With the new year upon us, there is widespread concern about recently announced dramatic increases in health insurance premiums by most carriers. Despite near universal interest in health care cost containment, health insurance costs continue to spiral upward. Small businesses, in particular, are reporting that their premiums are increasing as much as thirty and forty percent over the previous year. Increases of this magnitude appear to be out of line with national trends in health care spending. Clearly, an explanation from providers and insurers of the factors causing dramatic increases in premiums is required!

In particular, the impact of premiums on small businesses is especially unsettling. The Commonwealth’s economic recovery is closely tied to the ability of small businesses to grow and survive. With unemployment continuing to be a serious problem, despite other hopeful economic indicators, businesses are unlikely to increase their workforce if the added cost of health care benefits continues to overwhelm their bottom line. Even larger businesses are challenged to maintain the historic level of insurance benefits for their employees.

Additionally, state and local government budgets and those of human service providers are closely tied to employee benefit costs. Dramatic increases in health insurance costs make it more difficult of municipalities and non-profit service providers to retain or hire the employees needed to deliver essential services. Increases in the employee share of health costs in a time when wages are being frozen or cut, are a growing burden for workers in both public and private sectors.

Related to concerns about higher premiums is the trend toward higher co-pays and deductibles. With so few individuals holding health savings accounts, the crunch of credit card debt and lack of credit availability, these higher out of pocket health costs are likely to lead to health care related bankruptcy and, especially, to inability to access needed care. We all know that failure to have access to needed care early in the development of illness is likely to result in higher health costs as the illness progresses.

A report released last week by Centers for Medicare and Medicaid Services revealed that health care spending rose 4.4% in 2008 – the smallest increase in fifty years – since the spending was first tracked in 1960. How can higher premiums for health insurance and increase co-pays and deductibles can be justified in light of this report? There is widespread concern with dramatic increases in health insurance premiums that have been announced recently.

Small businesses, in particular, are reporting that their premiums are increasing as much as thirty and forty percent over the previous year. Increases of this magnitude appear to be out of line with national trends in health care spending. Clearly, an explanation of the dramatic increases in premiums is required!

Deeply troubling is the apparent reluctance by Massachusetts health care providers and health insurance plans to fully participate in public hearings regarding the rising costs of health care for small business. The Boston Globe reported recently (1/8/2010) that “leaders of some of the state’s largest hospitals failed to show up at a public hearing to answer regulator’s questions about what is driving up costs. A month earlier, officials of the state’s major insurance companies testified at an earlier set of hearings, but refused to answer key questions.”

It is unacceptable for providers or insurers – which are mostly tax-exempt non-profits – to demonstrate such utter lack of cooperation or respect. If there is a credible explanation, it would be a welcome piece of needed information to help policy makers and the public understand this lack of candor.

The Commonwealth has, historically, granted tax-exemption to hospitals and to the major health insurers through their non-profit status. Hospitals, in particular, also enjoy the benefits of legislation that limits tort liability. These exemptions were provided because of the essential public service that such institutions provide. Furthermore, health care professionals are granted license to practice their professions by the Commonwealth. However, the apparent lack of cooperation in exploring the fundamental obstacles to health care cost containment challenges the wisdom of such public policies. When public benefits are bestowed, public obligations are expected and must be honored!

The public deserves answers to some very serious questions. Specifically, why should the Commonwealth continue to allow these very valuable protections to remain in the face of such striking lack of cooperation and respect? Why should state officials oppose calls for rate setting of both provider charges and insurance rates when there is an unwillingness to work cooperatively for a solution to spiraling health care charges and insurance premiums? Why do the people of Massachusetts pay some of the highest health care costs in the Nation, and perhaps the world, when we cannot demonstrate that the care provided is of the highest quality or that the insurance coverage is primarily used to pay for care rather than administrative or other costs? How can the trustees of our non-profit health care providers and insurers justify the lavish levels of compensation and benefits so often paid to top executives and consultants?

The Legislature is looking forward to health care cost transparency hearings required by sections 23 and 24 of Chapter 305 of the Acts of 2008. The hearing are expected to focus on the impact of rising costs on all of us, not just small businesses. These hearing should have been conducted last year by the Patrick Administration and the Attorney General in time for the submission of the first of what will be annual reports to the House and Senate Committees on Ways and Means and the Joint Committee on Health Care Financing by December 31, 2009.

The purpose of this legislatively-mandated effort is to provide critical information concerning spending trends and underlying factors, along with any recommendations for strategies to increase the efficiency of the health care system. This information is vital to successfully implementing health care payment reform as recommended by a special commission last July.

As some pundits and so-called experts compare features of the landmark Massachusetts Health Care Reforms (Chapter 58 of 2006 and Chapter 305 of 2008), they assert that Massachusetts only addressed access and not quality improvement or cost control.

