Massachusetts Health Stats

Romneycare Health Reform Folding Like House of Cards

As the data about the results of Romneycare in Massachusetts get wider publicity, the realization that it hasn't worked for Massachusetts is permeating the national debate about what is likely to happen under the Patient Protection and Affordable Care Act (PPACA), which will explode on to the national scene in the next 10 years.  Ironically most of the people making the connection to the results in Massachusetts and the likely results nationwide are proponents of PPACA.  They don't seem to be aware that the proponents of Romneycare here in Massachusetts are desperately trying to re-reform it because of the bad results so far.

And the national proponents are using some very specious research methodologies and arguments in the process. I posted on January 13 about the "new research" concerning the effects of Massachusetts' individual mandate. Many others, including Austin Frakt at the incidentaleconomist.com, also posted on the "new research," which has lead to an interesting series of comments and replies that have the proponents arguing with themselves and tying themselves up in illogical knots. 

I'll leave the intramural squabbles to their own head-of-a-pin dancing.  But Austin's reply to me that the individual mandate was simply about the Massachusetts "merged market" is really a stretch.  Austin has posted in "This should cover it" and in a comment on the initial blog post about the relationship between the individual mandate and the likely success or failure of the PPACA that he does not want to mix up the Massachusetts mandate with any element of Mass healthcare insurance reform other than the "merged market." His position is that the mandate was a device to reduce adverse selection in about 10% of the Massachusetts healthcare insurance market called the "merged market" (because it let about 40,000 individuals buy insurance for the first time at the same rates as about 600,000 people that had been purchasing insurance through small groups). The other 90% of people in Massachusetts get insurance through an employer or the government. For the luckiest of us, their employer is the government.

In fact the mandate affects all 6,500,000 of us and when Turbotax adds a thousand dollars or more to a resident's Massachusetts state income tax bill on April 15 if you don't have a form 1099-HC, the Q and A doesn't say "could you have bought insurance via the merged market?" As the Massachusetts Senate president famously said

"It is complicated. If you move one little piece, something pops up somewhere else."

The mandate is one of the pieces that interrelate with and cannot be so simply decoupled from the other elements. An oft-quoted source on incidentaleconomist.com, Professor Gruber, explains many of  the interrelationships in a presentation made in Washington DC on Thursday January 13 (see http://www.iom.edu/~/media/Files/Activity%20Files/HealthServices/EssentialHealthBenefits/2011-JAN-12/1015%20Gruber.pdf)

Although there is no explicit mention of the merged market on the 1099-HC, one of the things that is included on the form is a checkbox related to "minimum creditable coverage." It is the "minimum creditable coverage" requirement in Massachusetts law that accounts for the rapidly rising costs of healthcare (and healthcare insurance) in Massachusetts. Not only are we mandated to buy insurance here in Massachusetts but we are mandated to buy very comprehensive insurance (that is, state decides what should be in each policy as a minimum -- e.g., IVR -- and calls the result minimum creditable coverage). 

 

To be fair however, the usual litany of other Massachusetts problems such as high income, sales and property taxes, a high concentration of teaching hospitals, more specialists than primary-care physicians, a dependence on oil and natural gas from overseas, etc. also probably makes our rates higher than in other states.  One thing that does not contribute is those dastardly for-profit insurance companies that you hear about: almost all of us get our insurance via non-profits that all have had medical-loss ratios around 90% for years (I think the PPACA goal for medical-loss ratios is either 80% or 85%)

 

As a sidelight, the reason that Professor Gruber was speaking in Washington DC on January 13 was to help the U.S. government decide what should be in everyone in the United State's "minimum creditable coverage," called Essential Benefits by the PPACA.  So their premium rates and healthare costs will catch up to ours soon.

 -- Dennis Byron

What Massachusetts "Individual Mandate" Stats Mean for Obamacare?

Over at CommonHealth, Carey Goldberg highlights a new New England Journal of Medicine (NEJM) study on the effect of the Massachusetts individual mandate on whether or not healthy or sick people sign up for free and subsidized healthcare insurance.  The authors of the NEJM article guardedly believe these statistics may have some implications for the success or failure of the nationwide March 2010 Patient Protection and Affordable Care Act (PPACA). For example, if only sick people sign up for healthcare insurance after 2014 when it becomes highly subsidized in the other 49 states, theoretically healthcare insurance premium rates will skyrocket.

