The State of Health Care in Massachusetts: A Conversation With Senator Cindy Friedman

In this episode, Will invites Cindy Friedman (Massachusetts State Senator and Senate Chair of the Committee on Health Care Financing) on the podcast to discuss the state of health care in Massachusetts from the need to shift the focus to patients, getting a handle on the health care assets in the state, what's currently driving costs, the new player of private equity in health care, and the effect federal changes will have going forward.

For more information on Will and to share your thoughts, please head over to willbrownsberger.com. Find more information about Cindy at cindyfriedman.org.

Transcript

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Matt: 0:00

Welcome to the Will Brownsberger Podcast. Hi, I'm Producer Matt Hanna. In every episode, I sit down for a conversation with Massachusetts State Senator Will Brownsberger to explore some of the biggest issues facing the Commonwealth and its people. This episode is a conversation between Will and Cindy Friedman, who is a Massachusetts State Senator representing Arlington, Billerica, Burlington, Lexington, and Woburn. She's also the Senate Chair for the Joint Committee on Health Care Financing, which is relevant to today's conversation, where Will and Cindy will be talking about the state of health care in Massachusetts. So let's get into the conversation between Will Brownsberger and Cindy Friedman.

Will: 0:37

So I'm super glad to have on the podcast this morning Cindy Friedman, my colleague, neighboring senator representing Arlington and points North and West. We've worked together for many years now, and I've just come to totally rely on her for everything about health care. And so I know health care is on everybody's mind, and I thought it'd be a great thing to just have Cindy on and just talk about health care because she's the leader of the health care finance committee for the Senate and very trusted in that role. So just maybe a little background. How'd you get into that?

Cindy: 1:06

I was the chief of staff for the late great Ken Donnelly. And I remember very early on in his tenure, I walked into his office and I said, Ken, mental health care in this state sucks. We should do something about it. And natural Ken says, yes, of course, let's do something. So over the next 10 years, we worked on mental health. And unfortunately, he passed away from a glioblastoma, a brain tumor. And when I won his seat, just by chance, the mental health chair left very soon after I came, and I was lucky enough to be made the mental health chair, the chair of mental health substance use disorder and recovery. What I learned in that two years of being on that committee was that you can't talk about mental health without talking about health care, that it's really part of this bigger system. And part of the problem was always that we carved it out and treated it as something separate. So I became interested in healthcare. And when Senate President Spilka became the president, she appointed me the chair of health care financing. And be careful what you wish for.

Will: 2:20

Be careful what you wish for, because then we went into COVID and it was just all consuming, right?

Cindy: 2:26

It was all consuming, and it is, I think after the budget, it's the most complicated piece of what we do. It's the biggest piece in the state, right? Health care and human services.

Will: 2:37

Yeah, no, I mean, as a segment of the economy, it's vast, and I think it's second to nothing as complicated. I mean, you know, all the dimensions of it. I mean, yeah, the state portion of it is what it is, but just the overall system, which you have a responsibility for contributing to the leadership of, is just so complicated. 

Cindy: 2:53

It's just so complicated. And it gets more complicated as we go forward because instead of saying, how do we systemically change the system, we just add more stuff on top of it, right. Either add more regulations or we add more taxes or we add more people or we add more, you know, relief. And so you're just building on a system that's already broken.

Will: 3:16

It's already so complicated. Well, so, let's start with the number one issue in people's mind, right. Which is costs, right. People are always thinking about costs. I mean, how do you think about healthcare costs?

