Wednesday, September 23, 2009

Cape Care plans to double your property taxes

This is a long post and I apologize for that, but there is little that would be more destructive to the economy of Cape Cod than the proposed single-payer health care plan from Cape Care Coalition. I do not need to editorialize. Just spend the time reviewing the transcript of their presentation to the Barnstable County Assembly of Delegates on June 17, 2009 (it is presented exactly as it was published, typos and all):

Speaker BERGSTROM: Have a Happy 4th of July. Next on our agenda is a presentation from Cape Care and we have a few people here. You’re going to have to share the mike and the green light has to be on. Please identify yourselves for the stenographer.

Ms. PERRY: Thank you very much. I’m Candice Perry. I’m the Coordinator of the Cape Care Coalition. I’m joined my Judy Harris and Dr. Brian O’Malley. When I spoke with Diane Thompson about this presentation, she said we should take, collectively, about 10 minutes to present and then we would have time for questions. Is that still the case?

Speaker BERGSTROM: Yes.

Ms. PERRY: Like the Commissioners, we were hoping to meet with them today also and we were told last night that that wasn’t going to be possible because of a schedule situation so we’re glad if they’re going to stay today. We’ve actually done an update with them earlier and so some of this may be repetitive but we’ll welcome the questions and the opportunity to talk to all of you.

We were before you and year and-a-half ago and at that time you gave us support and encouragement. What I’d like to talk a little bit about first is sort of where we are now. As the Commissioner said, we are moving forward – very much so. Then Judy is going to talk about some of the issues around the Connector. One of the Delegates was very concerned about that. Brian is going to talk more specifically about the model and financing. We’ve had so much happen since we spoke to you and I’d like to hit some of the high points.

We’ve had many endorsements, including an endorsement from U.S. Representative William Delahunt, Senator Rob O’Leary, and our bill has now been introduced into the State Legislature and it is co-sponsored. The lead sponsor for the House is Matt Patrick and is also co-sponsored by Sarah Peake from the 4th Barnstable, Timothy Madden from Barnstable and Nantucket, Cleon Turner from 1st Barnstable; and a couple of off-Cape folks, William Lantigua from 16th Essex and John W. Scibak from 2nd Hampshire. In the Senate, Rob O’Leary is the Senate sponsor. So we feel that it’s a pretty wonderful contingent from the Cape sponsoring the bill.

You all may know better than we do what it is like to put a bill before the State House and Senate. We now have a bill docket number but we don’t have a bill number yet. We’re waiting on that. We’re not sure which committee we’re going to go before. It could be the Public Health Committee. It could be the Health Care Financing Committee. We’ve also met with Senator Therese Murray who was very encouraging. She helped arrange for us to talk with Senator Richard Moore, who is the Senate Chair of the Health Care Finance Committee, and he was very helpful to us.

So we are learning our way through this legislative maze and getting more and more information. We anticipate that we will have a hearing before one of those committees sometime in the fall. That’s as close as we can get for information on that. We’re told that we might get a week’s notice or we might get less than that – we’re not sure. But when we get the notice, we should appear with lots of people and with short talks. So that’s what we’ll try to do.

Just to let you know, as you know this is a Cape-wide community effort. It’s citizen-led, citizen-driven. I am the only staff person. I’m very part-time but it does take some financial support just to keep us going. For instance, we brought some brochures today but not enough for all of you because we ran out of them and we’re getting new ones done and we will leave those on the table for you.

We’ve had some wonderful funding that we think is a great indictor of support for us – the Cape Cod Foundation. It was quite a big supporter for us. Bank of America locally. Cape Cod Health Care has given us funding. We were a finalist on the Robert Wood Johnson’s grant. We received some small funding from the Gramacey Park Foundation and the Haymarket Foundation. And we’ve just found out that we’re going to be funded for the second year by the Unitarian Universalist Fund for a Just Society. So we feel that this funding that comes from national sources and very local ones is a very good sign that there’s real interest in what we’re doing.

In the fall of last year, 2008, we helped a ballot initiative out, which many of you may know about. It basically said that health care is a human right. We managed to get that in three of our six districts, and the three districts are the 1st Barnstable, 4th Barnstable and Barnstable, Nantucket and Dukes. The voters that came out for that – 71 percent of them voted yes, that they thought health care is a human right; and we’re very encouraged by that. So we feel that there is a lot of momentum. We’ve had many other endorsements that I would be happy to tell you about later but I don’t want to take up all of the time. So I’d like now to turn it over to Judy.

Ms. HARRIS: Thank you, Candice. My name is Judy Harris. My background is both nursing and as a Certified Health Education Specialist in Preventive Health and Wellness Care, and I work nationally for the Army and the Army National Guard as a consultant in preventive care and management of health issues for communities. I wanted to talk a little bit about what’s going on with the Connector.

It probably comes as no surprise to you that there are rumors circulating that the connector may be the model for the national plan and that probably arose because there just are not that many state models out there of any kind of health care reform and Massachusetts now does have a couple years of experience with it. And I thought it would be worth looking a little bit at how that’s doing.

So far the 2008 data is just in and the number of insured in Massachusetts has increased by 42 percent so that only 2.6 percent of the citizens in the Commonwealth don’t have insurance. Costs, however, are going up almost exponentially on the thing. It’s forecast to cost the state $1.3 billion dollars in 2009.

Unfortunately, there has also been a decreased access to care. While there’s an increase in insured patients, there has been a decrease in physicians who are willing to take either Medicare or the Connector – the plan for lower income and/or poor residents in the Commonwealth. Physicians just don’t accept it.

There’s also been a 36 percent decrease in what used to be Massachusetts good Free Care Plan because Governor Patrick has had to take money out of that safety net in order to keep the Connector going. Also, there’s a waiver process so that people who really can’t afford any of the available plans don’t have to buy insurance even though it’s mandated that they have insurance, and 79,000 people statewide have now been wavered from having to buy insurance. So cost is still an obstacle under this plan.

