Unpredictable events and outside trends shaped Malloy’s health care policy
The last in an occasional series examining the legacy of the administration of Gov. Dannel P. Malloy and the challenges awaiting his successor, Ned Lamont.
Looking back, the eight years of health policy under Gov. Dannel P. Malloy’s administration resembles an obstacle course.
Many of the Malloy administration’s health care policies and budget decisions were reactions to events outside of the governor’s control, circumstances that took hold before he took office, or conditions handed down from the federal government.
His legacy in health policy, and the challenges Gov.-elect Ned Lamont will soon inherit, can be assessed in terms of Malloy’s handling of these challenges.
The outgoing governor’s two terms nearly dovetailed with the rollout of the Affordable Care Act, the federal health care law that expanded insurance coverage to millions of Americans and boosted federal funds for health care programs.
Connecticut’s early decision to expand Medicaid under Obamacare to more than 200,000 poor adults has had a positive effect on that population’s health, the state’s uninsured rate, and the program’s per-person costs.
But it also created a new set of regulations and funding mechanisms for Connecticut to navigate, and Malloy’s enthusiastic embrace of the law’s federal funding provisions often put him at odds with providers.
Malloy inherited a state in fiscal disarray, making his promise to maintain the state’s social safety net hard to keep as tackling a daunting budget deficit became the priority. And while he may have prevented some fiscal pain for future generations, social services and health spending were sometimes victims in his fight against the state’s budget demons.
The Malloy years also coincided with a dizzying rise in the numbers of people addicted to opioids — both prescribed drugs, like Oxycontin, and illegal drugs, like the deadly heroin mix-in fentanyl — in an epidemic that doesn’t seem to be slowing.
And, a year into Malloy’s first term, the shooting that killed 20 young children and six adults at Sandy Hook Elementary School pushed the state’s mental health delivery system into sharp focus, forcing a reconciliation with how the system failed to prevent that shooting and what needed to be fixed.
Medicaid expansion, a vulnerable safety net
Malloy came into office as Connecticut undertook an ambitious effort to bring thousands of people into the state’s Medicaid pool, making it one of the first in the country to voluntarily expand Medicaid coverage after the passage of the Affordable Care Act.
The expansion, enacted under Gov. M. Jodi Rell in 2010, meant more than 200,000 adults without minor children were able to enroll in Medicaid and access health insurance for the first time.
As a candidate and then throughout his years as governor, Malloy pledged to support the social safety net that came with the expansion.
And he honored that promise for the most part, advocates said.
While other states made severe cuts to their Medicaid programs, HUSKY grew dramatically, from covering around 457,529 people in June 2010 to more than 800,000 people today — about one in five Connecticut residents.
Under Malloy, the Department of Social Services (DSS) has prioritized getting Medicaid-insured residents primary care providers, supporting intensive care management programs for those with high needs, and delivering long-term care in people’s homes or communities rather than in nursing homes.
Malloy also altered the Medicaid system in 2012 by dispensing with the companies handling the state’s Medicaid benefits and switching to a system where the state pays hospitals and doctors directly.
That system, an unusual way to manage a state Medicaid program, explains how per-person spending has consistently dropped, making Connecticut one of the few states in the nation to bring down its Medicaid spending, said Roderick Bremby, the commissioner of DSS.
“What most states will tell you is Medicaid is driving more of the budget,” he said. “In Connecticut, it’s not the case.”
Malloy took office as one of the key components of the Affordable Care Act, the state-level, private insurance marketplace known in Connecticut as Access Health CT, was still in its formative days.
“It was a learning experience for all of us — how do you get this out, and what do you do?” said Lt. Gov. Nancy Wyman, who oversaw much of the administration’s health policy work.
Wyman praised the setup of the exchange, which the administration called the “most successful state-sponsored health insurance exchange” in a recent retrospective report, as a bipartisan effort.
“We worked with both sides of the aisle in our state,” she said.
In more recent years, Malloy was a vocal defender of the ACA against repeated efforts by a Republican Congress and the Trump administration in Washington to tear it down.
While GOP efforts to repeal the ACA haven’t been successful, Malloy and Barnes have consistently faced down threats that the federal government would limit federal Medicaid spending or allow states to install a work requirement for Medicaid recipients.
“He worked very diligently to implement the Affordable Care Act to meet the needs of Connecticut,” said Patricia Baker, president and CEO of the nonprofit Connecticut Health Foundation.
But faced with a slow-boiling fiscal crisis and a historic deficit, the state government needed to make cuts wherever it could, which meant that leaving the social safety net untouched was not an option.
