Monday, June 1, 2009

A Tale of Two States

For Massachusetts, it may be the best of times, and worst of times, for health care, but for California, it is only the worst of times.

I spent this weekend at a planning retreat of the governing council of the ACP Massachusetts chapter. These internists view the Massachusetts experiment as a very flawed one that is not sustainable and should not be replicated on a national scale.

What is wrong with Massachusetts? In the views of these internists, Massachusetts promised the newly insured that they would have access to a doctor, something that it could not deliver on, when the state is experiencing the same hemorrhaging of primary care physicians happening everywhere else.

A new Health Affairs study backs them up. It found that Massachusetts "has sustained gains in insurance coverage and access to care stemming from its landmark 2006 health reform and coverage expansion. However, some of the early gains in reducing barriers to care and improving the affordability of care had eroded by the fall of 2008, roughly two years after the Bay State began implementing its reform." Specifically, "about one in five adults in Massachusetts reported that they were told that a doctor's office or clinic was not accepting patients with their type of coverage or was not accepting any new patients. These problems were reported for both primary and specialty care (66 percent and 56 percent of those reporting such problems, respectively.)"

Then, as I flew back to DC, I read in the New York Times the shocking news that California may terminate its Children's Health Insurance Program (SCHIP):

"If lawmakers sign off on closing the health insurance program for children whose families make too much to qualify for Medicaid, California would be the first state in the nation to close the popular program. Begun in 1997, the program, known as S-CHIP, reimburses states at a higher rate than for Medicaid to deliver health insurance to children and teenagers. With the cuts to Medicaid, the state would probably increase its number of uninsured people by nearly 2 million, the California Budget Project says."

This, just four months after President Obama proudly signed into law an SCHIP extension that was supposed to cover four million more kids nationwide.

I think there are several important take-home lessons. First, health reform on a state-by-state basis won't work, at least over the long term. It is beyond the power of a state to institute comprehensive reforms of payment and workforce policies to increase the numbers of primary care physicians or to provide sustainable financing when times are tough. Only the feds can do this.

Second, Americans' aversion to tax increases is a dagger at the throat of health care reform. There are many reasons, including mismanaged spending when times were good, that got California in the mess it is in right now, but the current crisis also is due to the unwillingness of California voters to approve tax increases to sustain programs for the poor.

Finally, the California melt-down may be a glimpse into the health care Armageddon that may occur across the country if the United States Congress does not enact comprehensive health care reform, with sufficient cost controls, workforce, and revenue to sustain it over the long-term.

Today's question: What do you think can be learned from the Massachusetts and California experiences?


Jay Larson MD said...

A politician needs the ability to foretell what is going to happen tomorrow, next week, next month, and next year. And to have the ability afterwards to explain why it didn't happen.
Winston Churchill

james gaulte said...

Explain why such a failure based on not enough primary care docs to do the work at the prices offered would not be repeated on a national scale? A federal insurance mandate would not instantly increase the number of primary care physicians?Your take home lesson appears to be-it hasn't worked in Massachusetts lets do it on a national basis.

PCP said...

For those of you reading this. Look at the impact of Mass. reforms on Generalists. Generalists are running from Mass. despite the "void created" by newly insured. Read between the lines. I knew this the moment I saw the legislation and considered the impact on Generalist practices.
I fear this will be repeated on a national scale. That sadly will not just lead to displacement as the Mass. experiment has done but to mass retirement, alternative career choice, and other unintended consequences. ANPs and others will fill the void awkwardly and insufficiently as they are doing in Mass.