Primary care providers are just being pushed to the limit. A study done by the Massachusetts Medical Association in 2008 showed that about 35 to 40 percent of primary care providers are no longer accepting new patients. Fifty percent of them are very dissatisfied with providing patient care at all because of the amount of time they have to spend on administrative overhead dealing with a myriad of different insurers and that sort of thing. And close to 50 percent of physicians statewide are considering a career change.

So this is an issue that I think sometimes it doesn’t come up. It’s what are we doing to our docs when we try to fool around the edges of reform instead of working at what really needs to happen. I’ll skip some of this for time sake. Seventy-five percent of those people who were bankrupted in the Commonwealth for medical reasons had insurance. So they were bankrupted by the co-pays – the deductibles which are ever rising, and those kind of things, that they have to pay out-of-pocket.

So how can Cape Care help? We think that we can serve as a good model for a regional, community-owned public plan. There’s a lot of talk at the national level about a public plan, and as that we can be the Connector’s partner and provide them with a way to give cost-effective care to folks on the Cape who select this plan. We can eliminate the number of underinsured people, which has also grown greatly with the Connector. A lot of the private insurers came up with these policies for very young people who never get sick and very seldom get insured. They cost very little but they don’t cover anything, whereas our plan would cover everybody for everything.

We also provide insurance portability. We would tie insurance to an employer so that people who have seasonal employment would have their insurance year-round. Cutting costs through buying-purchasing, through attracting new providers because of the decreasing their administrative workload; and keeping the providers we have is also a feature.

Then there’s the effort on public health and prevention and this doesn’t get nearly enough attention nationwide, but keeping people healthier is a lot easier than having multiple CAT scans at multiple facilities, multiple one-day surgeries and that sort of thing – take care of people after something has happened to them. There’s strong evidence that just providing people with good prevention education reduces the cost of health care on a nationwide basis. My information comes primarily from two reports – one, as I mentioned, is the Massachusetts Medical Association Report of 2008, and the other is the Report from the Harvard Medical School and the Physicians for a National Health Plan that just came out in February. Thank you.

Dr. O’MALLEY: Good afternoon. It’s good to be back. My name is Brian O’Malley. I’m a primary care internist and have practiced out in Provincetown since 1978. So I’ve been tending to the community out there for sometime. I’ve served with George on the Board of Health. I’ve served as Chair of the Board of Health out in Provincetown for a public health prospective, and I’m a trustee of Cape Cod Health Care since the system was inaugurated ten years ago. So I bring a real prospective on the institutional needs and pressures when I speak.

What I would like to address today is to kind of bring what work we have been doing over the past five years. The Cape Care model plan has been in evolution since its first initiation back in late 2003. It has developed through a very open collaborative community process – hundreds of meetings, hundreds of discussions and questions, and I would really like to comment on we like the tough questions because then those become grist for okay what do we do about this? Where do we go with this issue that someone has identified?

Very recently we find ourselves remarkably positioned as the current national debate evolves to, what we think, play a very significant role in advancing the discussion and bringing in some prospective of the community – and I’ll speak to that. Clearly the elements of the national plan – the ones that don’t change on an almost hourly basis – are, I think, the consensus is emerging out of Washington that the elements that are going to be there that there will be in fact some form of a mandate – much as the Commonwealth of Massachusetts did – that everyone has to have insurance some way or another, whether it’s employer-provided or through some other system.

The continuation of employment-based insurance is going to go on. Washington has signaled that the time is not now for what would really be called a single payer – a national health plan that covers everyone. That’s not about to happen. Rather, as you all know, the discussion is focusing clearly on the potential for a “public plan,” and within those two words there is just an enormous breath of potential for issues.

The two that will emerge as the crux of what a public plan is about are the following: How is it financed? That is, is there public financing of the ”public plan,” or is it forced to ride on its own? Number two, what is going to be the quality of health care services under that plan? That is, if some factions in Washington have been right, the public plan will be a very striped down safety net, bare bones, Medicaid like, that will allow us to say everybody has an insurance card, but that is not going to translate into real health care and it will be a plan that essentially nobody goes into unless they have to.

What we would like to do is counterpoise the model that we’ve developed, for what is substantially the public plan, as the alternative. Let me explain why I think that’s a realistic comparison and what are the elements of the Cape Care model? Well, it’s public in the sense that it will be available as an option to any resident of Barnstable County. In many ways it would be like the library, which is to say the library is available to you if you live in whatever town you’re in but you still have to go and
register. You’ve got to take out a card, and that would be the case here. It wouldn’t apply to you unless you decided to sign up for it where it would be available.

It would be publicly financed. We’ve had a little discussion on this subject already about the financing. The last time that we met with the Assembly, these details had yet to be worked out. Even before I mention the financing I’m going to do a little bit of a caveat here. Cape Care, the model for a public health plan, is completely independent, frankly, of its financing. It needs financing. It needs a source of revenue somewhere to run it, but just exactly where those revenues derive doesn’t really make any great difference to how the thing runs.

Working at a County level as we are imposes certain very real restrictions on what our options are. We cannot create an income tax base when we do it at the County level. So when we think about this possibly as a model, we have to remember that the financing proposals that we’re making – that we’re talking about and I’m going to explain here in a moment – are very much a function of the circumstances of the political environment in which we operate.

Where there are different legal structures, where there are different sets of laws about what revenue sources could be raised, we can talk other things. But where we stand after these many years of talking with our political representatives about what the opportunities are, the two major revenue streams for this – and I should speak new revenue streams – it is the case that about half, slightly more than half, of all health care is already funded by the Federal Government and some of it passing through the state. That’s the Medicaid, Mass health money, of course, so more than 50 percent of funding is already there. We entire anticipate continuing that existing funding.