Critics suggested that health-related spending was often the first thing on Malloy’s chopping block.
At the same time Connecticut expanded Medicaid coverage to cover more childless adults, for example, Malloy moved to tighten the income eligibility threshold for Medicaid’s HUSKY A, program for parents with minor children. That proposal would have moved more than 35,000 people off Medicaid and onto subsidized private insurance plans from the Obamacare health exchange
Although the legislature rejected that 2013 proposal, three years later it changed direction and approved rolling back eligibility guidelines for HUSKY A, forcing an estimated 23,700 people off Medicaid. An attempt to further tighten the income eligibility for the Medicaid program was rebuffed by the legislature last spring.
While those cuts may have saved money in the state budget in the short run, Baker said it could make caring for those people more expensive in the long run.
“When they show up for care, it’s more acute and the health outcomes are worse,” Baker said. “I understood why he might propose it, but I don’t think in the long run it’s a wise policy.”
Malloy later fought with lawmakers on another proposed cut to state spending on health care, which would have reduced the population eligible for a program that uses Medicaid money to help Medicare enrollees pay medical expenses that Medicare doesn’t cover.
The legislature reversed that change, a decision that heartened seniors worried about their Medicare costs but that the administration saw as an irresponsible delay of needed cuts.
Support for the state and nonprofit agencies that handle the basic health needs of the state’s most marginalized residents became a perennial fight for advocates like Heather Gates, who has been the president of the mental health organization Community Health Resources for more than two decades.
Gates gave Malloy high marks for his commitment to improving housing stock for the mentally ill and incorporating mental health services into primary care despite those budgetary challenges.
“Malloy took office when the state was heading into its worst fiscal challenges in quite some time,” Gates said. “I think we were fortunate that he had experience running government. He’s smart … he has good policy sense,” she said.
But cuts to the multiple agencies that provide or support health care — from the Department of Children and Families to the prisons to the Department of Mental Health and Addiction Services — were frustrating, she said.
“What has been much more disappointing in a very significant way is for five years in a row, the … governor proposed very, very significant cuts and reductions, said Gates, referring to funding for behavioral health services. “I’ve never quite experienced in my career a period of time that has been so challenging financially … with the funding support for services for the most needy being under attack.”
Malloy’s 2016 cuts hit across the health care system, touching Medicaid, substance abuse, domestic violence shelters, nutrition assistance and mental health care particularly hard. So did the emergency cuts he made by executive order last year after a month without a 2017-2018 budget.
And the cuts had tangible results, Gates said. CHR reduced staff and closed one of its intensive housing and residential programs as a result of budget cuts.
“They were substantial, and they were real,” she said.
In the aftermath of the deadly shooting at Sandy Hook Elementary School in Newtown, and with an addiction crisis taking lives across the state, the cuts to behavioral health services were hard to swallow, said Patricia Rehmer, who led the Department of Mental Health and Addiction Services (DMHAS) from 2009 to 2015.
But, she conceded, those services made up a large chunk of the state budget and were an understandable place to look when the numbers weren’t adding up.
“In government, when you’re running a state agency, especially in human services, where do you cut?” Rehmer asked. “There’s no good place to cut.”
New priorities after Sandy Hook
The Sandy Hook shooting in 2012 forced the state to reckon with children’s behavioral and mental health services on several levels.
In the weeks after the shooting, the administration reversed its plans to cut more than $7 million in funding from mental health and addiction programs that had been approved the previous fiscal year.
Malloy and Wyman prioritized behavioral health over the following years, supporting the expansion of programs that serve people with serious mental illnesses and a system for pediatricians to consult by phone with child psychiatrists. New laws also changed how insurance companies cover mental health services.
“With the help of the lieutenant governor, [Malloy] always saw behavioral health as really a part of overall health,” said Rehmer. “He made sure that I had a seat at the table when they were talking about health care reform.”
Rehmer said she remembers speculation in the days after [Sandy Hook] that the closing of a nearby state hospital might have contributed to the circumstances around the shooting.
Malloy’s insistence that institutionalizing those with mental illness isn’t the answer was a relief, she said.
“Governor Malloy was great in terms of saying, ‘people deserve to live in the community, we don’t want to keep people institutionalized,’” she said.
Instead, Malloy doubled down on crafting housing policy to better serve those with mental health issues, like supportive group homes.
Gates, the Community Health Resources president, said while that work made a difference, the state still needs to bolster and improve access to the underlying mental health system. She said Medicaid rates still don’t adequately reimburse providers for behavioral health services, for example.
