Public Health Committee

JOINT FAVORABLE REPORT

Bill No.:

HB-6600

Title:

AN ACT CONCERNING THE ESTABLISHMENT OF THE SUSTINET PLAN.

Vote Date:

3/26/2009

Vote Action:

Joint Favorable Substitute

PH Date:

3/2/2009

File No.:

SPONSORS OF BILL:

Public Health Committee

REASONS FOR BILL:

To establish the SustiNet health insurance plan: to provide health care insurance coverage to Connecticut residents who otherwise would be uninsured and underinsured; and improve quality of heath care and access to health care.

Substitute language inserts:

“within available appropriations” in applicable sections.

● “ to the extent permitted by Federal Law” regarding policies and procedures related to HUSKY Plan Part A and B.

Substitute language replaces “patient” with “medical home” on lines 556 and 559; and replaces the date or inserts the date of “July 1, 2011” on lines 767, 819, 1266, 1274, 1364, and 1381.

Substitute language inserts on:

● Line 291 to ..“(A)”.. and “(B) help finance the administrative costs involved in the establishment and initial operation of the SustiNet Plan;”

Line 369 a new “(b) The board shall identify all funding sources that will be utilized to establish and administer the SustiNet Plan and such funding sources shall be included in the report prepared pursuant to section 22 of this act.” Existing (b) becomes “(c)”.

Line 607 “ and a patient's medical home may temporarily be with a health care provider who is overseeing the patient's care for the duration of a temporary medical condition, including pregnancy.”

Line 617 “ and shall be certified by the authority based on factors that include quality, safety and efficiency of the services provided. At the request of a core medical home provider, the authority shall make all necessary arrangements required for a qualified entity or individual to perform any medical home function not assumed by the core provider.”

Line 628 “entities capable of fulfilling”

Line 824 “irrespective of income levels” shall pay the “full”.

Line 879 “Not withstanding any provision of the general statuettes, an individual who enrolls in the SustiNet Plan pursuant to this subsection shall be counted as meeting any minimum participation requirement that a health insurance plan applies to an employer as a precondition of permitting the purchase of group health insurance coverage.”

Line 1050 “calculated as a percentage of the federal poverty level.”

Line 1094 The Departments efforts shall include seeking “any” waivers under “Titles XIX of” the Social Security Act “that are required for the effective implementation of the SustiNet Plan, including a waiver,” under Section 1115 “of said act” to obtain….

● Line 1095 adds “any matching funds provided under Titles XIX and XXI of said act that are available for services provided to SustiNet Plan members”

Line 1495 “Such report shall include information on the status of health care in this state in general, as well as, the design and implementation of the SustiNet Plan. The report shall include recommendations for legislative changes that should be made concerning the administration of the SustiNet Plan.”

Lines 1610, 1658 and 1705 “The members of the task force appointed by the speaker of the House of Representatives and the president pro tempore of the Senate shall serve as the chairpersons of the task force.”

Substitute language deletes:

● Line 666 delete [(c)] and (d) becomes (c)

● Line 1186 to line 1190 “The Office…….to employees.”

● Line 1494 to line 1499 “In addition, …..report is submitted.”

● Line 1610 to 1611, line 1658 to 1659 and line 1705 to line 1706 “The Governor……the task force.”

● Line 1719 to 1724 “Sec 30” related to the appropriation of ten million dollars.

RESPONSE FROM ADMINISTRATION/AGENCY:

Teresa C. Younger, Executive Director, Permanent Commission on the Status of Women (PCSW): House Bill 6600 attempts to expand the availability and affordability of health insurance benefits to all Connecticut residents. PCSW supports this intent because the increasing numbers of uninsured affects all genders, races, and ages.

In 2006, 11% of Connecticut's population ages 25 to 64, and one-third of young adults, ages 19 to 29 were uninsured. As of December 2007, the Kaiser Family Foundation estimated that there were over 130,000 uninsured women ages 18-64 in Connecticut.

Lack of health insurance increases the risk of undiagnosed conditions resulting in health disparities and deaths. Uninsured adults are more likely to be diagnosed with a disease in an advanced stage. Lack of health insurance also leads to financial ruin for many families. Fifty-six percent of medical bankruptcy filers are women.

PCSW requests that any plan developed address women's special needs and concerns to ensure that they have equal access to health care, which means ensuring that it is: gender appropriate, culturally competent, comprehensive and preventive, and confidential. It must include specialty care, mental health and substance abuse treatment, access to prescription medication, vision and oral health care, preventive care, acute and long-term care, rehabilitative care, and reproductive health services, including coverage for family planning, contraceptives, abortion, cancer detection and treatment, prenatal care, and inpatient overnight stays for childbirth and mastectomy when needed.

Consumers must be able to access an array of practitioners, including midwives and nurse practitioners.

Elizabeth C. Brown, Legislative Director, Commission on Children: The SustiNet Plan is a well thought out, research based approach that brings finance and health care delivery into an integrated system. The plan calls for a new quasi-public governance system that would have the authority to bring all the health care arms together into one body, subjected to evaluation, quality control, standards and cost containment. The Commission urges you to give special attention to the needs of children and especially children with special health care needs.

NATURE AND SOURCES OF SUPPORT:

Ellen Andrews, PhD, Executive Director, Connecticut Health Policy Project: SustiNet is the most detailed, researched, specific and realistic plan to provide relief to Connecticut's struggling health consumers and payers. The result of engaging stakeholders and incorporating their input: providers, payers, clergy, small business, labor and consumers in the shared goal of providing quality, affordable health care to every state resident.