The other half is the money that comes out of people’s pockets. That’s the premiums, the co-payment, the deductible – all the not-covered services – all the money that we spend collectively that isn’t being paid for somehow through government. So it’s that other half of the financing that we intend to make up. We intend to make it up through a mechanism that creates a social financing, meaning we pool resources. It creates an environment where it is not regressively financed – that is falling most heavily on poor people. It completely will eliminate the element of uncertainty for health care cost.

As you have probably read in the last few weeks, the latest Harvard study indicates that 61 percent of all bankruptcies currently are related medical costs – unanticipated medical costs, and the great majority of these are currently people who have insurance. It’s simply the case that the insurance is not adequate to cover and they’re left holding such bills that they’re broke. So public financing both spreads the cost equitably and avoids the potential, whatever, of catastrophic costs falling on any one individual or family losing their homes.

That said, this other half – this other non-federal half of the financing – is anticipated to come at this point from two sources; a County property tax and a payroll tax, and I’ll explain them both.

The County property tax was actually suggested to us by Senator O’Leary in discussion some while ago. He said you should think about the way we funded the Cape Cod Commission; that’s a County property tax. That’s established under General Laws, Chapter 35, Sections 30 and 31 is the legal underpinnings for that. Currently we are looking at a model that envisions approximately 0.85 percent property tax on all taxable properties with two exclusions. That is 0.85 percent – just under a percent.

The exclusions are – and this is a model. This is from a model – properties under $200,000 we would not tax on the assumption that that’s hitting people who are in the smallest homes and may have some difficulty with it, and we propose to cap homes valued at over $2 million dollars. That, again, could be flexible but the idea there is that there are certain properties that would wind up paying extravagantly high tax bills and we don’t want to make it too much on any one person.

The other component would be a payroll tax on all employers. It’s important to understand that this would be completely independent of an employer’s responsibility. This would not reflect coverage for their own employees specifically but rather they pay into the County health employer-supported tax. The seven percent is actually a number that we’ve had some very positive favorable responses to.

I know when we spoke to the Commissioners a month or two ago, the County Administrator did some quick figuring in his head and he said, “You know, I would go for that one in a flash. That’s great. That would save us a lot of money.” We ran this by the Administrator in the Town of Eastham and collected their numbers and they’re currently putting out 28 percent of their budget goes to employee health care. They would be instead paying 7 percent of their budget. It would save the Town of Eastham alone over $1.1 million dollars a year in costs.

So while, yes, we are talking about a tax here, I think for most employers it would be a matter of 7 percent – here, here’s the check cut to the Department of Revenue, I’m finished with it. I don’t need to negotiate. There’s no business for the employees. They’re all covered. They go get the health care wherever they want. It’s not a direct responsibility.

So, again, these are the mechanisms that we envision now. They are a function of what is doable possible at the County level. From all of the consultations that we’ve had at the State House level, these are our options. We understand this care will be provided by the existing network of providers. This is not a national health service for England. I would not suddenly be an employee of the government. This is not a government-run program in any way.

This is envisioned as sort of an authority form; that is with some involvement of County government – some oversight function but not a direct responsibility. It’s intended as a community board that’s elected and runs it. Then, as we’ve already heard, it would be lifetime, including all of the usual sorts of things that we think about as insurance coverage, of course, plus the unusual elements that anticipate of pharmaceuticals, dental care and long-term care.

Now long-term care, of course, is an enormous question to take on. Our prospective is that no plan that purports to call itself a health plan can ignore what is that enormous elephant in the room. In our current health system when an aged parent requires nursing home care, we know that it’s a catastrophe for every family. We basically lose everything.

How we propose to deal with it is fundamentally through the mechanism of – this is not just a health insurance plan; it’s a community health plan, and part of a community health plan means you focus your energy and your expenses as far upstream as you can. That means keeping the community healthy – keeping elders safely at home can be done so much less expensively than putting them in an institution.

Speaker BERGSTROM: Dr. O’Malley, I’m going to ask you to wrap up your presentation just because there will be a lot of questions from the Assembly and you’ll have a chance to hit some of those points in your in response to the questions that we get from the Members of the Assembly. So do you have a few more comments?

Dr. O’MALLEY: Just a couple. One of the pieces that we anticipate will be very significant – particularly for the Cape – as we’ve evolved this model is the enhanced access to primary care services. As everyone knows – particularly the mid-Cape area – that’s a very sticky issue. People are waiting many months when they come to the area. They either have to change plans or move to the area to get primary care physicians.

How do we intend to do that? Number one, primary care at the medical home is at the root of the system that we propose. We propose to both improve payments to primary care physicians, help to create and facilitate care teams that coordinate, health information technology, a single common source, a common platform, electronic medical records that communicate with everyone.

And we’ll practice facilitation. This isn’t running them but it’s helping them. As I referenced, an enormous focus on public health; that is, overweight, tobacco, alcohol abuse, exercise and those sorts of things. As we wrap up here, what we envision is that this model could be in the current debate where there is talk of how are we going to do this? Are there going to be cooperatives? Do we want the government running this plan? Do you want this to be run by non-government agencies?

We think we’re a model for what could be an element in a much larger picture; that is a regionally run, a regionally coordinated plan where in fact, if we had our druthers, the funding would be on a much higher level. We have to operate here but it’s not really where it should go. So that’s currently where we see ourselves positioned. There is this great dialogue going on and we think the work that we’ve done over these last number of years puts us in a place to have something to say.

Speaker BERGSTROM: We’re going to continue that dialogue right now. Ms. Perry, do you have something to add to that?

Ms. PERRY: Yes. May I hand out a funding sheet that kind of explains what Dr. O’Malley is talking about?

Speaker BERGSTROM: You can actually bring it up here and we’ll get it handed out for you. Do any Members of the Assembly have any questions for Dr. O’Malley or to the other advocates? They seem all stunned into silence. I’ll go over to the right here and point to Tom and Marcia.

Deputy Speaker KEYES: Thank you, Mr. Speaker. Wow – this is a very, very big ambitious proposal and I want to commend you for the amount of work that you have put into this for many, many years at this point. I’m trying to think of where do I start? This is a big proposal. I’ll start off with just a few questions.

