Ten things Dan Malloy thinks about health care

Dan Malloy at his desk  july 2014

CT MIRROR

Gov. Dannel P. Malloy

The Mirror is sitting down with the gubernatorial candidates to discuss health care issues. (Read our interview with Republican candidate Tom Foley here.) Today, Gov. Dannel P. Malloy talks about his track record and future plans on health care and social services.

As governor, Dannel P. Malloy said he’s managed to avoid major cuts to health care and social services while grappling with a massive budget deficit. He says the care of those who rely most on the state weighs heavily on his mind.

“I think that I have taken that very seriously, and far more personally than some other governors in our state or in other states,” Malloy said. “It’s really important to me that these people are cared for well.”

But the first Democratic governor in 20 years has also faced criticism for his handling of certain health care and social service issues, including from some of the left-leaning advocates his party usually counts on.

His responses often follow one of two themes: Look at the fiscal mess I had to deal with, or I’m better than the alternatives.

Safety net: Strained, but “largely protected”

Four years ago, as Connecticut faced an unprecedented budget deficit, Malloy ran for governor pledging not to balance the budget “on the backs of those who are most dependent on the government for their health and support.”

So how is the safety net doing compared to when he took office?

Malloy first pointed to the alternatives.

“What has happened in most other places is the safety net has been largely devastated,” he said. “And what happened in Connecticut is it hasn’t gone without strain, but has been largely protected.”

Malloy is right that the state’s social service and health care programs didn’t see the sort of large-scale cuts those in some other states did. And his administration oversaw a rollout of the federal health law that has gone more smoothly than in most other states.

But he also has angered some health care and social service providers and advocates for the poor, who say he has made proposals that could hurt vulnerable state residents. And he’s drawn the ire of hospital officials, who say state cuts and a new tax have hurt hospitals.

Malloy points to the economic situation he inherited, and says the safety net is in better shape than it would have been under a different governor.

“I don’t know what’s going to happen in the election, but I can look myself squarely in the face when I shave every morning and know that I did the best I could,” he said.

An Obamacare booster

Malloy has been an enthusiastic booster of the Affordable Care Act, touting Connecticut’s largely successful health insurance exchange and chastising governors of other states that opted not to expand Medicaid to cover more poor adults. (It was actually Malloy’s Republican predecessor, M. Jodi Rell, who decided to expand Medicaid after the health law passed in 2010, but Malloy maintained the expansion.)

Hundreds of supporters of a public health insurance option rallied in April 2011, hoping to convince Malloy and other leaders to embrace the plan. He didn't.

Arielle Levin Becker / The CT Mirror

Hundreds of supporters of a public health insurance option rallied in April 2011, hoping to convince Malloy and other leaders to embrace the plan. He didn’t.

Early in his term, Malloy disappointed those on the left who supported a state-level public insurance plan known as SustiNet. Malloy deemed the plan too costly and problematic, and instead banked on Obamacare to expand coverage. He also took heat from some insurance customers last year after declining President Obama’s offer to let states allow health plans that didn’t comply with Obamacare to be continued for another year. Malloy argued that insurance companies wouldn’t have continued the policies anyway, and that if they did, prices would probably rise.

Malloy has also tried to use Obamacare to save the state money, in ways that critics said could reduce access to care. His administration proposed reducing payments to hospitals and mental health and drug treatment providers on the grounds that they wouldn’t need the funds once more people gained coverage — a position hospital and agency officials disputed. He also tried unsuccessfully to scale back Medicaid eligibility for some adults who were in the program, arguing they could instead get federally subsidized insurance under the health law.

Rather than having multiple health care programs, Malloy said it made more sense to put all of the state’s strength into implementing Obamacare.

“Is it perfect? It’s not perfect,” he said. “Is it a hell of a lot better than other programs in other states? I think it is.”

Medicaid: Grown, but attempts to scale back

While governors in some other states slashed their Medicaid programs to cope with tight budgets during the past four years, Connecticut has not made major cuts to Medicaid benefits or eligibility. The state’s Medicaid program has grown significantly since 2011, from 391,054 the month Malloy took office to 739,524 in July, largely because of wider eligibility under Obamacare.

