Health Care — a coming concern

If the Trump agenda gets through Congress, it will be very costly for Massachusetts. The biggest single hit will come from the changes in the federal health care law.

The Trump health care changes may not take effect until 2020, but even without those changes the Massachusetts health care model is under stress.

The good news is that we have a very low uninsured rate — Massachusetts citizens have access to health care. And I’ll fight to protect that access.

Yet many who have coverage from their employer (whether public sector or private sector) are facing rising co-pays and deductibles and many of those who buy their own insurance are facing premium increases that they cannot afford.

One of the most troubling indicators of stress is this: Over the past five years, the population with commercial insurance has actually dropped by 450,000 people, down from 65% of Massachusetts residents to 58% of Massachusetts residents. In some instances, employers have dropped coverage. In others, people with low income have voluntarily shifted from employer coverage to MassHealth because of the high co-pays and deductibles on their employer provided plan.

In the same five-year period, while the uninsured rate has remained low and our economy has prospered, enrollment in the MassHealth has grown by 523,000 to almost 2 million people, nearly 30% of the state’s population. The number for whom MassHealth is the primary insurer has grown from 14% to 21% of the state’s population. MassHealth also provides supplemental insurance covering out-of-pocket costs for many on Medicare or commercial insurance.

MassHealth is the state’s combination of Medicaid and the Children’s Health Insurance Program.  It is the single biggest state program. Alone, it accounts for almost 40% of the state’s budget (although currently, the federal government reimburses more than half of that cost).

As an insurer, MassHealth appears to be doing a lot of things right. The MassHealth team is placing a lot of emphasis on program integrity — preventing “waste, fraud and abuse” and policing eligibility carefully. They are also embracing strongly the concept of accountable care organizations — organizations combining hospitals, doctors and other providers to work together to provide high-quality, cost-effective care for patients.

The cost per covered patient has grown only very modestly — rising under 2% per year over the past 10 years. And, at the same time, MassHealth is making progress on providing more and better care for people with substance use disorders.

Yet, with enrollment growth of 70% over the past 10 years, MassHealth’s total spending has roughly doubled. The Governor has proposed $41.0 billion in total state spending in Fiscal 2018, an increase of $1.3 billion or 3.2% over estimated total state spending of $39.7 billion in FY2017. Of that total increase of $1.3 billion, Masshealth accounts for $1.2 billion, making meaningful increases for other important priorities like local and education aid essentially impossible without new revenues.

The Governor has proposed a new “contribution” for employers who do not provide health care coverage for their employees. This proposal speaks directly to the problem of rising MassHealth enrollment — it might lead more insurers to preserve or reinstate coverage. At the same time, it would raise an estimated $300 million in FY2018 — creating just a little headroom for other priorities. The “contribution” would be required from all employers with over 10 employees.

This proposal has drawn substantial opposition from the business community — it is certainly a substantial charge that will loom largest for businesses that are least profitable and/or pay the lowest wages. Massachusetts included in its original 2006 health care reform proposal a much smaller charge which was repealed in favor of the national employer mandate in Obamacare. However, the national mandate has never actually been imposed, which is one factor contributing to the slide in employer provided health care coverage.

Rising health care costs are the root cause of the stress in the system as a whole. Massachusetts has among the highest systemic per patient costs in the world. In 2012, we put in place a host of measures to control systemic costs, but those have not been sufficient to alleviate the pressure that many individuals and public and private organizations are experiencing.

The Governor has proposed new direct controls on costs, but these have also attracted opposition The concept of “controlling health care costs” is a mixed bag politically and economically — health care is one of our employment engines in Massachusetts.

We need to preserve access to health care.  At this stage, I’m not offering a personal recommendation, but really looking for ideas and resources. I know that many of my constituents have more expertise than I do on this issue.