I received this document yesterday. There was a summary that was sent to us and then I subsequently asked for the entire document, which is 37 pages roughly, and there’s a difference in the two.

Dr. O’MALLEY: May I ask, the 37-page document are you referring to the bill as opposed to the model plan? They’re two separate documents.

Deputy Speaker KEYES: Are they different in scope?

Dr. O’MALLEY: The model plan is the piece that we have been working on for years. It’s the one that really fully describes it. In preparing legislation, our guidance has been – strip this down to the absolute essentials. The essentials here are the formation of a public corporation – a public trust – it’s purposes, it’s governance and it’s finances. So much of the material that describes how the health system would work is not actually part of this. The model plan has that much more
flesh-out. You have the bill.

Deputy Speaker KEYES: Understandable, and it does describe that in there. It says that moving forward it needs to address certain areas. That’s in there.

Dr. O’MALLEY: Correct.

Deputy Speaker KEYES: But there is still an awful lot of detail because there is plenty in here that I would just like to have some clarity on. Now where do we start? Let me start with the finances – something that’s near and dear to my heart. Because I obviously represent the Town of Sandwich, I’ll have to explain that to them and I’m sure that they’re going to have questions.

Now I see that there are two main areas where you’ll receive funding beyond the federal end – the first one being, of course, the property tax. That will be part of the County assessment to the municipalities. Secondly will be the employer – it’s based on the payroll for the employer. They’ll pay into a fund that’s part of the program. Now my question to you is since the assessment to the municipality – and I’ll use Sandwich for instance – it will be just like right now the Cape Cod Commission has an additional assessment that goes to the town. That’s exempt from Prop 2

Dr. O’MALLEY: Right.

Deputy Speaker KEYES: Now if employers have a reduction in the amount of employees they have, then the amount that they pay into the system will go down because it’s based on the DOR number of employees. In that case, where do you compensate for the reduction in funding since there are only three sources? It’s looking like it’s going to be borne on the households when there’s a reduction in the employer payment.

Dr. O’MALLEY: I’m sorry, I missed something. You’re talking about a reduction in employees?

Deputy Speaker KEYES: To keep it simple, there is the federal funding – federal, state and other agencies. There’s the employer fund that all of the employers will pay into based on the number of employees they have – the payroll. Then there are the individual households that make up the town assessment. When the number of employees during say a downturn like today, every business has a 10 percent reduction in force that means that they’re paying less into this system.

Dr. O’MALLEY: Correct.

Deputy Speaker KEYES: Now the health costs don’t go down. The increase will have to be borne on the only one that doesn’t have a restriction, which is the Proposition 2 ½ exemption, so it will come on the households. Now I have a real problem with that because I have a home in Sandwich and I wouldn’t want to see that happen, and the problem with that is that it will happen at the worst time. It will happen when there’s a down in the economy – people are being laid off, but the assessment on their home will go up. At least that’s the way I see it and if I could have some clarity on that I would appreciate it.

Dr. O’MALLEY: Well I think unfortunately you’re absolutely right. I think it’s the same issue that the state is facing with downturns in income tax with people not working. A down time – it’s pretty tough. I don’t have an answer. I think you’re absolutely right. That’s going to be a problem. That’s at a hard time. I don’t find any easy answers at this time.

Deputy Speaker KEYES: Thank you for that. Let me move on to another question that I have.Do you know at this time based on the population of Cape Cod – Sandwich has 10,000 households, and again I’ll use my Town of Sandwich as a guinea pig here – do we know what that assessment is going to amount to individual households?

Ms. PERRY: Individually?

Deputy Speaker KEYES: Is it broken down by town?

Ms. PERRY: You have the form that was just handed out to you – the green and red one. I should say that Dr. Jim Garb, who is on our advisory group, helped put this together and none of us are economists and we don’t have the funding right now to get someone to do all this so we’re all kind of making this up as we go. But he did a pretty thorough study and if it’s a 0.85 percent commercial property tax and property tax – you can see the numbers here on individual property. On $80 billion dollars worth of housing, we would get $680 million dollars from that. Does
that answer your question? It’s not broken down by town.

Dr. O’MALLEY: $8.50 per thousand. That’s the property base.

Deputy Speaker KEYES: Okay, $8.50 per thousand.

Speaker BERGSTROM: Hold on. Do you have an issue, Chris?

Mr. KANAGA: Yes. To me I’m looking at 0.85 percent. So that’s $8.50. So if you’re in a town with an $8.50 assessment per thousand, you’re going to double your property tax. I think that’s what we’re talking about.

Speaker BERGSTROM: Tom is just about to wrap up his questions and we’ll get back to him later for some follow up. So once he finishes shortly, we’ll get back to you.

Deputy Speaker KEYES: So if you have a house that’s assessed at $350,000, which is a going-rate home, it’s $2,975 on top of what you’re paying already. That’s roughly an average tax so this will double the property tax. So this needs to be cleared up so that everybody understands where we’re going. Mr. Chairman, I have plenty of other questions but I’ll have to yield to my colleagues.

Speaker BERGSTROM: I have a couple of questions. I’ll jump in and use my prerogative here for a minute. The savings on a program like this – for instance, most people get their health care through their employer. So they pay a percentage. Let’s say they pay 20 percent. The other 80 percent is borne by not just the employer but is borne by the consumer. When I go to the store and I buy a container of milk, or I go and hire a plumber, part of that is going to the health care costs of their employees. So my expense is spread out over a lot. I don’t recognize the nickel that I give here and the fifty cents that I give there. But if you accumulated it – for instance the total expenditure toward health care, the health care costs in general, you’d find that it was an enormous amount.