The health law also provided federal funding for two years to boost payment rates to primary care providers who treat Medicaid patients, to ensure those who joined the program could get care. Malloy proposed making Connecticut one of just a handful of states to use its own money to maintain higher payment rates once the federal funding runs out.

But Malloy has also angered advocates for the poor by floating proposals to scale back eligibility and benefits. In 2011, the governor proposed charging some Medicaid clients copayments for medical services, something his budget director said was bad policy but necessary given the state’s dire finances. The legislature ultimately rejected the idea. In 2012, the Malloy administration tried to save $50 million by temporarily scaling back Medicaid eligibility, but the federal government rejected the plan.

And last year, Malloy proposed changes to Medicaid eligibility that would disqualify about 37,500 parents from the program. The administration argued that the parents could instead get federally subsidized insurance through the state’s health insurance exchange. Legislators rejected that plan too, with concerns that it would place burdensome costs on poor parents and could make them less likely to get care.

Was that proposal based on the need to save money given the state’s tight budget or on a policy view that the parents would be better off in private insurance plans sold through the exchange?

“I think it was both, actually,” Malloy said.

Human service funding woes: Sympathetic, but no short-term fix
A rally urging lawmakers to maintain funding for human services.

The CT Mirror

A 2013 rally at the state Capitol against cuts to social service programs.

The state spends about $1.3 billion on private nonprofits that serve people with developmental disabilities, mental illnesses and addictions, kids in the child welfare system and others.

The leaders of those agencies have been warning for years that their funding levels are unsustainable. They say years of flat funding — largely continued under Malloy — have led to high staff turnover, a workforce that receives low pay, and the possibility that the agencies won’t be able to serve as many people in the future.

Because services provided by the private nonprofits typically cost less than services provided by the state, some nonprofit agency leaders have pushed for Connecticut to shift more of the services to the nonprofits. They say that moving away from the costlier state-run services could free up money to be used to better fund the social service system.

Malloy said he’s sympathetic to the nonprofits’ financial concerns, and that to some extent, they’re correct that the funding situation isn’t sustainable. But he said that’s a problem that predates his administration.

“That was a problem which was tolerated in very good times, for whatever reason they tolerated that, and then I come along in the worst of times, and I’m actually trying to do something about it,” he said.

One effort was providing $50 million in bonding funds for grants that nonprofits could use for capital expenses like building improvements, IT systems and vehicle purchases. Malloy also created a cabinet-level post to serve as liaison to nonprofits, and said he has a better appreciation for nonprofits than state leaders had in the past.

Does Malloy worry about the nonprofits’ ability to continue providing services, or about agencies closing?

“I have concerns about, and I’m sure they have concerns about what would happen, if I’m not governor,” he said.

Then he added: “But that may be too political.”

Malloy said he doesn’t have a short-term fix, but is working on a longer-term one.

He said his administration has been open with the agencies about what’s possible, and said he feels good about the relationship.

“Not that they’re not under pressure, they are,” the governor said. “But hey, [they] should have my job.”

Hospitals: Closely watching, expecting consolidation

Malloy made a similar comment to hospital executives in 2011, shortly after introducing a budget that cut their state funding and imposing a new tax. “I would trade my deficit for any one of yours today,” he told them.

Waterbury Hospital

Erin Covey / Waterbury Republican American

Waterbury Hospital

Hospital leaders haven’t spent much time cheering Malloy since then. In addition to the tax, a fraction of which is returned to hospitals, his administration has cut funds hospitals had received for caring for uninsured and underinsured patients.

The Malloy administration has argued that hospitals will actually come out ahead, since they’ll see more patients with coverage because of Obamacare, and because overall spending on hospital care for Medicaid patients has increased in recent years. But hospital officials say treating more Medicaid patients hasn’t offset the funding loss, in part because Medicaid tends to pay less than the cost of care, and that Connecticut’s uninsured rate was already so low before Obamacare that the coverage expansion hasn’t produced a drop in the level of charity care they provide.

