ONE COMMONWEALTH AGENDA
Reimagining Health Systems to Achieve Health Equity
Imagine a Commonwealth where health care is truly universal, simple, and affordable. Where health outcomes like life expectancy are high across all communities, regardless of race, class, gender, sexual orientation, disability, or place; where public health crises from opioids to asthma to maternal mortality that burdensome communities more than others are treated with the same urgency and sophistication as we bring to treating cancer; where our response to COVID strengthens rather than weakens our public health infrastructure, and where everyone can afford to get the care they need, when they need it, without jeopardizing their safety, housing or families. Imagine a Commonwealth where we breathe healthy air in all our schools and neighborhoods, always access clean water, and can grow and secure nutritious food.
Massachusetts has been a leader in laying a foundation for universal access to high-quality health care. In surveys, we express higher rates of satisfaction on average with our health systems than in most other states. But our job is not done.
Costs are rising unsustainably for all, and what is good on average still fails some profoundly. Life expectancy is 68 years in New Bedford and 94 years in Newton. Throughout the Baker-Polito administration, five people have died every day of opioid overdoses, and the crisis appears to be worsening by the day. Springfield has some of the highest rates of asthma in the country. In 2020, Massachusetts had the third-highest number of COVID-19 deaths per capita in the country, and two-thirds of these deaths were in nursing homes. Chelsea was among the municipalities with the highest COVID-19 mortality rates in the nation.
We have a shared moral responsibility to see and address these failures by focusing our efforts on health equity. That is why my agenda will prioritize:
- Equitable pandemic resilience;
- Addressing the social determinants of health;
- Fully integrating behavioral health into our health system;
- Ensuring health coverage is truly universal;
- Bringing health services to where people are and supporting healthy and resilient communities; and
- Making health care affordable.
The agenda below is the outcome of community collaboration at every level. It was developed in discussion with advocates and policy experts across our Commonwealth. Most importantly, we listened to so many of our fellow citizens who are struggling to secure the health resources they need. Thanks to their wisdom and insight, we have a health agenda that will deliver health equity worthy of the One Commonwealth we aim to be. But work to refine this agenda remains: we’ll continue to engage with communities across Massachusetts so that all voices are heard in our efforts to knit the Commonwealth together.
This agenda is just the beginning of the process. As we seek stakeholder engagement across the Commonwealth in the months ahead, the next critical ingredient we need is YOU. Together, we can secure the foundations of healthy lives and healthy communities for all.
I have been in the business of building organizations, hiring staff, and forming teams for some twenty years. I have been fortunate to work in large-scale environments where employer health insurance continues to be viable.
But I have often had employees who found themselves making choices about life and career not in order to pursue their passions or professional development, but simply in order to maintain access to decent healthcare.
And as an employer I have too frequently found myself stretching and straining team structures and work functions to help protect coverage for team members who really needed our employer-provided health insurance for things like mental health or spinal surgery or cancer.
It’s a terrible thing for human beings to be caught in the trap of our healthcare complexity. And it’s bad for businesses too to have distortions to decision-making created by the inequities in our healthcare system.
We can’t fix this overnight but we can head in the right direction by centering health equity, supporting access to employer-provided insurance where necessary and also augmenting public insurance, strengthening our public infrastructure for preventive and primary health care, and driving toward value-based systems.
EQUITABLE PANDEMIC RESILIENCE
The pandemic pressure-tested our health systems, and we came up short — with some communities seeing significantly more severe impacts than others. During 2020, Massachusetts had the third-highest number of COVID-19 deaths per capita in the country, and two-thirds of these deaths were in nursing homes. Chelsea was among the municipalities with the highest COVID-19 mortality rates in the nation. Student-learning has been profoundly disrupted by lack of sufficient support to educators from a robust public health infrastructure. Businesses focused on personal services, and their employees, have faced a constantly shifting environment with insufficient public health support. COVID-19 is becoming an endemic disease and we need to integrate a capacity to protect ourselves from it into our routine functioning. And we are experiencing serious strain in our healthcare workforce, including for eldercare facilities. These urgent problems require immediate solutions — and if we had had equitable access to healthcare and the foundations of health from the get-go, our experience of this long pandemic would have been very different.