They concede that Massachusetts did succeed at expanding access to health insurance based on the current estimates that some 97.5% of Bay State residents are now insured, which is a higher percentage than any other “health reform state” has been able to achieve! However, claiming that Massachusetts only achieved expansion of access misses two important features of our success. Furthermore, claims that health reform is unaffordable for Massachusetts have been soundly disproven by the Massachusetts Taxpayers Foundation.

First, expanding access does, in fact, improve quality and ease cost shifting. People with health insurance are generally healthier and are less likely to have to rely on expensive emergency department care because they are able to get lower cost routine preventive care and better management of their chronic conditions. A study by Harvard Medical School for the Centers for Medicare examined Medicare claims between 1996 and 2005 and found that individuals who were uninsured before becoming eligible for Medicare at 65 had significantly higher spending than did those with coverage prior to Medicare enrollment. The uninsured have postponed needed care, making them generally sicker and therefore, more expensive for taxpayers. Access to health care saves lives and money! It improves quality of life and helps contain costs.

There is much more to Massachusetts Health Reform than expanding access, however. Both Health Reform I [Chapter 58] and Health Reform II [Chapter 305] established a strong foundation for improving health care quality and reducing health care costs – in short, making health care accountable.

Recently, the Boston Globe reported significant improvements in reducing hospital acquired infection rates. According to this report, Massachusetts’ largest hospitals say they have significantly cut the number of patients who acquire painful, costly, and sometimes deadly infections in their operating suites and intensive care units (ICU’s), suggesting that pressure from government regulators and patient groups, as well as a shift in doctors’ attitudes, is starting to make medical care safer. This fifty percent reduction in intravenous line infections and reduction of pneumonia from patients on ventilators has reduced current costs and even contributed to cancelling capital expansion of the ICU at Beth Israel Deaconess Hospital.

This is exactly the sort of improvement in quality and cost reduction envisioned by legislators when provisions – and funding – for a statewide infection prevention program and links to the CDC infection reporting system were included in the Massachusetts health reform law in 2006 and the Quality and Cost law of 2008.

Other provisions of the two Massachusetts Health Reform laws, include the establishment of the Quality and Cost Council and the Health Care Disparities Council, funding for the Betsy Lehman Center for Patient Safety, reorganization of the Massachusetts Public Health Council, establishment and funding of the eHealth Institute and eHealth Fund, as well as funding of the Nursing and Allied Health Trust Fund. In addition, the two laws provided for the establishment and funding of the Primary Care Workforce fund and development of goals for electronic health records.

E-health has become a rapidly expanding area of health reform, and Massachusetts has been established as a leading example in implementing health information technology. Through the Massachusetts Technology Collaborative, a statewide health information network and the development of standards for physician competency in meaningful use of health information technology are both beginning to make a genuine difference in reforming our health care delivery system.

Perhaps most significant, Health Reform II provided for a one-third reduction in the expensive storage of health records, simplifying the convoluted and excessively burdensome bill coding system. Instead, what has been created is soon-to-be unveiled transparency in the setting of health care provider charges and insurance premiums. Providers and insurers will finally be held accountable of increasing costs!

While it would be wrong to downplay the significant achievement of expanded access, enrolling people in health insurance is far easier, and can be achieved more quickly, than changing the entire culture of health care to improve quality of care and ensure that it is delivered more efficiently.

The process developed by Massachusetts is a comprehensive, step by step approach to long term improvement and consumer-friendly reform. It is an approach that is continuing to be developed and implemented as the legislature and administration begin a very complex effort to reform the health care payment system so that it provides the right incentives for improving primary care and coordinating the care of all patients, but especially those with expensive, chronic conditions.

The foundation for quality improvement and cost reduction embedded in Health Reform I and II, and the changes being developed in Health Reform III, will take at least the next five years before we experience maximum benefits. However, Massachusetts is on a bold, innovative path to more competent, compassionate care for all of its citizens. We have proven that health reform can be achieved at the state level, and we hope it inspires other states—and even our federal government—to demonstrate the courage and commitment to deliver on the opportunity for, and promise of, good health for every American.

While I always take into account the legitimate concerns of my constituents, many mistruths have been promulgated over the past several weeks. It is worth noting, that NONE of the provisions of this bill take place, unless the Governor were to declare a statewide public health emergency, which in itself is very rare. For any of this to take happen, it would be an extremely dire situation. I would like to further clarify what this bill does not do, and what it does do:

