Following the recent approval of double-digit rate increases for fully insured health plans, pressure is mounting on lawmakers to tackle the escalating cost of health care, to expand access to health care and to address other health-related priorities in the upcoming legislative session.
Beginning Jan. 4, legislators will gather for a long session that runs through early June. Some familiar issues are expected to resurface, such as a proposed ban on flavored tobacco products, a measure that would allow physicians to prescribe a lethal dose of medication to terminally ill patients, and an expansion of Medicaid to residents regardless of their immigration status.
There will also be new ideas for tackling the rising costs of health care, addressing the opioid epidemic and bolstering the health care workforce.
“If we want people to have access to health care, it needs to be available and affordable,” said Rep. Cristin McCarthy Vahey, D-Fairfield, who was recently appointed co-chair of the legislature’s Public Health Committee. “We’ve had a bumpy ride in public health over the last couple of years. My goal is to help us to continue to rebuild, recover, prepare and bring folks together.”
In July, insurance carriers asked for an average rate hike of 20% on fully insured, individual health plans, drawing sharp criticism and outrage from consumers and advocates. The state approved an average increase of 13%.
Insurers also asked for a 15% average increase on small group plans; the state approved 8%.
Lawmakers and residents have expressed a need for reform.
Rep. Kerry Wood, D-Rocky Hill, a co-chair of the Insurance and Real Estate Committee, said during a forum this month that members of her committee have been gathering “some of the brightest and best in Connecticut” to convene discussions about the drivers of health care costs.
“We’ve taken a step back on just putting forward legislation [to] really understand the costs that go into care,” she said. “I think it’s worth the time to dive into that, and you have my commitment … that that will be a priority in the next year. When we pass legislation, we want to pass something that’s effective and that does make the proper change.”
Here are some of the top health care issues up for debate this legislative session.
Health care workforce
Recruitment and retention of health care workers across multiple practices, from acute care hospitals to nursing homes, is expected to be a focus in the coming months.
“The pandemic has had an impact on our society on multiple levels, but the impact on the health care system has been the most significant,” said Sen. Saud Anwar, D-South Windsor, a co-chair of the Public Health Committee. “The people providing health care to patients, the pressure and the stress has been most significant to them. And the nursing staff, the [certified nursing aides], the physicians — they have not been getting the appropriate level of support based on the lack of payment reform. That is resulting in people moving away from it.”
The Governor’s Workforce Council estimated the state’s annual workforce demand in health care topped 7,000, “with significant shortages in nursing, certified nursing assistants, skilled technician roles and long-term and home health care.” But since the start of the pandemic, the number of people employed in Connecticut’s education and health services sector has declined by 14,500.
Nationally, nearly 20% of health care workers left their jobs during the pandemic, and a third of those remaining said they have thought about quitting, according to a survey by Morning Consult, a marketing research firm. The health care worker shortage has left many states scrambling.
Even before the pandemic, the workforce faced challenges. In 2019, the U.S. had nearly 20,000 fewer doctors than needed to meet the country’s needs, according to an estimate by the Association of American Medical Colleges.
The situation in the long-term sector care has been dire. From February 2020 to March 2022, the industry lost 406,200 jobs, including 241,000 in nursing homes (15.2% of its workforce), data from the Bureau of Labor Statistics show. Advocates say the sector is facing a 15-year labor low.
“The labor shortage is so severe within the long term care industry that many facilities have been forced to limit the admission of new residents or close altogether,” officials with the American Health Care Association and National Center for Assisted Living have said.
Anwar envisions legislation that would provide incentives for people to undergo training at Connecticut’s colleges and universities and further incentives for them to stay in the state and join the health care workforce.
“The inpatient detox units and the behavioral health units, they don’t have enough staffing,” he said. “We also don’t have enough physicians in primary care. There are not enough trained internal medicine and family practice doctors in our state. And we’re losing specialists.”
Aid in dying
Supporters of a bill that would allow terminally ill patients to access lethal drugs are pressing to revive the proposal again this year. The measure has come up several times over the last decade, and during the past two years, it has been voted out of the Public Health Committee, most recently with bipartisan support. But it has never received a vote on House or Senate floor, and it has run into trouble while being debated in the Judiciary Committee.
To qualify for access to life-ending medication under the most recent proposal, patients with a terminal illness must submit two written requests to their attending physician, the second at least 15 days after the first. Each written request has to be witnessed by two people who are not immediate family members or entitled to a portion of an estate at the time of a person’s death.
Aid in dying is legal in Oregon, Washington state, Montana, Vermont, California, Colorado, Hawaii, New Jersey, Maine, New Mexico and the District of Columbia. The legislation has been raised more than a dozen times in Connecticut.
“I knew coming in as co-chair that the conversation about aid in dying would be one that is important to continue,” McCarthy Vahey said. “Many, many not just committee members but also constituents from around the state are interested in seeing that conversation continue and what kind of progress we can make in that area.”
“I have had heartbreaking conversations with families whose loved ones have waited, and people who lost their loved ones [while] waiting” for the bill to pass, Anwar added. “It is sad that we have failed so many people who would have made that choice. And it’s important for us to at least take care of the ones we can help at this point.”
In 2021, the General Assembly approved an expansion of Medicaid, known as HUSKY in Connecticut, to include children 8 and younger regardless of their immigration status (as long as their family meets the qualifying household income). A year later, lawmakers voted to expand that group to all children 12 and younger.
But some advocates have argued that the program should be open to everyone 18 and younger. Others say it should be open to those 26 and younger, since that’s the cutoff under the Affordable Care Act for children and young adults to remain on their parents’ insurance. And still others have pressed for all residents to have access, regardless of age and immigration status.