Across the whole of our health agenda, we will move swiftly to build the public health infrastructure we need for equitable pandemic resilience — working towards a paradigm shift towards health equity, where all our communities have a strong health foundation for resilience. In addition:
- We will develop stable, transparent protocols for converting wastewater
and hospitalization data into surge warnings that will trigger effective public health actions, as well as triggering all-clear communications to end those response measures when the surge subsides.
- We will maintain ongoing structures of horizontal coordination and communication connecting grassroots organizations and critical stakeholders to the state agencies responsible for crisis response. We will clearly communicate which measures are undertaken to keep individuals safe and which measures are undertaken to slow or stop transmission.
- We will work with the biotech sector to accelerate the development of the rapid-testing field, develop quality standards for communicating around recommended models, and work with the federal government and existing interstate compacts to achieve a reliable surge-ready supply of accessible, affordable and/or free rapid tests in periods of surge. We will also run a public education campaign on effective use of these tests to help protect oneself, one’s family, and the vulnerable.
- We will maintain and/or complete development of vaccine mandates for public employees, healthcare, eldercare, and childcare workers, educators, staff, and students in the K-12 system; we currently anticipate that those mandates will evolve into a requirement for an annual seasonal booster.
- We will invest ARPA funds in building out public health infrastructure, including investments in stronger school-based health teams (please see our Education Agenda); these school-based health teams will support community education around vaccines, maskings, and infection, prevention and control, and will help anchor routine vaccine clinics in partnership with community health organizations.
- We will also invest ARPA funds in green and healthy-school buildings (please see our Education Agenda).
- We will work to strengthen health care worker pipelines and supports, including by working to raise reimbursement rates to healthcare organizations, including nursing homes, that meet critical quality standards, contingent on those organizations passing on those increases in the form of higher wages to Certified Nursing Assistants and Licensed Nursing Assistants (please see our Good Jobs Agenda).
- We will be ready to use vaccine passports for restaurants
and public services during surges as part of a surge-response public health toolkit but we will not support ongoing, open-ended
requirements for vaccine passports for restaurants
and public services. We will also make rapid testing
resources readily available to businesses in the personal
services sector for use during surges.
- We will seek opportunities to support and strengthen the community organizations that have done so much to improve vaccine distribution in the state, from the Black Boston Covid Coalition to the Berkshire County Covid Collaborative and more, and build on their strengths to complete full support of our residents in facing a new endemic disease.
ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH
When we lack proper housing, do not receive a decent paycheck, or cannot access nutritious food, we become vulnerable to sickness and ill health. This reality means that achieving health and well-being requires more than good health care. It also requires having access to social and economic conditions that help us flourish individually and as a society. These resources are referred to as the “social determinants of health,” and they include things like having an affordable home, a good-paying job, and a thriving neighborhood.
We will invest upstream to secure the social conditions for good health. Doing so not only directly improves the lives and health of those most vulnerable, but also has the potential to preempt costly uses of medical care that contribute to an unaffordable health care system.
- Across our One Commonwealth Agenda, we address the social determinants of health directly by focusing on the building blocks of housing, transportation, schools, good jobs, and justice.
- To support reduced care costs and improved health outcomes for our most vulnerable residents, an Allen Administration also will activate our health care system in the service of patients’ social needs by, for example, expanding funding for the Flexible Services Program that enables MassHealth to provide direct assistance with nutrition and housing and broadening the range of social supports financed through this unique component of MassHealth. We will also partner with the Health Policy Commission to identify ways to engage private insurers in similarly innovative programs responsive to the social determinants of health and support provider-led initiatives focused on meeting patients’ social needs through increased funding for grant programs like the Health Policy Commission’s “Moving Massachusetts Upstream.”
