Massachusetts, always a leader in health reform, is on the move again. Last month, the state released a draft plan to shift its Medicaid program, MassHealth, from a fee-for-service model to one that relies on Accountable Care Organizations (ACOs). Under this new approach, provider-led ACOs will be responsible for the quality, coordination and total cost of many MassHealth beneficiaries’ care.
This move has been a long time coming. Even as the state led the nation in creating near-universal health coverage in 2006, it had already started to plant the seeds to improve the way care is delivered and paid for. Now, the state is on the verge of big changes that will impact up to 1.8 million low-income beneficiaries: children with special health care needs, adults with physical and behavioral disabilities and vulnerable older adults.
So what do these beneficiaries think of the proposed reforms? Our state advocacy partners in Massachusetts at Health Care For All (HCFA) and Disability Advocates Advancing our Healthcare Rights (DAAHR) – both of whom submitted comments last week in response to the state’s proposal – clearly outlined both the promise and the peril of these reforms for beneficiaries. Among the promises are better coordinated, more comprehensive care and a more financially-stable Medicaid program. Notably, the state also seeks to “address the opioid addiction crisis by expanding access to a broad spectrum of recovery-oriented substance use disorder services.” Also laudable is the requirement that ACOs must work with community-based organizations which will provide critical long-term services and supports and behavioral health services.
But the risks are also real: to give just one example, the state is proposing that beneficiaries be “locked in” to one ACO or Managed Care Organization for a year. This lock-in provision means beneficiaries could face increased costs, reduced provider choice and control, and a disconnect from critical supports and services they are currently receiving. This could place our most vulnerable consumers – those with chronic care conditions and children with special care health care needs – at risk.
In part, advocates’ concerns arise from simultaneously proposed reforms in the state’s Primary Care Clinician (PCC) plan, an existing managed care option for MassHealth beneficiaries. These changes are meant to incentivize members to move to a managed care organization or to an ACO, but in fact, they would penalize those who want to stay in the PCC plan. For instance, proposed PCC changes include eliminating coverage of chiropractic services, eyeglasses, hearing aids and orthotics and increasing member copays. Of particular concern to children’s advocates is the fact that reduced benefits in the PCC plans limit access to federally-mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service, which provides comprehensive coverage for dental, vision, hearing and medical screenings and treatment. EPSDT is the gold standard for children’s coverage, ensuring that children under 21 enrolled in Medicaid have full access to developmentally appropriate preventive and treatment services to support their growth and long-term health.
Advocates included specific recommendations for improving the proposal but they aren’t stopping there. For example, the day after submitting its formal comments, DAAHR hosted