This bill does NOT mandate, require, or force vaccinations upon individuals, in the event of a statewide pandemic or public health emergency. While the Commissioner of Public Health may recommend statewide vaccinations, every individual has the right to refuse that recommended vaccination. This bill simply enforces common sense by ensuring that if someone refuses the vaccination, they stay home and stay out of risk of infecting themselves, loved ones, co-workers, children, or the general populace.
There are NO “quarantine camps” or institutions that individuals would be placed in if they pose a risk to the general population’s health. Individuals who act irresponsibly in posing a risk to society can face a punishment that results in an order to stay home, or a fine. Again, this fine is simply a protection against individuals that act irresponsibly in the case of a pandemic.
There is NO provision for martial law within this bill. Any language of a military presence within this legislation simply doesn’t exist, and this bill offers no language that would indicate martial law.
Warrantless entry is addressed in this bill as being suitable only as it relates to probable cause of a health violation. Under current, normal, every-day standards, this practice of law exists. This bill simply addresses warrantless entry to specify probable cause, under a statewide public health emergency, to a public health violation. Under this legislation, officers must follow-up with a written warrant, as they would under normal circumstances. Nothing changes with this law!
This bill consolidates the power of the administration. As our emergency laws are currently written, there is hardly any delineation of power in the event of a public health emergency. This bill focuses response powers to the Commissioner of Public Health, with guidelines as to how they may utilize that power. While opponents of this bill cite the infringement of civil liberties with its passage, this bill would actually protect those liberties by focusing what can be done by the Administration in a public health emergency.

This summer, vividly and loudly dominating our TV news and print media, America witnessed a raucous display of distrust of our own elected government in the health care town hall meetings. The President and Congress are seeking to expand access to affordable health insurance, and therefore health care, to all Americans. But some of our fellow citizens, skeptical of anything government does, demonized those who tried to explain the proposals before Congress and shouted down explanations rather than engage in a reasonable discussion of the problems and possible solutions.

The anger over health reform efforts by the national government to help Americans expand their right to life, health and happiness has, apparently spilled over to Massachusetts in the form of anger at efforts under discussion in the state government to protect the rights of all citizens during a time of public health emergency. For more than a century, government has had extraordinary powers to respond to an epidemic, and it has generally exercised those powers responsibly. However, legislation aimed at modernizing and refining those powers to preserve individual liberty while protecting everyone from epidemic has been seen by some as more “big brother” government.

“Life, liberty, and the pursuit of happiness” is one of the most famous phrases in America’s Declaration of Independence. These three aspects, which are listed among the inalienable rights that we all enjoy, are based on the writings of English philosopher John Locke. Locke expressed the fundamental belief that “no one ought to harm another in his life, health, liberty, or possessions.”

However, just saying the words doesn’t guarantee that we have, or can keep, these rights. Each of us must stand up for our rights and the rights of others. In our democracy, we expect our government to preserve, protect, and defend those rights.

Around September 11 each year since 2001, we remember events when a small group of terrorists tried to take those rights away. In fact, they did deprive several thousand innocent civilians and dedicated emergency responders of their lives, health, liberty and possessions. A few months later, one or more individuals tried, once again, to deprive Americans of their inalienable rights when letters containing the deadly Anthrax was mailed to media and government offices. Some postal workers who handled those letters became ill and died.

Most of us believe that our government has, or should have, the authority and the responsibility to take necessary actions to protect us from those who are intent on harming or killing us or depriving us of our liberties. We also expect that our government will take steps to protect us and our loved ones from the spread of deadly viruses or the consequences of natural disasters, even if protecting all of us might temporarily limit our individual freedoms. After all, while we all have basic rights as Americans, most of us understand that we also have a fundamental responsibility not to harm anyone by our individual actions or decisions.

We have conferred on our government the resources and the authority to protect us when society is threatened as with the threat of a major disease epidemic on the magnitude of the Great Influenza Epidemic. That epidemic killed thousands of Massachusetts residents in 1918. In recent months, there have been numerous reported cases of a virus called H1N1, or Swine Flu, that have renewed health concerns and we expect our government to offer protection.

Although Massachusetts, and other state governments, has the authority to require us to be vaccinated, no one has proposed that vaccination for any flu be mandatory. Certainly, there is no H1N1 vaccine currently approved for use, but even when a vaccine becomes available no one is planning to require that we all get vaccinated. Nevertheless, under existing law – upheld as constitutional by the U.S. Supreme Court in the landmark case of Jacobson v. Massachusetts [197 U.S. 11 (1905), mandatory vaccination is deemed “a legitimate exercise of the state’s police power to protect the public health and safety of its citizens.” The state has the authority to vaccinate, but has stated that it will not mandate such action in the case of H1N1.

In an effort to protect all of us from any arbitrary abuse of this authority, legislators and public health experts began to review state public health emergency laws in 2001 following the Anthrax experience. Leading legal and public health scholars from around the nation worked under the guidance of the Georgetown Law School Center for Public Health Law along with public health experts from Johns Hopkins University Medical School to draft a model act to guide state efforts to update public health laws that, in most cases, had not been reformed since the 1918 Influenza Epidemic. To date 45 states have introduced bills in their legislatures based in whole or in part on the Model State Emergency Health Powers Act, and 38 states have passed those bills, including many Northeast states. The Act has become one of the most widely used models for public health legal reform ever.

