of a new statewide Office of Health Equity to lead efforts within the Executive Office of Health and Human Services and across the other Secretariats to coordinate efforts that would lead to the elimination of disparities in health in Massachusetts. The statewide coalition of advocates representing over 70 groups and organizations comprising the Disparities Action Network (DAN) who worked with this as their chief policy agenda and pushed it thorough the legislature sincerely thank Representative Rushing and Senator Wilkerson for their leadership on getting this initiative through the State budget process and as Co-Chairs of the Health Disparities Council established under Chapter 58.

The DAN envisions this Office as providing the high level state authority and infrastructure necessary to make disparities elimination not only a priority for all state health and human service agencies, but to coordinate with other Secretariats (transportation, housing, education, environment, etc.) and their respective agencies to address the ways that their policies and programs can support elimination of health disparities and promotion of health equity in the Commonwealth.

The Office will also be critical in providing staff support and organization for the work of the Health Disparities Council and as the liaison with the Health Care Cost and Quality Council both of which have a crucial role in the system achieving health equity. The role for the DAN involves supporting the implementation of the legislation and the work of the Office. It is also to be vigilant in its monitoring of the work of both Councils as they move forward with implementation of the challenging issues in Chapter 58.

The DAN recognizes an alignment of forces and an opportune time in Massachusetts, with a Governor taking leadership on the issue, a Health and Human Services Secretary who is passionate about the issue, and a Public Health Commissioner who understands it. This is our best chance to realize just and equitable health for all our citizens.

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Inc. and Co-Chair, Disparities Action Network.

As we get ready to “celebrate” the second anniversary of the Massachusetts health care experiment, the message in the House budget is clear; there is no political will or budgetary authority for addressing the most challenging issues for true health reform. For the past two years the Connector has extolled the success of Chapter 58 as if access is the only measure of success. Other provisions of the law have failed to deliver the real promise of health reform. The Quality and Cost Council has no apparent agenda for controlling spiraling costs and have failed to make the link between cost and quality for consumers, despite their dependence on “an educated consumer” for ensuring accountability in the health care system. The Disparities Council was just named and put in place at the end of 2007 and has met only once since then despite the report of the Special Legislative Commission chaired by Senator Dianne Wilkerson and Representative Peter Koutoujian calling for such an Office as to eliminating disparities and creating health equity.

The time and the circumstances present a unique opportunity for Massachusetts to address the persistent racial and ethnic disparities in health and health care and lead the nation yet again in what is clearly the leading human and civil rights issue of the 21st Century. Dr. King’s assertion in 1966 … “of all forms of inequality, injustice in health care is the most shocking and inhumane” has never been more true. Excess mortality and morbidity and unnecessary deaths of racial and ethnic minorities, the shame of the American health care system has been the focus of a seminal report of the Institute of Medicine, the research efforts of the National Institutes of Health, the Massachusetts Legislature and State Department of Public Health, and the Boston Public Health Commission. Advocates for change know that health disparities are a downstream outcome of the varied social, political and economic determinants upstream that have to do with education, jobs, transportation, housing, and environmental policy. An Office of Health Equity at the Cabinet level under Secretary Bigby ensures the coordination of state policy at the highest level in the Executive branch to shape policy upstream to change outcomes downstream. It could provide the structural home and administrative support for the work of the Disparities Council. It is the essential authority needed to lead an initiative that will eliminate disparities through coordinated and collaborative efforts between the Secretariats.

It’s time for the Legislative branch to get on board. The members of the DAN call on Speaker DiMasi, House leadership, and members to support the amendment of Representative Rushing to restore the Office of Health Equity to the House budget.

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Inc. and Co-Chair, Disparities Action Network.

From my previous entries on this blog, you know I have not been enamored with the promise of reform in Chapter 58. The real opportunities for reform take a backseat to increasing access by expanding coverage and simply pumping more dollars into a system that is almost irreparably broken.