In my opinion, the NEJM article raises as many questions as it answers. (Perhaps NEJM subscribers get more access to the underlying data or more detailed analysis than casual Internet surfers like me.  It appears the available .pdf file and the NEJM .html page to which I link are the same but perhaps the .pdf file has more data.) For example:

• Isn't the survey period -- from passage of Romneycare through the first 18 months -- both too late for good comparison and too early in the so-called reform process to be meaningful? The initial annual $219 penalty for not getting insurance was really not that much of a stick.  Beginning in 2008 or 2009, the penalty was closer to $1000 and it has moved up substantially since then in tandem with the continued rapid increase in healthcare insurance premiums in Massachusetts (see related bullet at end of this list).
• Isn't the survey period too short? As I understand it, the authors were limited by the data they could get from the Mass state government about these lower middle income people and the fact that they had to at least give the people a chance to get a doctor's appointment (or need a doctor) after they received their free or subsidized insurance before they could be diagnosed (apparently 12 months after enrollment but that is unclear).
• What is the "n"? According to the state, 158,000 people subscribed to Commonwealth Care during this period but looking at the NEJM article's "new enrollee" chart, it looks like only about 50,000 are accounted for. Presumably, given that the article says the study is based on claims data, the statistics in the NEJM article only cover people that went to the doctors or maybe just the ER or ????.  What happens if the other 100,000 are included?
• How many of these people just moved from private health insurance over to the Commonwealth Care?  They were "new enrollees" to use the academics' term but were they really newly insured and/or had they never gone to the doctors before? Also the state of Massachusetts says about 50,000 people also signed up for private healthcare insurance during this period.  Did the same pattern apply?
• How do these numbers compare to other states and/or earlier time slices and/or some better control group than "lower middle income people living in Massachusetts in 2006?"  In particular, the current applicable argument over the individual mandate is that the pool needs young people in it to be financially viable. So you would think that's what the academics would be measuring. 
• What does it tell us that healthcare insurance premium rates did skyrocket in the last five years in Massachusetts under Romneycare despite decades of near universal coverage (all the numeric increases in the insured in Massachusetts noted above -- both in private plans and in Commonwealth Care -- are relatively small in percentage terms and not even statisticaly significant in my opinion)? If a mandate is needed to keep premiums from skyrocketing but premiums skyrocketed in the state that had a mandate...

In the end, the NEJM article seems to be written to continue an argument between the far left Dr. Howard Dean and the far left Professor Gruber.  I don't think anyone else any where on the political spectrum disagrees with the math vis a vis mandated participation in an insurance pool.  The real disagreement has nothing to do with math and will be settled by one very simple statistic: which way the Supreme Court comes down on a 5-4 vote.

(Note 1:  Do these academics have access to my medical records as a Massachusetts Connector customer?  I have a query into the Connector's lawyers.

-- Dennis Byron

Boston Globe Gets It Half Right on Massachusetts Health Statisitcs

One of the stranger Massachusetts-healthcare-statistics-challenged press reports I've seen lately came from Robert Weisman of the Boston Globe on Saturday January 8. He claimed

"Officials from the Massachusetts office of the US Department of Health and Human Services sought to bolster (Secretary) Sebelius’ case (that repealing the 2010 Patient Protection and Affordable Care Act -- PPACA -- was bad for Massachusetts)... by releasing estimates that more than 9,800 young adults here would lose insurance coverage through their parents’ health plans if the law is repealed.

"The (Health and Human Services) officials also said that nearly 4.5 million state residents with private insurance would be subject to lifetime limits on how much insurance companies spend on their health care, which is forbidden under the (2010) law."

To be fair to Weisman, he is probably a straight beat reporter and he has to report whatever comes out of Health and Human Services, even if it didn't sound like such dire failings could have possibly slipped through the cracks in the Massachusetts legislature for five years.  Remember Romneycare not only goes back to its 2006 passage but there have been three or four subsequent re-dos of Romneycare (depends on whether you want to count the dozens of changes slipped quietly into the October 2010 Supplemental 2011 Budget).

