Report of BOD Subcommittee onCentral Line proposal:

Advocacy for Health Care Reform (Action)

BOD Subcommittee Recommendation:

A motion to support the Central Line proposal, Advocacy for Health Care Reform, failed on avote of: 2 yes; 4 no; 1 excused absent; and 1 present and not voting.

The subcommittee’s findings following a methodical work plan and intensive discussion are:

1. Significant majorities of policy influencers and CMS membersstrongly favor continued workon health care reform starting from the premise of the ACA in order to expand coverage, address affordability, reduce administrative burdens, increase transparency and hasten payment reforms that increase care value.

2. Although pursuing any advocacy beyond protecting recent hard-fought gains in coverage is politically unrealistic in the short term, there are ways to continue to expand coverage systematically through Medicaid and the commercial market over time.These efforts must also include steps to ensureadequate reimbursement and quality of care.

3. The subcommittee view is twofold:

a)CMS cannot successfully pursue any version of universal coverage expansion that upends a public-private model currently supported by a wide array of stakeholders, public officials and CMS members; and,

b)CMS should not pursue a universal coverage expansion agenda if other influencers can split physician opinion to the left (role of government) and right (market forces).

4. The subcommittee urges:

a)The Central Line authors and supporters to stay engaged to be an influence inside CMS as health care reform evolves and opportunities open to advance their cause; and

b)That the board of directors begin strategic discussions to identify and prioritize health care reform issues for CMS to address during the remainder of 2018 and beyond.

BOD subcommittee members participating and voting on February 7, 2018:

Mark Johnson, MD (no)

Richard Lamb, MD (no)

Patrick Pevoto, MD (no)

Brandi Ring, MD (yes)

Brad Roberts, MD (absent; excused due to night shift)

Rocky White, MD(no)

Deb Parsons, MD, President-elect (yes)

Robert Yakely, MD, Subcommittee Chair and President (PNV)

Subcommittee work plan findings: The following outlines each element of the subcommittee’s work plan and a summary of findings:

  1. Membershipperspective: This aspect of the work plan included 3 parts:
  2. Kupersmit Research: Summary recommendation: The key issue for CMS is emphasizing clearly that “aggressive incremental” change does not mean CMS is abandoning its long-standing efforts to achieve meaningful health system reform. Indeed, CMS should remind members at every opportunity that the actions being taken are part of health system reform, and part of meeting the wider goals outlined in CMS health care reform policies and supported by members across polling for the past decade.

Summary conclusion:The question facing CMS at this point is not whether it should engage in efforts to continue to meet health care reform goals (detailed in the matrix and other policies over the past decade), but rather, whether CMS should either seek incremental gains that drive towards these goals or convene stakeholders to find a comprehensive solution to the health care financing and delivery system problems that could be approved by the legislature and the general public. We see two key factors at play in the member survey data that lead us to conclude that the former option – pursuing tangible, significant, aggressive, incremental progress – is the best way forward for CMS:

  • It is almost impossible to see how a single plan for funding and covering the remaining uninsured in Colorado can be found that won’t be vocally opposed by a substantial portion of members; and
  • It is clear from the data that there are areas of very strong consensus that are not small or insignificant, despite being incremental steps toward advancing (or preserving) the goals of health system reform. Bear in mind the levels of burnout that are well documented inthe profession; in our view, the need to create real wins and address specific, acute issues(affecting affordability, coverage/access, administrative efficiency, etc. which are driving burnout) asbest you can, when and however you can, is critical in the short run.
  1. Central Line votes: Support: 60% (221); Oppose: 27% (99); Maybe: 13% (47). Subcommittee members did not think that these numbers represented the needed consensus to launch a major strategic initiative (universal coverage) given Kupersmit Research and findings from the Colorado Health Institute (CHI).
  1. In-person member input:

Input from the proposal’s author and at least one member opposed to the proposal: Proponents attended both meetings of the subcommittee. They were allotted time on the agenda to address the subcommittee, were often allowed to participate in subcommittee discussions, and were timely provided all subcommittee documents. Opponents participated in the subcommittee’s first meeting.