Now the difference is since I have employer subsidized health care, I get my health care subsidized. If I didn’t have that, like some of the people here, not only would I pay for my own health care but I would also pay that nickel on the container of milk and the fifty cents an hour for the plumber – so all of that extra cost is going to that employer subsidizing their employees. So if you have in theory a government-sponsored health care system that covered everybody, then all of those costs would be eliminated. In other words, it would be direct costs. Either the government would pay it or I would pay it, but I’m not paying the nickel. My employers are paying it and so on and so forth. But in your system it’s both.

In other words, I’m paying into your system but I’m also paying for everybody else’s health care because in a way I’m subsidizing it. I don’t know if you’re following me. It’s very complicated how our health care in this country is financed. Now if I double my property tax – I don’t know what I pay. I’m in Chatham so I probably pay $800. But let’s say I pay $2,500 a year. If I could get medical and I doubled that to $5,000 a year, that would be a bargain. People my age paying for their own health care pay $1,200, $1,300 or $1,400 a month. I like this thing for the same reason that Tom doesn’t like it, but my burden that I place on you would be to show that you’re having some value added to the system that’s not in place now.

In other words, what are you giving us now that we don’t have already. Also, the other question is that health insurance companies would cherry pick if they could. In other words, they’re mandated to cover certain things like AIDS. They’re mandated to cover pre-existing conditions because if they weren’t mandated to cover that they wouldn’t do it. So the first question is what are you adding? And the second is how do you make sure that this won’t be – and I’m going to use these words – a dumping ground for the most sick and the most expensive that insurance companies will shed off on this plan?

Ms. PERRY: I’ll just answer part of that, briefly. One of the analogies that we’ve made is that it’s like the library – everyone is going to contribute to it so you don’t get to cherry pick. Everyone is contributing to it. If you choose not to use it, you don’t have to.

Speaker BERGSTROM: Insurance companies who cover people, they’ll say we don’t have to cover the sick because basically you’re saying that you’ll do it.

Ms. PERRY: If Cape Care is covering everyone in Barnstable County for all of the services that we’ve listed, I’m not sure why insurance companies would come out here unless they’re going to cover some of the special features, like face lifts or something. Do you agree?

Ms. HARRIS: Yes.

Ms. PERRY: Does that answer your question, Mr. Speaker?

Speaker BERGSTROM: I’m just worried that what’s going to happen is that this is going to become an insurance of last resort for people who are going to be the most expensive and the most sick, whereas now in the current system insurance companies cover everybody so that the healthy people pay for the sick people. That’s what I’m saying.

Dr. O’MALLEY: You’re absolutely right, and that issue of cherry picking has been the failure of every effort in every state so far to address this issue because what has been done repeatedly is you create a system to cover all of those people who can’t get insurance otherwise. Those are low income, difficult to insure, chronically-ill people, and guess what? It breaks the bank over and over again – in Tennessee, Maine, every example that we’ve had so far that sort of reform.

The way we intend to avoid that cherry picking, since we understand, we’ve know from the beginning that we cannot be the only player in town. We have no way of prohibiting anybody else from selling health insurance. The way we’ve approached this from the very beginning is we’re going to be the best health care plan anybody can have. We would be the one anyone in their right mind would take because it’s so good. People say, what about people who are really happy with their insurance? Where are all those people who are really happy with their insurance? Anyway, we think we’d be the plan that you would want.

Speaker BERGSTROM: Some of us are happy with our insurance because somebody else pays for it.

Dr. O’MALLEY: Exactly. I will answer the question that you asked what do we add – with one word – a system. It has to be recognized. Currently what we have for health care in our culture is not a system. We are in fact unique in the developed world in not having any organized format for overseeing health care and its delivery.

What we would be doing is actually creating a health system; one that organizes, as I’ve already indicated, from the ground point of public health – maintaining an adequate approach to public health, universal immunizations that are done public health-wise, adequate nutrition, exercise facilities, etc., and then medical care, homes for primary care, specialist referrals; and, frankly, and integrated coordinated system. What we have now is a series of sellers looking to purvey their goods at the highest value.

Speaker BERGSTROM: I’ve taken up enough time so I’ll go back to the rest of the Assembly. Chris?

Mr. KANAGA: I was wondering if you’ve given any thought or this has come up what the sort of macro-effects of such an incredible system might be. I’m thinking particularly if I’m in Michigan and I’ve been laid off or I’m bankrupt and living in New Jersey and on some form of public assistance, why wouldn’t I move to Cape Cod where there is also free health care? And what would the effect of that be on hospitals and the health care system here?

Dr. O’MALLEY: I don’t mean to be facetious but we haven’t had a huge immigration to Canada. One could say, why wouldn’t everybody go to Canada because of health care? I’m not trying to play games. You’re right, it’s a concern. If it’s really great, why wouldn’t people come here? Well, because packing up and moving is a big deal. You don’t do it without a place to work and live. You’re right it is a concern. How do we define “resident.” Who get benefits? Has Massachusetts had a big influx? I don’t think so.

Speaker BERGSTROM: Marcia?

Ms. KING: Thank you, Mr. Speaker. Your form has for this funding a tax of .87 percent, but your legislation also has a couple of other things. You talk about all the money that are collected by the cities and towns – from municipal workers you’re going to collect their premiums, is that what you’re saying? That’s what your legislation says. That’s what it says. Section 4 says that all monies collected by cities and towns and other government subsidies change of health care services or health insurance premiums under section 20 and 4.

So I’m a little confused because you’re saying that you’re going to tax spending municipalities and they’ll give you their people but then you’re also asking for the premiums. How are you going to get through the union issue? It’s a great idea but I totally agree with also with Chris’ point a minute ago. It could have some real adverse consequences that are not mentioned.

I think the issue becomes when we do something like this in a small area and it’s not spread across the whole country it does become baggage. I hate to use that word because it has a negative connotation. But, again, I actually did read this last night but I have some deep concerns exactly that because it will end up increasing property taxes more than $2,975 because as your notice says, you’re going to exclude property under $200,000 and exclude property over $2 million. So somebody has to pay. So that’s that middle group.