But before I could spend any time checking these facts, which sounded fishy to me because I would be part of that 4.5 million (that is, not yet part of the 2.0 million Massachusetts residents on Medicare/Medicaid/etc) and my insurer (one of the largest) says it has no lifetime limits, here comes the Boston Globe's Deborah Kotz on Sunday January 9 saying the same thing I was thinking. She spent the time to look up the facts. Kotz says:

"Oddly, the press release (about the statistics proving PPACA repeal would be bad for Massachusetts) made no mention of the fact that Mass. had already implemented many of the federal provisions in its own 2006 state law... I'm fairly certain that Mass. residents would be far less impacted than Virginians or Iowans -- who don't have universal coverage laws -- if the federal law was repealed...The press release also seems to ignore the fact that the state already had provisions in its health coverage law that the federal government merely tweaked in the PPACA.

 

"For instance, the press release states if the federal law was repealed: "9,830 young adults would lose their insurance coverage through their parents' health plans... Actually, the 2006 Massachusetts law required coverage for children who are no longer dependents but limited it to two years after they became independent or upon reaching age 26, whichever came first.

 

"The press release also stated that "nearly 4.5 million residents of Massachusetts with private insurance coverage would suddenly find themselves vulnerable again to having lifetime limits placed on how much insurance companies will spend on their health care." But that's not exactly true since Massachusetts' health insurance carriers participating in the Health Connector, the state's insurance exchange, already didn't have coverage caps, according to the Massachusetts Executive Office of Health and Human Services."

 

Just so you know, the "insurance carriers participaing in the Health Connector" include all the companies most of you care about.

 

And, according to Kotz, the release stated (not mentioned in Weisman story in Globe) the if the federal law was repealed, 236,000 folks in Mass. would be "at risk of losing their insurance at the moment they needed it most" since insurance companies would "once again be allowed to cut off someone's coverage unexpectedly when they are in an accident or become sick because of a simple mistake on an application." Again this language is inaccurate since Mass. law prohibits insurance companies from dropping enrollees due to preexisting conditions.

I guess Kotz doesn't talk to Weisman. 

-- Dennis Byron

Left Misleads with Healthcare Reform Statistics; Right Runs from Them

Right-wing fanatics such as the group running a web site supporting the U.S. presidential candidacy of former Massachusetts governor Mitt Romney are just as bad as supporters of current Massachusetts governor Deval Patrick in terms of making false claims about the so-called progress of Massachusetts so-called healthcare reform.  I say so-called healthcare reform because so far in Massachusetts, so-called healthcare reform has nothing to do with healthcare but just healthcare insurance.  Starting in 2011, Deval Patrick and State Senate President Murray want to double down and set up our healthcare delivery system for the same failure that we have seen so far in he healthcare insurance market.

The problem that the fanboys in the Romney camp are having is not that they are just not as good as Deval Patrick supporters at using statistics in a misleading fashion to back up their claims. The problem is that the statistics argue strongly as to what a failure Romney's signature accomplishment in Massachusetts has been. That's why the web page on Romney's healthcare reform efforts at the Romney for President web site has sat "under development" for at least 6 weeks (status as of January 10).

It's going to be very hard for Romney to run on what has happened here in Massachusetts since passage of Romneycare: 

• crippling state budget deficits
• a doubling of healthcare insurance premiums, at least for individuals and small groups
• much larger co-pays and co-insurance arrangements for everyone
• a shortage of doctors
• out-of-control hospital rates
• longer wait times for patients
• two temporary freezes on the Massachusetts healthcare insurance market in 2010
• a very slow increase in the percentage of people covered under Massachusetts' so-called universal coverage
• tens of thousands fewer Massachusetts residents actually buying healthcare insurance
• other devastating provable statisitcs that have emerged during the 2006-2010 timeframe 


The problems are so bad here in Massachusetts that at the same time the Romney is dancing around the Massachusetts experiment, the left-wing government of Massachusetts, both the governor and the legislature, is claiming it is in trouble and needs to be re-reformed.

-- Dennis Byron

Did Romneycare Lower the Amenable Death Rate in Massachusetts?

Did Romneycare lower the amenable death rate in Massachusetts? Or did the Red Sox and the Patriots? It depends on how you read the document, Massachusetts Deaths, a report that comes out annually from the Mass. Department of Public Health (DPH).  A subject covered in some depth in 'Massachusetts Deaths, 2008' (and perhaps in earlier years) is what the epidemiologists call "amenable mortality."