  1. Assessments:
  2. Stakeholder assessment: The work plan sought to evaluate interest in a stakeholder process to achieve universal coverage, including at least one organization representing business, consumers, hospitals and health plans. CHI was retained to perform stakeholder interviews and to provide a written and oral report to the subcommittee. Stakeholders interviewed include: (1) Colorado Hospital Association; (2) Health insurance brokers; (3) Office of the Governor; (4) Colorado Consumer Health Initiative; (5) public opinion pollsters –one that historically works for republicans and one for democrats.

Summary findings: CHI emphasized that there was a lot of commonality across these stakeholders regarding key concerns including affordability, transparency, administrative burden and payment accountability. Coverage was explicitly missing, with stakeholders noting that this issue has largely been addressed. Stakeholders unanimously supported incremental change by building upon the ACA, rather than seeking comprehensive reform. Stakeholders reported that support for health care reform is higher than it has been in the recent past, largely driven by frustration with the current system. Stakeholders also emphasized that physician leadership in health care reform is essential.

In a separate report submitted by senior CMS executives, the Denver Chamber of Commerce is focusing a major project on cost control. This new initiative stems from business community frustration with the entire health care stakeholder community because of unaffordable health care costs. CMS has already engaged with the chamber.

  1. Federal assessment: The work plan called for an assessment of whether the 1st Session of the 115th Congress stabilizes or repeals and replaces the ACA or takes some other action. It also sought an assessment about what is expected during the 2nd Session and beyond.

1st Session summary: (1) Actions of the Trump Administration in 2018 are expected to continue to try to undermine the ACA; whether and how quickly this happens could accelerate state change. Consumers are already signed up for 2018 ACA coverage. The mandate and its penalty are still in effect in 2018.

2nd Session summary: Efforts in Congress to provide funding for health plan cost sharing reductions and some type of a reinsurance proposal for states failed during budget negotiations to keep the federal government open. Senate Majority Leader Mitch McConnell (R-Kentucky) has already signaled in the media that the Senate would not take up repeal and replace in 2018.

The 2018 elections: If the House and Senate flipped to democratic control, two camps would emerge as follows: (1) Single payer; very expensive, political uphill climb; (2) The more incremental camp, with two ideas brewing: (a) Buy in early to Medicare; and, (b) Buy into Medicaid.

  1. State government assessment:

Executive branch disposition: Determine whether Governor Hickenlooper will stay the course (ACA implementation) or tack to some other coverage and health care reform scheme.

Summary findings: Governor John Hickenlooper strongly supports the Medicaid expansion, the sale of subsidized health insurance tied to a mandate to purchase insurance, and preservation of employer-sponsored health insurance system. It is almost certain that his administration will not transition to a different coverage scheme during the remainder of his term in 2018.

Legislative branch: 2018 priorities

Summary findings: The 2018 General Assembly will be focused on the opioid crisis, the budget, divergent views about how to fix the Colorado Public Employees’ Retirement Association and highway funding, with each side positioning its approach to best serve the reelection of its members and respond to the needs of their constituents. Now that Congress has passed the tax bill and a continuing resolution in February to keep the government open, nothing at this time is forcing the hand of states in the short-term. In addition, given that 2018 is an election year, it is highly unlikely that a new coverage scheme will emerge or be politically viable if it does.

  1. 2018 election cycle: Key questions include:
  • What would need to be done to tee up universal coverage-comprehensive health care reform?
  • Gubernatorial candidates
  • Legislative branch
  • Public opinion on importance of HC reform versus cost
  • What would need to be done in 2020?

Summary findings: CMS senior executives explained to the subcommittee that gubernatorial candidates competing in the general election would need to be interviewed and qualified by COMPAC on support for universal coverage; it was further explained that support by the next governor would be important if legislation or regulatory change we needed. It was noted that COMPAC would also need to begin interviewing legislative candidates in the 2018 election cycle on support for universal coverage.

