Cape Care Makes Case For Community Health Trust

(Falmouth Enterprise, Jan. 22, 2010)

By ELISE R. HUGUS

Members of the Cape Care Coalition made their views on health care known at the State House on Wednesday, as the joint Committee on Health Care Financing heard their idea for a Cape Care Community Health Trust (H 4138).

After six years of organizing in towns from Falmouth to Provincetown, 25 Cape Codders donned lime green T-shirts and headed to Boston to ask their representatives for help with the next step: a legal mechanism for funding a single-payer, not-for-profit, private health insurance as the "default policy" for Barnstable County residents.

"We're here to encourage the committee to give the green light to these people in green shirts," said state Representative Sarah K. Peake (D-Provincetown), a cosponsor of the bill, who said she supported the effort since its inception at a 2004 Provincetown Town Meeting.

Coming a day after the victory of Senator-elect Scott Brown, Cape Care advocates presented their plans as a model for a more efficient and affordable way to deliver health care than the plans proposed by Congress. "If [the election] was a referendum on health care, it may not be because [voters] don't want a health care plan; they want us to approach it in a different way," said Representative Timothy Madden (D-Nantucket).

Cape Care is "Medicare for all. People will understand what that means," said Representative Matthew C. Patrick (D-Falmouth), who introduced the bill to the House just over a year ago. "This is an attempt, in a small, confined geographic area where we can try to implement this in small steps and see what works." He told his fellow committee members that he had discussed Cape Care with Congressman William D. Delahunt and Senator John F. Kerry, "and I made sure they have allowances in their budgets for these kind of experiments."

While state or federal money would be useful in studying the mechanics of implementing Cape Care, Dr. Brian O'Malley, a Provincetown internist, said that the community health plan would not require additional government funding. He estimated the total current cost of delivering health care to Cape residents at $2.2 billion per year, half of which is paid for by Medicare, a federal program. The remaining billion dollars, he said, would go into a "community pot," rather than into insurance company coffers.

"The other half [of health care funding] now comes from all of our collective pockets, the money each of us now pays into the health care marketplace. To replace the regressive, out-of-pocket half of current revenue, Cape Care seeks a new tax authority. [Health care] must be funded just as our citizen right to an education is funded, or how police and fire protection are funded," said Cotuit resident Beth Verani, a teacher at Dennis-Yarmouth Regional High School. "Good health is something we are all entitled to, [but] the 'pursuit of happiness' doesn't hold much meaning if you're suffering from a chronic toothache or back spasm."

One option to fund Cape Care would be to levy a countywide property tax, which is the mechanism that funds the Cape Cod Commission, said Dr. O'Malley. However, raising a billion dollars through property taxes could place a heavy burden on homeowners, some of whom are struggling with their tax bills already, he said, so organizers ruled it out after meeting with community groups across the Cape. "It's politically awkward. There are people with big houses, but no big money," he said.

The alternative, imposing an income tax "overlay" for Barnstable County, may not be legally possible, as one member of the committee pointed out. Another option could be a seven to eight percent payroll tax, which Ms. Verani said would reduce health insurance costs for employers, including towns that spend 25 to 30 percent of their payroll budgets on health insurance.

According to the Small Business Bureau of Worcester, the average rate increase for insurance plans in Massachusetts went up by 28 percent this year, forcing some employers to drop or reduce their employees' coverage, despite the tax penalty.

Representative Cleon H. Turner (D-Dennis) told the committee that the current system, which requires companies over a certain size to provide insurance to their employees, puts an unfair burden on small businesses. "The backbone of our economy simply cannot afford the extremely high cost of health care in the commonwealth. I've heard from many people in my district that can't afford it, or who had it before but now are paying more for less coverage. Clearly, we're not finished with health care reform in the commonwealth," he said.

Recognizing that new taxes, as well as coverage for non-residents or the unemployed, would have to be worked out in an equitable fashion, members of the coalition asked the committee for their advice.

"In keeping with a social justice perspective, we will expand our search for progressive, sustainable funding. A regional income tax overlay would be ideal, but would also be new to Massachusetts. We would therefore welcome any ideas you might have or names of individuals who might offer us some expertise in this regard," Ms. Verani told the committee.

Acknowledging the obstacles in financing Cape Care through a property or payroll tax, Rep. Peake asked the committee to consider funding a study, "a real study, not something headed for the graveyard."