Cindy: 3:26

Where you want to start and always should start is with the patient, right. It should all be around focus on patient and what are people's health care needs. It has become a big business, and the focus is much more now on the business side. And if you're going to think about it, you need to look at it as how do you shift the focus back onto the patient. So what's driving it is what patients need. And then secondary to that is what do the providers need to provide the care that patients need. But you have so many players and there's so many corporate interests that you can't just say, okay, everybody, let's go focus on the patient. Having said that, we live in a world where we are being told and where we get this message that we can fix anything, we can do anything. Here's a pill. You know, but I mean, I think one of the most egregious and profound things that has happened is when we've started to allow pharmaceutical companies to commercialize, to put commercials on TV. And all of a sudden, did you know all these illnesses that you could have? Did you know they even existed? And so we've corporatized medicine and at the same time we give this message to people over and over again, come to us, we're going to fix this. We can fix this, we can fix that. Instead of focusing on what do people need, what helps the most people, and how do we make sure that health care is delivered in a way that it's available and accessible. So all of these things, you know, this is our economy in Massachusetts, right. We are meds and eds. And so changing that system is really hard because it will cause great upheaval.

Will: 5:21

That's very well said. So start off with the patient, think about what the providers need to serve the patient, build the system around that, but we've lost our way a bit with all the corporatization. So, I mean, how do you, how do we as legislators, what can we do? Or how do you think of that?

Cindy: 5:36

I think we have to make really hard decisions. And that's the hardest thing to do as a legislator is to make really hard decisions. 

Will: 5:46

Yes. 

Cindy: 5:47

Somebody's, many people will not be happy, right?

Will: 5:50

Right.

Cindy: 5:51

So there's always this pull between do you do what you know will ultimately be the best thing, or do you, you know, make people feel immediately comfortable right away. I mean, it's a really hard balance. But I do believe that we have to bring the stakeholders and the drivers to the table. And I do believe that if everybody were to give a little bit, if everyone were to say, I will do this to bring down costs, I will do this to bring down costs, if you do this to bring down your costs, I think we can make a huge difference. If you look at what all the research tells you about what the most effective health care is, you talk about primary care, family medicine. Just imagine if we could move another two or three percent of our health care dollars to primary care, that would be an enormous shift. Well, getting 2% out of this whole system that has a gazillion million, billion, trillion dollars in it shouldn't be that hard. You're not asking people to don't make money, don't make a profit, don't be successful. What you're saying is you need to give a little more. And I really think that if people, if the entities involved would do that, would be willing to do that, I think we could make some real seismic change.

Will: 7:16

All right, let's break that down a little bit. I mean, you know, we say the entities give a little more. I mean, tell a story, give a context or an example of that. You're talking hospitals. How do you think about that process, the pieces of that?

Cindy: 7:27

Well, look at a health care system, okay? Look at an MGB, BILAE, all of those big systems. Their money goes into filling beds. That's their job, right. Their job is to provide this tertiary care in these hospitals. They've been set up, right. Now they've grown and they have many more. Now they're sort of a whole system. But their money goes to beds and their money goes to their hospitals.

Will: 7:52

Their money goes to beds and it comes from beds.

Cindy: 7:54

And it comes from beds. That's right. And so it's really going to be really hard if you say to them, listen, we want you to take some of that money out of beds and we want you to put it into primary care. They're going to say, well, we can't do that because we got to keep our beds full, right. Now, that drives you back to, okay, well, is it best to be filling, like, why are we filling these beds? Are these beds needed? And then you start to have to look at the whole system. So one of the really hard questions that we have to ask is, what's our inventory? What's our health care inventory? Where are our hospitals? Where are our providers? Where are our systems? Where are we?

Will: 8:31

What's our inventory of health care assets?

Cindy: 8:32

Healthcare assets, yeah. And it's like base closings, right? You remember the whole base closing when they started out by doing an inventory of all the bases? They could barely get through that because nobody wanted to be able to give that information because maybe they were going to be seen as, well, we don't really get any value out of this. Or we get value out of this, but there's this other system right over here that if we close this one and focused on this system, then we could reduce some of our costs, provide care, make this maybe into something else that we don't have that we need, like emergency room or, you know, ambulatory care, right. But just doing that one thing is seen as very, very disruptive. And it is disruptive.

Will: 9:22

Yeah. No, I mean that's the perennial problem, right? I mean, it's like school closings in the city of Boston. Can't close school.

Cindy: 9:27

Can't close schools, right.