In Massachusetts, the Department of Public Health, the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts Public Health Association, and others have been working with legislators for the past eight years to craft a bill to update public health emergency preparedness statutes in light of the views of today’s society. As the bill has been developed, it has had several well-attended public hearings and formal debate in both branches of the Legislature. It has been improved with each responsible criticism. The bill under consideration attempts to narrow the current broad state public health authority to protect individual liberties while protecting the rights of all citizens in the spirit that John Locke espoused that “no one ought to harm another in his life, health, liberty, or possessions.”

Contrary to what some have been saying in the media and in blogs, the bill – Senate Bill No. 2028 – does NOT mandate vaccination. It does say that if public health officials believe that vaccination is the recommended prevention measure, and someone does not want to be vaccinated to protect themselves and those around them, the public health officials MAY order that they be isolated or quarantined. While some states ordered quarantines last spring because of H1N1 virus, Massachusetts health officials did not. In fact, throughout the last century, public health officials have used their emergency powers sparingly and responsibly.

The “Pandemic Public Health Emergency Preparedness” bill would allow arrest or entry into property for violations of quarantine, but only if there is “probable cause.” This is a high standard defined by numerous court decisions over the years, and those officials who abuse or ignore that standard get into serious trouble. The bill actually sets a framework of standards in place to narrow the sweeping emergency powers that are already in place so that individuals have legal protection from abuse by any government official. While some who distrust any government are opposing passage of this bill, if they fully understood its purpose and studied the bill in the context of existing law, they ought to be calling for its swift passage rather than protesting and demonizing those who advocate for the law.

Admittedly, no law is perfect or is universally applicable regardless of the circumstances. We are all subject to the errors of being human. Therefore, if there are legitimate concerns with the bill, they can be considered in the coming weeks as the Massachusetts House debates the issue. Even if the bill is passed and signed by the Governor, the bill – as with most complex legislation – will need to have regulations drafted to implement its provisions, and public hearings will give people another opportunity for input. The facts are that those of us who are advocating responsible public health emergency preparedness are not acting out of any nefarious, “big brother” mentality, but out of a genuine concern for protecting the health and lives of all citizens without arbitrary restrictions on the rights of any one citizen. Debate on the issue should focus not on personal and slanderous attacks on individuals, but on the merits of the legislation. A debate on the merits and the substantive issues is another American right, outrageous personal attack against others is not a respected means of dissent – at least not up to now in America!

Our Congressmen, and many of their colleagues across the country, are being subjected to attack from those who don’t want to change how health care is delivered or funded, because special interests and partisan politicians want a system which keeps taking more of our money and delivering less care. Others want to derail reform purely for partisan gain. However, anyone who has studied the trends in health care costs and quality knows full well that individual citizens, businesses, and government can’t afford to keep doing what we’ve been doing in how we deliver or pay for care.

What we need right now is clear, factual information on what the proposals under discussion in Washington will do, not the misinformed diatribes that fill the talk shows, blogs, and yes, town meetings aimed at shouting down any attempt at reasoned discussion. The shouters are denying the majority of people an opportunity to learn and ask the many thoughtful questions that need to be answered before a bill is ultimately passed. We can’t roll up our sleeves and get to work on health care reform if we’re too busy wringing our hands.

As a state legislator who has worked on health reform at the state level and helped to write our landmark Massachusetts Health Reform Law (Chapter 58 of the Acts of 2006), I know that health reform is needed at the national level. Nearly 70% of Massachusetts residents support our state version of health reform which is serving, to some degree, as a model for the plans now being considered in Washington. Our health reform is working and 97.3% of our residents have health insurance. But beyond our borders, many of our fellow Americans aren’t so fortunate.

It’s never been the tradition in Massachusetts to say, “We’ve got our health care law and it’s working pretty well, so we don’t need Washington to share our success with the rest of America.” In fact, we are already getting help from Washington in the form of a Medicaid waiver and significant funding. We would certainly welcome a little more federal help.

Even our successful health insurance law would benefit from national health reform if it helps us to be able to slow the growth of insurance premiums, expand access to more primary care providers, promote the use of electronic health records to improve quality, and reduce mistakes, as well as payment reform that will allow better coordination of care—especially for those with chronic illness.

On the other hand, some of the suggestions under review by the President and Congress could undermine the success Massachusetts, Vermont, Maine, Minnesota, and other states have had that have led the way in health care reform. We need our congressional representatives to understand that reforming health care cannot be a one-size-fits-all proposition. There are other legitimate concerns among physician, hospitals, skilled nursing facilities and others that must be addressed if health reform is to succeed in Massachusetts and in our nation.

If some of our neighbors have other suggestions to achieve reform, let’s hear them. Just shouting “NO” won’t give affordable health insurance to those without access to care; or allow those of us with health insurance and trusted providers to sustain our successful state level reforms. We certainly will never get to tell our Congressmen about our concerns or be able to ask honest questions until the shouting matches end!

Richard T. Moore is a Democrat from Uxbridge who is Senate Chairman of the Legislature’s Joint Committee on Health Care Financing. He is also Chairman of the Special Senate Committee on National Health Reform.