  1. Testimony of Secretary Mary Lou Sudders, March 21, 2017
  2. Testimony of Assistant Secretary Daniel Tsai, March 21, 2017
  3. Materials provided by Secretary Mary Lou Sudders on federal changes
  4. Senate Ways and Means background materials
  5. Summary of Baker Administration approach to addressing systemic and MassHeath cost issues
  6. Blue Cross Foundation Overview of MassHealth
  7. Blue Cross Foundation on MassHealth Enrollment
  8. MassTaxpayers Comments on the Baker Administration assessment on businesses
  9. MassBudget on the federal funding risks for health care
  10. Massachusetts Access Monitoring Review Plan

Response to comments, April 28

I’ve read through the comments here — it took me a while to come back to because I was daunted by the diversity of thought here. I’ll let the thread speak for itself.

The bottom line is this. There are powerful arguments for radical change. For this year, radical change is not on the table. The space we are working in is what kind of assessment will we levy on employers to help close the MassHealth cost gap. I expect we’ll work out a narrow-gauge solution in that space. Not a satisfying answer.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

56 replies on “Health Care — a coming concern”

  1. OK. Here goes.

    I am a Chiropractic provider so some of my suggestions will look a little self serving.

    Before patients with back pain and surgery as diagnosis and before MRI, patients should have to go a three week trial course of Chiropractic, physical therapy or massage first. This could save the state thousands if not more from unnecessary surgeries and unnecessary MRI’s.

    Second. So many of my Mass Health patients DO have jobs and while it is nice they have NO co pay or deductibles for care, many, with jobs could afford to pay something. I would propose that if those are on Mass Health DO have a job, that they would have to pay a $25 or $50 deductible and than a $5 or $10 co pay. This could help give them SOME skin in the game and could also help to lower the total cost to the Commonwealth.

    Those are my suggestions.

  2. The Governor’s tax on employers re: health insurance is a tax per employee, even if that employee is insured through a spouse or partner’s plan. That seems unreasonable and penalizing the employer who is doing the right thing.

    I’d advocate for greater regulation of for-profit pharmaceutical companies which seems to be having the greatest impact on the rising costs of premiums paid by employers and individuals.

  3. Will, I’m a former constituent of yours when you were in the House. I’m a lawyer by trade so take my comments with a grain of salt. But I would suggest, when it comes to investigating possible ways to contain healthcare costs, that you look at some of the value-based care models that US HHS is piloting now. For instances, the ESCO (End-Stage Renal Disease Seamless Care Organizations) model is one that provides a lot of hope for keep costs contained without negatively affecting care. As a legislator concerns about this area, learn about these value-based alternative care models and see whether Massachusetts, either through legislation or the HPC, can encourage adoption of them by the healthcare community.

    1. Yes, I assume the value-based care concept is the same as Accountable Care organizations — definitely a big movement to that in MA and elsewhere. I do believe in the concept, but it is not an easy transition.

  4. A few thoughts:

    1. I wonder if Massachusetts would have more luck through embracing a managed care model for Medicaid- giving an insurer a fixed price per patient, and leaving the ball in their court to make a profit. Massachusetts could have companies bid to try and lower per-person costs. Additionally, MassHealth could better bundle payments for procedures, identifying 1 or 2 hospitals per county that offer the best mix of costs and results and moving all non-emergency treatments there for each given procedure.

    2. While unlikely, I can’t help but wonder what results a program run directly through the state might get. Instead of paying an insurance company to take Medicaid patients and then have them negotiate for access, simply have the state hire doctors and basic care facilities, and then negotiate with local hospitals for complicated surgeries/procedures. Cutting out all the billing specialists and middlemen might dramatically reduce costs. It would be interesting to at least try this program in a county to see what results would be. If it’s successful, potentially expand the program. If it fails, then at least we tried.

    3. I don’t hate the assessment on companies that don’t provide health care for workers, because it seems like it would directly drive Medicaid costs, especially for companies with lots of low-income workers. However, I’d be curious to see how much research has been done on this, and what, if any, other ideas there are. We have top health care policy thinkers at Harvard, MIT, Northeastern, BU, and beyond, surely they can put their heads together and help identify ways to improve the system.

