How will Connecticut’s next governor fix the state’s healthcare system?
The biggest challenge to fixing healthcare in Connecticut is our lack of trust, mainly of state government. Mistrust derails things faster here in our state than elsewhere. Our 2017 health thoughtleader survey found the level of trust among stakeholders extremely low, averaging only 26 percent. Many of the high-priced health policy consultants who’ve rotated through Connecticut have remarked on our trust issues.
Regarding those consultants, please don’t waste money on yet another expensive report peddling the latest shiny new toy in healthcare reform from faraway, where it may not really be working either.
It’s a well-kept secret, but state government has a lot of power to influence Connecticut’s healthcare system. One in five state residents is covered by our Medicaid program — the federal government paid 62.5 percent of the costs last year, but we run it. The next largest coverage group is state employees at about 200,000. That’s a lot of market clout.
The state also licenses all healthcare providers, both individual clinicians and large institutions like hospitals and nursing homes. Institutions also have to come to the state for permission to expand or limit service capacity. The state regulates insurance premiums that cover almost half of the commercially insured in our state. Most public health and prevention programs, our best hope of improving health outcomes, are funded through the state. Issues upon which the state has influence — such as income, housing, education, transportation, and the environment — all have a big, grossly underestimated impact on the health of Connecticut residents.
So it’s a big job but you’ll have a lot of leverage.
Questions for the next governor
How are you going to make insurance affordable? In 2016 Connecticut had the sixth highest single premiums for employer-sponsored coverage and eighth highest for family coverage. State regulation of insurance premiums doesn’t consider affordability. Don’t say you will increase competition and let the market do its thing. Our insurance market is concentrated, just like the rest of the country. And it’s too late to unravel that mess. Next you will likely think about lowering the prices that contribute to premiums.
How are you going to bring down healthcare prices? The biggest driver of health costs in Connecticut is drugs. We spend more per person on prescriptions than all but one other state, and our drug costs are growing faster than all but two other states. Lucky for you, some good work has been done by the Healthcare Cabinet on what the state can do to control drug costs, so you can use that answer. But the next big driver of Connecticut health costs is hospital care, and just before you go back to the competition thing — that market is also consolidated and getting worse.
How are you going to expand and use the state’s regulatory and enforcement powers to improve competition and give consumers some choices? The problem is both horizontal consolidation, hospitals and insurers merging with each other, and vertical consolidation, hospitals buying physician practices.
The feds are part of the problem, applying serious financial pressure to create huge “Accountable Care Organizations” — massive health systems that are too big to fail (or regulate). Please don’t answer that we’ll just monitor quality and we’ll react if we see a problem. Connecticut has a poor history of monitoring healthcare; we usually stick our heads in the sand and make excuses. But even when problems become obvious and can’t be ignored, it is extremely difficult and disruptive to unravel these conglomerates after they’re entrenched.
How are you going to improve Connecticut’s lackluster record on the quality of care, despite our high costs? Connecticut’s hospitals have struggled to reach average quality levels for many years. Connecticut has a terrible record on health IT, a lynchpin of safety and coordination.
But you could change that. Powerful new data analytics tools can find problems, target resources and track whether interventions are working. But Medicaid has conveniently resisted using those tools, especially when they are pushing their latest scheme. Proven innovations from other states that improve the value of healthcare, like palliative care and interventions for high-cost/high-need patients, have had trouble here.
How are you going to re-balance resources to favor primary and preventive care with specialty and institutional care? Specialists make 47 percent more than primary care physicians. But areas with more primary care capacity have lower total costs and better health outcomes. Connecticut buys a lot of healthcare services; we can change how we spend our tax dollars to support our goals.
What are you going to do about low public health spending in Connecticut? Medical care is only responsible for 10 to 20 percent of health outcomes while factors addressed by public health interventions account for between 60 and 80 percent of outcomes. But we spend 66 times more of our state budget on healthcare services for Medicaid members, state employees, and retirees than we do on public health for every state resident.
To build trust, hire trustworthy leaders and keep your promises. Be inclusive and respectful of all voices. Nobody is going to help you implement a plan they had no say in developing. You never know where the best idea will come from — even a blind pig finds an acorn now and then.
Listen to everyone, especially people who aren’t looking for a job. Banish conflicted interests from all health policymaking — no exceptions. It’s not fair, but you are disadvantaged by previous administrations’ bad behavior, so you need to be squeaky clean.
Recognize what is working and get out of the way. The prime example of this is Connecticut’s Medicaid program. Since leaving private managed care plans in 2012, our program leads the country in controlling costs, while we have also expanded access and quality now rivals private insurance. Why are we now trying to return to a similar but arguably more dangerous payment model? Another shiny new toy from the health policy braintrust that doesn’t work. First, do no harm.
Nothing works perfectly the first time so don’t get emotionally attached to your designs and plans. Evaluate what works, with a clear eye and independent monitors. Then have the political and moral will to make changes.
Healthcare is not a jobs program. Controlling costs will necessarily mean that some very lucrative current businesses and influential stakeholders will be “disrupted.” This is the perennial excuse to kill good ideas and defend the status quo. You will need to be brave and strong (see drug prices above).
In this year’s survey, Connecticut health policy thoughtleaders offered you a wealth of advice, the kind you can’t buy. It’s going to take both brains and backbone to fix Connecticut’s healthcare system.
You won’t be popular. Are you sure you still want the job?
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