Regardless of how it is funded, by introducing cost control measures (known as "global payment") and purchasing drugs and medical equipment collectively at a discount, Cape Care stands to reduce administrative costs and distribute resources according to the needs of residents, Dr. O'Malley said. The Cape Care model also calls for using a computer-based record system like the one used extensively in the United Kingdom (and by American doctors) to identify the best methods for treating complicated symptoms, he said. This is an "evidence-based" approach to treatment that has been falsely linked with the concept of "death panels" in the media, he explained. In addition, Cape Care would offer preventive medical care; programs to encourage a healthy lifestyle; dental, eye, and mental health coverage; and long-term care for the elderly and disabled - services that would reduce costs in the long run, Dr. O'Malley said.

"Cape Care is built on the premise of community ownership and direction of our health care system. By keeping the funds in the community, directing them to local needs, we can do more with them," said Dr. O'Malley. "This care will be delivered by the existing network of private and institutional providers, with the anticipation of expanded numbers of primary care providers, in order to ensure access for every resident to a medical home, responsible for the oversight of their care."

In contrast with the national health care bills in Congress, he said that Cape Care would make the health care system simpler and more effective for both patients and doctors.

As the only private primary care physician in Provincetown, Dr. O'Malley said that he is overworked and underpaid. "I feel like I run around all day and never have time for patients. We run the practice like a McDonald's: you put in an order, and get a fee for service. I spend hours each day filling out forms for the insurance companies so the suppliers can get paid. But I'm really badly paid myself," he said.

Massachusetts state law requires all residents to enroll in a health plan, including a variety of plans offered by the Commonwealth Connector. However, Candace Perry, coordinator of the Cape Care Coalition, told the committee that 11.7 percent of Cape Codders were still uninsured in 2008, according to the Barnstable County Department of Human Services. When polled, 39 percent of Cape residents said that the biggest obstacle to health care was the fact that doctors do not accept their insurance.

Representative Mary E. Grant (D-Beverly), a member of the committee, asked why doctors on the Cape were not accepting Commonwealth Care.

"Open practices said they would not accept it. Most were quite honest about the low reimbursement they receive [from that plan]," said Peter L. Waasdorp Jr., a self-employed carpenter from Falmouth, who said he became a patient at the Community Health Clinic because it was the only local practice that would accept his Commonwealth Care insurance.

Low reimbursement, coupled with the high cost of living on Cape Cod, has put a squeeze on primary care doctors, said Mr. Waasdorp. "We have now had four primary care physicians in the last 10 years [leave], as doctor after doctor has shut their doors in frustration over declining revenues and increasing bureaucratic headaches," he said. One of these, he said, is a Falmouth doctor who diagnosed a melanoma on his wife's arm, thereby saving her life, but who was forced to close his practice due to financial difficulties last year.

State Senator Richard T. Moore (D-Worcester) asked the coalition members how they would raise doctors' salaries through property taxes. "I don't know that the year-round population of the Cape is more wealthy [than the part-time residents]. I think it's the other way around. I'm at a loss to how this adds up to sufficient money," he said.

Ms. Perry, the Cape Care coordinator, said that the coalition assumes nearly 100 percent enrollment of residents, even those who live part time on the Cape. "With a not-for-profit plan, we don't have to answer to stockholders," she added.

Sen. Moore pointed out that the pharmaceutical and medical supply industry, as well as private hospitals and specialist doctors "like the money they're getting already...Global payment involves shifting the funding. People who were happy with the money going to them won't be happy with payments going to primary care physicians."

Referring to a state-wide initiative to reduce health care costs, Sen. Moore asked, "If we're successful with payment reform and administrative reform, why do we need the trust? I'm hoping there's some real geniuses living in Barnstable County who will help solve the problems that the whole country faces."

Dr. O'Malley replied: "If you could accomplish all the things we're trying to do on the state level, we'd be happy to go back to the Cape and enjoy ourselves."

Following the formal testimony, the committee members spent several minutes discussing the next steps with coalition members. Before heading back to the Cape, Ms. Perry said that Representative Harriet L. Stanley (D-Newbury), chairman of the committee, promised to send some of her staff to research the issue this summer, using Rep. Stanley's Orleans home as their base.