Tom Marsh draws from personal experience when he talks about health care.
The Republican-turned-Independent Party candidate for governor speaks of having no health insurance just two months before his wife was diagnosed with breast cancer, giving him an understanding of the pitfalls faced by people who can’t afford insurance.
He recalls caring for his parents and mother-in-law at home at the end of their lives, experiences that fuel a goal of making it easier to keep seniors out of institutional care.
And he speaks of the challenges of finding health insurance when he started a small business and says that, despite his tendency to favor less government, he would consider funding a public health insurance option if state residents want it.
If Marsh’s opponents, Republican Tom Foley and Democrat Dan Malloy, occupy two ends of a spectrum in their health care views, Marsh falls toward the side of his fellow Republican, if a bit closer to the center.
Marsh, the first selectman of Chester, supports incentives to get people on public insurance programs to make behavioral changes like quitting smoking and wants to make it easier for seniors remain at home. They’re the right things to do, he says, and they can also save the state money.
But Marsh acknowledges that the savings won’t come immediately, and the state’s massive budget deficit will likely mean making choices in health and social service spending.
Marsh would not cite specific items to cut or consolidate, saying that, “in the realm of social services, everything seems important.” But he said some state programs are “wants” more than needs, and said he would give lower priority to those that focus on workplace or societal rights and special interest advocacy.
He also has faith that some money-saving changes, like getting people to take a more proactive approach to their health, can pay off quickly. And he said the state must begin to make more long-term changes that pay off later.
“The other option of continuing what we’re doing now and just doing it with less money, it doesn’t work,” Marsh said. “And we don’t have any more money.”
Crisis to Intervention
Marsh speaks frequently about changing the way government works, making it function better, not just on more or less money.
In health care, the country has a “sick care system, not a health care system,” he says. Changing that means moving from crisis to intervention, treating problems before they become worse and more costly.
A big part of that shift, Marsh believes, is focusing on wellness.
Marsh wants to offer wellness training to people on state programs, and supports requiring people receiving state assistance to take classes – on topics that could include nutrition, lifestyle management, parenting skills or how to create a resume. He also favors financial incentives for people to make behavioral changes.
“Why not get people together and say, you know what, if you stop smoking, we’re probably going to save a whole lot of money later on, so here’s the program, and we’re going to pay you $50, $100,” he said. “And if you complete the cessation program, you’re going to be rewarded for that.”
Marsh acknowledged that wellness efforts are not likely to produce immediate savings, although he believes they will ultimately pay off.
Rigorous research on wellness programs has been limited, although the experiences of some employers have suggested that the programs could save money over time. Much of the research focuses on companies and voluntary programs, which could be difficult to generalize to a broader population or for required programs.
Marsh believes the state could test wellness approaches through focused pilot programs, which he calls “charter agencies.” The idea would be to identify an outcome, pursue it with more leeway to avoid red tape than state agencies typically have, then expand or reduce the program based on how it turns out.
Marsh would also consider reimbursing preventive care at higher rates, giving providers incentives to accept patients with public insurance. Many providers do not accept Medicaid because of the relatively low rates it pays, although even people with higher-paying commercial insurance can struggle to find primary-care providers to treat them, part of a shortage of providers that is expected to get worse.
When talking about making budget choices, Marsh points to Oregon, where the amount of services covered by Medicaid can fluctuate.
Oregon uses a prioritized list of health services to cover its Medicaid recipients, and the legislature can decide how much of the list to include in the budget, although changes must be approved by the federal government.
Even without a list, Connecticut will need to start prioritizing its services if money is limited, Marsh said.
“To me, you look at your children and your elderly first to make sure that they’re well covered, and then in the middle, you start looking at how can we best spend the money,” he said.
Marsh suggested flexibility with cuts – if the state can’t cover all dental work for adults, for example, what about one annual check-up?
“All of that stuff has to be on the table,” he said. “We have to have basic health care for our most needy and then have a discussion once we take care of that population, who comes next, and then what comes next for those services.”
Aging at Home
One way to save money, Marsh believes, is to shift the way long-term care is provided from institutional care to care based at home or in the community. Marsh’s motives are not just financial.
Over about a decade, Marsh’s parents and his wife’s mother lived at the Marshs’ home before they died. Marsh observed changes in the long-term care industry, and said he was struck by the difficulty of arranging for home care, even though doing so cost less than a nursing home.
“I just thought, who wants to be sitting in the nursing home and why is it so difficult to have competent care, or at least assistance if you’re trying to do what we thought was the right thing anyway and keep them at home?” he said.
Marsh wants to make it easier for people to choose to stay at home as they age, a concept called “aging in place.”
Long-term care is a major piece of the state budget – the state is budgeted to spend $1.3 billion in Medicaid funds for nursing homes this fiscal year, although at least half gets reimbursed by the federal government.
Just over half of the state residents whose long-term care is covered by Medicaid receive care at home or through community-based services. The state’s Long-Term Care Plan calls for increasing that to 75 percent by 2025, a move that one study suggests could save up to $900 million a year.
Marsh said he would begin tackling the issue during the first week of the next legislative session.
“What we as a state need to do is to say, ‘the default should go to how can we keep you at home as long as possible, not how can we get you out of your house as soon as possible?'” he said.
Getting there would likely require other actions, such as making sure there are enough workers trained in the appropriate skills to keep up with the demand, Marsh said.
Researchers have noted other challenges. To receive Medicaid funding for home and community-based services, people must fit into one of the state’s many waivers or pilot programs, which are narrowly defined. The governance structure for long-term care in the state is fractured between multiple state departments and agencies, and it can be difficult for consumers to learn even basic information about their options.
Saving on Coverage
To save money, Marsh would also seek to change the way state employees’ health care coverage is managed, using a model from Chester. The town, which provides health insurance to 15 employees, uses a high-deductible health plan and pays the deductible for its workers. The model, referred to as a health reimbursement account, saves money because having a higher deductible comes with lower premiums, Marsh said.
Marsh believes it could be expanded to state employees as part of negotiations for the next labor agreement. The current one runs out in 2017.
But Matt O’Connor, a spokesman for the State Employees Bargaining Agent Coalition, said that model would not be better than what state employees have now. Unionized workers with similar plans have not found them to be better for their families, he said.
O’Connor said it could also be difficult to translate something that works for Chester’s 15 employees to the state’s health insurance plan, which covers about 200,000 workers, retirees and their dependents.
It would be a simplistic analysis, he said, “to say, ‘well, if it works in Chester, it will work for the whole state’s workforce.”
Marsh sees virtue in the state offering a viable way for people to get health insurance, something that could take place through the SustiNet plan. SustiNet grew out of an effort to establish universal health care coverage in the state with a public option. The version that ultimately became law was scaled-back, and its future is not clear, although a board is developing a health plan that supporters hope will be offered to state workers, Medicaid recipients and the public.
“From a default level, I like less government,” he said. “But good government comes from providing what constituency wants and doing it while providing them a good value. So if the state as a whole felt that it was a worthwhile investment to provide for the common good, that we were going to buy down the rates on things like that, I’m OK with that. I’m not OK with saying we have to subsidize it because we don’t do it very well.”