- We will support low-income seniors by expanding PACE to include a broader range of wrap-around services, while similarly seeking to expand wrap-around services connected to day programs for people with disabilities and to “Turning 22” infrastructure.
- To address food insecurity, a common cause of poor health, we will also close “the SNAP Gap.” Over 700,000 MassHealth recipients are probably eligible for the Supplemental Nutrition Assistance Program (SNAP) but are not receiving it. An Allen Administration will pursue a single application procedure for households to apply for MassHealth/Medicare Savings Program, SNAP, Transitional Assistance for Families with Dependent Children (TAFDC), or Emergency Aid for the Elderly, Disabled and Children (EAEDC). Streamlining this application process for all eligible families will secure their access to several building blocks of good health at once, while reducing the administrative complexities that contribute to government waste.
ENSURING TIMELY, ACCESSIBLE BEHAVIORAL HEALTH SUPPORTS
Behavioral health care is not nice to have, it’s a must-have for overall health. Behavioral health has long been identified as in need of new investment, modernization, and integration into the Commonwealth’s overall health strategy. These needs are particularly urgent considering the immediate and anticipated long-term mental health impact of the COVID-19 pandemic and the ongoing opioid crisis ravaging communities across the Commonwealth: more than 2,000 residents died from an overdose in 2020 alone, the highest ever recorded in the Commonwealth; and the number in 2021 is predicted to be even higher.
The time has come to make sure everyone has access to affordable and accessible behavioral health supports when they need them. We will do this by fully integrating behavioral health into our health care system with coverage on par with coverage for physical health, supporting the development of an expanded, diverse behavioral health workforce, and developing robust protections for stigmatized and vulnerable populations.
- To ensure community-based behavioral health centers are prepared to meet need and deliver culturally competent and widely accessible care, we will strengthen pipelines for a diverse workforce and secure insurance coverage for the full range of providers, including recovery and peer-support coaches, as detailed in our Good Jobs agenda.
- We will also increase our available workforce by making it easier for out-of-state behavioral health care workers to provide service in Massachusetts through licensure reforms and licensing agreements with other states.
- We will increase mental health provision in schools and support parental training programs to respond to the short-term gap between the need for mental health care and our network of available service providers, as advanced in our Education Agenda.
- We will make permanent telemedicine resources developed during the pandemic as a critical element of expanding behavioral health provision. We will ensure that those who require opioid use treatment can readily use telemedicine to receive proper, timely, and culturally-competent care. This effort aligns with the Allen Administration’s priority to integrate telemedicine into the suite of health care options that all residents can rely on, not just some.
- We will also fight for coverage of an annual mental health wellness exam by supporting “An Act Addressing Barriers to Care for Mental Health” (S.2584). If the bill is not passed in this session, we will work to secure passage in the first session of an Allen Administration.
- We will expand access to in-patient substance use disorder treatment beds and also to community-based, peer-support centers and healing communities, like Kiva Centers, that support individuals with their self-healing process related to trauma, emotional distress, and substance use experiences.
- Last, but not least, we will create a multi-agency and stakeholder Health Equity Commission to address behavioral health disparities system-wide and map the work required to fully integrate behavioral health care into a health system designed to deliver accessible, affordable care to all, in line with the 2021 Health Equity Commission’s recommendations.
Ensure health coverage is truly universal
Massachusetts has made significant progress toward the goal of universal coverage – but our work is not done. Three percent of Massachusetts residents still do not have insurance coverage, and for many of them, the obstacle remains their immigration status. Moreover, for many who are insured, the cost of care is prohibitively expensive, causing residents to delay the care they need. This is especially true for those employed by small businesses or low-wage employers, and for racial minorities with low incomes.