I want to focus on two parts of the SustiNet Plan: promotion of “medical Homes” and auto-enrollment and the absence of an individual mandate. First, everyone should have a patient-centered medical home (a primary care provider who knows you and your health needs) available when you need help and coordination of your care.

Second, the planners left out an individual mandate, requiring every state resident to obtain health care coverage. There is ample evidence that an individual health insurance mandate would not work in Connecticut and would cause significant harm to low income consumers. Instead, SustiNet includes auto-enrollment measures to ensure that everyone has coverage while respecting consumer rights. The proposal is to enroll anyone without insurance automatically when they begin or end employment, request unemployment benefits, file a tax return, seek health care and when children start school. People can opt out of coverage but must verify that they understand the risks and liability of that choice.

Frances G. Padilla, Vice-President, Universal Health Care Foundation of Connecticut: The bill is based on detailed policy analysis for health care reform. The Universal Health Care Foundation seeks to improve the health of the people of Connecticut and make the health care system work for everyone. The foundation evaluated health outcome and health spending data, and sought the ideas and advice of a range of stakeholders.

Three points about SustiNet: First, it considers the prudence of phasing in the various groups covered. The economic impact was simulated over five years, from 2011 through 2016. The SustiNet coverage costs first being incurred in 2012. The micro-simulation shows that by 2016, if measures such as chronic illness management, electronic medical records and quality standards are robustly implemented, Connecticut can expect to slow the rate of total health care spending. When fully implemented, by 2016, that rate will begin to decline by 2-3%.

Second, SustiNet leverages the state's ability to secure better value for the healthcare dollar, through its negotiating power. It will save businesses and households $1.7 billion in lower premiums and out of pocket costs. Its expansion of coverage eligibility will leverage at least $800 million in new federal money. That is a return of $2.60 for every dollar of state investment. The SustiNet Authority will govern both the policies of the health plan and health system innovations with a focus on results, accountability and transparency.

Third, regarding sources of new costs to the state government. If coverage begins in 2012, by 2014, 98% of the states uninsured will have coverage, either through SustiNet or through their employers' plan. In 2014 the state of Connecticut begins full scale provision of premium subsidies to that part of the working middle class whose earnings make them eligible for Medicaid but who still cannot afford the coverage their employers may offer. That year, the state also increases, on a graduated basis, reimbursement rates to providers who care for people on Medicaid and HUSKY, thereby reducing the shift of costs for uncompensated care to the private sector.

Matthew Katz, Executive Vice-President, Connecticut State Medical Society (CSMS): CSMS believes that our health care system needs to be reformed and the reform must: provide for greater access to medical care for all residents; be based on scientific evidence; ensure quality medical care is delivered; be based on transparent information associated with how care is delivered and paid for; and be appropriately and adequately funded. CSMS supports the SustiNet proposal as meeting these objectives.

CSMS partnered with the Universal Health Care Foundation of Connecticut in conducting the first state physician workforce survey in 2008. The survey showed that physicians were supportive of creating a large insurance pool to cover the uninsured, those on public insurance programs and others. They were equally supportive of backing the expansion of the current safety-net programs.

SustiNet emphasizes primary care and preventive services through the medical home concept; disease management; care coordination; quality reviews and quality guidelines; safe harbors from medical liability; health information technology; and payment approaches that not only increase the level of payments to physicians and other providers but also anticipates further changes in payment approaches and provides the flexibility necessary to account for evolution in payment methodologies.

CSMS also commends this proposal for its approach to assisting physicians in the redesign of their offices to allow for more rapid transition to a computerized, interoperable and interconnected system of health information through training and consulting services, as well as access to incentives and discounts for electronic medical record and health record systems.

CSMS appreciates how SustiNet could negotiate on behalf of physicians who participate in the plan to obtain discounted prices for vaccines and other health care goods and services.

SustiNet if implemented could strengthen insurance markets by providing consumers and providers additional choices and increased transparency. It will establish a repository of claims and patient information that can be used to improve both the transparency and quality of care by tracking the medical care provided and the associated outcomes. The phased-in approach avoids issues with implementation, such as inadequate networks of physicians, especially medical specialists and subspecialists.

Physicians must be part of all facets of the SustiNet Authority including its board, associated committees and task forces. Guidelines and procedures must be based on sound scientific evidence, an understanding of medical care, and allow for the necessary flexibility associate with the uniqueness of each patient and their treatment requirements.

CSMS supports and is advocating the adoption of the SustiNet proposal's guidelines for health care reform in Connecticut in order to move forward not only the debate on true health care reform, but to speed toward a health care system that is based, and will be judged on, its collaborative approach to providing access to quality medical care that takes advantage of health information technology while remembering that the individual patient matters most.

American Cancer Society: In the absence of a system that ensures adequate, affordable coverage, a cancer diagnosis can quickly translate to bankruptcy for families and in the worst case scenarios, the inability to access potentially lifesaving treatments. Therefore, we must ensure that healthcare reforms in Connecticut meaningfully meet the needs of all individuals diagnosed with cancer.

All people should have unimpeded access to comprehensive, quality health care services. This care includes cancer prevention, early detection, diagnosis and treatment, rehabilitation and long-term care through the end of life.

The SustiNet plan takes an innovative and bold step towards bridging the gap between the insured and underinsured and the health care programs and services they need. It is intended to ensure health care coverage that is affordable to both employers and individuals regardless of significant circumstances such as employment status, divorce, pre-existing condition or other life changes. The plan is designed to include mental health and dental services in addition to a focus on preventative care; and be comprehensive to protect the individual from incurring catastrophic expenditures.