Malloy says hospitals occupy a lot of his time. “What their margins are is very important to us,” he said. “We know that we have hospitals that are experiencing difficulties.”

His administration was involved in the lengthy attempt to come up with a solution for Waterbury, which has two competing hospitals, one of which was on the brink of collapse. Waterbury became the focal point for a change in state law, passed this year, that cleared the way for hospitals to become for-profit. (Malloy vetoed a more narrow measure in 2013 that would have allowed Waterbury Hospital to be acquired by a for-profit company.)

Malloy said he prefers for hospitals to be operated as nonprofits, but said if the choice is between going out of business or being acquired by a for-profit company, the latter is the better option. Connecticut won’t be isolated from the national trend toward hospital consolidation or affiliation into larger groups, Malloy said, predicting that while the state won’t end up with just one hospital system, it won’t have 20 independent hospitals either.

A developmental disabilities issue society didn’t see coming

Hundreds of people came to the Capitol earlier this year to register their deep worries about a problem they say the state has been failing to address: How to provide services to adults with developmental disabilities whose parents or other caregivers are becoming too old.

The two-year budget Malloy and legislators adopted last year cut close to $30 million from the state Department of Developmental Services. And advocates say that cut, on top of years of underfunding, has left the department unable to provide residential services to hundreds of people with developmental disabilities, unless they’re in emergency situations.

That’s left families worried that adults with developmental disabilities won’t get help with housing until their parents die, forcing them to experience the dual trauma of losing a parent and a home at once. (Lawmakers added back some funding this year for residential services, but it doesn’t make up for the full cut or address the full housing needs.)

Malloy said he’s been working on the issue. “I’m not sure that society, including government, saw that one coming,” he said.

“It’s not a system that’s going to be built overnight,” he added. “But it is a system that we’re very much looking at, and what are less expensive alternatives to that? Is someone else providing in-home care, or is there less expensive congregate or group operation that meets the needs of that audience?”

“It’s not intractable, but it’s a very difficult issue,” he said.

Mental health: Connected to housing policy

In the wake of the Newtown shootings, policymakers and the public devoted increased attention to mental health. Some advocates for people with mental illness, while pleased the topic was getting attention, nonetheless worried it could lead to policies based on an inaccurate link between mental illness and violence.

Malloy drew praise from advocates when, three days after the Newtown shootings, he pushed back against a suggestion that the state had failed by closing mental-health facilities. Malloy countered that group homes or other community placements are better than institutions in assuring positive outcomes for people with mental illness, drug addiction or other maladies. The governor also said people must recognize that most people with mental illness recover.

The topic isn’t new to him.

“I’m a guy who’s worked on mental health issues for a long period of time, been affected by mental health issues,” he said recently. One of Malloy’s sons has dealt with mental illness, although the governor rarely mentions it publicly.

Malloy says the state has made progress on mental health issues. He cited legislation and programs aimed at training people in schools to recognize mental health problems in children or faculty, and the expansion of insurance coverage that means more people can access care. He has also spoken of the need to reduce a stigma that keeps people from seeking treatment.

More recently, Malloy made a point to emphasize his opposition to expanding institutional care, a pointed contrast with Foley, who says society has gone too far in closing institutions and that most people with serious mental illness need to be medicated and in a long-term institutional environment.

Malloy instead pointed to his housing policy, which he said is closely linked with mental health issues. Malloy said it makes sense to create housing with built-in services.

“Congregate housing, particularly with respect to an aging and mentally challenged population, is mental health and it’s housing, and it’s less expensive than the alternative,” Malloy said. “It crosses all those things, and at least in me you have a guy who understands the interrelatedness of those things.”

Alicia Woodsby, executive director of the Partnership for Strong Communities, which advocates for affordable housing and ending homelessness, said previous governors have also recognized that permanent, supportive housing for people who have been chronically homeless is effective and saves money.

“I think the difference is that the Malloy administration has been exceptionally committed to the issue and has dedicated new rounds of permanent supportive housing development and also scattered-site permanent supportive housing,” she said.