Will: 9:29

If you’re the MBTA, you can't shut down routes that are totally underutilized. And, you know, we see that again and again. It's just very, very hard to say this thing's going away for those people who are most affected. And of course, you can also understand, you know, that they're speaking for themselves.

Cindy: 9:42

You understand how scared people are, right. I mean, we saw it in what happened in the Merrimack Valley with Nashoba and with, you know.

Will: 9:48

Well, what happened there?

Cindy: 9:49

Well, what happened was the state closed, so as part of Steward health care.

Will: 9:54

Let's back up and remind people. Steward, yeah, yeah. There's so much in here, right?

Cindy: 9:58

So Steward was the famous Ralph Delatory who came in, bought Caritas hospitals, turned them into private equity, then sold all of their assets to a real estate investment trust. Oh, by the way, they were involved in every single company that they sold to. So they continued to make money, but in the meantime, they took all that, all their debt that they had created, and they put it on the backs of the hospitals. So instead of the hospitals being able to provide care, they had to pay the debt on these sales. So the whole system went under. And that was St. Elizabeth's and it was Carney and it was Nashoba, and everybody was affected. There were seven or, I think seven Steward hospitals in Massachusetts. So Nashoba was one of the hospitals that was not bought. You know, so BMC bought Good Sam and Saint E’s, and Brown brought two hospitals, but there were a couple that were left. Nashoba was one of them, and it closed. And everybody went ballistic, rightly so, right. The state did not do a good job of saying, how do we transfer assets? How do we make sure that care is still being given, but what kind of care should it be? They closed the hospital, or they didn't support the hospital, so it closed. And then they went and said, okay, well, what should it be? As opposed to the other way around, which is the way you should do things. But Nashoba is now, you know, it's got an emergency care, it's got a couple of beds. It's really, I would say, it's what it should be. It's not a full hospital. It doesn't need to be. It's in an area where they can get to a hospital when they need to, but it really needed an emergency room. And that's what it became. Okay. That's the kind of thing that we should be looking at and talking about. Do you need these beds here? What kind of beds do you need? And can we better utilize what we have and then create what we need? And that's really, really hard to do.

Will: 12:03

So that's a very helpful way of looking at the big picture. You've got this huge system with a lot of pieces. It's hard to repurpose them in a way that's efficient, that does a better job of serving people's needs for less money overall. And it is like base closing and so forth. So from a state leadership standpoint, I mean, from your role, how do you approach that challenge? It's not that easy. So, but it's also partly the executive branch, right? It's not all on us.

Cindy: 12:28

Oh, it's totally not all on us. I mean, if you when you look at, I mean, first of all, I'm so lucky to be in the Senate because we have a Senate president who's willing to say, we really want to figure this out. Like we really want to try and make this better. So let's go do that. It takes a lot of conversation and an enormous amount of planning and a lot of going back and forth. And then it takes a lot of, it just takes a lot of courage, right. Because you're gonna have to say, here's what we are gonna do. And some of that means that this in this world is gonna change. But just to go back to the point that I was making, when you have systems and their goal is to fill beds, and that's how they make money, if you have too many of those systems, then you're never gonna be able to shift those dollars, right. So how do you shift dollars to primary care? And that's what we're really trying to do. Well, if you know, this I am not in any way advocating for this. I'm absolutely not. But let's say if you had three tertiary hospitals across the state, you wouldn't have any trouble filling those beds, right?

Will: 13:34

How many tertiary hospitals do we have? Dozens?

Cindy: 13:39

Well, a lot, right. Okay. And so that will shift the sort of dynamics of where your money would go. Now, we need more than three tertiary. I'm not again, I'm not advocating for that.

Will: 13:50

Yeah, yeah. Underline that you do not mean that. You're just trying to illustrate the fact that concentrating the resources would make them better utilized.

Cindy: 13:58

Concentrating the resources would make them better utilized. Having the right resources, which isn't necessarily a hospital, in the right places would also better utilize it, and I believe would be more cost effective. So that's why I was sort of talking about that.

Will: 14:14

Yeah.