So say on my $400,000 house, I’m going to pay another $4,000 or $5,000 a year, plus I’m still paying my own insurance regardless, and then you say I have a choice, that I don’t have to have insurance. But then you’re also saying to me, great, if my insurance doesn’t want to pick up this stuff, I can say, screw my insurance. I’m going here. So I’m on the verge on bankrupting myself. I’m going to come over and give you my bills. Is that what you’re telling me? If I pay $5,000 a year for a couple of years, and God forbid something happens to somebody in my family, will you then kick in? I guess I’m just concerned that you are opening up, to some extent, a Pandora’s Box.

And this is a problem I think I’ve had for 18 months with you – is I actually believe in a single payer but I think it has to be done across the wide spans of the USA. I’m concerned that if Barnstable County does something like this, there will be a huge adverse impact on employers and on residents. I do think there will be an influx. I’m just concerned that we’re having a hard enough time on the Cape where we have second homeowners, people are losing their homes, to hand them another $3,000 or $4,000 bill is not going to go over well. I know you had a vote but you did not say in the vote – and my town didn’t have a vote – but all the questions that were asked were very positive, and I would have said, “Absolutely, everybody should have health care.

But by the way, you all have health care – it’s just the emergency room,unfortunately. So I think you didn’t say in your question that you’re going to have to pay on a property tax another $3,000 or $4,000. So maybe I’ll sell my house and start renting and I won’t have to pay that burden. So I’m just concerned on the bigger picture.

On another note, I would ask the Speaker – I know you’re really big into this, Mr. Speaker – but I think that you think that maybe Tom is on it and that’s not true. I think that you feel people are for or against something and that’s not necessarily true. This is a great idea but I’m just concerned from the magnitude of what it is when it is on the national level and when we are facing all of this that Cape Cod could be ahead of the game but also could pay a very high price on the negative side for people to say I can’t live here anymore and I will have to move. I may stop and say I’m not sure I want to pay this and I can move to Marlborough and I’m not going to pay it, or I could move somewhere else. And I think people will move here. It’s a great place to be and I wish I lived here.

Speaker BERGSTROM: Fred and then Tony.

Mr. SCHILPP: Thank you, Mr. Speaker. Most of my comments really have to do with some of what I’ve heard. I think we’re having a very good discussion and I hope you guys are feeling that way too. I’m not sure I understand on one hand it’s a problem because it’s such a great plan that people are going to want to come to the Cape, and that’s adverse; and on the other hand employers are going to be hurt by this, and that’s a bad thing. Yet we hear from our County Administrator that any
employer who is going to cut their bill down to 7 percent would be jumping up and down with glee.

So I think there are a number of things which oppose each other in some of the arguments that I’ve heard. What happens when the employment drops and the payroll tax then drops and then it goes to the property owners to pay it? What’s going on when General Motors has just cut 20,000 people in Detroit, or however many in Detroit; and 200,000 in Michigan? How are those people getting health insurance since General Motors is no longer giving them health insurance?

The state is obviously going to try to give them health insurance. The Federal Government is going to try to give them health insurance. There are going to have to be other ways that they can continue to have some health insurance. Somebody is going to have to pay for their health care at some point. So I think the business of how property tax is going down, and how much the increase is going to be or fewer employees, those mechanisms that create the amount of money are going to be changed constantly as employment changes and as property values change.

But one of the things that I think Ron was pointing out – and I’m not sure whether you had mentioned that and I did not read the material – the broad piece of paper that was 37 pages – but when Ron says that the person is delivering goods and services to him, he right now is paying for their health insurance. When he doesn’t have to pay for their health insurance, isn’t the cost of those services going to go down so that all of the people who provide services to us and goods to us now who pay this exorbitant amount of money to provide health insurance to their employees, are they going to reduce the cost of gasoline, reduce the cost of housing, reduce the cost of other aspects of life on Cape Cod or other areas?

Ms. HARRIS: It’s certainly hard to say on just our one region level that that would happen but that’s certainly a potential. Insurance companies have an administrative overhead of 40+ percent so only 60 percent of your insurance premium, your insurance co-pay dollar, your employer’s insurance dollar is going to your health care. Medicare, on the other hand, has overheads of about 1 to 3 percent, which is what we imagine for this plan. That wastage alone can bring down, even on a county level, some of the expenses.

I had a conversation with Howard Dean two weeks ago. He is now the health care reform guru, if you will, for Democracy for America and he at heart a single-payer supporter. What he said to me when I asked him about some of these issues was we have got to have regional plans that draw lots of attention and lots of people to support them – even people moving into their districts to get them – in order for this to happen on a national level. It’s not going to happen without some good regional models.

I think we have a unique community here in that we are fairly isolated. Yes, some people may move in to take advantage of health care, but we also have a population that kind of sits out in the ocean and it’s not everyone’s cup of tea. So I think our population is likely to stay fairly stable and we have an opportunity to show what a public plan can offer that private insurers refuse to offer because they make their money off of technology and specialty physicians. They don’t make their money on prevention. You can count on the fingers of one hand the number of private insurers who offer any prevention benefits and most of those are mandated because they serve federal employees.

Speaker BERGSTROM: Tony?

Mr. SCALESE: Thank you, Mr. Speaker. I’ll leave the finances to the folks that you’ve been listening to. I think that having been in the workforce for a whole long time any time there was a problem with the cost of health insurance, the employer generally goes out to get a lesser expensive plan for him and a more expensive plan for me. The lesser expensive plan also brings with it poorer coverage, less choice. I will leave that, again, to the others.

When Fred asked about the General Motors’ employees and Chrysler employees that lost their jobs, my guess is that they went out and had to buy their own insurance at a pretty expensive cost. What continues to be my concern is I have health issues here and there.

Let’s take the homeowners’ insurance, for example. Many companies didn’t want to insure homes on the Cape because of potential problems. There are going to be a number of health providers who are going to want to not provide health care to people like me or people who have health and medical problems because they’re not going to get the same amount of money that they were getting from private insurance, which I paid for, okay?