    1. Yes. There is a huge movement towards managed care in MassHealth in Massachusetts. That is absolutely where we are headed and need to be. Not so sure that we’d get lower costs though in a state run system.

  5. Greetings,

    Suggest you consider the companies that self-insure and as a result have employees outside of the pool of employees that set regulated insurance rates in Massachusetts. If those employees were in the pool it would be less expensive for the (mostly small) businesses that are now in the pool using commercial insurance.

    There could be a tax or other means for companies that self-insure to help out with paying for bringing health insurance to all people – that’s only fair.

  6. Will, one area that needs to be addressed directly is companies that offer healthcare coverage with a) very high deductables; b) unreasonablly low caps; or c) very high employee-paid premiums. Offering healthcare coverage that doesn’t cover much, or is unaffordable, doesn’t really provide adequate coverage.

    I’m not prosposing an answer to this problem–just identifying it as an emerging trend that needs to be tracked closely and taken into consideration.

    Thank you for your thoughtful reflections on this crucial problem for Massachusetts citizens.

  7. Thank you for your thoughts. As a student of health policy and business, I understand that the idea of caps or ‘price controls’ are huge bogeymen. But the fact is that our country’s health spending is so out of proportion to other similar countries because payers do not have enough leverage over providers. Every country that has lower healthcare costs consolidated payers or has rate-setting. See the paper below

    Massachusetts has done rate-setting in the past, and there is plenty to learn from that time period, but we should look to Maryland as a model for the future. Global budgets and capitation give doctors the ability to actually manage risk and control costs, rather than a convoluted balancing game of reducing volume while still being mostly paid FFS.

    Consider this news story as a guide

    The thing to remember, however, is that Maryland did not become that way over night. It took a long long time, with lots of cooperation and building of trust. MA can start by standardizing cost-reporting across all providers so that we can actually assess what makes our healthcare expensive.

  8. Maybe the collapse of employer-sponsored health insurance and the budget-busting growth of MassHealth enrollments is a backdoor opportunity to move towards single-payer insurance — acknowledging that this would also require a substantial increase in revenue via various types of new taxes to replace the money that employers and the rest of us are currently paying to insurance companies.

  9. Dear Senator,
    I know my health insurance agent said a big reason for the uptick in my company’s premium was for one reason. Under our old health care model before Obamacare, insurers in this state could set the rate based on SEVEN different factors (don’t ask me what they were, no idea). Under the ACA, the number of factors insurers were allowed to consider dropped to FOUR, which limited the amount of factors insurers could use to bring down the cost. Our MA delegation in DC was asked to request a waiver from the Fed. so we could continue to take advantage of those seven indicators, but they did not.

    I would like to raise this possibility again. The old system seemed to work well. If we could allow insurers to project costs based on more factors rather than less, they can come up with a more precise premium (I.E. lower premiums) which benefits everyone. Just my two cents.

  10. what type ofhealthcare coverage does the Commonwealth of Mass. provide for elected officials and at what cost if any.? do you pay co-pay for pcp and specialists? if so what cost?

  11. thoughtful replies from others — appreciate what the chiropractor had to say, as there are alternate therapies that are much less expensive than doctors-first (and also less invasive outcomes, and more whole-body health and healing).

    support a tax on non-insuring employers but would have a graduated level for the 11-20 employee businesses (some cost-sharing is better than none)

    Single payer IS the way to go, but not in this national climate. It cannot be implemented state by state.

  12. does the COMMONWEALTH provide free healthcare to elected officials and family along with one of the most generous pay scales in the country?


    1. While I support the concept of single payor. I have always thought the best way nationally to do this was to expand Medicare first for the newborn to 26 and than ever year, move down 5 years from the top to include everyone else.

      That being said, the current paper work requirement by Medicare are a disaster. I call meaningful use meaningless use. Much of it is meaningless garbage and a waste of time. So for that, single payor by the Government worries me as a provider. If we can do it without all the meaningless regulation, it truly is the way to go.