Cindy: 14:14

But back to the question you had about the executive branch, I think it was. So if you look at the major pieces of health care that we've done over the past 30 years, or starting with Romney care, what I think you see is you have very, very strong leadership from the administration. It's not that they tell you what to do, it's that they have a commitment to solving this problem and they are equal partners.

Will: 14:44

Equal partners with the legislature.

Cindy: 14:45

With the legislature. And they have a bully pulpit and they have a way of convening things, other you know, entities and groups that are different from the ones that maybe the legislature has. So if you don't have that leadership in the executive branch, it's really hard to get things done. And we need that leadership if we're going to get through this period of chaos and this very, very dangerous period of our healthcare system crumbling, which it is doing.

Will: 15:17

Okay, well, let's talk about that. So you've painted a big picture, which I think people can understand, which is you've got too many resources out there in some of the wrong places, and the real challenge is 

Cindy: 15:27

Right, and not enough resources.

Will: 15:28

And not enough resources and others. So the question is how can you transform that? And you know, even moving it a little bit would make a big difference. So now talk about the system crumbling. That's another part of the conversation. What do you mean by that?

Cindy: 15:40

Well, if you look at Blue Cross Blue Shield asked for, I think it was somewhere between 14 and 16 percent increase in their premiums. You know, they negotiated that down. But if you look at the premiums, which are on average around 12 percent are going up. MassHealth has the health safety net, which provides care for people who are underinsured or uninsured. This year was $260 million in deficit, and next year it will be quite, quite, quite a bit more. You have pharmaceutical increases are around 10% a year. So the cost of care is just skyrocketing. Then you have our federal government who's decided that poor working people shouldn't get health care, and so they're cutting back on Medicaid and access to care. And all of that is, just it's squeezing the system. It's to the point where I don't know that it can continue the way it's going. Because just the losses, the cost is so high. I mean, what do you do about, you know, when you get to a billion dollar deficit in Medicaid, what do you do, right.

Will: 16:49

So there's the whole federal thing, and you know, you can see the cloud in the horizon, and we're kind of waiting for the storm to hit and see how much rain's actually gonna fall, and then we'll be able to, you know, sort of start to calibrate the state's response. But so there's underlying things, though, that were happening before, you know, the new administration in Washington, you know, in terms of strains on the system. What's driving those costs? Is it just the failure to have the kind of conversation you were talking about before? Or is it, you know, other things? I mean, labor shortages?

Cindy: 17:16

It's all of that. Right. I mean, I think pharma is a huge part of that. Pharma, I think, was the largest cost driver in this last year. And it's especially around things like GLP1 drugs. I mean, just alone between the GIC and the state, we spend about $400 million just on GLP 1 drugs. So the cost of drugs is absolutely a major driver of that. Labor costs are very much a driver of that because we don't have, well, we're missing labor in certain sectors of health care. And I cannot enforce enough what the immigration policies are doing to our health care system because so many people that work in our health care system doing critical jobs are now under threat. And so those people aren't coming to the U.S. And the people who are here are scared to death and are either being deported and many of them just are afraid to go to work. So that's the other so cost of care, cost of labor is a lot. And then just the unit cost of health care is going up. The prices for, you know, for medical equipment and things you need in a hospital, they're going up. And with tariffs, because a lot of that stuff comes from abroad, that will increase it. Now, having said that, the other part of this is we are an incredibly costly state. And the cost of housing is what is driving so many people out of the state. So you can't salary your way out of this problem.

Will: 18:55

You can't.

Cindy: 18:56

Salary your way out of this problem. Because you can't pay. I mean, should a personal care attendant make $60 an hour? I think so, because it's an incredible job, right? People working in nursing homes. Yeah. But we can't do that. But when the cost of a single apartment is $3,000 a month and you're making 19, that doesn't work.

Will: 19:19

Right. So you're saying when you say you can't salary your way out of the problem, meaning, it's not like you could really control people's salary and hold them down to control cost. That's your point, because there's, you know, otherwise they’re just going to leave.

Cindy: 19:27

Right. And you can't increase their salary to the point that they can actually afford housing and food, et cetera, et cetera.