Some of the statistics about amenable deaths (meaning those that could be prevented with timely health care) and some of the commentary in the report have found their way intentionally or unintentionally into the debate about the benefits of so-called healthcare reform in Massachusetts.  On page 30, the report says in part:

"When the amenable mortality for 2000 is compared with that of 2008, it has declined for the state overall... When amenable mortality for 2006, before the implementation of health care reform in January 2007, is compared with amenable mortality for 2008, there has been a significant decline for the state as a whole..."

That wording might make you think that the decline prior to so-called healthcare reform was not significant; that it was just the decline after Romneycare kicked in that was significant. But you need to ask some questions about the word "significance" when it shows up in a statistics-laden report.

It turns out if you ask the DPH guys involved in running the numbers you find out the declining trend before the implementation of Romneycare was just as statistically significant as the "significant" decline that the state report brags about for the period between 2006 and 2008. In other words, Romneycare had nothing to do with it. I asked them: "Does it make sense for the state to imply that the 2006-2008 decline was related to healthcare reform, when the earlier decline -- before healthcare reform -- is just as significant?"

The DPH's reply via email:

"We will have to be more careful when we make comparisons that lead to such implications in the future.  We will have to include more language like,

'healthcare reform was concurrent with an already declining trend in amenable mortality.'

"Thanks for pointing this out."

The response is a little weaker than I would like to see given that the pre-Romneycare declining trend covered 6 years and the post-Romneycare concurrency only covered two years.  I'd like to see the DPH withdraw the report and rewrite it without the propaganda. Otherwise this misleading information exists forever on the Internet.

Or maybe the DPH could just amend the report to say that the amenable mortality rate declined concurrent with the Red Sox winning a couple of World Series and the Patriots winning a couple of Super Bowls.  Maybe the old town teams are the reason for better health -- as measured by amenable mortality -- all through the past decade in the years before so-called healthcare reform.

-- Dennis Byron

Healthcare Indexes: Worse than Misleading Healthcare Statistics

I post here whenever I see some misleading statistics about the healthcare insurance and delivery markets in Massachusetts.  But to use the terms misleading and healthcare indexes (or indices) is needless repetition.  Indices are by definition misleading.

I was reminded of this when reading this recent article in Insurancenet attributed to Cengage Learning about how Massachusetts fared in a recent index. I think we have pretty good healthcare delivery here in Massachusetts.  It's expensive (as is everything else in a cold mostly urban environment) so as a population Massachusetts residents have all long used insurance to help afford it.  I don't need an index to help reinforce that, especially one that appears to boost a state's score based on misleading statistics. 

In Insurancenet, Cengage, a $2 billion limited partnership, writes:

"Critics of Massachusetts' health reform law, after which the federal reform law was modeled, will be surprised to learn that it actually helped the state move up a notch to No. 2 in the AHR rankings. Massachusetts' steadily declining uninsured rate, now at 5%, is down from the previous year's low of 5.4%. Massachusetts also has a low prevalence of smoking, which dropped to 14.9% in 2010 from 18.5% five years ago, and high rates of immunization, with 93.4% of children 19 months to 35 months old receiving vaccinations."

Cengage makes its $2 billion a year selling to academia so it has clearly picked up the fast-and-loose-with-the-facts bad habits of the academics that are always trying to convince us that the government knows best. 

Specifically I am a critic of the Massachusetts "health (insurance) reform" law and I am not at all surprised about the number of people insured in Massachusetts, the low smoking rates and the high childhood immunization rates. That's because none of the above statistics have the least bit to do with the "health (insurance) reform" law known popularly as Romneycare.

• As explained in this recent post, Massachusetts has always had a high percentage of its residents insured and it appears there has been no stastically significant movement in those rates since Romneycare was implemented.
• The reduction in smoking rates in Massachusetts far precedes Romneycare and dates to a concerted education and enforcement effort by local governments in the 1990s, using higher taxes on tobacco products and some settlement money from the tobacco industry.  In fact, more recently the state's Democrat legislature took the tobacco taxes intended for use in smoking cessation and spent the money elsewhere, slowing the reduction in smoking rates and drastically cutting enforcement of laws against selling to minors.
• And the idea that the percentage of immunized children from infants to three year olds in Massachusetts has anything to do with Romneycare is just absurd.  Those percentages probably predate Romney, never mind Romneycare.

 -- Dennis Byron