Driving Value for Tax-Payers, Patients in Maryland

Republican efforts to dismantle President Obama’s hallmark legislative legacy have faltered despite persistent popular opposition to Obamacare. President Trump’s attempts to “repeal and replace” the Patient Protection and Affordable Care Act (ACA) have ultimately fallen on deaf ears in Congress perhaps as a result of the successful expansion of health insurance coverage to millions of Americans and of its success at bending a stubbornly accelerating healthcare cost curve. With Obamacare here to stay, at least for the time being, it is up to state legislatures and private actors to continue moving the ball forward with healthcare reform to achieve the holy grail of the Triple Aim: improving care experience, improving population health, and reducing healthcare costs per capita. 

Healthcare is the single greatest driver of both the federal and Maryland’s budgets, accounting for the greatest percentage of government spending when compared to any other sector of the economy. Our budgets, and indeed our very lives, depend upon the delivery of high value (low cost, high quality) care. 

The United States currently spends more than twice per capita on healthcare than any other nation in the world and yet with regards to healthcare quality on a population level, we rank well below many developed, Western nations on such basic metrics as infant mortality and population-level life expectancy. Much of our poor performance is attributable to the large swaths of our population that is uninsured or underinsured, of whom 80,000 reside in Maryland. 

The uninsured population is not, however, forgoing medical care. Instead the uninsured often are forced to inappropriately utilize ambulances and emergency rooms for basic access medical care. The cost of providing uncompensated care is shared by the rest of the population in the form of increased health insurance premiums and in form of forgone corporate income tax revenue that the State would otherwise collect from non-profit hospitals and health insurance companies that are largely able to maintain their tax exempt status by providing community benefits in the form of uncompensated care. In this environment it quickly becomes apparent that universal health insurance coverage, perhaps in the form of Medicaid for All on the state level, is not only morally correct, it’s fiscally responsible. 

It is equally apparent that our society can no longer afford to rely on prisons to provide access to mental health care to those with a history of substance abuse and/or of mental illness. Recently Maryland’s Acting Health Secretary was held in contempt of court by a Baltimore circuit judge for effectively relying on the criminal justice system to handle the mentally ill. Mental Health Courts, like those operating in Montgomery County, are designed to reduce recidivism, prevent crime escalation, and to treat defendants as citizens afflicted with a disease rather than as derelicts dragging down our society. Maryland needs to strongly consider expanding Mental Health Courts and Drug Courts across the state.

And in providing greater access to the medications that Marylanders require to control their mental illnesses, the State should leverage its purchasing power to drive down prescription drug prices for Medicaid beneficiaries and State employees, thereby bending the health care cost-curve and making Maryland's budget growth more sustainable. Incentivizing counties and municipalities to join State employees and Medicaid beneficiaries in one large risk pool could augment savings. The State has already shown its willingness to tame pharmaceutical excesses by passing legislation to control price gouging efforts, which came into effect on October 1, 2017. Maryland must build upon this success and take further action to drive down drug prices while Congress remains fettered from doing the same by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. 

Maryland must continue to work to align financial incentives to reward physicians for providing appropriate levels of care. The current Fee for Service model of reimbursement has, perversely, incentivized the systemic overuse of diagnostics and therapeutic treatments. Maryland has a model unique to the nation that has proven successful in containing rising healthcare costs below the national average. Maryland should extend the Health Services and Cost Review Commission's All Payer Single Rate Setting authority to all ambulatory and outpatient settings so as to realize the proven cost-saving and disparity-reducing benefits that have been found in the inpatient setting. The standardization of health care services pricing across all settings of care will introduce transparency, accountability, and affordability for premium-payers and tax-payers alike across the state. 

Congressional inaction on healthcare reform need not incapacitate Maryland from ensuring that Marylanders continue progressing towards higher value healthcare.