Will: 19:37

Right. Got to keep people afloat.

Cindy: 19:39

You got to keep people afloat. So if you're not willing to look at this as a total, you know, all of the pieces of it, it's gonna be really hard.

Will: 19:46

So we've sort of talked about it, and it's interesting, you know, you've brought the conversation a lot to sort of the systems and the assets. How are our insurers behaving in this picture? How do you think about the insurers? I mean, because they're sort of really a pass-through to the underlying problem, right?

Cindy: 20:00

I wish they were a pass-through. I'm not sure they're totally a pass through.

Will: 20:03

Well, no, I mean there's a path through, they're a path through and a profit margin, but I mean.

Cindy: 20:07

I think it's really different for different insurers. I think we can't lump all the insurers together because there are some insurers, like you have a Fallon health system, which fundamentally takes care of dual Medicaid, Medicare and low-income folks. And they're really struggling, but they're trying to keep all their folks, you know, afloat. Meaning, you know.

Will: 20:29

When you say they're folks, you mean. 

Cindy: 20:32

Their members. Their members. 

Will: 20:33

Right. Meaning they're holding down their costs.

Cindy: 20:34

They're small, they're trying to hold down their costs. And they don't have the res, you know, if you look at their reserves are very different than the big blue in the room. The big blue in the room is a different story, right. You know, they have lots of reserves. I know they've lost a lot of money, but comparatively and even alone, they are in a much better place to weather a storm. So it really depends. But I think my issue with the insurers is they have to play their part in how they negotiate, right. And again, it's very difficult. So if you're negotiating with a, you know, with South Shore as Blue Cross Blue Shield, versus if you're negotiating with Mass General Brigham, right. Different systems, one is much, much more powerful than the other, and one is a high cost system. MGB is the highest cost. You get to a smaller that maybe has even percentage-wise more public payers, you know, they don't have the same bargaining power. So the insurers are sort of in a bit of a bind, and they would have to make very hard decisions about how they negotiate. But the other thing is I have no visibility or understanding into their pharmaceutical, into their PBMs, pharmacy benefit managers. So there's two things. I think there's a whole part of the insurance system that we don't understand. What we know is that it's incredibly expensive. And what we also know is they kind of carve it out, right. So that's what the benefit manager does. It takes the pharmaceutical portion of the insurance and it manages that.

Will: 22:10

So that's something you've really worked hard on to legislate and increase the transparency of. Because I rely so totally on you in this, I can't even keep track. We passed that, but then did the House do it last year?

Cindy: 22:21

Well, we have yes, we now require benefit managers to be licensed. 

Will: 22:25

Pharmacy benefit managers. In Massachusetts. 

Cindy: 22:27

Yes. We require them to be licensed in Massachusetts, and DOI is working on the regulations for that. So that's our first step. Also, pharmacy benefit managers and pharma are now part of cost trends.

Will: 22:39

Cost trends. Okay, so cost trends is.

Cindy: 22:42

Is the mechanism that we use to track costs for health care within the state, across the state. And that's the health policy commission. That is their job. We have set a benchmark for how much, what percentage increase health care costs can go up. We've pretty much blown past it every time.

Will: 23:04

Yeah, so that goes back to what, 2012. 2012 or so.

Cindy: 23:09

2012, I think it was.

Will: 23:10

Yeah. I mean, so you were working for Ken then when we put that. 

Cindy: 23:13

Yeah, but I was like, I didn't know like, nothing to do with it. 

Will: 23:15

But that was something Senate President Murray really drove, right? I mean that was the person on her staff who's now the chair of that or executive director. 

Cindy: 23:23

Oh, David Seltz. 

Will: 23:24

David Seltz, yeah. I mean, he was the staff person who really was.

Cindy: 23:27

Yeah, he really drove the writing of that.

Will: 23:29

Yeah. And you know, created this monitoring structure for the whole ball of wax, our total picture of health care costs. But of course, it's been very hard to control nonetheless.

Cindy: 23:37

Yeah, because we don't give them any power to control it.

Will: 23:40

Right.