There are also a significant and growing group of our fellow Americans who have no health insurance, have inadequate benefits, or who are worried that if they lose their job, they will lose their benefits.  Estimates suggest that the number of uninsured in the U. S. will grow from the current 46 million to 65.7 million people by 2019 – ten years from now.  How health care is reformed nationally should be of direct interest and concern to all of us, especially to Massachusetts where significant reforms are already being implemented with 97.4% of our people already covered. 

The U.S. House of Representatives and U.S. Senate are now working feverishly to mark up health reform bills over the next few weeks that, if successfully reconciled and enacted into law, will make health care more affordable and reduce the cost of care.  Everyone – individuals, families, employers, taxpayers, health care professionals, insurers – has an important stake in the outcome of the growing debate.   It is President Barack Obama’s top domestic legislative priority.

We know from the media that the Obama administration and congressional leaders have made a very public commitment to build on the existing employer-based insurance system.   The President has promised that those of us who like our health coverage and who like our current health care provider are likely to be able to keep that coverage and that provider.  We can also expect that the costs might not rise as fast and the quality of care will remain or improve if the new law includes many of the provisions that are under consideration on Capitol Hill in Washington.  The principles under discussion are: coverage for all; right care at the right time in the right place; insurance market reform; and individual coverage mandate; determining how to pay for the cost of reform; and the possibility of a public option for providing affordable insurance.

The specifics of the national health care reform bill are still not finalized given the many, often competing ideas under consideration.  Congress is working to have proposals from each branch finalized by the end of July to be negotiated in conference committee during August and September. All of us in Massachusetts hope that it succeeds in ways that complement the progress we’ve made and, perhaps, provides additional resources to support the steps we’ve taken.  We certainly hope that it also strengthens and hastens our efforts to improve health care quality and safety, and to reduce costs and wasteful practices.  A very hopeful bi-partisan proposal presented by the Brookings Institution also has advanced the idea of a comparative effectiveness institute to make sure that medical procedures being used on us reflect the best and latest scientific research.

The Massachusetts Senate has established a special committee to follow the unfolding debate on national health reform and to guide our Congressional delegation as they work on this important policy.  The special committee will be holding informational meetings with experts on our Massachusetts plan and how it could be complemented or harmed by provisions under consideration in the Congress.  We will, then, be better able to advise our state’s Congressional delegation, especially those who along with Senator Kennedy and his staff, are working directly on committees with jurisdiction over various components of the national reform plan.  Every citizen can become informed about national health reform through the media.  Those who want to follow the developments at the national level can also do so through www.healthreform.gov.

Richard T. Moore is the Chairman of the Special Senate Committee on National Health Reform. He was among the key leaders in developing and implementing the landmark Massachusetts Health Reform Law (Chapter 58 of the Acts of 2006) and the Health Care Quality Improvement and Cost Containment Law (Chapter 305 of the Acts of 2008).

Beginning with the 2005-2006 Session, the Legislature laid the foundation for a Healthy Commonwealth with the passage of our landmark health care reform law – Chapter 58 of the Acts of 2006. In addition to expanding access to affordable health insurance, the reforms included development of a statewide infection control program, the creation of the Health Care Quality and Cost Council to set quality improvement and cost containment goals, initiation of a first-in-the-nation pediatric palliative care program, and enhancement of the state’s prevention agenda. Several other important steps such as the purchase of hypodermic needles without prescription also contributed to improving the health of the people of the Commonwealth.

By 2008, Massachusetts achieved nearly universal health coverage with an estimated 97% of her citizens with health insurance. These reforms have received much attention and praise both here at home and across the nation. Significantly, the Massachusetts example and reform principles are among the building blocks for national health reform being discussed at the federal level. However, the changes enacted in Health Reform I were just the first steps toward creating a world-class health care system for everyone in our Commonwealth.

During the 2007-2008 Session, the Legislature took another major step toward that system. Recognizing that to sustain, and move beyond the dramatic gains being realized with the passage of Health Reform I, key quality, safety, and cost control measures were needed. The signature bill of the most recent session is Chapter 305 of the Acts of 2008 – An Act to promote cost containment, transparency and efficiency in the delivery of quality health care.

This comprehensive measure established the statutory foundation for greater transparency in health quality and cost for consumers and providers, set realistic goals of moving health care into the 21st century with dramatic expansion of e-health initiatives and health information technology, provided mechanisms for real cost containment, established programs for expanding the availability of primary care providers, and established goals and benchmarks for measuring progress toward improved quality and cost containment.

The legislation also set in motion the opportunity for dramatic reform of health care through a review of health care payment which could trigger fundamental change in how health care is delivered in Massachusetts. While some providers may simply hope for more money, the goal of payment reform needs to address a more effective use of existing resources and funds as well as compensation for a different delivery model along the lines of “medical home” care delivery, especially for managing those with chronic disease.