  14. Well it is interesting how much the state and feds are already paying for health insurance. MA is one of the most wealthy states, and if it was a country we would be one of the most wealthy countries.

    Why don’t we put our mind to a Single Payer system? 30% of our insurance costs go to overhead that wouldn’t be there if we had single payer.

    We are already talking about taxing businesses. How about a tax on high earners to cover what can’t be covered by taxing us all as workers to cover universal insurance.

    1. Those are national overhead numbers. It’s much lower in MA, more like 10% — our major insurers are non-profits. Not obvious at all that state government would run the payment system with less overhead. But I like the concept of making health care portable, not employer dependent.

  15. Everyone knows MassHealth is a Cadillac but priced like a Kia.

    -No MassHealth for able bodied adults with no dependents without proof they are seeking full time employment. Continued verification of seeking full time employment. Continuous coverage and lifetime caps.

    -No MassHealth without written employer verification that insurance is not offered

    -No MassHealth without written employer verification stating the offered healthcare plan and cost. Cost is compared to employee income to determine if employee truly “can’t afford” employer plan. (People don’t get to determine if they can afford a mortgage or child support for example, standards and verification are used.)

    -MassHealth should be for society’s most vulnerable. Rethink income limits. Family of four is currently $49,200.

    -As was stated by someone else, higher deductibles add skin in the game (except for the most needy)

  16. I was downsized out and left with no coverage by a major university in Cambridge. Then I was left a widow of a Homeland Security employee and couldn’t afford the health care “benefit” that he left behind. Now I work 2 part time jobs with no benefits.
    I think that the core problem is employers who — one way or another — can and do weasel out of providing health care.

  17. As a professional in the study of health cost/quality optimization, I know there are 3 major solutions.

    1. Single payer. (“Medicare for all”).
    2. Limit “choice” to high quality plans and providers that stress prevention…yes, the HMO model( but not the evil mutations that proliferated). See Kaiser and Tufts Health Plans.
    3. Support for docs that stick to policies such as offering alternatives to over-prescribing antibiotics, emphasis on exercise and healthy eating vs. pills and surgery, etc.

    None of these are new ideas….all are quite successful in other parts of the world. So many countries exhibit health outcomes that are superior to ours, at lower cost.

    It’s the politics that are the biggest challenge, not identifying solutions.

    1. I agree, and note that one challenge of ACO’s is that they aim to be efficient by being big. Many people, including I, think being big tends to undermine the relationships of smaller primary care and family medicine practices, which (often) have better results in long-term, preventive measures like those you mention.

  18. Dear Will, no one likes additional taxes, but I do think it reasonable for there to be a minimum employer contribution toward the healthcare costs of their employees. MassHealth may one day grow into the single payer system that would be most logical. In the meantime, minimum employer contributions are the way to go. As for the other priorities, yes we need more help for education, transportation, and other needs. But healthcare is primary and will need to be a first priority. Best, Mike

  19. One of the best things that Massachusetts can do for cost control would be to move toward a single payer/Medicare for All system. I would encourage you to support S.619, Senator Jamie Eldridge’s bill to that effect, as well as S.610 from Senator Julian Cyr.

    Republicans are pushing to roll back health care reforms, and Democrats should be pushing to improve and expand upon them.