Cindy: 23:40

We have very little power. I mean, they can tell us everything. They're amazing. Their work is extraordinarily good. They are on top of many of these issues. We just haven't given them any power to truly enforce those benchmarks.

Will: 23:55

So let's just sort of back up and frame a little bit. You've painted this picture of, you know, this big amorphous system where we kind of tend to lose sight of the core job, which is patients and supporting the people who are trying to take care of patients. There's all this money making going on and it pulls people in different directions, and it creates a thing where it's just very hard to control the costs. It's very hard to focus resources where they need to be. And, you know, our wish is that we could bring people to the table and make some of those really difficult, sort of base closing type decisions where you've got a big system, you've got to get rid of some parts of it, move assets around a little bit. Very, very difficult. It's a challenge in public and private life that leadership faces all the time. You know, we're facing it right now in the correctional system. We've got you know resources all over the state that are underutilized. It's the same picture. Schools in Boston, routes on the MBTA, although the MBTA has kind of squeezed down quite a lot already. We've talked about the roles of the different players. We've talked about the hospitals, we've talked about the insurers, we've talked about the pharmacy benefit managers as kind of another place where it's hard to see what's really moving around. What's the role of private equity now? What have we been, you know, that seems like a new thing on the scene. It's a new problem, if you will, that we seem to be facing that we weren't really talking about 10 years ago.

Cindy: 25:08

I mean, Steward is the poster child for real estate investment trusts and private equity. And here's the problem with private equity. The problem with private equity is that unlike venture capitalists, which is very different, private equity's job is to take other people's money, buy something, get in, get out fast, and make a profit. It is not about building anything. It is purely a money-making venture. And health care is long-term, it's relationship, it's delivering services to people. There's no Venn diagram in which those two things come together. But private equity has been very good at coming in and buying up assets that are losing money, like physician groups, hospitals, long-term care, because there is something in it that they see as a way to make a profit. And it's a short-term profit, not a long-term profit. That just doesn't fit with health care. It just doesn't. And I have asked over and over again, can you show me an example of a private equity in health care that has been really successful, meaning that patients and providers have together gotten more access, better care at a good price, and have been able to do the jobs that they have been trained to do. And I've yet to get one thing. Somebody said, oh, well, this place was good, but then it got sold to private equity, and I don't even know where it is anymore, right. So it has done enormous amount of damage to the healthcare system. And again, Steward is the poster child.

Will: 26:49

And all too often, right, these private equity firms are sort of identifying a cash flow that may have a public source. I mean, with nursing homes and Medicaid, and so they figure out the rules and they can just sort of push the right buttons and meaning designate their services in a certain way, and then they're going to get a cash flow from the state until the state figures out what's going on.

Cindy: 27:10

Right. Right. And then if you put that with the corporate practice of medicine, which is the corporate practice of medicine is a set of laws that are on the books that basically say you can't corporatize medicine, right. You can't have a non-health care entity running a health care entity, I think is the easiest way that I can put it. Well, that's just been whittled down and whittled down and whittled down. So, and what will happen is there'll be management services organizations that are basically part of a non-health care entity, that the non-health care entity affiliates that MSO with them. And then they go in and they basically, under the guise of health care, begin to manage a practice or manage that entity. But what they're managing for is dollars. They're managing for profit. They're managing for making sure that certain vendors get picked. They're managing based on, you know, how many patients you see they know. 

Will: 28:12

How many tests you do.

Cindy: 28:13

How many tests you do, you know, all there's a loose affiliation that's not so loose between that corporate entity and the health care thing. Very, very and very complicated to get into the nitty-gritty of that because, not the least is because these health systems are so big that it's hard to know where the corporation stops and the care starts, right?

Will: 28:37

Right. You have this incredibly large opacity, you know, they have their own complicated internal accounting.

Cindy: 28:43

Sure. I mean, like these are huge systems, Mass General, BI Leahy, Tufts, they're huge systems. Then you had the for-profits Optum and United Healthcare, and you know, are they a health care company or are they, you know, a corporation that's making dollars?