“Those that were in the administration when (the shooting) happened were deeply affected by it, and took efforts to improve services very seriously,” she said. “I don’t think there’s been enough attention paid to the behavioral health system for kids across the board, though.”
The new limits on gun ownership that the Malloy administration fought to get passed in the months after the shooting had their own public health implications, said Jeremy Stein, the executive director of CT Against Gun Violence.
“I think the reality was that it was a response to a horrific act,” Stein said. “Whether you call it public health or public safety, I think it’s just two sides of the same coin.
Stein said he hopes Lamont will go further, as the public safety committee for the governor-elect’s transition team has recommended.
Fighting the opioid epidemic
Another event outside of Malloy’s control was the opioid epidemic. Deaths from drug overdoses nearly tripled over six years of Malloy’s time in office, from 357 in 2012 to 1,038 in 2017.
Fentanyl now drives the state’s drug epidemic; of those 1,038 deaths, 677 involved the synthetic opioid drug, which is 30 to 50 times more powerful than heroin.
Using a combination of local, state and federal resources, Connecticut has pushed prevention education and medication-assisted treatment.
Those and other efforts — like expanding access to the drug overdose reversal drug naloxone, restrictions on the prescribing of prescription opioids, and a program connecting recovery coaches to people in emergency rooms — earned Connecticut a ‘B’ grade from the National Safety Council when it evaluated what states are doing to protect their residents from opioid overdoses.
In 2016, Malloy convened experts from Yale Schools of Medicine and Public Health to create a three-year planto address opioid overdoses in the state, while a statewide public awareness campaign, Change the Script, pushes messages related to addiction prevention, treatment, and recovery.
Wyman said that strengthening opioid prescribing laws was another important tool in the state’s fight against opioid addiction.
Malloy pushed for new laws limiting initial opioid prescriptions for acute pain in most cases and that helped prescribers identify patients who might be misusing drugs. Opioid prescriptions dropped from just over 2.6 million in 2015 to almost 2.2 million in 2017, according to state data.
But that hasn’t made the situation the Lamont administration will inherit any less of a crisis: 2017 data from the Centers for Disease Control and Prevention showed that Connecticut’s increase in overdose deaths that year was around 10 percent, the second highest increase in New England.
Reversing his predecessor’s stance against medical marijuana, Malloy favored making Connecticut the 17th state to legalize it for the chronically ill.
Five years after Rell vetoed a medical marijuana bill approved by the legislature, Malloy supported and signed legislation allowing patients with debilitating diseases like cancer, Parkinson’s, and post-traumatic stress disorder to buy it. The law also created a licensing process for dispensaries and growers.
While potential patients and medical marijuana advocates cheered the program and its later expansion, the medical community was skeptical, said Matthew Katz, CEO of the Connecticut State Medical Society.
“The problem was that there was no evidence that it was medically effective — there was no research,” Katz said.
But the program has proven popular. Under the oversight of the Department of Consumer Protection and a board of medical professionals it has expanded to cover more than 30,500 registered patients with one of 31 approved conditions.
A new way of doing business
Recently, the Malloy administration focused on one way to simplify the health care system in Connecticut.
In February he chose Wyman to oversee the consolidation of a the complex web of agencies, regulations and funding mechanisms that influence health care with the creation of a new entity, the Office of Health Strategy.
The new office, led by former Healthcare Advocate Victoria Veltri, brings together three programs: the federal grant-funded State Innovation Model, the Office of Health Information Technology and the Office of Health Care Access.
The new office serves as an umbrella organization for all health policy, including collecting and using health data, managing federal grant money, developing ways to keep down costs like the price of prescription drugs, and supporting a long-delayed effort to create a state system for sharing health records electronically between practices, Wyman said.
As independent hospitals consolidate into massive health care systems, insurance companies adapt to protect their bottom lines, new public health threats emerge, federal health care laws remain in flux, and racial and socioeconomic discrepancies in health care access become more clear, Wyman said the office will be a crucial part of the state’s health landscape for years to come.
“Health care is just changing by the minute,” Wyman said. “We needed an office that could really react to those changes quickly.”
That changing environment, alongside the chronic issues plaguing the state’s health systems, will pose a daunting challenge to Malloy’s successor. Lamont, through his spokesperson, declined to comment for this article.
At a meeting of the committee of health experts advising Lamont’s transition team in December, Dr. M. Saud Anwar, the mayor of South Windsor and the chair of the internal medicine department at Manchester Memorial and Rockville General Hospitals, summarized the wide array of stubborn health policy hurdles facing the state’s leaders.
“If someone could fix this,” he said, “you’d get a Nobel prize.”
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