I’m concerned, and I will continue to be concerned that I will not be able to go to the doctor of my choice; that my primary care physician who is not on Cape Cod, but off Cape Cod, who sends me to specialists for the problems that I have off Cape Cod, may say no, Tony, I can’t help you. You’re going to have to get somebody down on Cape Cod. And I’m sure that I’m not the only one that’s going to have these issues. It’s going to be expensive. There’s nothing that I can do about it. I’m going to have to pay. Everybody here is going to have to pay, whether it be my house taxes, my employer raising something, or taking something else away.

Just recently Blue Cross/Blue Shield had a fairly substantial price increase. A lot of employers dropped Blue Cross/Blue Shield and went to less expensive plans because it made their cut lesser expensive. The lesser expensive plans are just that – lesser expensive plans that provide lesser coverage for the employees. So I’m concerned about that. I would be the first one to admit that I haven’t read this. I wasn’t able to pull it off of my computer, to tell you the truth, so I guess that was my computer’s fault.

As concerning in this economy that somebody is saying to me that my taxes are going to go up because I need to pay for somebody else’s health insurance, and I’ve been paying for my health insurance for all these years, more concerning to me is that doctors will stop doing what they customarily do to help the patients on Cape Cod. You say, well, they’re going to lose money.

You know what? Look at the number of major home insurance companies that pulled out of Cape Cod and how money did they lose, and how much money did they really care that they lost because I don’t think that they lost anything or they never would have pulled out of Cape Cod. So my concern – as much as the financial is concerned which I think Chris, Fred and Tom brought up very valid points – my concern is the quality of care will go down. I can sit here until you’re blue in the face and I’m blue in the face and I will not agree that I will not be hurt by the type of care that I’m going to get. Thank you.

Dr. O’MALLEY: I think, briefly, I would just say that you’ve touched on what is a very critical central point here. If this plan does not attract widespread involvement, if it’s a very limited, small-scale thing, it will fail. We know that. This is understood from the beginning and it’s the reason why I said earlier our goal is to make this be the plan that anybody would want to be in because it’s superior. Now if we can get to that point –

Mr. SCALESE: Excuse me. Define “anybody.” Is it anybody who needs insurance or anybody who provides health care?

Dr. O’MALLEY: Everybody needs insurance. Everybody needs coverage.

Mr. SCALESE: You’re tying your hat to the people who provide care and those are the people that I’m concerned about.

Dr. O’MALLEY: Follow that. I’m going with you. If I’m a physician practicing here in an environment where every person who walks through the door has their Cape Care card to hand to my front desk, of course I’m going to take it, particularly because I know built into this is the notion that for me as a primary care physician I’m going to make out better than I do now. I make out really badly now. That’s the reality.

It can’t get a whole heck of a lot worse and I stay working. So I’m not real threatened about an environment that actually works to promote primary care to enhance my life, that takes away the piles of paper that I face at the end of every single day, all that literally hours of unpaid work. I don’t have any problem losing this system and I would really welcome something where I would get paid a little bit better when I spend my day taking care of patients and not doing the nonsense work.

Mr. SCALESE: Assuming you get paid.

Dr. O’MALLEY: That’s intended. I’m a doctor. I’m a trustee at a hospital. I’m not in this to make it worse for the hospital system, nor am I in this to make it worse for the doctors.

Speaker BERGSTROM: We have an expression in the fishing community that our boat is so small and the ocean is so big – well our boat, our authority here and our lines of responsibility are very limited. The health care debate is huge and we can go on for hours so I’m going to ask the indulgence of the Members of the Assembly to try to ask a few more questions and wrap this up and not get into a general argument over health care reform.

Dr. O’MALLEY: I would like to point one thing out as a follow-up to that question. This is actually quite critical and we missed it. This entire budget is built upon recent years of health care spending for the entire County. This is a full, fleshed out, take-care-of-every-single-individual, of course, and we build towards this. The numbers are not nearly this big. This is what we’re now spending, how we would finance it. We wouldn’t be there right away.

Speaker BERGSTROM: We’ve got Tom, Leo, Teresa and then we’re going to try to wrap this up.

Deputy Speaker KEYES: Thank you, Mr. Speaker. I just want to state that this is an admirable goal to provide this level of service to everyone in Barnstable County, but I also believe that most bad legislation came out of good intentions. There are a lot of bad laws out there that if you look at who brought them forward, their intentions were good. Now the law of unanticipated consequences makes you look deep further into this – multi years down the road what could happen.

And looking at your document under this is a health plan for the residents of Barnstable County, the definition of “resident” has in there that “there needs to be a provision that for the purposes of this chapter, the terms ‘domicile,’ and ‘dwelling rights’ are not limited to any particular structure or interest in real property.” So a resident can be someone that does not have a domicile nor dwelling rights, or any interest in real property. And it goes on to say further “homeless individuals meeting
criteria above.”

Now we are already wrestling with the homeless population on Cape Cod. It’s something that we deal with on a constant basis. If they’re instantly considered a resident and therefore eligible for their health care, paid for by all the homeowners here on Cape Cod – in Sandwich it’s 10,000 households – that is a very attractive thing to an individual. Now you commented earlier that we live on a sandbar and we’re far out in the ocean, there are towns that are like that. The Town of Sandwich – we straddle both sides of the canal. We will be extremely attractive, I would imagine.

Again, I’m looking – not today – I’m looking years down the road as individuals understand that there are possibilities. When someone falls into hard times, they look for the possibilities. When individuals are literally becoming bankrupt because of health care, their choice could be either we go bankrupt or we move to Barnstable County. That’s not good for all of the other residents here on Cape Cod if you’re a homeowner. It could turn into a very sizable bill that does not have the protections of Proposition 2 ½. Right now we’re looking at doubling our taxes. And I have to look at different scenarios. I was a Selectman in Sandwich for six years and I already know a lot of bad situations that go on in municipalities.