Will: 28:59

All right, so that's all depressing enough. And those are trends that were going on for the last decade or two. 

Cindy: 29:05

Absolutely.

Will: 29:06

Now we've got a whole new equation, I mean, which is an administration that's hell-bent on cutting health care services for the poor. So, I mean, in a nutshell, what are we looking at there?

Cindy: 29:16

What we're looking at is I think the biggest challenge right now for Medicaid, and I want to say something about Medicaid, okay? Our Medicaid is called MassHealth.

Will: 29:25

Right.

Cindy: 29:25

And you will hear many people say, oh, it's the biggest part of the budget, oh, it's a budget buster, oh, it's you know, costing the state. MassHealth is one of the things that this state should be the most proud of.

Will: 29:38

Amen.

Cindy: 29:39

What MassHealth does is deliver appropriate care to people. We should live in a world where all of our hospitals and our insurance companies deliver the same care that MassHealth does because it's appropriate care and it's done with a very strong set of values that basically says we need to get care to people. And yes, it's not perfect. And yes, it's a huge system. And yes, you can gripe about this and that, but it is fundamentally a well-run, very, very, very efficient, affordable system. Not affordable, affordable for the people who need it, right?

Will: 30:16

And that, by the way, is 2 million out of our 7 million people.

Cindy: 30:19

And that is 2 million out of our 7 million people. And so what's happening though with MassHealth is they are being hit by the cost. They have huge costs around pharmaceuticals, huge costs around their long-term care and personal care systems, and then the fact that their rates, their rates to their providers, can't keep up with the increased cost of care that's happening in the system. So they're being hit very hard. But in addition to that, we are going to lose on January 1st, minimally 36,000 people will lose their health care in this Commonwealth because of the federal government's new rules about immigrants. And let's be clear: these are immigrants that are here on legal status. They're not undocumented, they’re legal status here, but they're going to lose their health care. The group of people are now only going to be able to access emergency care. Emergency care is very expensive. It will increase the cost of the whole system. MassHealth, through the health safety net, pays for, along with hospitals and insurers, pays for that health safety net. That health safety net is underwater and will continue to go underwater. So we're going to be seeing huge deficits in that space. The connector basically is our ACA, Affordable Care Act.

Will: 31:39

Which reaches more middle income folks. Lower middle income.

Cindy: 31:43

Lower middle income. Okay. Again, excellent system. You know, the insurers are required to provide a vehicle in there. Many people in the connector get a subsidy through the extended tax credits that came with the ACA. So there's subsidies.

Will: 32:02

The ACA being the federal act that happened under Obama, also known as Obamacare, right.

Cindy: 32:06

Also known as Obamacare. So there are subsidies in our connector. That is one of the things that is shutting the government down. The Democrats want to continue those subsidies. The Republicans want to take away those subsidies. These are all working people that have an income above the U.S. poverty level. Okay, so we're really we're talking about subsidies that are keeping working people and their families in the health care system. The Republicans want to take that away. The Democrats are trying to keep it in place. It is going to have and is having a profound effect on health care affordability and health insurance affordability in the Commonwealth. 

Will: 32:49

And so how many people are on the connector? 

Cindy: 32:51

Okay, so the estimate, the elimination of the premium, that's what they're called premium tax credits, for individuals with income that is greater than 100% of the poverty level, that's 36,000 people. So they'll lose coverage.

Will: 33:08

Well, they'll lose the tax credits. 

Cindy: 33:09

They'll lose the tax, yes. 

Will: 33:10

So their costs are going to go up and they're already high enough. Right. And this also includes some small business owners as well, right?

Cindy: 33:16

Oh, yeah, yeah, yeah. Yeah. So the modifications to the marketplace eligibility and operational rules will impact about 20 to 40,000 people. So you can't be on Medicaid and get the premium tax credits. So these are all people that are not eligible for MassHealth.

Will: 33:33

Right. So there's a whole nother tier of people. 