Yesterday I attended presentations by graduate students at Northeastern University who were among some 40-50 students who attended a two day seminar sponsored by the Massachusetts Health Policy Forum for graduate students from many local area universities studying medicine, nursing, public health, public administration and other disciplines. The student forum was held in January and included two full days of talking with policymakers, legislators, administration officials, practitioners, etc. all focused on Massachusetts’ great health care experiment, Chapter 58. The students consider it a success only if measured by the singular objective of increasing the numbers of Massachusetts residents with health insurance of some sort. However, it did not take long for them to realize the absolute impossibility of sustaining increased coverage in light of rising costs for everything from food, to gas, to prescription drugs and health care. They were all looking for the answer … how do you keep it affordable, when the price keeps going up?

Everyone knows we have to do something about spiraling health care costs or our experiment will fail. One of the key elements of Chapter 58 that could help, the Health Care Quality and Cost Council, remains dormant. The questions here are do we have the political will to “mandate” price controls and other reform strategies as we have done with coverage? And are we willing to penalize those that do not comply? Clinging to a market based ideology in health care makes no sense especially when market principles, such as the relationship between cost and quality, have no influence whatsoever on consumer decisions in the market of health care goods and services. Do we take lessons from the US automobile industry that didn’t realize that “quality is job one” until it was almost too late.

To meet the promise of universal coverage, we have to keep it affordable for it to be a success and everybody has to ROW HARDER. Under Chapter 58 we have witnessed a corporate take over of our health care system … and we need to take it back.

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Northeastern University.

I’m pleased to report a 100% response rate and that 100% of the students responding to the survey are insured: 88% on their parents plan with 6% on Medicaid and another 6% that purchase the plan offered by the University. As future health professionals a substantial majority, 78% report that having health insurance is very to very, very important to them mostly for security as a way “to ensure payment for a catastrophic event or illness.” Only 30% reported feeling they understood enough about health insurance, coverage and benefits to make an informed decision in selecting from among the “too many” Commonwealth Choice(s). Many, 66% were discouraged by the complexity and lack of information available. Try here.

The vast majority, 81% report being minimal consumers of health care services over a 24 month period, except for few chronic diseases, and one or two acute episodes, services were limited to occasional physicals, immunizations for college, and routine gynecological/family planning visits.

Only 21% disagreed with or expressed doubt about the individual mandate. However, 70% felt that it was unfair to use the young and healthy to subsidize care for the old and infirmed, trying to justify it with “they need to pay for the elderly, sick people, which they will eventually become.”

Finally, there were varying points on the dysfunction of the health care system with many recommendations for change. There was reference to The Boston Paradox: Lots of Health Care, Not Enough Health and the disproportionate amount of $$ and resources go into health care and how little we receive in terms on health status.

I hope we’re seeing the development of a new cadre of physician activists and public health advocates.

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Northeastern University; Co-Chair, Critical MASS

Chapter 58, the Massachusetts health reform legislation introduced the notion of “pay-for-performance” (P4P) by tying increases in hospital reimbursement rates to measures of quality performance. Unlike other pay for performance programs implemented in other states, Massachusetts for its Medicaid program, given the populations covered in the state, is including measures for the reduction of racial and ethnic health care disparities, hoping that such efforts will contribute to reducing disparities in the health of those covered by MassHealth. They are not only testing the pay for performance model but also testing the relationship between health care disparities and health disparities; looking at the process of health care delivery as a determinant of health outcomes. The Chronic Disease Collaboratives of the Health Resources and Services Administration working with community health centers to better manage chronic disease care among their patient populations may be a model with some important lessons learned.

The concern with P4P in MassHealth is that it has the potential of possibly making disparities in health worse for this population. The word is still out on pay-for-performance programs and particularly with the Medicaid population. We are all too familiar with the “creaming” and “cherry picking” that was evident in the early years of managed care; and the more recent outright denials of service to Medicaid recipients due to lower than cost reimbursement; and the potential of some providers to select better off patients. There is also the potential for penalizing certain providers such as community health centers that serve greater numbers of minority patients than most other providers. One of the most significant disparities in health care is the number of poor, uninsured, and minority patients utilizing emergency departments as their primary source of care… those without a medical home. It is very disconcerting that Lori Berry, Executive Director of the Lynn Community Health Center in her posting to this blog documents how the Connector’s policy of auto assignment, under the Commonwealth Care program, to the lowest cost plan has disrupted existing primary care relationships with health center patients. This is the kind of policy that potentially can make disparities worse and this advocate joins Ms. Berry in calling for the Connector to reexamine its policy.