  20. It is obvious that there are underlying problems and fundamental philosophical or ideological differences about health care in the US, which in my opinion is both a financial nightmare for too many citizens and residents as well as a moral disgrace. Some people argue that the health care “system” should rely on “market forces” to achieve good value for money, which strikes me as ridiculous in this context, as if health care were like consumer electronics. I believe access to health care should be a right, at least equal if not more basic than the right others claim is theirs from the 2nd Amendment (arguably this latter right enhances the chances you will need access to health care). There are multiple examples of better overall health care outcomes from around the world than in the US, e.g. France and Taiwan, as well as practices within the US that produce better results in some places than others. Unfortunately there seems to be no chance at all in the current US environment to implement fundamental widespread improvements in health care access and provision. Instead we are faced with a strong push to make things even worse that is being enabled by the depraved indifference (i.e. a selfish lack of regard or sense of moral concern for the lives of others) of many legislators, driven by the depraved indifference and greed of special interest groups with powerful lobbying influence. This influence is manifest in a refusal to act in the interests of society or to acknowledge that in addition to the moral imperative it is commonsense, as a matter of public safety, to have everyone around us as healthy as possible. I am appalled at the argument I frequently hear that everyone has access to health care because they can go to an emergency room. This argument ignores not only the huge financial burden this access of last resort generates but also the value of and critical need for preventive monitoring and measures and services such as prenatal care. Moreover I also hear arguments along the lines that I should not pay for health care insurance, or should pay much less, because I am healthy and/or I do not need some of the services or procedures that the Government mandates are included in the coverage I purchase. This argument reveals ignorance about the basic principle of insurance without which it cannot be financially sustainable. So what’s to be done? One source of hope for at least stemming deterioration in the health care available to many Americans may lie in concerted action by multiple states that will all suffer as a result of current proposals before the US Congress if these are implemented. It is beginning to dawn (I hope) even on Republican-run states and Trump voters that it is not a good idea to increase the number of people (especially if voters realize they will be included in this group) who will have no timely and affordable access to health care when they need and should have it, both for preventive and maintenance purposes and to deal with medical issues when they arise. I hope the Massachusetts Legislature works with Governor Baker to build a coalition of as many legislators as possible at both the Federal and state levels in both major parties to introduce common sense and decency into the directions that health care access and provision take, despite the appalling amoral Congressional leadership and psychotic administration now in power. Americans overall are not getting what we pay for in health care, although some interests are profiting handsomely and even obscenely. Current proposals to reverse much of the ACA (which does need improvement) are an attack on the wellbeing and security of millions of Americans across the country that is much more serious and potentially effective in the harm it inflicts than the acts of terror that typically receive 24/7 coverage.

    1. You are right that state governments should be pushing back against the ACA changes and I am under the impression that they have been a significant factor in the debate — especially the communications between Governors and the President.

  21. The real problem we have which no one addresses is the actual cost of health care – hate to say it but we need to put limits on Hospitals , Dr. and the cost of drugs – we have run a way costs on medical care far more than any other country in the world

  22. Tail is wagging the dog. When I was growing up (77 now) there was no welfare, no food stamps, no free school meals, no DR’S facing lawsuits forcing them to raise their fees.
    Thanks to big gov’t politicians for allowing this system to grow so out of hand.
    Thankfully, I get all my care thru the great VA system here. They’re not all great, but Mass. can be proud of the VA system here.
    We earned it. Perhaps the public might someday also earn it. There is nothing free, Senator. Even your overpaid salary comes from TAXES paid by we the people.

  23. Hi Will,

    We all know that the solution to healthcare problems needs to be solved in Washington. It seems that the best way to solve this problem is to mandate a minimum level of coverage for employers who offer health insurance that matches the level provided by MassHealth. Maybe the answer is to allow small to medium employers offer MassHealth to their employees and then have the state charge them for the costs. The State should be able to negotiate lower costs with drug companies and the big hospital networks for the increased volume of subscribers and pass those savings to small companies.

  24. Thanks for this.
    The answer is SINGLE PAYER.
    How about demanding everyone in Congress forego their salaries and get their own insurance. For one month.
    One Month and this is for their families, too.

  25. It is obvious that we need to consolidate all the government-supported healthcare plans (Medicare, Medicaid, etc.) into one single-payer “Medicare for All” plan. However, that is not going to happen anytime soon.The American people’s only “hope” is that the Republicans (who wish to return to the pre-ACA era) and corporate Democrats (who believe that minor adjustments to the ACA will solve the problem) will create such a mess, resulting in millions of uninsured Americans running to the Emergency Room, that the American people will finally demand radical reform of our health care system.