Some examples of other pieces of legislation that lay the groundwork for different delivery models, successfully passed by the legislature this past session, are Public Health Regionalization and Collaborative Drug Therapy Management. The regionalization bill strengthens the Massachusetts public health system by pooling the resources of multiple towns to provide state and local municipalities with the means to deliver public health services more efficiently and effectively.

Additionally, the collaborative drug therapy bill pools resources and improves pharmaceutical care for patients by combining the skill and expertise of physicians and pharmacists and enabling them to collaborate their practices, which has been shown to increase patient safety while also reducing medication errors as well as health care costs.

With all of these accomplishments behind us, there is still much progress to be made on the road ahead. Massachusetts has become one of the pioneering leaders of health care reform in the United States, and it should remain so as we capitalize on the popular sentiments of change and hope. Recognizing this, on Monday, I will be officially releasing “A Healthy Commonwealth 2012 – Progress Made… Challenges Ahead,” as my health care legislative agenda for the 2009-2010 legislative session. It is the Second Edition of “A Healthy Commonwealth 2012,” which was originally released by me in January 2007. It builds off the foundation established by the landmark health care reform achieved in Chapter 58 of the Acts of 2006 – which was inspired by then-Senate President Robert E. Travaglini, and the equally impressive Chapter 305 of the Acts of 2008 – crafted under the leadership of Senate President Therese Murray.

The bills that comprise “A Healthy Commonwealth 2012 – Progress Made…Challenges Ahead” collectively represent the third phase of the state’s health reform agenda. Each of these initiatives will bring Massachusetts even closer to the goal of quality, affordable health care for all, and will help to grow and stimulate the critical health care sector of our state’s economy. The major features of “Health Reform III” include: health care payment reform; further strengthening of health care reform; comprehensive prevention and wellness strategy; stronger leadership in health care quality improvement and cost containment; strengthening the DON review process and protecting community hospitals; health care workforce and workplace improvement initiatives; medical malpractice reform; and further regulation on the Pharmaceutical Industry.

I encourage you to view the full agenda of “A Healthy Commonwealth” here and urge you to comment with your thoughts on “Health Reform III,” and the challenges that lie ahead.

Senator Richard T. Moore
Co-Chair, Joint Committee on Health Care Financing

“We’ve given each other some hard lessons lately,
But we ain’t learnin.’
We’re the same sad story, that’s a fact;
One step up and two steps back.”
Bruce Springsteen – 1997

These are among the words of the title song of a Bruce Springsteen album a decade ago talking about blue-collar woes, lost loves, found loves that didn’t pan out, and lives chafing against the status quo. They could just as easily be the theme song for those of us working to advance health reform during an economic recession.

Massachusetts’ landmark health reform law passed in 2006 has, according to the Connector Authority’s October 2008 report, achieved an unparalleled 97% health insurance coverage. About half of that coverage is privately paid by employers and workers, and the rest is paid by taxpayers either completely or with some individual financial participation. The Commonwealth is on the verge of providing virtually universal health coverage, and the individual stories of lives saved are truly heartwarming!

Surely, no one can again ask if it’s possible to achieve universal health coverage. But now we must ask, for how long? Health care in America is expensive, and the cost keeps rising. The cost is also hard to justify when matched with outcomes in the quality and safety of the care! Making health care reform sustainable was the focus of Chapter 305 of the Acts of 2008, Senate President Murray’s “Health Reform II” – the Quality Improvement, Cost Containment legislation.

In an economy that will, undoubtedly, make more people eligible for tax-supported health care coverage because incomes will slip below the federal poverty level standards, and more employers and employees will reduce coverage to cut costs, the historic expansion of coverage achieved in Massachusetts is now at risk. However, in our zeal to find budget savings, we must not make it more difficult to maintain our successful experiment in health reform or to sustain that reform in the future by cutting back efforts to improve health quality and safety or to contain spiraling cost increases.

Among the 9C cuts announced recently by the Patrick Administration were reductions in the funding for expansion of primary care providers or electronic health technology; and for continuing the work of the Betsy Lehman Center for Patient Safety, the Massachusetts Quality and Cost Council, and the Statewide Infection Prevention Program. In a period when cutting back, reducing expenses is required by tough economic times, there is a tendency to wrongly focus only on the short-term savings. We’re missing the larger picture of health reform sustainability through quality improvement and cost containment. These cuts fit the definition of the old adage of being “penny wise, and pound foolish.” They irresponsibly undermine our state’s ability to sustain health coverage, not just for the working poor, but for all residents of Massachusetts!

The Betsy Lehman Center, named for a woman who was the victim of medical mistakes, has demonstrated the need for focusing on safe best practices in health care. At a time when one-third of patients responding to a Kaiser Family Foundation/Harvard School of Public Health Survey on Consumer’s Attitudes on Patient Safety report having been personally involved in a preventable medical error, we should not be curtailing efforts to improve health care safety.