The plan contains a minimum standards package which preserves hard fought consumer health care mandates, including coverage for durable medical equipment, hospice care, prosthetics and wellness programs for chronic disease patients. It will ultimately provide coverage to 98% of Connecticut's citizens with a strong emphasis on preventive services. SustiNet provides for a stronger coordination of patient care thus eliminating treatment delays.

SustiNet takes a major step forward, calling for the widespread use of electronic medical records and allowing enrollees to choose their own doctors and maintain their option to keep existing plans. Affordability being key, premiums are on a sliding scale based on income.

Karen C. Nepomuceno, Connecticut Health Policy Project: While the SustiNet plan aims to help those who are unable to get insurance coverage, it can also be beneficial to those who are insured through their employer. Many people who have insurance are reluctant to visit the doctor's office when they become sick knowing they will have to pay for that visit in full until they reach the deductible.

A self-insured plan like this one would promote competition among private coverage options to offer affordable high quality benefits. By creating competition, large companies would be able to offer reasonable plans that would encourage proper health care utilization.

Dr. Mary Jane Williams, Chairperson of Government Relations, Connecticut Nurses Association (CNA): CNA has been providing health care to the uninsured and underinsured as a policy issue. The SustiNet plan being offered is to control health care costs, saves Connecticut families and businesses money, and makes care coverage available to everyone. With a growing shortage of primary care providers, coupled with an aging population, increasing rates of chronic illness, nurses need to have a strong voice in the discussion.

Nurses represent the largest group of health care providers. They practice in all health care settings, as consultants to business and industry, as primary providers of health care services, as educators and researchers, and as the constant in disease care and prevention. Nurses want to make sure the following questions are addressed:

● Is it a truly inclusive system?

● Does it improve people's access to health care?

● Does it reallocate resources and infrastructure to support primary care and prevention?

● Does it rely on evidence-based care and reward quality?

● Does it tackle disparities in health care quality and outcomes?

● Is it affordable for working families and protect them from financial ruin?

● Does it offer affordable and predictable costs to businesses and employers?

● Does it demand accountability, transparency and equity from the private health care marketplace?

● Does it invest in nursing?

● Does it open the door for RNs to optimize their skills, knowledge and abilities in all roles and settings to help patients?

● Does it provide a coherent health care vision and strategy?

● How will it affect my patients?

Brenda Kelley, State Director, American Association of Retired People (AARP): AARP believes all individuals have a right to health care services. Coverage that provides adequate financial protection against health care costs; high quality health care; a reasonable choice of health care providers; and the financing of the system should be equitable, broadly based and affordable to all. Methods of reimbursement should promote high-quality medical care, efficient service delivery, cost effectiveness, and compensate providers fairly. Efforts to promote health and prevent disease should be strengthened; incentives to promote healthy behavior should be coordinated and integrated in order to effectively address an individual's multiple and/or changing health care needs.

HB 6600 merges state employees and retirees with HUSKY and SAGA into a self-insured pool, and eventually other groups will enter the pool. The plan allows people to keep their existing private coverage.

AARP supports medical home services; major medical, mental and behavioral health care services; drugs; preventive and wellness care; chronic disease management; and even dental care

AARP also supports the provision for no out of pocket cost increases for Medicaid and HUSKY beneficiaries and open and voluntary enrollment of the uninsured with a provision to keep premium costs affordable for the low income.

AARP commends the provision in which prevents rate variations based on individual characteristics such as age, gender, or health status. This will help make insurance more affordable for 50-64 year olds that often have to pay very high rates in the private market.

AARP commends the out reach methods to find uninsured residents and auto-enroll those who are eligible for low-cost insurance. We also support the opt-out provision for those who would have to pay premiums. Finally, AARP is supportive of the task forces on obesity, tobacco and especially one dedicated to workforce.

The bill also raises the following concerns for AARP:

● There is insufficient detail to determine the resources that will be required to support the start-up of SustiNet and its ongoing operation. Without this information, we cannot determine if it will be able to accomplish it's agenda.

● The composition of the SustiNet Authority outlined in section 2 is a concern. AARP believes consumers and older residents should be represented. There is no representation of the uninsured and 50 to 64 year olds.

● AARP believes the principle of health care affordability must take into account total health care costs. Affordability should be gauged based on the total cost for coverage (premiums) plus all out-of –pocket costs. High deductibles and co-pays can easily become barriers to health care.

● State contracts with Health Information Technology (HIT) providers and business associates should require compliance with all applicable federal standards and interoperability with federal, Medicare and Medicaid systems. We suggest expanding the HIT provisions to incorporate advance health care directives, including living wills and health care proxies and the collection of data that would show any disparities in access to care and outcomes based on age, race and ethnicity.

● AARP is concerned with the broad waiver of liability contained in section 7. We are not comfortable with the elimination of all provider liability for avoidable injury to patients contained in 7(c). There should be some recourse against the board if they are negligent in developing the guidelines.

AARP encourages taking the best provisions of efforts currently underway, the best provisions from SustiNet and other proposals and turn this into a comprehensive, bipartisan
Connecticut health reform solution.

Brian Ellsworth, President and CEO, Connecticut Association for Home Care & Hospice (CAHCH): CAHCH is pleased to see that the minimum standard benefits package includes home health and hospice services. These are important cornerstones of any insurance plan. Both home health and hospice care have been found to be cost effective and desired by the general public.

CAHCH supports a central role for home health agencies in any health insurance reform approach that adopts a medical home model, as introduced in Section 6.

CAHCH is hopeful that the health reform plan will motivate the widespread adoption of home-based telemonitors for chronically ill persons and increase rates of immunization of enrollees.