Malloy has not drawn the same praise from those concerned about funding for mental health services. Last year, his administration proposed significant cuts to state grants for mental health and substance abuse treatment, arguing that the providers would be able to make up the money because more patients would be insured under Obamacare and providers would be able to bill their insurance.

But the state Department of Mental Health and Addiction Services delayed implementing the cuts because of concerns about whether providers could withstand them. The agency later determined that the administration’s assumptions weren’t being realized and that some providers could be left with major shortfalls. Legislators and the administration restored some of the funding earlier this year.

Skeptical about outpatient commitment

After the Newtown shootings, some lawmakers and others sought to re-open discussions about allowing court-ordered treatment, under certain circumstances, for people with serious mental illness who are not hospitalized. Nearly every other state has a law allowing the practice — often called outpatient commitment or assisted outpatient treatment — but in Connecticut, mental health officials and advocates have long argued it would be counterproductive.

Malloy expressed skepticism about the idea.

He said people can legitimately choose to not treat a mental illness or not take medications that have side effects they find egregious, as long as they don’t become a risk to someone else. And if someone is a danger, there are already laws that allow that person to be temporarily committed, he said.

“What I think should probably answer that is what do the professionals say?” Malloy said. “What do the psychiatrists or psychologists who are treating that person say is necessary?”

Insurance: Doing “things that are real”
Aetna headquarters in Hartford

Aetna

Aetna’s Hartford headquarters

Connecticut governors have to navigate a sometimes tricky balance: an insurance industry responsible for more than 60,000 jobs in the state and a legislature with a propensity for passing measures that health insurers don’t like.

Some of Malloy’s decisions have drawn charges that he’s too cozy with the insurance industry. Senate Minority Leader John McKinney, when seeking the Republican nomination for governor earlier this year, called Malloy a “puppet” of the industry. Malloy has also faced criticism from some on the left.

“You want to protect the jobs, but we side with the consumer,” Malloy said. “So things that are real and will advance a cause, we do.”

“When it comes to health,” he added, “I’m not sure you’re going to find too many things where I didn’t side with the consumer, if anything, quite frankly.”

Critics point to two vetoes. In 2011, he vetoed a measure that would have made it easier for the healthcare advocate or attorney general to compel public forums on proposed health insurance rate hikes. As a compromise, his insurance commissioner agreed to hold up to four public hearings per year on proposals to raise rates by at least 15 percent.

This year, Malloy vetoed a measure that would have required insurers to report information about the substance abuse treatment they covered and their networks of mental health and substance abuse treatment providers. The Connecticut Insurance Department, the state’s health insurance exchange and the insurance industry raised concerns about the bill.

Malloy said the bill “might have merit if it was properly drafted,” and said there was time to get it right because the bill wouldn’t have required reporting by insurers until 2016.

Assisted suicide: Conflicted
A divided audience intently listened to public testimony at a hearing on an "aid in dying" -- or, to opponents, "assisted suicide" -- bill earlier this year.

CT Mirror

A divided audience intently listened to public testimony at a hearing on an “aid in dying” — or, to opponents, “assisted suicide” — bill earlier this year.

Malloy is conflicted about whether people with terminal illnesses should be allowed to get a physician’s help to end their lives, a controversial issue that has been the subject of intense advocacy in the legislature.

“I don’t think we should unreasonably prolong life, and I do believe that people have a right to participate in that decision,” he said. “I don’t believe in the death penalty, executed by a governmental entity, and I’m not sure who we leave it up to to make the decision on an individual case-by-case, disease-by-disease basis. So trying to find the right balance is important.”

Malloy said he’s pledged to talk to people on both sides.

He said he’s very comfortable with people being able to give orders for their care, such as those allowed under a measure he signed this year creating a pilot program for people with terminal illness to document their wishes for end-of-life care as medical orders — a format that doctors say has more weight than advance directives.

But what about allowing people to seek intervention to end their lives? When asked, he didn’t say.

“I don’t have a perfect answer,” he said.

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