  26. Will,
    Lots of good comments here. I am particularly supportive of exploring single payer. Martyn Roetter was very articulate in this regard. There are many models throughout the world worth looking at, including the Swiss model, which is a bit different: insurance companies must all offer a basic plan, the components and price of which is set by the state. In order to do ANY other business in insurance, they have to offer this. Sort of a pay-to-play, if you will.
    The other elephant in the room, called out by at least one other commenter, is health care costs themselves. It will be hard to have a good health insurance policy of any type without costs being reined in.

  27. “new contribution for employers that do not offer…” I am not sure how effective this is. Most jobs I see posted are temp jobs, although in-state the agency is out of state. Maybe a loop hole that needs to be plugged. Some temp positions are 1099 so who gets dinged?

  28. Will … I am a very high consumer of healthcare BUT I did not ask for it; I “earned” it the old-fashioned way, I inherited it. 🙁 I would be happy to share my experiences as a user and as a healthcare IT professional for thirty-five years.

  29. It’s my impression the DC politics is about preserving revenue and profit for hospital networks and drug companies. As long as elections are for sale, I am not optimistic about universal access to health care regardless of ability to pay. So the first thing to address this corporate fascism is to eliminate private funding, and replace it with taxpayer funding, for federal election campaigns. Not that I’m optimistic about the likelihood.

  30. I agree single payor is the best option. With a private pay option on top for those who can afford more. However too many special interests to see it happen I am afraid.

    If we could consolidate, Auto, Work Comp, Medicare, Medicaid and private insurance into one large pool, there would be ample monies to pay for the system by reducing duplication and waste. You have to have some reasonable cost controls which is not easy to implement. In the past, they had a program called certificate of need, but it stymied innovation.

    Heath Care is a very tricky topic indeed since it involves peoples lives and the new drugs sometimes cost a fortune.

    No easy answer. Read the book, Who Shall Live.

  31. I think we need to end the expectation that employers should be responsible for providing health insurance. Truman wanted socialized medicine in the 40s, but GM said, no, we want to provide our own insurance. Instead of viewing increased enrollment in Masshealth as a problem, we should view it as an opportunity to remove profiteering from the health insurance system. We should move toward public insurance for all, just as they have in Europe. It will require a different financing structure. Taxes instead of premiums and deductibles. But imagine how much less administrative costs there would be without every employer needing someone to figure out insurance. It would free businesses to do what they do. Society should take care of the sick, not employers.

    1. Good point that there is a lot of overhead within employers. I think the payment itself in Massachusetts is relatively lean and not necessarily that easy to improve on. But I agree that the larger picture favors getting away from employer-funded care. I still kind of like the managed competition that Hillary was talking about in 1992.

  32. It is time for Massachusetts to take a serious look at single-payer. Yes, taxes will have to be raised, but it will represent our best chance to control costs and increase access.

  33. The Deathcare bill may be dead for now, but our troubles remain. Three things:

    1. Introduce statewide long-term care insurance; everybody buys a minimum, some can buy more. Scale payments to income a bit. Why? Nursing home care consumes a massive share of all Medicaid dollars. The average person doesn’t realize how it works: shell out 100K a year, spend yourself into poverty, go on Medicaid to keep yourself alive in a nursing home, then have Medicaid go after your children to get its money back. It’s like something out of Soviet Russia. All private solutions at this point have failed. We need state action. If benefits can be paid for home care as well, then you can reduce overall costs by keeping people out of nursing home care.

    2. Reach out to other states and create a multi-state solution independent of the federal government. Solutions like single payer will probably require a bigger risk pool and more bargaining power than we have in MA. Just look at how Vermont folded. Given the fact that even the damn Canadians are now warning travelers to the U.S. about our “political instability,” we need to face the fact that federalism is failing. States need to turn elsewhere, and that’s to each other. There is plenty of precedent for states working together (the UCC etc).