  1. Assessment of current CMS operational plan:What are the priorities in the current plan given 2017 membership survey data and the external environment? What can be sacrificed if the board approves the Central Line proposal?

Summary findings: CMS senior executives provided the subcommittee with fiscal year operational project plans that would need to be discarded should the subcommittee approve the Central Line proposal, Advocacy for Health Care Reform. Given the recommendation of the subcommittee that the board of directors not support the proposal, the subcommittee did not discuss these recommendations in any depth.

  1. Other research and data
  2. Colorado’s uninsured trend 2009-2017 (available from strategic planning session)
  3. Drivers of change (available from strategic planning session)

Meeting 1: January 9, 2018: 6:00pm, CMS headquarters and-or teleconference (303) 248-0285; Access Code: 2191795#

  1. Interact with the author of the Central Line proposal and at least one physician representing a minority view
  2. Review and discuss assessments
  3. Give staff additional direction

Meeting 2: February 7, 2018: 6:00pm, CMS headquarters and-or teleconference

(303) 248-0285; Access Code: 2191795#

  1. Review and discuss
  2. Additional direction requested from meeting 1
  3. Final assessments
  4. Vote on recommendation to the board of directors

The motion approved on November 17 by the board of directors on“Advocacy for Health Care Reform”:

That a subcommittee of the board of directors be appointed by the President to:

(1) Pursue in greater detail the mechanics of the proposed undertaking, including a methodical assessment of the practical considerations thus far contemplated but not at this point fully explored or vetted;

(2) Evaluate the potential for disruption or delay of other medical society priorities;

(3) Evaluate membership views; and,

(4) Prepare a report that includes action item(s) to the board of directors no later than March 16, 2018.

The board’s rationale for the referral:

CMS as a matter of long-standing policy and moral principle supports in concept the authors’ stated motives and underlying themes notwithstanding ambiguities and substantive concerns regarding the political, structural, economic, and membership components that require analysis and refinement as a condition of any decision by the board of directors. Assumptions regarding the timing of such an initiative may in reality be problematic rather than propitious given the profound uncertainties of federal Medicaid funding streams, the unknown future stability of private coverage through the Affordable Care Act, as well as troubling uncertainties regarding any prospective Medicaid ‘block grant’ type waiver.

Central Line proposal: “Advocacy for Health Care Reform” (as submitted)

Problem-Issue Statement:

Health Care Reform

All physicians know from personal experience the chaos of our health care system, the ravages to our society of the high cost of care, the adverse effects on individuals ranging from neglecting care to medical bankruptcy, the waste and inefficiency, and the burnout of physicians.

At this year’s Annual Meeting the panel of state Senators and Representatives clearly expressed their respect and admiration of the Colorado Medical Society and support for health care reform. Rep Bob Rankin stated, “We don’t know what to do about it” and "We need thinking and input from the CMS”.

The CMS now has an unprecedented opportunity to actively lead advocacy for affordable, continuous, high quality care for all Coloradans. It should allow for diverse views in order to develop policies that are bipartisan stemming from broad consensus with compromise that fosters cooperation. We respectfully request the board of directors acknowledge the priority of this effort and commit the resources required to see it succeed.

Policy Proposal

  1. CMS Advocacy (Directs specific actions):
  1. The CMS takes an active leadership role in health care reform.
  2. The CMS uses it influence to educate the legislature, the governor, and other stakeholders on the importance of adopting universal coverage as our shared goal.
  3. The CMS actively develops feasible recommendations to achieve universal coverage.
  1. General Aspects of a Proposal
  1. Proposals should aim for a comprehensive change in our current system of health care.
  2. Such change should focus on achieving affordable, continuous, universal health care.
  3. A new system should simplify and make transparent all financial arrangements for health care and result in health security for all Coloradans.

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