We are pleased that the plan intends to bring provider rates up to “market levels.” The penny-wise, pound foolish practice of inadequate reimbursement by insurers and the State results in missed opportunities for even bigger savings and enhancements to enrollees' quality of life and should be ended.

Connecticut Public Health Association (CPHA): Despite having the best training, healthcare providers, and medical infrastructure of any industrialized nation, the United State's healthcare system ranks 37th in the world. Administrative costs are 50-100% more in the United States than in countries with a single payer system.

Studies show that the uninsured are three to four time more likely than those with insurance to report problems getting needed medical care, and are less likely to have a regular source of healthcare. As a result, 20% of uninsured say their usual source of care is the emergency room, compared to 3% of insured individuals.

Uninsured, non-elderly adults are 50% less likely to receive preventive care. They are also more likely to receive poor care for chronic diseases, leading to an increased risk of hospitalization and disability.

The costs of not achieving universal healthcare are high. The annual cost of diminished health and shorter life spans for uninsured Americans is $65-130 billion. Uninsured children are more likely to suffer delays in development due to poor health; and contribute to poor health later in life, less productivity, and a greater burden to society.

SustiNet would create a comprehensive, high quality and affordable healthcare system that would be available to all Connecticut residents. It will also save money by encouraging preventive healthcare and early interventions in medical illness.

Beverley Brakeman, Community Action Program Council Representative, UAW Region 9A: Several components of the SustiNet plan are particularly exciting to the UAW:

● Pooling state employees, those on Medicaid and SAGA ensures that costs can be kept down, risk can be spread and healthcare can be provided to more people.

● Medical home model proposed in the bill includes care coordination, 24 hour consultative services and patient education.

● Electronic medical records will eliminate the need to recap our medical history every time one visits a specialists or emergency room.

● The financing mechanism is fiscally responsible and politically feasible.

● The benefits included in the SustiNet plan are preventive, address chronic illness and comprehensive.

● Mechanisms are built in to insure the uninsured.

● Accountability is built in to measure SustiNet's effectiveness.

● Immigrants will not be denied health coverage based on their immigration status.

Linda St. Peter, President, Connecticut Association of Realtors: We support the SustiNet Health Care Plan because too many Realtors and members of the public are shut out of the rating structure currently benefitting large employers and unions. Many must resort to being underwritten and rated as individuals, settle for inadequate coverage, or depend on others for coverage. Thirteen percent of our members have no health insurance.

We agree with the principles guiding the SustiNet Plan that health care coverage should be: 1) universal and continuous; 2) affordable to individuals and families, and sustainable for society; 3) enhance health and well-being by promoting high quality care that is effective, efficient, safe, timely, patient centered and equitable.

The plan provides choices for Connecticut citizens and creates competition within the insurance industry. Connecticut Association of Realtors, as a business group, favors SustiNet for the following five reasons: 1) it is the most innovative and comprehensive; 2) realtor leadership agrees that private employer sponsored insurance plays and must continue to play a vital role in providing healthcare insurance to employees; 3) high health care costs put Connecticut businesses at a competitive disadvantage; 4) SustiNet will be a public-private partnership with a governance board that has a wide array of expertise in its makeup and will be accountable to the Governor and General Assembly; and 5) it will not only control cost, it will correct flaws in the current system, including cost shifts.

Deacon David W. Reynolds, Legislative Liaison, Connecticut Catholic Conference: The Conference feels that the SustiNet health care plan is the most comprehensive proposal

before the legislature; and should be the centerpiece for any future health care discussions.

Catholic social teaching holds health care as a basic human right. The continuing increase in medical costs and its financial burden on business and family budgets, and the large number of uninsured persons, are the two primary factors pushing the call for reform.

The SustiNet plan addresses the key factors that other plans lack. It makes coverage available for all Connecticut residents despite their employment status, has affordable co-pays and premiums, provides quality levels of coverage, including dental, and supports preventive medicine. It also has medical management provisions aimed at reducing costs.

David D. Thompson, Jr., M.D., President, Connecticut State Medical Society-IPA, Inc.:

A program that just creates access or mandates universal coverage but does not control costs will cause the present health care crisis to intensify. Already high costs would escalate at even a faster rate as the increased demand would cause unchecked utilization to rocket even higher.

Presently our health care system is focused on management of disease rather than health. The system reimburses providers for caring for the sick instead of keeping them healthy. The Medical Home Model outlined in the SustiNet plan reverses this emphasis. Primary care physicians would be paid to keep the patients healthy and to coordinate the care of sick people in a manner designed to keep them as healthy as possible while providing appropriate resources.

All other countries of the developed world spend less on healthcare than the United States, but score much higher in health analysis because they emphasize health rather than illness. They achieve much better value for their healthcare expenditures.

The Medical Home Model would be enhanced by adoption of Electronic Health Records which incorporate e-prescribing and allows for quality data aggregation and electronic data exchange to improve quality and reduce needless duplication of testing and harmful drug interactions.

Connecticut Chapter of the American College of Physicians (ACP): The ACP supports state expansion of access to health care coverage as a means to achieving universal access to health care. Universal access to care is a key component of a system of health care that can provide high quality, cost-effective, affordable, and equitable health care for all Americans. The SustiNet Plan will significantly expand access to health care coverage for groups currently among those at greatest risk for being uninsured or underinsured.

SustiNet incorporates elements that are in accordance with ACP policy and recommendations for health care reform, such as patient centered medical home as the basis for primary health care, an emphasis on prevention and coordination of care, expansion of Health Information Technology to improve storage and exchange of health information, quality of care improvement programs, portability of coverage, and incentives to promote high quality, cost-effective care.

