What Connecticut can do in an election year, with a tight budget, in an unsettled economy, and Washington in gridlock
ACOs and provider financial risk
Accountable Care Organizations (ACOs) are large and growing systems that touch every aspect of healthcare. They make money by reducing their patients’ care costs. Unlike insurers, ACOs are completely unregulated. As large systems, they can potentially offer better care coordination with less fragmentation and duplication. Unfortunately, they also consolidate the market, prices go up, and we have no ability to hold them accountable. There is little evidence of either lower cost increases or improved quality. Connecticut’s prime ACO example, Medicaid’s PCMH Plus program, doesn’t work but the state expanded it anyway. Payers and consultants are doubling down, pressing for more extreme financial risk on ACOs to get them to cut costs. Serious concerns are rising about insurers partnering with ACOs. These extremely powerful corporate partnerships leave patients in the cold with no information and no resources.
Prices are driving rising health costs in Connecticut and drugs are driving prices. Connecticut policymakers are considering applying for permission to import lower-priced drugs from Canada. This option has been bolstered by good news from the federal government. This is an important first step, but it’s not a long-term solution.
Social determinants of health
Ignored until recently, social determinants are having their moment in the health policy spotlight. Social determinants are the community conditions we need to be healthy and take care of ourselves, such as access to healthy food, personal safety, employment, education, affordable housing, and clean water. Social determinants have a lot more to do with our health status than does healthcare, but our spending levels don’t reflect that. Even as the world of healthcare comes to realize the importance of social determinants, there has been little movement to connect healthcare and community services in a meaningful way.
Tweaking health insurance affordability
It’s an election year and healthcare costs are polling high, so we can expect some efforts to address affordability. Health insurance deductibles grew twice as fast as premiums from 1999 to 2014. By design, deductibles reduce utilization by creating a barrier to getting care, but they don’t discriminate between high and low-value treatments. There are many calls to rein in deductibles in Connecticut. Poorly-designed deductible relief could raise premiums creating more uninsured state residents. Reinsurance is another idea to make individual premiums more affordable. The Trump administration ended the Affordable Care Act’s reinsurance program that partially reimbursed insurers for their patients with very high medical bills. The program did lower premiums a bit and stabilized the market making it more attractive to insurers. States are considering re-instating the program, but it would only help people who buy insurance without ACA subsidies, will last only as long as the taxpayer subsidies do, and it removes incentives for insurers to keep high cost members healthy.
Creating a publicly-accountable, non-profit health insurance option for Connecticut is an appealing idea, but making it work would be tricky. Proponents believe it will be more efficient and out-compete private insurance options. But using public programs as a platform has raised concerns about higher costs (using the state employee plan) and lower provider reimbursement rates and harming current programs (using Medicaid).
Sleeper issues we should be following
The quality of care in Connecticut is average at best, especially in hospitals, but our prices are among the highest. Just a few recent headlines include persistent hospital quality problems, high readmission rates, and rising medical error rates.
Most economists agree that we are overdue for a recession. While recent federal reserve policies may have bought us some time, we need to prepare. Unlike other states, Connecticut still hasn’t recovered from the last recession in 2008. Among the many concerns is the likelihood of a large increase in both Medicaid enrollment and the number of uninsured while tax revenues drop.
Connecticut policymakers are building a health information exchange to fill the gaps in communication between providers treating the same patient. But proposals that ignore privacy rights and patient control over their medical records will cripple those efforts. The level of trust in Connecticut’s Health Information Technology sector is about as low as possible. Ensuring privacy, data security and patients’ rights to control who sees their own data and how it’s used must be a priority. Proposals to fund the exchange by selling patient data to ACOs and others who could use it to harm patients are a massive mistake.