At the same time, health coverage without availability of reliable, high-quality care is of little use. Currently, essential health services are not equally accessible across the Commonwealth: 13% of Massachusetts’s population lives in counties that do not have abortion providers, an essential component of sexual and reproductive health. And too often we are seeing our essential providers struggle under the weight of inadequate resources to sustainably serve their communities.
Ensuring truly universal coverage will require a range of tailored solutions including controlling costs for the Commonwealth’s small businesses and their employees, where the burdens of unaffordability are particularly stark; making being insured the default for all children and adults; and strengthening essential health providers and protecting essential health services.
Controlling costs for small businesses and their employees:
- First, to relieve small businesses, their employees, and the employees of low-wage employers of increasing burdens of unaffordable health expenses, we will initiate a planning process to study and design a public-private partnership plan that small businesses can buy on the Health Connector’s Small Business Health Options Program (SHOP), building on research that has been done to date on leveraging Medicaid structures to offer affordable and high-value health plan options for the small-group market.
- In addition, we will establish a structure of subsidies for small businesses to purchase eligible health plans on the Health Connector’s SHOP and drive market-wide affordability, building on proven ConnectorCare strategies that have encouraged low premiums on the individual market. This initiative will leverage under-utilized federal ACA funds designated for support of small businesses.
Making being insured the default for all children and adults:
- We will extend MassHealth coverage for all eligible children regardless of immigration status. We will also explore utilization of state Health Safety Net funds in an insurance model to ensure that people who are undocumented and who are ineligible for other forms of coverage have reliable access to comprehensive, coordinated health services, instead of relying upon emergency department visits.
- Moreover, we will make being insured the default. MA residents should not miss out on or lose health coverage simply due to administrative hurdles. An Allen Administration will work with the MA Department of Revenue, MassHealth, and Health Connector to automatically enroll residents in MassHealth and zero-cost Connector Plans when they are found to be eligible for these insurance programs. These new enrollees will receive an insurance card with information on how to access care and the option to switch plans or decline coverage altogether. In addition, we will support data-sharing between MassHealth and the Connector to identify MassHealth enrollees experiencing changes in eligibility and facilitate their automatic enrollment into zero cost Connector plans, if available, and vice versa, when life circumstances change.
- We will also build from data to focus on-the-ground enrollment efforts in communities and areas with high uninsured rates, and we will empower community-based organizations to support community awareness of, and enrollment in, available insurance options.
Strengthening essential providers and protecting essential health services
- An Allen Administration will strongly support community health centers, community hospitals, and safety net providers that provide a health foundation for the underserved and play a critical role as anchors for cost-effective, high-quality, and accessible care.
- Specifically, we will deliver a sustained commitment to pursuing enhanced reimbursement for Medicaid providers and use regulatory and legislative powers to reduce the current unfair disparity in commercial rates paid to safety net hospitals and academic medical centers for the same services, including supporting legislative action to establish a rate floor for lower-paid community hospitals. This will also be coupled with policies to achieve fair prices, as discussed in this agenda’s section on fair pricing and value-based approaches.
- We will also work to protect community hospitals from being crowded out by powerful hospital systems through careful monitoring of the impact of hospital expansion plans via the Health Policy Commission, expanding authority to establish conditions and deny transactions based on market impacts, and supporting the Attorney General in enforcement of antitrust provisions.
- In addition, we will continue the partnership between safety net providers and the Massachusetts Executive Office of Health and Human Services to pursue care-enhancing innovations for their patients, and secure through Medicaid waivers the necessary supplemental federal funding in the Safety Net Care Pool to support this care.
- Finally, an Allen Administration will secure and protect access to essential health services for all residents. We will, in particular, focus the spotlight on gaps in access to sexual and reproductive health services that persist in the Commonwealth and contribute to startling inequities in access and outcomes for Black women and those living in Western Massachusetts and the Cape.