    3. You’re going to have to deal with Partners, a middleman who adds nothing to healthcare other than overhead. Administrative costs (executive salaries) are some of the biggest drivers of cost increases in both medicine and education. There is no getting around this if you want to hold costs down.

  34. One problem with health-related spending is that prevention is short-changed. We will never get health care spending down until we increase our commitment to keeping people healthy so that they don’t need to access costly medical services. Good public health involves reducing tobacco use, promoting healthy diet and physical exercise, etc. An example of savings: When the MA Health Care Reform Law (Chapter 58 of the Acts of 2006) was adopted it included funding for a comprehensive tobacco cessation benefit for MassHealth enrollees. Within a short period of time the state recouped much more than it spent just on the avoidance of expensive in-patient cardiovascular care. The evaluation of the initiative didn’t even measure other in-patient and out-patient savings due to reductions in asthma, other CV illnesses, cancers, low birth-weight babies, etc. Initiatives like these should be adequately funded. They are not. The goal should be keeping people healthy, not waiting for them to get sick so that they require extensive (and expensive care).

  35. Now that Trump/RyanCare is off the table in its current format, we will have to wait and see what happens when Trump instigates the failure of the ACA.

  36. Can you run a back of the envelope estimate as to how much a single payer plan for all residents of MA would cost? I believe the overhead for Medicare runs about 7%, much less than commercial insurance. That plus negotiated drug prices, and doing procedures at the best site for having them (blue ribbon commission to decide that). Otherwise, thank goodness that Obamacare is alive for a while..Best, John M.

    1. Medicare is not a good proxy for what single payer health care would cost — Medicare and Medicaid exist within a system that can cross-subsidize them.

      No one knows what Single Payor would cost (nor, for that matter, is there agreement on what it would really look like).

  37. I made a comment before reading the great number who favor single payor. so I will add the political issue of “socialism at the people’s republic of Massachusetts” (a quote from a former patient), “taxachusetts” also. Someone needs to develop language to take these images on head on. There is always the churchill chestnut “americans always do the right thing, after they have tried everything else. JM

  38. Dear Senator Brownsberger:
    I am not a health care professional, and do not work in the health care industry. I do know, however, that we are experiencing a health care crisis, and appreciate your thoughtful synopsis of the issues and challenges we’re facing.

    Although I am not an expert, I know enough to recognize two of the most significant contributors to the problem and described in your analysis. These are the lack of employer-provided health care insurance and rising costs. As for the latter, I am not close enough to the situation to offer a particularly useful appraisal. But I do not think the way to control costs is for insurers to dictate, by limiting coverage, what a doctor may or may not do or prescribe for his or her patient. This is an unwarranted intrusion in the doctor-patient relationship, and doesn’t address an even more egregious problem, which is the cost of drugs and medical equipment. Big Pharm is a bad actor in this arena, and while they do put their capital into research and development, a lot of that money has come from US taxpayers in the form of NIH grants. In addition, they have the benefit of the protections afforded by the the U.S. Patent Office, which rewards their tweaking of drug formulae and therefore additional patents, which is all about the bottom line and not about health care. Medical equipment costs are a huge drain on hospitals and health care providers.

    If one looks at the big picture, it’s not really the doctors, or the nurses, or the physician or nurse assistants, or the home care professionals or the therapists making so much money. Perhaps with the exception of some percentage of medical specialists, the people helping people are not the multi-millionaires. Once again, it’s the corporations and the CEOs and their lobbyists making the real money, and they’re the loudest to squeal when lawmakers talk about reining in health care costs – because they have the greatest profits to protect.