Cindy: 33:33

So there's a whole nother tier of people. So you're looking at, you know, 100,000, maybe more people that are going to be impacted in some way. Some will lose some subsidies, some will lose all their subsidies.

Will: 33:47

So we've got a system that's expensive, really hard to control. And by the way, right, this conversation about how to control health care costs has been going on for the last 50 to 100 years, right. I mean, it's this is the challenge, right. This incredible challenge of sort of reigning in the profit incentive, keep the focus on patients, and somehow we're just not doing it that well in America, anyplace, right?

Cindy: 34:10

No, but we are a country that's run by profit, right? We're all about the money.

Will: 34:17

Yeah, there it goes. Big picture, challenging. You're in the trenches trying to wrestle with it. I'm sure that as a result of all the wrestling that we are doing, it's better than it would be otherwise.

Cindy: 34:29

Yeah. I mean, it's hard, you know, if you look at the rest of the country, I guess it's just what the feds are doing alone will affect just millions and millions of people.

Will: 34:38

Yeah. Well, you're fighting the good fight. Do you sleep at night at all?

Cindy: 34:43

I do sleep at night. I do sleep at night. But I always wake up thinking, you know, you wake up thinking.

Will: 34:48

Yeah, yeah. We have early morning meetings. I hear those thoughts. What are you hopeful about? 

Cindy: 34:54

What am I hopeful about? 

Will: 34:55

Yeah, what are you hopeful about?

Cindy: 34:57

I'll tell you one thing I found so relieving. We had a meeting with the Attorney General's office, their division of, what's their division called?

Will: 35:07

Well, I think we were meeting with multiple divisions. Yeah, and I'm glad you brought that up because that was very hopeful. Go ahead.

Cindy: 35:12

The folks that are out there fighting what's happening on the federal level and protecting Massachusetts, especially in terms of the money that comes into Massachusetts from the federal government and some of the policy changes.

Will: 35:23

Fighting on the litigation.

Cindy: 35:26

Through litigation, they were fighting in courts. And to the person, they all seemed brilliant and articulate and able to explain what they were doing. And what they were, are doing just gave me so much hope because they are on the front lines and they are protecting to the full extent of the law, the values and the people in Massachusetts. And they were extraordinary, and their work is so important and so meaningful and impactful. So that gave me hope.

Will: 35:56

No, that was a great meeting. And a couple of things. I mean, one is they have great people that are doing great work as litigators. But I think the important thing that I took away that a lot of people don't know is that the litigation is working. 

Cindy: 36:10

Yes. That's right. That's why it was hopeful. 

Will: 36:14

When the Trump administration exceeds their authority and they're brought to account in the courts, they then change course. And so they do obey the courts at the end of the day. And it's not like all these cases go up to the Supreme Court and get overturned. Many of them they don't even bother to appeal. They just say, fine, we're releasing the funds. And so a lot of the worst things that could happen are being addressed in the courts. And, you know, the rule of law is in an important way still functioning.

Cindy: 36:42

And the rule of law is what's holding us all together. Let's be clear.

Will: 36:45

That's it. No, I mean these federal courts are where it's at.

Cindy: 36:49

So that to me, I was very optimistic in that. I think the other piece of it is we have an opportunity to make a real change for people. And the real question is, are we going to take that opportunity in this crisis?

Will: 37:04

Right. So yeah, that's an exciting way to look at it. I mean, look, we've painted this picture of, you know, all the challenges, and those challenges are reaching a point of high intensity, but maybe that's just what we need.

Cindy: 37:13

Yeah, and if there's a will, there's a way.

Will: 37:15

Amen. Well, if there's a Cindy, there's a way. All right, we'll go with that. Thank you so much.

Matt: 37:20

So that's it for this episode. If you'd like to join in the conversation, please head on over to WillBrownsberger.com. As this is an ongoing conversation, Will would love to hear your thoughts on the issue and how it's affecting you. You can find more information about Cindy at CindyFriedman.org. And you can subscribe to this podcast wherever you listen to podcasts so you can know when the next episode is out, where Will will continue to dive into the issues and share his thoughts on them. Thank you for listening and take care.