We believe that primary care internists and other primary care physicians are best suited to serve as leaders of Medical Home teams, and should be directly involved in committees that set standards for care and operation of Medical homes. We urge that in implementing the SustiNet Plan, compensation for clinical services and coordination of care be set at levels that ensure adequate participation of providers and maintenance of the primary care workforce.

By emphasizing prevention and coordination of care through the Medical Home model, the SustiNet plan promises to bring the overall costs of care down, improve health outcomes, and provide better access to other beneficial services. It also places emphasis on improving information systems to reduce inefficiencies, reduce errors, and enable monitoring of care services and patient outcomes. We agree with the plans of SustiNet to support financing for the transition.

We strongly support the participation of physicians in the process of developing quality standards and analyzing data collected; the plan for a no-fault compensation system for patients harmed despite adherence to quality guidelines.

Madeline McClave, Interim Executive Director, Connecticut Oral Health Initiative (COHI): COHI encourages support of this bill because it will increase access to comprehensive, affordable, portable and efficient health care including dental services. SustiNet would benefit huge numbers of Connecticut residents as well as small nonprofits such as COHI in making health insurance more affordable and health, dental and mental health services accessible.

Make sure that oral healthcare continues to be included in the definition of health care in this plan for these three compelling reasons: 1) the links between oral health and other serious health problems; 2) the cost-effectiveness of ensuring residents get early, regular, preventive dental care; 3) the inaccessibility of oral health care for so many Connecticut residents.

The integration of dental care into any state health care plan is extremely important to the oral health as well as the general health and well being of Connecticut residents because of the links between oral health and a growing list of many serious and systemic health problems. These include diabetes, heart disease, stroke, cancer, systemic infection and per-term births.

Through Sustinet, the State of Connecticut could finally address the real and sustained crisis that children, pregnant women, older adults and others face every day in trying to access dental care. By ensuring access to early, regular and preventive dental care through a new plan, the state would prevent significant pain and suffering as well as the huge medical and other costs incurred across the health system now due to the lack of access.

Mary Jane Lundgren, RN, MSW, National Association of Social Workers (NASW): NASW believes that it is morally and fiscally imperative that every resident of Connecticut should have equal, comprehensive and affordable access to health care. The SustiNet plan is comprehensive, inclusive, sustainable and economical. By leveraging the purchasing power of the state and using taxpayer dollars, this plan is designed to reduce costs and improve health care. Employers will pay more affordable premiums for their employees, and households will have lower personal health care costs. All Connecticut residents will have access to their choice of high quality health coverage and health care.

SustiNet will pay health care providers fair compensation; thereby, increasing the availability of care to lower income residents. This will eliminate racial and ethic disparities in health care. A healthier population will enhance job productivity and creativity; and students will be able to maximize their educational experience.

Sarah Guggino, Master's Student, Department of Public Policy, University of Connecticut: I strongly support this legislation because it is crucial for me and everyone in Connecticut. Because of the financial impact of our medical bills, my parents struggled all through my childhood and adolescence to provide for us. I was constantly worrying about what would happen to my family if I were to get sick. My parents bickered incessantly with each fight stemming from the same issue, poor health care and endless medical bills. Children are not blind to their parent's struggles.

Right now, I am extremely fortunate to have good health insurance for the first time in years through my position as a graduate assistant. I should be excited about what comes next in my life. Instead, I am worried about losing my insurance and what I have.

I am young and healthy, but I recently learned that I have a health condition that needs to be monitored. Without coverage after graduation, I could face serious health repercussions in my future. Unfortunately, this is the very harsh reality for young adults. The SustiNet plan will give us peace of mind by providing quality, affordable health care coverage if we are in between jobs or in between school and a job.

Modern medicine teaches us that we can get sick because we are stressed; but we are stressed because we don't know what to do when we get sick.

Craig Czarsty, M.D., Legislative Chair, Connecticut Academy of Family Physicians (CAFP): CAFP wants the legislature's universal health care plan to cover all Connecticut Citizens. The plan needs to assure basic services including: prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; evidence-based periodic evaluation and screening services; outpatient physician services and visits; services in hospital outpatients department; services in ambulatory centers; outpatient laboratory and radiology services; outpatient mental health services; and outpatient prescription medications.

In addition, CAFP advocates that the plan include: protection against extraordinary medical costs; leaves in place the current insurance market; establishes a public/private oversight body; implements a resource-based relative value payment system with adequate payment for covered services; and promotes the expectation that every patient have a personal physician or family doctor for their usual source of care.

The CAPF developed the concept of the “medical home” and believes that everyone should have a personal medical home that serves as the focal point through which they receive acute, chronic and preventive medical services.

Lesley Mills, Director/owner, Griswold Special Care: As an owner of a homecare company, I am concerned about the needs of elderly clients. In order to provide the best care, we spend 73% of our fees on the caregiver as opposed to the industry standard. Based on our mission of a 1% profit margin, there is no where for health insurance premiums to go other than directly to the elders receiving care.

SustiNet's requirement of a “medical home” for each person aggregates patient data across providers and payers providing the opportunity to eliminate wasteful duplicative diagnostic testing while simultaneously providing opportunity for enhanced diagnosis. By comparison, the present state of dispersed medical data is woefully inadequate and more expensive.

A significant component of SustiNet is the requirement that all public and private insurers provide patient based anonymous data showing services, outcomes, quality of care and satisfaction. This provides the opportunity for a wealth of systemic improvement.

Barbara Edinberg, Assistant Director, Bridgeport Child Advocacy Coalition: We urge you to support SustiNet on behalf of the many working parents who worry every night about losing their jobs and benefits. Also on behalf of small business owners who struggle to provide health benefits for their employees.