    Which brings me to employers. Too many people are in jobs that provide no health care benefits. Why? Because many employers now only hire part time employees for the express purpose of avoiding the need to pay health care benefits. This is doubly underhanded. First because it denies health care benefits, second because it denies a weekly wage that might allow the worker to afford his own health insurance. Unless we can change the culture of shorting the American worker in this way, it is an excellent idea to charge an assessment (or tax or penalty or whatever one wants to call it) on employers who fail to pay health benefits. If it’s true that this assessment will fall more heavily on small or less profitable employers because of some waiver that benefits the larger, more profitable businesses, then eliminate the factor that makes it so. But there should be no exception. Health care is necessary for everyone, and unless our society is willing to accept an ever sicker work force that can’t afford to stay well, never mind pay the exorbitant costs of hospital or skilled nursing care, then we either require employer contributions towards health care, or finally institute a universal health care single payer program with a tax system that covers the costs and the real bargaining power to negotiate what those costs are.

    Thank you very much for providing the opportunity to comment on this complicated and important issue.

  39. If Baker is proposing changes, you know those most in need will come out on the short end. Is there anything that can be done at the state level about drug prices? I believe there is Canadian alternative. The no new taxes pledge by Baker is unsustainable. The legislature needs to seriously look at a progressive tax structure for the Commonwealth. Wealth emphasized, they are doing extremely well in this state.

  40. Hi Will,

    The biggest problem with ACA is that it expanded demand without expanding capacity which violates basic economics. Here are some thoughts on how to address the fundamental issues.

    * Everyone should have access to catastophic plans capped at 20% annual income contribution
    * Provide incentives / Rebates on premiums on people who live a healthy lifestyle. If you smoke or don’t make an active effort to manage your weight, you can pay for it out of your own pocket but we as a society should not be held accountable for your choices. Have the numbers work for a younger healthier population vs a tax penalty.
    * pharma / biotech get bad press but drugs are the lowest cost of intervention vs medical devices (particularly implantable devices) and services i.e., cost 24hr nursing care. Costs are driven in part by time and money to gey a drug approved given the regulations. There could be a bargain had with pricing vs lighter regulations / quicker / cheaper approval thresholds. I do disagree on huge mark up on previously generic drugs with no additional value add
    * PBMs are a big component of drug costs and with today’s technology it should be easy to cut out the middleman here
    * death squads get a bad rep but from a tangible basis how much of an extra 3 – 6 months of a not great quality of life worth? If you can afford it and it is worth spending your heirs’ inheritance, all the power to you but we as a society can’t afford 250k-750k / patient for the last few months of life. Those dollar would be better spent provide for education of the the next generation
    *provide incentives to improve supply of healthcare i.e, forgiving medical school debt for years served in needed areas
    * with the tightness in the labor market. Employers need to be competitive to attract the best employees. That’s a better incentive than burdening small employers with costs they can’t afford since that is a choice they make in running their business. I’m sorry but MickeyD’s was meant to be a high school kid’s job and not supporting a family of 4 where you need to make $15-20/hr to make ends meet. Pay should be driven by the amount of value you generate for your employer otherwise there’s a robot to take your job in the near future without complaints.

    Not a complete solution but these are components in a broader solution vs the tax the rich single payor answer that seems to be popular but unsustainable. Happy to discuss further.


  41. Thank you for your work on this. I’ve gotten emails from business groups concerned about the new employer tax. Meanwhile, I am worried about my own health insurance premiums, since I am self-employed and pay a very high monthly premium.

    But I am even more worried about the impact on the dual labor market — as healthcare costs (or avoidance of these costs) pushing up the number of positions that are part-time rather than full-time; and with both full-time and part-time positions paying very low wages.

    In the long run, the number of people in unstable employment (and therefore unstable housing as well) will be a greater strain on health and wellness.

  42. In my situation, without premium tax credit I will have to just plain drop coverage until I am eligible for medicare. I was forced to retire very early and now have to pay 29% of my agi in property taxes. So until I can fully deduct my health insurance from my property tax bill, it will remain crowded out of my budget.

  43. I think the answer to our Health Care issues is clear. We need a Single Payer system. It seems that there are two bills right now supporting a Single Payer system. (Senate 619 & 610) I know the task is daunting but over & over again the members of this Commonwealth have supported this idea. Perhaps it’s time has come

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