What happens next in state, national health care?
The Supreme Court upheld the Affordable Care Act on Thursday, setting in motion a federal law that requires most Americans to obtain health insurance. Massachusetts has been down this road before, when it became the first state to pass universal health care in 2006. To find out what’s next in health care, the Globe conducted a roundtable with industry leaders: Lynn Nicholas, chief executive of the Massachusetts Hospital Association, a trade group; Robert Restuccia, executive director of Community Catalyst, a consumer advocacy organization; James Roosevelt Jr., chief executive of insurer Tufts Health Plan; and Azzie Young, chief executive of Mattapan Community Health Center. Here’s an edited excerpt:
GLOBE: How significant a moment is this for the health care system?
NICHOLAS: The family of health care here in Massachusetts, which is a very large extended family, was absolutely elated. It is an incredible historic moment for the Commonwealth, for the leaders who did health reform, and validates the leadership that being a commonwealth is all about.
YOUNG: It’s a great moment for community health centers. It means more access to more individuals in more communities across the state, across the country.
RESTUCCIA: It’s very exciting for the rest of the country to see that Massachusetts reform is the model, and we’re going to be moving forward on it.
ROOSEVELT: It’s a great moment for the American people in terms of the improvement of their well-being and their access to health care across the country. And it’s great that the country has our model of success over the last five years in Massachusetts so that they’re not just going into this with fears.
GLOBE: What lessons have we learned in Massachusetts since the 2006 law passed that are relevant to the nation’s transition to universal health care?
YOUNG: We have 97 percent coverage — that’s almost universal health care in this state. Moving ahead to implementation, one of the things we would suggest [to other states] is you elect a governor like Governor Patrick — he appointed individuals who could implement the law.
NICHOLAS: We can’t say every single thing about this is Kumbaya and wonderful, but there are some lessons learned. One of them is that you expand the Medicaid population, and bring more and more deserving individuals under coverage. In that respect, that part of the state’s budget gets larger and larger, and then it becomes a target.
In Massachusetts, as enrollment has just gone up, payments to providers and health plans that do Medicaid-managed care and work with providers to community health centers, etc., have not kept up. And when we did our reform, there was a stated promise to improve the Medicaid payment to the cost of care. That started happening for a couple of years and has precipitously declined. That’s a lesson learned — you can’t do the expansion at the sacrifice of paying adequately for the coverage.
RESTUCCIA: One of the most important lessons we bring to other states when we talk about Massachusetts reform is its impact on racial and ethnic minorities. It is quite remarkable what the reform has done — basically eliminating the disparity in health insurance among blacks and Hispanics. Most of us never thought it was going to happen.
GLOBE: What are some of the provisions in the national law that are not part of the Massachusetts law?
ROOSEVELT: One already in effect is no copays and deductibles for preventative care. That comes from the federal law; we do not have that in Massachusetts.
Secondly, all children up to age 26 are eligible to be covered under their parents’ policies. In Massachusetts, that was limited to people who were within two years of still being dependents on their parents’ federal tax return. That has to do with the fact that only the federal government can say that it’s not taxable income. So that could only be in the federal law.
But the big change is making people eligible for Medicaid up to 400 percent of the federal poverty level, instead of 300 percent.
And of course, only the federal law could reduce the cost of prescription drugs under Medicare, because Medicare is a federal option.
YOUNG: For health centers, we have always been positioned to serve the broader population of low-income individuals, and with this law we’re going to have more health centers, more access. We can serve more people. We’re going to look at wellness care instead of illness care.
GLOBE: While the majority of Massachusetts residents like the state law, polls say the majority of US residents don’t like the individual mandate. How much more turmoil is the nation going to go through before the issue is finally settled?
ROOSEVELT: I’ve looked at those polls in detail, and the majority here even supports the mandate. These are people who’ve lived under it. The federal law, there’s a small margin that comes out against the law overall, 5 or 6 percent. If you break it down in the federal law, every single provision — usually comes out favorable in the polls, except the mandate. People don’t know what the mandate means to them yet. They don’t know that if you have actual insurance, you don’t have to pay it.
Secondly, they don’t know that the federal mandate is less than half as expensive as the Massachusetts mandate, and people have learned to live with that here and realize the benefits from it.
This is a key thing — supporters of the law, in particular the president and the Democrats running for Congress, have to explain the law much more clearly than they have up to now.
I have this hunch that until we had the Supreme Court ruling, supporters were afraid to go into a lot of detail explaining it, because if it was found unconstitutional, they would be made to look bad. Now, they’re freed up to do that.
RESTUCCIA: You look at the claims that this is the largest tax increase in history, well, just think about Massachusetts, and how many people are paying [the penalty]. It’s 48,000 people out of 6 million. So where do you get the largest tax increase in history?
The individual mandate, it’s complicated, and I can understand why people have concerns about it; but it’s fundamentally individual responsibility, and our responsibility to each other.
If [people] can afford it, and they get health care, and we have to pay for it, we’re asking them to contribute.
NICHOLAS: We’ve got to do a better job of explaining what this means for patients in real life. We know the drivers of health care are chronic disease. It’s not someone choosing to have a knee replaced or not; it’s people with diabetes, overweight, obesity, congestive heart failure, asthma, and all that. We need to repackage the dialogue away from it’s an insurance mechanism to it is a model of care that is better care for you and your family.