“We’re recommitting to the fight, because health care is a human right. No one should be denied health care — a chance at survival — because of their immigration status, no matter their age,” Carolina Bortolleto, a volunteer with the HUSKY for Immigrants Coalition and a co-founder of Connecticut Students for a Dream, has said.
Rep. Jillian Gilchrest, D-West Hartford, a new co-chair of the Human Services Committee, said the proposal will likely come up again this year, though it’s not clear what the new age range might be.
“There is a lot of momentum behind that policy to either bring it up to age 18 or to even expand it to age 26,” she said. “I do think there’s a recognition that it needs to be done incrementally for cost purposes, even though many of us think all individuals should be eligible for health care.
“Personally, I believe everyone, regardless of immigration status, should be eligible for Medicaid. In the role of chair, I’m going to be looking at … a lot of competing interests. And so if we need to continue doing it incrementally, my hope is, we will continue to do that. I want to go in the direction of ensuring the greatest number of people have access to health care.”
Rising health care costs
Several legislators have acknowledged that the ballooning cost of health care must be examined and legislation to provide relief must be addressed. Lawmakers and state officials have said they are looking at hospital and pharmaceutical expenses in particular, but no specifics have emerged yet on how they plan to lower costs.
For the last two years, Gov. Ned Lamont has unsuccessfully proposed capping annual increases in the cost of prescription drugs at a rate of inflation plus 2%. His most recent proposal would also have authorized the state Department of Consumer Protection to oversee the importation of lower-cost drugs from Canada.
Legislators have not ruled out taking another look at those measures.
“There’s still a lot of appetite out there, politically, for Canadian pharmaceuticals,” said Sen. Matthew Lesser, D-Middletown, a new co-chair of the Human Services committee who was most recently a co-chair of the insurance committee. “I think we’re going to see a bunch of different approaches. The bottom line is, drug prices are a leading — if not the largest — reason why health care costs are skyrocketing.”
Some lawmakers have recommended exploring regulation of hospital prices. Mandatory hospital rate setting systems were popular in the 1970s and 1980s, with evidence suggesting they slowed growth in expenses per day and per admission during that time, according to the Kaiser Family Foundation.
One state, Maryland, currently regulates hospital costs. Maryland added a global budget provision to its long-standing hospital payment system in 2014. Under that provision, each hospital in Maryland receives a fixed budget based on historical spending and forecasted changes in use, among other factors, Kaiser reported.
“Maybe we should open the door to a regulation of hospital prices,” Lesser said. “I think there’s a lot we can do there.”
Seven states have prescription drug affordability boards — independent panels charged with analyzing the cost of medications and recommending ways to lower spending. Some legislators have suggested considering that in Connecticut.
And following the approval of double-digit rate hikes for individual health plans this year, advocates have called on the state to change its policy so that consumer affordability is a factor when deciding whether to sign off on rate increases.
“I hear from the same nonprofits and small businesses in my district who struggle each and every year to offer essential health care benefits to employees,” Rep. Kate Farrar, D-West Hartford, said at a hearing in August. “I would encourage that we use a consumer affordability measure as a central element of the insurance department’s rate review process.”
Efforts to pass legislation that would prohibit the sale of flavored tobacco or flavored vaping products have failed three years in a row in Connecticut. But proponents and legislators say it will probably be an issue again this session.
The 2022 bill would have banned the sale of flavored vaping products, but earlier proposals, like the 2021 measure, would have outlawed the sale of flavored cigarettes, tobacco products and e-cigarettes. Committee leaders say they are not yet sure what version might be resurrected in 2023.
“The number of children in middle school and high school who are taking up [these products] remains high,” Anwar said. “We have to have a way to prevent this from happening. The on-ramp of nicotine addiction goes through flavored tobacco and flavored vapes. And that on-ramp will only be stopped if we intervene as a state [with] policy.”
Connecticut is one of few states in the region that has not adopted a prohibition on flavored e-cigarettes. New York, New Jersey and Rhode Island have barred the sale of flavored vaping products. Massachusetts banned all flavored tobacco items, including flavored cigars, cigarettes and vaping goods.
Republican lawmakers have expressed interest in again pursuing reinsurance, a program that would pick up a portion of residents’ health care costs rather than having insurance companies pay, which leads to lower premiums.
They also have suggested exploring a possible crackdown on “spread pricing” by pharmacy benefit managers. Spread pricing happens when pharmacy benefit managers charge health plans and payers more for a medication than what they reimburse to a pharmacy, and then pocket the difference.
A bill raised in 2022 would have required the state’s Office of Health Strategy to submit a report to the legislature that includes an analysis of pharmacy benefit manager practices “regarding spread pricing arrangements, manufacturing rebates and transparency and accountability.” The measure was not successful.
“We know that PBMs buy it at one price and then sell it to a pharmacist. … Well, now you have a middleman. What’s the markup? What does that middleman do?” Senate Minority Leader Kevin Kelly, R-Stratford, said. “And in large part, the middleman — the PBMs — are now owned by the insurance companies. So we need to look at that relationship, and does that add additional cost at no benefit.”
Anwar said he hopes to introduce a bill that would devote money to standing up overdose prevention centers in Connecticut, dedicated spaces where people can take pre-obtained drugs in controlled settings under the supervision of trained staff. Facility staff also provide referrals to social services, drug treatment programs and counseling, according to the Drug Policy Alliance. New York City recently opened two overdose prevention centers.
“This is a model that has worked,” Anwar said. “We need to create a similar setup in our state so we can save as many lives as possible and increase the likelihood of survivors going to rehab.”