The Commission report recognizes the broad determinants of health in its comprehensive range of recommendations for ending disparities in health in the Commonwealth. The work of the usual and customary subcommittees, access to health care, health care quality and delivery, and workforce development and diversity, in this case was eclipsed by the committee on the social context of health. It addresses the social, political, economic and environmental factors that influence health and contribute to health inequity and health care inequality experienced by racial and ethnic minorities.

The Disparities Action Network along with Critical MASS and Health Care for All supports HB 2234 An Act to Eliminate Racial and Ethnic Health and Health Care Disparities in the Commonwealth for its comprehensive approach similar to the Commission recommendations. It represents a strategic beginning for all who to want to work to end disparities and calls for a Center charged with the goal to end racial and ethnic health disparities in the Commonwealth but falls short of placing it at the level of the Governor’s cabinet. There is real opportunity here.

“The real measure of success is not just access to health insurance. It’s not even access to health care. What we want is improved health.”        Governor Patrick

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Inc. (CCHERS) at Northeastern University and Co-Chair, Critical MASS for Eliminating Health Disparities and the Disparities Action Network.

It is expansion of health insurance in its various iterations, employer based, individual and group, and government sponsored, to uninsured residents of Massachusetts. It is not health reform, and that’s the problem. It is increasing dollars spent on a broken system. It is not changing the system. It is giving people access to care. It is not improving care. It is investing more money with no return on that investment in terms of decreased cost, improved quality or increased accountability.

In a recent television interview, candidate for President, Hilary Clinton was being pressed by the reporter on whether she would call for an increase in taxes in order to institute the kind of reforms she envisioned in health care. She said no. He pushed her with candidate Edwards position that any candidate unwilling to admit that taxes would have to be increased for us to accomplish health reform, which to Edwards, like Massachusetts politicians think means universal coverage, was not being honest with the voters. Senator Clinton’s response, as someone who had occasion to study real health reform, was that she would refuse to invest any more dollars in what is obviously a broken system. Exactly the opposite of what we have done in Massachusetts. We’re pumping more money into a system that’s becoming increasingly more expensive, with decreasing quality, and will not improve the health of the citizens on Massachusetts. The only winners in Massachusetts health reform are the insurance companies and health plans.

Who would dare to speak against universal coverage? However, how many of us wonder at what cost? For example, how much money is being spent on advertising, marketing, outreach, enrollment, and all the “administrative” costs associated with the creation of the “quasi” governmental Connector as yet another layer of administration, and the implementation of only the affordable access aspect of Chapter 58? Could this money be better utilized to decrease the costs of health care and support real reform through a single payer system?

The group, Physicians for a National Health Program, suggest taking advantage of this moment in time … with a Presidential election on the horizon and the heightened visibility of the American health care system crisis, as a result of Michael Moore’s film, “Sicko”, to organize a national campaign promoting a single payer system. On the national level they have sponsored legislation, HR 676 General Resolution, that calls for creation of a US National Health Insurance system, giving everyone access to affordable quality health care paid by saving $300 billion, according to Harvard researchers, in administrative costs.

The group suggests organizing on the state and local level to have state legislatures and city governments pass resolutions supporting HR 676. They also suggest organizing events to coincide with showing of the movie; scheduling grand rounds at hospitals and health centers; panel discussions in communities; securing Representatives and Senators to co-sponsor single payer legislation; and becoming politically active in the Presidential primaries and challenging the candidates to address real health care system reform.

We in Massachusetts are uniquely positioned to step out in front of this movement, just as we did some forty years ago with the beginning of the community health center movement here in Boston, another movement for health access, equity and justice. To paraphrase a favorite son of Massachusetts … if not us, who … if not now, when.

LINKS:
Sicko: Sickocure.org
National Health Insurance Bill: PNHP.org
HR 676 Resolution Campaign: PNHP.org

Elmer Freeman, Executive Director, Center for Community Health Education Research and Service, Northeastern University; Co-Chair Critical MASS.