When the Institute of Medicine, in its Guidelines for Clinical Practice, reports that “the evidence base for known effective and safe care–especially medical practices–is limited,” does it make sense to cut the Lehman Center or to wipe out the staff of the Quality and Cost Council, especially when the Council is just beginning to share comparative data on health providers?

Research has demonstrated that e-prescribing and electronic health records, as well as expanding access to more primary care providers over higher costs medical specialists can save lives, but also trim millions of dollars in avoidable costs in the delivery of health care. It will take much longer to achieve these goals and send the wrong message to health care providers and their patients by cutting programs designed to improve the effectiveness of health care delivery.

If the Patrick administration and the Legislature hope to close the revenue gap and restrain budget growth in years to come, reining in the cost of health care, improving quality and safety, and expanding access to primary care providers needs to be a priority. The latest round of state budget cuts suggests that they are not!

Senator Richard T. Moore
Co-Chair, Joint Committee on Health Care Financing

If a small portion of businesses continue to get away with shifting the cost of their uninsured workers to others – including the substantial portion of businesses who help cover the uninsured through the Safety Net Care assessments, as well as paying for their own employees, how will Massachusetts support universal coverage? The businesses that already pay the Safety Net Care assessments got a hint when the state approved recently a supplemental budget that provided “one-time” increases to those assessments. Let’s remember that the “fair share” contributions were considered a more reasonable solution to funding health reform than an across-the-board payroll tax. If some businesses continue to enjoy avoidance of the “Fair Share” contribution, those who already pay for employee health insurance will be faced with closing the gap.

The Patrick Administration’s proposed changes to the Employer Fair Share Contribution regulations governed under M.G.L. c. 149, §188(a) deserve to be implemented! When the legislature, supported by a wide-ranging coalition, originally drafted and negotiated the terms of the Chapter 58 Health Care Reform Act, our intent was to equalize the burden of expanding health care access among all employers. The regulations that were implemented shortly thereafter failed, however, to effectively represent the intent of this historic health reform funding compromise, and the impact of that failure is evident in the underperformance of revenue generated from employer contributions. Now that we can assess the true impact of the Fair Share Contribution regulations as implemented under the Romney administration, we can see that our employers have not met the contribution goals that we had anticipated, and it is crucial, now more than ever, to make sure that employers put forth as much as all other stakeholders are being asked to do. These new regulation amendment proposals do not demand anything more of our employers than was expected of them at the outset.

In July of 2006 I wrote to then-HCFP Commissioner Amy Lischko, a letter assessing the proposed draft regulations at that time. In that letter I stressed that it was not the intent of the legislature to exempt employers from the fair share contribution if they simply “offered” insurance to their employees. My proposal at that time (and as it still remains) was that that primary and secondary test be combined so that not less than 25% of employees must be enrolled in the employer’s plan and the employer must contribute to the plan. In addition, I stated clearly that “my recollection of the Legislature’s discussions on defining a ‘fair share employer’ was that employers would be expected to contribute at least fifty percent of the premium cost.”

In fact, at the time of the negotiations (which included leaders of the business community) that ultimately helped forge the historic compromise dropping the House proposal for a business tax, legislative leaders were assured that no Massachusetts insurance company would write a group health insurance policy with less than fifty percent participation by employees and that employers generally contributed above fifty percent of the cost. In fact, the average employer-sponsored health insurance package in the state includes seventy-two percent employer contributions. Therefore, it seems unfair to the ninety percent or so of employers in our Commonwealth who have been providing health insurance for their employees to let a small percentage coast along not paying their fair share. I continue to support my proposal to require at least a fifty percent contribution by employers in addition to a fifty percent participation rate by employees. While the current proposed amendments stop short of increasing the contribution and participation rates, I applaud your efforts to continue to move us in that direction.

Originally, we had anticipated $45 million dollars in revenue from the Fair Share Contribution, but the state has only received $7.4 million. This discrepancy in numbers leads me to believe that employers are getting off for less than what was originally bargained for. At this point in time, we are not requesting that the employers pay anything more than what they had agreed to when the Health Care Reform bill was signed into law. These new regulations anticipate an influx of $33 million dollars in revenue, which would bring us much closer to what we had originally calculated into the equation as far as shared employer responsibility. The low-income recipients of CommCare have been asked to pay more, and so have hospitals and health plans. It is crucial that all stakeholders contribute equally in order to ensure the continued success of Health Care Reform.

Senator Richard T. Moore
Co-Chair, Joint Committee on Health Care Financing

The Massachusetts Legislature recently adopted a comprehensive proposal to improve the quality of health care and to contain the rapidly increasing cost of care. Both goals are essential to sustaining the Commonwealth’s landmark health care reform law and keeping high quality health care affordable to all our residents.

Some of the most exciting and meaningful reforms in the bill – promoting reform and efficiency in the health care system, improving access to health care services, enhancing transparency of health care costs and quality, and encouraging the adoption of health information technology – will dramatically improve the care provided in Massachusetts as we expand access to care for all of our residents. However, one provision of the bill – regulating drug marketing practices – has generated heated, but not well-informed, discussions with representatives of the bio-pharma industry.