- Specifically, we will support existing legislative proposals that would expand access to coverage for doula care and midwives before, during, and after birth – which is proven to improve maternal health outcomes for Black and Brown people as well as immigrants and low-income people. We will also solidify access to medication abortion via telehealth; require all public universities to provide coverage for and access to medication abortion; establish subsidies for clinics in underserved areas; and launch an information campaign to make sure women avail themselves of a 2017 law that provides a 12-month supply of birth control with no copay (in 2020, only about 300 women covered by Massachusetts’ largest insurers got a 12-month supply).
BRINGING HEALTH TO WHERE PEOPLE ARE AND SUPPORTING HEALTHY AND RESILIENT COMMUNITIES
We know that care delivered in the wrong setting, at the wrong time reduces health outcomes and contributes to the high and growing costs in our health system. In Massachusetts, our emergency department and acute care hospital use are well above national averages. Three-quarters of insured low-income residents who avoid care in more appropriate settings due to cost say they prefer ED visits because they are more confident those visits will be covered, while others miss out on needed care due to difficulty navigating the medical care system. As a result, patients and providers struggle to achieve a focus on the whole person and a continuum of care. Meanwhile, common outpatient procedures are shifting from physician office settings to high-priced hospital outpatient departments, driving up costs without discernible quality gains.
We need to build a culture of health– where we are oriented first toward prevention and healthy communities. We will do this by bringing health out of the hospital walls to where people are, and by supporting healthy communities, including in the face of health challenges introduced by pandemic threats and the climate crisis. We can reimagine and make new uses of our current infrastructure to meet the challenges of our warming climate and to address persistent gaps in community-based health and public health, including activating and resourcing schools as sites of health, modernizing local public health offices, strengthening community health centers, and strengthening partnerships among all three.
- An Allen administration will tighten connections between schools, public health offices, and community health centers to provide a robust foundation for primary and preventive health across the Commonwealth, building on learning from the pandemic about leveraging schools as easily accessible sites to provide basic health resources ranging from healthy lunches to vaccinations.
- We will jumpstart this effort using COVID relief funds offered under the American Rescue Plan Act (ARPA) to increase the presence of health personnel in schools, including nurses, counselors, social workers, and psychologists, prioritizing districts and schools serving students of color and students from low-income backgrounds including those who live outside of big cities.
- We will similarly use COVID relief and ARPA funds to modernize and regionalize the Commonwealth’s local public health infrastructure in line with the recommendations of the 2019 Commission on Public Health. Robust public health offices at the state and local level will be needed to support the transition to healthy and green school buildings, as advanced in our Education Agenda; as well as to improve water and waste management at municipal and regional levels and manage the nature-based solutions and tree-canopy that are advanced in our Climate Agenda. And school-based family health education teams, working in collaboration with public health offices and community health centers, can help broadly educate for climate resilience.
- We will also elevate the Massachusetts Department of Public Health (MDPH) within the structure of executive agencies, in line with the 2021 Health Equity Commission Recommendations. These recommendations focus on the need for greater funding and a more central role on cross-agency task forces and working groups. We can facilitate this by separating the Department of Health and Human Services into a health cabinet and a human services cabinet.
- In line with our previously described commitment to fair payment for essential providers, we will similarly ensure enhanced reimbursement and fair commercial rates for federally qualified community health centers (FQHCs) and community health centers (CHCs). FQHCs and CHCs provide culturally competent, community-based health service work by deploying a comprehensive, all-inclusive model of care that delivers high value for low-income communities and serves a high percentage of patients who are racial or ethnic minorities.
- We will further strengthen community health centers by charging the MDPH to support the development and deployment of more community health workers, through actions such as loan repayment for health center providers with service commitments and strengthened career ladder programs for Community Health Workers, Medical Assistants, Social Workers, and behavioral health clinicians. We will also invest in community health centers’ innovative programs to grow their own workforces through partnerships with community colleges and other educational institutions, aligned with our Good Jobs Agenda.
