I was born and raised in Massachusetts. I offer that disclaimer lest anyone think that I am picking on our friends in the Bay State. To the contrary, if you’ve spent any time in the state, you know that some of the residents — particularly those in and around the state capitol of “Bawstin” — have a wonderfully rich dialect and a unique vocabulary. As we review the state’s three-year experiment with health insurance reform, it seems right to appropriate some of that local color to add a bit of authenticity.
The title of the 2006 legislation was, “An Act Providing Access to Affordable, Quality, Accountable Health Care.” Governor Mitt Romney’s goal was to reduce the number of uninsured residents. They have accomplished that goal, reducing the number of uninsured from 8% to 2.6%. Bravo! Regardless of how the uninsured are counted, or what the number may be, adding more people to the rolls of the insured is laudable.
While the governor’s goal has been met, it is unsurprising that unintended, yet entirely foreseeable consequences have kept the state from achieving the three criteria (access, quality and accountability) enumerated in the act’s title. At least one of those objectives has been significantly undermined over the past three years. Access to providers, which was difficult in the state prior to the legislation, has deteriorated significantly.
A recent study by Merritt Hawkins and Associates revealed that the average waiting time to get a doctor’s appointment had increased nationwide. Merritt Hawkins is a consulting firm specializing in recruiting physicians and other health care professionals. In this survey, it contacted 1,150 medical offices in 15 cities, and surveyed family practices as well as four specialties: Cardiology, dermatology, obstetrics/gynecology and orthopedic surgery.
Merritt Hawkins wanted to learn how long someone new to the community would have to wait to schedule a non-emergent physician appointment through a generally accessible source, such as the Internet, the Yellow Pages or a PPO Physician directory. The conditions for which they were requesting the appointments were routine: A heart checkup; a routine skin exam to detect possible carcinomas or melanomas; an injury or pain in the knee; a routine “well woman” gynecological exam; or a routine physical at a family practice.
The nationwide average wait is 20.5 days, but residents of Boston wait an average of 49.6 days to see a physician. The next longest wait is in Philadelphia, where it takes an average of 27 days to get an appointment. The survey says, “Long wait times in Boston may be driven in part by the health care reform initiative that was put in place in Massachusetts in 2006.” Based on its results, Merritt Hawkins delivers the following caveat: “Long appointment wait times in Boston also may signal what could happen nationally in the event that access to health care is expanded through health care reform.”
A second strike at the heart of the Massachusetts reform initiative is that the cost of the plan and the subsidies has risen exponentially and has exceeded projections. In May, the Massachusetts Taxpayer Foundation concluded that the state budget spending on health reform has grown from a base of $1.041 billion in fiscal year 2006 to a projected $1.748 billion in fiscal year 2010.
The Massachusetts plan is a pay or play variant. Employers with 11 or more employees who do not offer health insurance pay a penalty of $295 per employee per year. Early information indicates that some companies in the state have chosen to pay the penalty. The Massachusetts Division of Health Care Finance and Policy reports that 1,023 employers have opted out of providing health coverage.
Yet coverage through employers appears to have increased. According to the Massachusetts Association of Health Plans, from Jan. 2007 to Jan. 2008, the number of people with employer-based coverage increased by 85,000. The Boston Globe (July 10, 2009) reported that this number has increased to 150,000 in the past year. Most observers believe that this increase is due to the individual mandate that was an integral part of the legislation.
Yet, behind those numbers are a growing number of stories of employers offering coverage but compensating for the cost by hiring fewer employees or closing offices. Some employers have decided to contribute to their employee’s insurance, but have elected to curtail bonuses or some raises. For every action there is a reaction, and the shadow of California and its employer mandates hangs over any health reform discussion that increases costs for employers. No one wants to win the battle but lose the war.
Mindful of the cost increases and the widespread consequences they bring, the legislature created a panel comprised of key state legislators, as well as associations representing doctors, hospital associations and insurers. This commission suggested that the state stop paying doctors and hospitals for each visit or procedure, but instead pays a monthly or annual fee per patient. The headline in the Wall Street Journal (July 17, 2009) read, “In Massachusetts, a New Idea for How to Pay.” In the “old days,” I think we just called it “capitation.”
The commission said that the current fee-for-service arrangement “rewards overuse of services and is a primary contributor to the problem of escalating costs and pervasive problems of uneven quality.” They believe that their recommendations would provide the “efficient delivery of the full range of services that most patients need.” I don’t know whether the insurance industry should laugh or cry. After years of excoriating insurers and HMOs for capitating physicians, the payment shoe is now on the other foot and it seems to be pinching a bit.
Yet it may surprise you that the real warning to be taken from the Massachusetts experiment is neither longer waiting times nor increased costs and been-there-done-that payment models.
Politicians need to spend the public’s money the same way human beings need to breathe. They can’t seem to help themselves, and “Tax-achusetts” legislators are among the best — or worst — of them. Amidst the climate they’ve already created, this year’s legislative session will deal with more than 70 bills that would exacerbate the already mounting costs of their over-budget system by adding a myriad of mandates.
These bills — twice the number introduced in the last legislative session — would mandate coverage for everything from hearing aids for children to aquatherapy and vitamins. Of course, should any of the initiatives proposed by these “chowdaheads” actually pass and become law, “you know who” will get blamed when the cost of the new mandates are reflected in the premiums charged.
This is the real danger of allowing politicians to get involved in health care. The second and third bite of the apple is always bigger and more damaging than the first. Even as they applaud the state’s efforts at reducing the number of uninsured, Massachusetts residents must feel as though they’ve been taken to the “cleansers.” Let’s hope that Congress takes note of this “bizah” behavior before we all end up in the soup ... er ... “chowda.”
David Saltzman, RHU, is a past president of NAHU and has been a health, disability, life and employee benefits broker for more than 25 years. He is director of the large group segment for Carolina Care Plan. Readers may write to him at Carolina Care Plan Inc., 201 Executive Center Drive, Columbia, SC 29210.