GLOBE: Since the federal tax is so low — in some cases just $95 — on people who can afford health insurance but choose not to buy it, is that going to work? Is that going to get them to buy insurance?
ROOSEVELT: That’s a concern. It would actually be better if it were closer to the Massachusetts level [starting at $228 a year] because it’s pegged to essentially the equivalent of a premium for getting coverage. So that would be a more direct connection.
However, we’ve seen in Massachusetts, for most people, the concept that this is what you’re supposed to do, just like you’re supposed to get a driver’s license, just like you’re supposed to have fire insurance on your house even though the fire hasn’t started yet. I think that having a tax that you have to pay only if you don’t do what you’re supposed to do, [that] does change the whole mind-set in the country.
GLOBE: Talk about your own organizations, and how they’ll be affected by the ACA.
YOUNG: Mattapan Community Health Center is in the process of building a new health center. It’s more than doubling the space that we have right now, so that means we’ll be able to serve more individuals, have more visits. All of this was made possible through [federal stimulus funding].
There are a lot of health centers now that have new buildings, preparing to serve the additional individuals who will be insured. Health centers in general have about 20 to 30 percent uninsured annually. Hopefully we’ll be able to bring that number down and have more and more individuals get care.
NICHOLAS: There are cuts that are coming to all hospitals nationwide to help pay for the [additional] coverage. Even though we already made those sacrifices at the state level, we’re still getting those cuts. And not just hospitals — community health centers and other providers. It amounts to over $5 billion starting in 2010 and ending in 2019 in Massachusetts. Almost all of that $5 billion is directed to hospitals.
But there’s additional cuts coming on top of that. Those were done to implement the ACA. We have cuts coming in Medicare and Medicaid. Because Medicaid pays 71 cents on the dollar [for medical care] — and Medicare pays 92 cents on the dollar — most Medicare recipients don’t realize that every time they go to the hospital the hospital loses money on you. There’s a lot of financial pain yet to come.
ROOSEVELT: There is a tax on health insurance premiums for so-called fully insured, and that tends to be individuals and small businesses, as opposed to self-insured. For for-profit insurers, that’s a 4 percent tax, for nonprofit that’s a 2 percent tax. We don’t like to see anything that increases premiums. And yet there had to be cobbled together in the bill a number of sources to pay for the expansions of coverage.
On the other side, we at Tufts Health Plan include Network Health, which is a Medicaid plan. I hope and believe Massachusetts will opt into the further expansion of Medicaid.
RESTUCCIA: Community Catalyst works with organizations in about 40 states. We’re working all over the country around implementation of the Affordable Care Act with advocates in their states. Part of our job is to take the experience in Massachusetts and explain what’s happening here in other states. Some of it’s around outreach and enrollment in other states.
But as you look across the country, how lucky we are to have an administration that really wants to move forward on the ACA. Because when you go to Louisiana and you read [Governor] Bobby Jindal [saying] that Republicans must drive hard toward repeal [that] “this is no time to go weak in the knees.” The advocates in that state are in a very different position.
GLOBE: Assuming the law is not repealed, look 10 years into the future. Will we have better, more affordable health care?
RESTUCCIA: When I think about Louisiana, Texas, Florida, it’s actually a revolution there. This is the biggest thing since the Civil Rights Act. We just do not understand the impact that it’s going to have in states like that, where you have 25 percent uninsured or close to it.
You just think about those people getting health care, what’s that going to mean? The workforce issues, think about the money that’s going into that state. I mean it’s crazy that these governors are opposing the ACA. It’s going to be an amazing experience for those people.
GLOBE: Azzie, do you think things will be better in low-income communities, health care will be better?
YOUNG: Absolutely, I do. Basically, we’re going to have more health centers around. We will, hopefully, have more and more health care providers available to us to make all of this work. Because just having an insurance card doesn’t necessarily give you access.
With the ACA, and particularly with earmarks for community health centers, we expect to expand, as well as improve where we are now with existing health centers. The future is bright, and with all of our health care partners, we’re going to be able to build a healthier Commonwealth, a healthier America.
NICHOLAS: We will, regardless of what happens with the Affordable Care Act, have a more effective, affordable health care system in the Commonwealth. We may have fewer hospitals in the future, but we’ll probably have more sites for primary care, and our hospitals will be working more in systems of care. They’ll be aggregated to really provide more value, and chase volume less.
A big unknown is people’s personal responsibility for their care. If we don’t crack the nut on obesity, smoking, and all the factors that drive bad health in the first place, it will be harder to get there, so that’s the next new battle when we get all the technical things worked out, but I’m very hopeful. Hospitals will do better in the long run. In the short run, many will suffer greatly with these cuts, and I expect that we will lose some hospitals in the process.
ROOSEVELT: We will have a healthier country. Right now, we’re 27th in the world in health care outcomes. We can start moving that by having universal coverage. There are over 50 provisions that have to do with more effectively delivering care and encouraging wellness and treating or eliminating chronic disease.
Coverage is sort of the first step so you don’t feel, “I can’t get nutrition counseling, or I can’t get a flu shot.” The next steps are all the ways that you actually get to the treatment programs that you need, and to the advice that you need on how you keep you and your kids healthy.