Those of us who helped to draft the Massachusetts Health Care Quality Improvement and Cost Containment legislation firmly believe that marketing practices of pharmaceutical and medical device manufacturers are an important factor in driving up health care costs without, necessarily improving the quality of care that’s delivered to patients here, and across the country. There are numerous books, articles, and academic research papers that clearly demonstrate the pervasive, even corrupting, influence of such marketing practices as gifts, travel, honoraria, and other valuable incentives offered by industry to those with the state licensed power to prescribe medication. Legislators are not alone in our sincere concern.

Dr. Mark A. Levine, Chair of the American Medical Association’s Council on Ethical and Judicial Affairs recently wrote: “While industry and medicine share the overall goal of improving health, their interests and obligations diverge in important ways. Commercial entities have a responsibility to their shareholders and other vested stakeholders to thrive as businesses and maximize returns on investment. Medicine has a responsibility to put the needs of patients first. As relationships between medicine and industry continue to expand, there is growing concern about the impact of industry funding on the integrity of professional education and its implications for public confidence in medicine as a profession.”

As Harvard Pilgrim CEO Charlie Baker wrote in his blog: “A task force that was put together by the Association of American Medical Colleges to study industry funding of medical education just issued a report that recommends, among other things, banning free food, gifts, travel and other services to doctors, staff and students at medical colleges. The report will be reviewed by the AAMC’s Executive Council shortly. He added that, “David Korn, the AAMC’s Chief Scientific Officer, didn’t deny the need for ongoing interaction between practicing clinicians and pharmaceutical and device manufacturers, but said, in effect, that whatever happens needs to be cleaned up, transparent, and tied to the specific practice of medicine.”

This is exactly the goal of Section 14 of Senate Bill No. 2863 which would add a new chapter to the Massachusetts General Laws – Chapter 111N “Pharmaceutical and Medical Device Manufacturer Conduct.” It directs the state Department of Public Health to develop regulations to establish a standard marketing code of conduct for all pharmaceutical or medical device manufacturing companies that employ a person to sell or market prescription drugs or medical devices in the commonwealth.

It’s important to understand that this new code must be based on applicable legal standards and incorporate principles of health care including, without limitation, requirements that the activities of the pharmaceutical or medical device manufacturer agents be intended to benefit patients, enhance the practice of medicine and not interfere with the independent judgment of health care practitioners. In other words, the Massachusetts law puts patients first, the integrity of physicians a close second, and enhancing corporate profits further down our list of priorities.

These regulations that DPH develops must be no less restrictive than the most recent version of the Code on Interactions with Healthcare Professionals developed by the Pharmaceutical Research and Manufacturers of America and the Code on Interactions with Healthcare Professionals developed by the Advanced Medical Technology Association. In other words, the codes that the industry itself has developed would be the basis for the Massachusetts code, and it will be legally enforceable if violated – something that the industry code does not provide. If the industry is serious about its own code of marketing and wants its member companies to follow, how can it be opposed to adopting that same code as the law for such companies doing business in Massachusetts?

The other industry concern – some say “red herring” – relates to the requirement to report payments to physicians in excess of $50 per year. Drug companies suggest that this reporting requirement and subsequent public disclosure will put them at a disadvantage to competitors in other states. However, information from all clinical trials is already public information through a federal clinical trials database. Other states already collect and publish information about research and clinical trials. Certainly, if there are any legitimate issues with the reporting and disclosure provisions, the Department of Public Health can address them in the regulations that must be developed to implement this section of the Quality Improvement and Cost Containment Law.

Massachusetts is not alone in passing legislation to require reporting of payments by pharmaceutical and medical device manufacturers to those who prescribe medication for their patients. Minnesota, Vermont, Maine, the District of Columbia, and West Virginia have all enacted laws to achieve this goal. Eleven other states, including New York and California have seriously considered legislation of this type during the current term, and more will undoubtedly take action in the next session. In every case, the pharmaceutical industry has vigorously opposed such legislative initiatives claiming that they can regulate themselves. However, professional lobbyists for the Pharmaceutical Manufacturers Association traveled all the way from Washington, DC to Boston to testify in opposition at a public hearing on a similar bill that was considered during the current session of the Massachusetts Legislature.

Massachusetts sincerely values the research and products of the Bio-pharma industry. We believe that the industry is a vital part of the state’s economy, and we’ve offered to invest a billion dollars to encourage the development of that industry in the Commonwealth. We accept the word of the industry – as stated in their marketing codes – that the industry wants to preserve the integrity of the medical profession. And our legislation will help them attain this most laudable goal. Therefore, we urge the Governor to sign the Senate Bill No. 2863 into law without amendment!

Senator Richard T. Moore, Senate Chair, Committee on Health Care Financing