Making health care simple and affordable
Even for those who have adequate coverage, far too many residents are paying too much for their care or facing unnecessary administrative burdens to access. Surprise bills, overly complex systems and soaring costs are causing many families to forgo preventative care or are forcing impossible choices between health, housing and safety.
We need to make health care affordable so everyone can get the care they need without jeopardizing their safety, housing or families.
- An Allen Administration will establish new authority to limit price increases and unfair variation that are together driving cost growth in the health system. Specifically, we will support legislation to cap prices for the highest price providers and limit price growth. These proposals, supported by the Health Policy Commission (HPC), will reduce unfair price variation and improve equity across providers and patient populations, by allowing future price increases to accrue to lower-priced providers and ensuring the viability of these critical resources. We will also explore how best to integrate across our system the model of reference pricing for those services designated as “shoppable” by the Centers for Medicare and Medicaid Services (CMS). The goal throughout will be fair pricing.
- We will also hold health care entities accountable for meeting the state’s target cost growth limits including, per the Health Policy Commission’s recommendations, augmenting the annual performance improvement plan process and increasing the financial penalties that health care entities are subject to if their spending exceeds the MA Cost Growth Benchmark or if they otherwise fail to comply with the HPC’s procedures.
- In addition, we will increase the power of public purchasers to negotiate fair prices on drugs by exploring consolidated purchasing pools and/or interstate compacts. To increase the power of these negotiations, we will also support legislation authorizing the expansion of the Health Policy Commission’s drug pricing review authority and scrutiny over the value of pharmaceuticals, opening up the process by which drug prices are referred for review not just to drugs purchased by MassHealth, but for other public purchasers like the prison systems, and to include all drugs with a financial impact on the commercial market in Massachusetts.
- We will also increase transparency and accountability standards for pharmacy benefits managers with regulation to require PBMs to adopt the “pass through model” where PBMs must charge payers the same amount they reimburse pharmacies plus a set administrative fee, rather than manipulating payment levels to increase profits.
- An Allen Administration will work to empower patients and community members with cost information to develop insight and voice in health care decisions and in collective reforms. To begin, we will enforce pricing transparency requirements that have been Massachusetts law since 2014 but have failed to meet their potential. Currently, insurers are required to provide a cost-estimator tool for pricing different providers and services, but use of sites by members has been very limited due to poor site usability and low consumer awareness. We will strengthen this intervention by implementing usability requirements and investing in consumer awareness and education.
- We will accelerate development of provider capacity to employ value-based payment models and, as detailed above, shift investment toward providers, for instance FQHCs and community hospitals, that already deploy high value service models to meet primary, preventive, and acute care needs. In addition, we will support models of service provision that provide better value-based outcomes, including telehealth, team-based care, and culturally competent community health workers.
- We will also support the adoption of value-based insurance design throughout commercial health insurance markets, securing maximum affordability for effective, high-value treatments. The introduction of a public-private partnership plan for employees of small businesses with a value-based insurance design and price setting power will help drive this shift through competitive pressure, and we will further use regulatory and legislative power to accelerate this shift and hold health plans accountable for affordability.
- Finally, an Allen Administration will work to reduce unnecessary complexities of health care bureaucracies by standardizing and streamlining rules and processes and supporting investments in efficiency promoting innovations like digital health and data frameworks.
Housing, health, transportation, schools, jobs, justice, community, sustainability, and empowerment. These are the building blocks of a livable life, and they have to fit together for life throughout our Commonwealth to be livable. What’s more, every person in Massachusetts deserves not just a livable life but opportunities to create their best life. Being excellent on average is not good enough. The next frontier in Massachusetts is to achieve health equity. We must refocus on the goal of health, not health care, and know that achieving this requires addressing health needs with the right care, at the right time, in the right place, in the right way. The basic building blocks we propose throughout our One Commonwealth Agenda, and a health system designed to build on and reinforce them, are what every single one of us needs to have a foundation to stand on and to live a healthy life.