Factor in you have a 67 year old widow in a very nice home. She’s going to pay for a substantial health care cost for one person, yet possibly the neighbor could live in a home that’s worth $200,000 or be in an average home of $300,000 or $400,000 and they could have six individuals, and they will pay less. Again, you have to get equity in this also. I’m not saying that that widow who is living in that home is someone that is affluent. She could have had this home and it could have been paid for already. She’s going to bare a huge cost and potentially have to sell that house. These are the things that we have to look at. These are the law of unanticipated consequences.

Again, admirable goal, but boy there’s a lot of things to discuss here that we can’t obviously solve here, but there’s legislation up at the State House now and I fear that it might pass, because we don’t have answers to these questions and a lot of people can get hurt by it. So we have to be very careful what we do here.

Speaker BERGSTROM: Leo?

Mr. CAKOUNES: I know that we have an electronic copy of the bill but you had mentioned that there’s an actual copy of the plan. Could I request that you either give us a paper copy or send one to us electronically. Maybe Diane could send it out to all of us so we could have it.

Dr. O’MALLEY: It is on the website. It’s there for download. I have a paper copy that I could leave.

Mr. CAKOUNES: Thank you. I’m computer stupid. I do have one other question too. I understand through the discussions that you had that property tax – if it is implemented – is going to be towards those who are obviously not users of this. I personally own a number of pieces of property so my taxes are going to go up for all of the properties that I own and there is only my wife and I and my child, so there is only going to be three people. But as far as the employment tax, is that anticipated to only go up for the employees that are using the plan or is that an employment tax that would be –

Dr. O’MALLEY: No, it’s a payroll tax, period. It’s independent of employees’ individual health care.

Mr. CAKOUNES: I kind of have a little bit of a problem. First of all I commend you for the work. I think, again, I agree with everyone and they said it here today, this is way bigger than we’re ever going to solve today but I do often like to take the chance and say “I told you so,” because in the Town of Harwich when this was in front of our Town Meeting I believe as just a Referendum question, the discussions on Town Meeting floor were very lengthy and there was a lot of people that brought up points, myself included, about being a multiple-property owner and there were some people there that were concerned that non-resident property owners, and there were also concerns there by a specific gentleman who is also quite vocal at Town Meeting, as well as I am, about his elderly mother who has excellent health care from some large firm she had worked for the last 60 years and did not need health care.

It was really expressed by those opponents of this at that time that this was looking to be funded by a user-funded mentality, and that really was expressed, and I hope that people have stayed and continued to watch this today because I said then at Town Meeting that there is no way that this plan is going to be user-funded strictly. It can’t be done. The numbers are too high. I think that if we could work toward a situation where the plan is so good that with my rental properties when I rent an apartment to someone that I can now give them health care as part of their rent because, quite frankly, my tax bill is going to double on that piece of property. It’s more of a comment than a question and I just want people out there to be aware that this – as my colleague said – something that may be passed and needs to be looked at and dealt with further.

Ms. PERRY: I would just like to add that we’ve been through so many phases with this. We’ve had a lot of public meetings and at one point we did talk about a user piece, but we did decide that if we wanted this to truly work for the whole community we had to not charge premiums, not base it on that, but find some other way to fund it. I’m very impressed by the collective intelligence here and I hope you all will continue to stay in touch with us because we are changing it and evolving it.

The odds of us passing this in this session of the Legislature apparently is really, really slim, but we have high hopes. We’ll still keep trying, but we know that there’s more that needs refinement and that’s why we come to you; that’s why we come to the Commissioners is because we think that there is a lot of knowledge here and you all can help us.

Speaker BERGSTROM: Teresa?

Ms. MARTIN: I just have one short pragmatic question. Providers are an important part of this mix. The reality is we’re part of the Boston medical region. What kind of buy-in in relationship do you have with people like Partners in Children?

Dr. O’MALLEY: At this point there is certainly no formal relationship. We’re not in a position to be contracting but very clearly we anticipate that Boston-area hospitals, as our regional referral center, would be contracted in. We have clear delineation of what are frankly fairly standard out-of-network coverage provisions, but given that Boston is so critical – and that actually answers Mr. Scalese’s question about a doctor somewhere off Cape – where we clearly would be able to give payment to people who are not in our system. We would have contracts with the Boston hospitals.

Ms. MARTIN: I believe that Partners is a big part of the national discussion right now and I’m curious if you’re having a dialogue with them and what kind of relationships are you building with people who can be key if this become reality?

Dr. O’MALLEY: As I say, we’re not negotiating contracts at this point.

Speaker BERGSTROM: Thank you very much. I appreciate your coming here. I know it’s a very difficult discussion and it’s timely because of course right now probably in the House and Senate in Washington they’re debating the same issue so that’s why we all have such an interest in it. This has been on my mind for two days. I’d love to rant and vent but they wouldn’t put up with it so I’m not going to do that.

Dr. O’MALLEY: We’d love to stay all night.

Speaker BERGSTROM: No, we’re not going to do that. Tony?

Mr. SCALESE: Do you have a docket number?

Ms. PERRY: Yes, the docket number is 1565, and as I said, we don’t have a bill number yet. We actually have the cover page if you would like that. Should I give that to Diane?

Speaker BERGSTROM: Yes.

Ms. PERRY: And we will provide you with the plan

Speaker BERGSTROM: I’ve also received a copy, through town hall in Chatham, with the idea that you were actually going to come before us. Are you also going to do this before individual towns because that was asked of me in Chatham?

Dr. O’MALLEY: We’ve been advised by our legislative sponsors that we are required to deliver notice to each town.

Speaker BERGSTROM: Okay, so that’s what you did.

Dr. O’MALLEY: So this is fulfilling a legal obligation to notify the towns.

Speaker BERGSTROM: So the individual towns may get a chance to bring this up?

Dr. O’MALLEY: Yes.

Speaker BERGSTROM: Thank you very much and good luck.

Ms. PERRY: Thank you.

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