Eva Csejtey, American Friends Service Committee: On behalf of the American Friends Service Committee, I implore you to address the health needs of Connecticut residents to live a healthy lifestyle and promote economic justice. The lack of affordable health care influences major life decisions. Twenty-seven years ago my decision to marry was based on my need for health care coverage. I was identified by insurance companies as a medical risk because of my age and was unable to afford an individual plan. With the SustiNet plan, Connecticut residents would be guaranteed quality health care and make life decisions based on their desires and not their health care needs. SustiNet eliminates problems of health care access with better reimbursement rates, local physicians, improved communication and reimbursement for case management.

Stephen A. Karp, MSW, Executive Director, National Association of Social Workers (NASW): NASW supports SustiNet as a comprehensive approach to health care coverage for Connecticut residents. It is time to admit that taking incremental steps and tinkering around the edges has failed. The health care system in Connecticut remains fragmented, with high numbers of uninsured and untold numbers of underinsured. SustiNet is a comprehensive proposal that addresses issues of affordability, access, universitality, quality, comprehensive coverage, and racial and economic disparities. Particularly appealing is that it builds a new health care plan using a self-insured pool approach.

As an organization that represents social workers, the profession that provides approximately two-thirds of all mental health services in Connecticut, we support SustiNet for its inclusion of mental health coverage. Recognizing the mind/body connections in health care is essential to the delivery of complete and holistic health care services.

You Sung Sang, MD, President, New London County Medical Association (NLCMA): NLCMA is impressed with the SustiNet plan which was developed with input from physicians, healthcare, resident's statewide, business, labor and policy makers and consumer advocates and puts an emphasis on primary preventive care and measures. It creates a “medical home” which promotes healthy behaviors and management of chronic illness and coordinates care with timely access.

As physicians whose practices are small businesses with overhead expenses, we know first-hand the difficulty and expense of acquiring healthcare insurance for our patients. A pooling system such as the SustiNet plan will help to guarantee Connecticut residents access to healthcare insurance and would help control costs

Maggie Adair, Policy Director, Connecticut Association for Human Services (CAHS): This bill will ensure that all Connecticut residents will have access to comprehensive, affordable, quality health care. Access to health care is narrowing; people aren't getting the care they need; as a result people are getting sicker; the cost of treating more serious illnesses is going up. The health care system is a drag on the economy. Reform is critical to the future of the economy.

SustiNet offers a high-quality health insurance plan that promotes competition in the marketplace. It invests in prevention strategies to keep people healthy, lowers costs and promotes sustainability of the health care system. SustiNet addresses the insured and uninsured. It will improve care and access to families on HUSKY and individuals on State Administered General Assistance (SAGA). SustiNet promotes logical ideas; having a 'medical home' to coordinate care and services and universal health information technology to centralize health care history and needs. The large pool of participants will create leverage and lower costs. There is no mandate to participate in SustiNet, workers can choose to remain with an employer sponsored plan and businesses can choose to join SustiNet.

Phil Sherwood, Deputy Director, Connecticut Citizen Action Group (CCAG): Skyrocketing health care costs are crippling state and local budgets, stalling job growth and making it difficult to afford health care for a family. SustiNet offers comprehensive reform that includes the choice of a public health insurance plan over a private carrier. Health insurance premiums in Connecticut have been rising 8 times faster than wages. SustiNet will establish affordable coverage, comprehensive benefits, and choice of private or public plan and equal access to quality care. A public health insurance plan such as SustiNet will compete directly with private companies and help control health care costs for Connecticut families.

Samuel Agyei, Student, University of Connecticut School of Social Work: The lack of health insurance has serious consequences; increased severity of illness, increased cost of health care, reduced worker productivity and lower educational attainment for children. One in eleven Connecticut residents lack health care coverage. The public and private costs that result from the increasing number of uninsured makes it essential to support SustiNet for universal, affordable and sustainable health care for all residents of Connecticut.

Dr. Michael Deren, Council Chairman, Connecticut State Medical Society (CSMS): SustiNet provides access to medical care, ensuring that whoever needs to see a doctor can see one. It gets patients out of emergency rooms and into doctor's offices and builds a healthier Connecticut. The concept of a 'medical home' will help patients in accessing medical and surgical specialists; and it addresses the spiraling costs of those who suffer from a chronic illness through monitoring and coordination. The SustiNet program offers new opportunities for small practice physicians such as; implementation of electronic medical records program, which would otherwise be cost prohibitive and the ability to increase patient care by being relieved of insurance company intervention over patient needs. These important changes will help attract more doctors to Connecticut.

Jennifer C. Jaff, Esq., Advocacy for Patients with Chronic Illness, Inc.: This bill will manage chronic illness in an effective and patient centered way, by creating a patient advisory committee that will help govern medical homes that will assist the chronically ill to monitor, manage and improve their conditions. The 'medical home' will be available 24/7, it will empower patients to manage their own care, resulting in greater compliance with doctor's orders, resulting in improved outcomes and reduced health care costs. The “care coordinator” will provide nonmedical services to support those with chronic illnesses.

Sharon D. Langer, Connecticut Voices for Children: Many of the building blocks of the HealthFirst report are reflected in this bill. The plan adheres to the Institute of Medicine principles of healthcare reform and builds on and improves the HUSKY program by raising income limits for family coverage and gradually raising the fees paid to providers in order to increase access.

Suzanne Haviland, Health Policy Analyst, AFSCME: SustiNet is a move toward guaranteed, comprehensive, affordable health care coverage for all residents. The health care options go far towards meeting the goals of cost containment; requires employers to contribute; prevents cost shifting and makes critical system improvements. It establishes a base of coverage that allows people to enroll if an employer's coverage doesn't meet that base. Recent polling has shown that a public insurance choice is very popular. Some areas noted for further development are: increasing employer contribution, developing affordable guidelines for higher income people and providing broader patient representation on the SustiNet Board.

Melissa Karvelis; Elsa Peterson Obuchowski; and Marybeth McNamara: They shared personal testimony in support because of the increasing cost of health care coverage, limitations in care when more affordable options are chosen and the frustration of choosing between medical care and other necessities. They stress that every resident should be entitled to affordable, quality health care coverage.

NATURE AND SOURCES OF OPPOSITION:

MetroHartford Alliance: The Alliance believes it is important to focus on market based solutions and engage in public-private partnerships to reach the goal of improving the current health care system, which covers over 90% of Connecticut's residents. This is among the highest percentages in the country. The Alliance supported and participated on the Connecticut Health Insurance Policy Council (CHIP) in 2007, a non-profit entity which focused on controlling health care costs and expanding access to quality health care, recommendations that the Alliance endorses.

The CHIP recommendations focused on encouraging individuals to take personal responsibility for their wellness, make appropriate use of the state's robust health care system, and participate in one of Connecticut's existing health insurance plans. The CHIP report specifically emphasized the need to:

● Reduce the number of existing mandates and allow greater efficiencies in product development and approvals at the department level to create flexible benefit options, and improve access to affordable care

● Promote health lifestyles with employer-sponsored wellness programs and greater emphasis on prevention overall

● Increase Medicaid reimbursement rates to hospitals

● Use e-medical records, electronic information exchanges and telemedicine effectively to improve patient safety, expedite treatments and reduce redundant care

● Provide more quality data to consumers to help them make more informed health care choices

The HealthFirst Connecticut Authority report included several meaningful recommendations consistent with the CHIP report.

Given the constructive and comprehensive set of recommendations set forth in the CHIP and Authority reports, it is not necessary to create yet another bureaucracy to sell insurance, as suggested in HB 6600. Creating an entirely new government entity when we can't afford the government we have would actually increase the cost of health care, which is the opposite goal intended in the quest for affordable, quality care. Additionally, the SustiNet proposal establishes a bureaucracy that would sell self-insurance plans without being required to comply with many of Connecticut's protective health insurance laws. It is critical to retain the integrity of consistent regulatory oversight in order to protect the consumer.

More importantly, before us is the opportunity to implement some of the CHIP and The Health First Authority recommendations, a step that should be pursued deliberately and aggressively before we create another layer of bureaucracy or expand the state employee plan that is proven to be to expensive.

It is vital to the state's fiscal health and the health of all our residents that the public and private sector work together to strengthen our current system by identifying and pursuing practical and economically feasible market-based solutions to expand access improve quality and increase affordability. The blueprints already exist, and it is time to begin implementing these recommendations. If we are to foster long-term prosperity for all of Connecticut's citizens, we must ensure that our insurance and health care economic engines remain resilient and strong in the competitive climate of a global marketplace.

Connecticut Trial Lawyers Association (CTLA): Although the CTLA fully supports the goal of expanding access to quality health care, we urge the rejection of any bill which includes a provision like Section 7(c) of the SustiNet bill. The authors of the SustiNet Plan have created unprecedented special rights and immunities for physicians and hospitals, which will do great harm to those Connecticut citizens who suffer injuries as a result of negligent medical care. Section 7(c) of the bill completely undermines the goal of increasing access to quality health care by putting the goal of immunizing negligent medical care before that of increasing patient safety. CTLA completely rejects the premise that health care providers should be afforded special rights for merely doing what is in their patients' best interest.

Any attempt at health care reform should have as its central goal an effort to avoid medical errors, as “over 75,000 people die every year from medical malpractice.” Increasing patient safety should be the one goal that all sides of the healthcare debate can unify around and the development of “clinical care and safety guidelines” could have such an effect. Unfortunately, the SustiNet plan attempts to take away the rights of Connecticut citizens, injured or killed by negligent medical care, by allowing an appointed Board, rather than a court or jury, to determine if medical care was negligent under all of the applicable circumstances.

Moreover, Section 7(c) of the bill contains no estimate of the cost of the “no fault” system it proposes to the State of Connecticut. According to every estimate, a “no fault” system which compensates patients injured by medical malpractice will either, (1) cost far more than the current system where negligent physicians must be liable in court; or (2) unfairly harm the patients who are most seriously injured by negligent medical care.

Tanya Court, Business Council of Fairfield County: Health care reform should be a central part of our state government's effort to protect its most vulnerable citizens, stimulate its economy, increase workforce productivity and control spending. This reform should be comprehensive in scope, phased in implementation, build on the strengths of the current system while remedying its deficiencies, and be undertaken in coordination with new directions in federal health care policy.

The SustiNet proposal makes a serious effort to address Connecticut's health care crisis; and much in the plan is useful and worth adopting. However, the questions and reservations we raise are fundamental to the viability of the overall plan. Comprehensive solutions need to work in their entirety. Therefore, until the following issues are addressed satisfactorily, we cannot support this legislation:

● Notably absent from the proposal is any fiscal analysis of the plan. How much will each component cost? What savings can be achieved by this proposal?

● What will be the impact upon state government? Will any state departments be eliminated? Will current functions now under the purview of state agencies/departments be assumed by the new authority? There appears to be overlap with the Departments of Social Services, Public Health, Insurance, Office of health Care Access. The proposed authority would have extensive responsibility; a staffing plan needs to be developed to fully understand the proposal.

● The SustiNet plan indicates that providers who follow care guidelines provided by the authority can not be sued. Additionally, the authority will develop a no-fault compensation process for individuals who have had bad outcomes. While the idea of a no-fault compensation process has merit, we believe that an individual should retain the right to sue or pursue another process.

● We are concerned about using the present state employee health plan as abase upon which to build this new program.

Andy Markowski, Connecticut State Director, National Federation of Independent Business: Small business supports bringing health care costs down; however, they object to a system that imposes a new mandate, results in a payroll tax penalty, or uses a convoluted new system of “employer vouchers”. The state should not serve as a proving ground for sweeping comprehensive health insurance reform; it needs to be led at the federal level.

Susan Manganello, Vice President of the Board of Directors, Connecticut Center for Patient Safety: Shared personal testimony on the loss and suffering of her daughter due to medical negligence. She feels that doctors and other health care providers need to have accountability for their actions and patients, who feel their care has been insufficient or inappropriate, should have access to the court system for remedy.

Bill Tyra, Vice President, Connecticut Center for Patient Safety: Shared personal testimony on the loss of a son due to medical malpractice and negligence. He is concerned that a physician, participating in the SustiNet plan is no longer accountable to the patient. He believes it is an oversight that an individuals access to the courts, under this plan, would be denied.

Joanne Doroshow, President and Executive Director, Center For Justice & Democracy: Although we favor health insurance coverage to help anyone in need of medical care and the bill's attempt to improve patient safety, the provision of such medical care should never be accomplished by taking away the right to trial by jury for someone who was injures through no fault of their own, or reducing the accountability of anyone who commits wrongdoing, which will only lead to less safe medical care.

We are opposed to Section 7 of the bill which would eliminate the right to trial by jury for anyone injured by medical malpractice provided the provider complies with standards of care consistent with guidelines approved by the board. This board would consist mainly of political appointees and would come from the medical and business establishment. Decision-makers, who would ultimately determine whether to take away the right to jury trial for an injured patient, would be largely connected to the medical industry or business community. That is a conflicting financial interest favoring the rejection or reduction for individual claims.

Rebecca Ball: Do not support section 7 of the SustiNet bill. It removes a constitutional right, the right of every citizen to have access to our courts.

Ten years ago my ten year old son's neck was broken in a head on collision. He was sent to three different hospitals that day and then discharged three days later. We were told he would make a full recovery. I trusted the doctors and did as they said. All of the health care professionals missed the spinal cord injury. They did not do a simple full MRI despite warning signs. He was left paralyzed from the chest down. Calls were made to doctors and they were not returned.

A slow progression of a hematoma that formed on his spinal cord cut off the blood supply and oxygen to the cord. This killed the nerves and caused his paralysis.

His medical debt rose to over $1,000,000 in a nine year period. Although a law suit scared me, it became a part of the nightmare. We finally settled out of court. That settlement repaid the debt, and allowed for the installation of handicapped accessibility to our home. The capping of non economic damages in my son's case would have been disastrous.

The courts are our only access to justice. Keep in mind holding doctors accountable for their devastating mistakes is one of the key components to bringing awareness to the flaws in the medical system. Only then are doctors and hospitals forced to review their protocols in the treatment of patients and make changes to prevent further medical malpractice.

Susan C. Winkler, Executive Director, Connecticut insurance & Financial Services Cluster: Connecticut's health plans are the second highest ranked in the U.S. for quality, access and customer satisfaction. We also have the 3rd highest percentage of employer provided insurance in America. Multiple health care reform proposals have been developed for Connecticut, these are generally sound in their intent, but have fundamental weaknesses. Adopting any of them in their entirety would be detrimental to the health of our state.

For example, one component of the SustiNet Plan is a type of pay system requiring employers and employees to either pay into the system or suffer fiscal and public penalties. An effective, enforceable individual mandate may be a better solution. The Plan also calls for the creation of the “SustiNet Authority.” Is this really the time to create another state bureaucracy? Additionally this bureaucracy would not have to comply with Connecticut protective health insurance laws. Consistent regulation is an effective means of protecting the consumer.

Christine Cappielo, Director of Government Relations, Anthem Blue Cross and Blue Shield of Connecticut: A basic insurance principle regarding healthcare premiums, which are the combination of retention expense and projected claim expense, is that medical claim expenses account for 80 -90 % of total healthcare premiums. To be successful and address the underlying needs of affordability in health insurance, there needs to be an understanding of how important it is to develop an actuarial model that addresses projected claims cost within the constructs of this proposal.

Voluntary participation, as stated as the goal of this legislation, creates a unique set of actuarial challenges. You will attract those groups that carry higher claim expense due to higher utilization, more catastrophic illness, or difference in demographics, this will threaten rate adequacy in the initial years and could threaten the viability of the pool in later years.

The goal of a group health insurance system is to provide access to quality healthcare benefits and the appropriate distribution of risk. A number of techniques are used to estimate the expected claims of a group: age, gender, type of industry, group financial strength, ease of administration, level of participation, prior persistency, current and future benefits, level of managed care and prior claims experience are used to develop an actuarially sound group rate.

SustiNet needs to create a rating model that aligns the risk associated with each group participating within the pool. Without the option to align risk, two things can occur: rates for the entire pool could possibly be inadequate and groups with better risk could potentially seek insurance outside of the pool; unanticipated change in enrollment among the plans within the program could create inappropriate funding in one of more plans. This could set up inadequate funding in the first year followed by significant rate increases for the pool upon renewal.

Unless the SustiNet program is structured to be sustainable for the long term, it will only provide a temporary benefit. A program structured on strong actuarial principles provides a plan that can last into the foreseeable future.

Reported by: Randall Graff

Date: April 2, 2009