State Health Care Advocate Ted Doolittle questions representatives of insurance companies at a public hearing on the request for double-digit rate hikes on 2023 health plans. Courtesy / CT-N

Small business owners struggling to afford health coverage for their employees, staffing problems in hospitals and nursing homes, and Medicaid for residents without permanent legal status.

These are among the top health care issues that advocates are calling on lawmakers to address in the legislative session that begins Wednesday. One of the most common priorities among advocates is affordable, accessible health insurance for individuals and businesses.

“There are things we are keeping an eagle eye on this session, and the highest priority for us is the expansion of coverage to immigrants, regardless of documentation,” said Lynne Ide, program lead for communications outreach and engagement at the Universal Health Care Foundation of Connecticut.

“Everyone needs health care,” said Carolina Bortolleto, a volunteer with the HUSKY for Immigrants Coalition and a co-founder of Connecticut Students for a Dream. “We’ll be fighting for health care for everyone.”

Nursing homes and hospitals are understaffed, and workers are experiencing burnout. In some hospitals, mandatory overtime is driving nurses out of the field, said Sherri Dayton, a registered nurse at the Plainfield Emergency Care Center, a standalone emergency department that is part of Backus Hospital.

“Every place is short staffed,” she said. “It’s exhausting. There’s no time to eat lunch, you barely get a chance to pee. Your feet are killing you by the end of the day.”

This year’s legislative session will run from January to June. Here are the key issues advocates hope lawmakers will take up.

HUSKY for all

The legislature in 2021 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 household meets the income qualifications). A year later, lawmakers voted to expand that group to all children 12 and younger.

With that momentum, advocates plan to call on lawmakers to expand the benefit to everyone in Connecticut, regardless of whether they have permanent legal status. Leaders of the legislature’s Human Services Committee, where past bills on the subject have originated, have already signaled they are supportive of debating the topic again this year.

“I think this year there’s more room to get things done,” Bortolleto said. “The momentum is on our side, and the long legislative session makes it better for us to get this issue in front of as many people as possible.”

A study by the RAND Corporation, a nonprofit think tank, found that expanding HUSKY to undocumented residents could reduce the cost of uncompensated care in Connecticut by $63 million to $72 million.

The state currently has a Medicaid program that covers emergency care for people who qualify based on income, regardless of immigration status. The cost of that program — about $15 million in 2021 — would “presumably be substantially reduced by the decrease in uninsurance among undocumented” residents, according to the study.

The study’s authors estimated the direct care cost of the HUSKY expansion to be $83 million for 2023.

In addition to the HUSKY for Immigrants Coalition and Universal Health Care Foundation of Connecticut, Health Equity Solutions, an organization that advocates for policies and programs resulting in equitable health care access, is calling for a HUSKY expansion this year.

Whether this year’s proposal will be drafted to include everyone regardless of immigration status, or extended to age 18 or 26 (the cutoff under the Affordable Care Act for young adults to remain on their parents’ insurance) is still being determined.

“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,” Rep. Jillian Gilchrest, D-West Hartford, a new co-chair of the Human Services Committee, told the CT Mirror. “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.”

Health care workforce

With hospitals, nursing homes and other health care facilities facing staffing problems, pressure is mounting for lawmakers to craft policies that offer relief.

“Staffing is bad. I think, hospital-wide, we have been hovering around a 30% to 35% vacancy rate. And we’ve been using a lot of [traveling nurses],” said Dayton.

On any given day, the nurse-to-patient ratio at her facility is one nurse to every six patients. Sometimes it is one nurse to every eight patients. A 4-1 ratio is safe and ideal in an emergency department, Dayton said.

Mandatory overtime is driving some nurses out of the industry. Connecticut law prohibits mandatory overtime for hospital nurses, except under certain scenarios, such as adverse weather conditions, widespread illness or catastrophe, public health emergencies, if a nurse is participating in a surgical procedure, or if a nurse is staffed in a critical care unit and has not been relieved by the worker on the next shift.

“They’re only supposed to do it during emergencies. However, they’ve been using the fact that we’re in a pandemic now for years,” Dayton said.

Some union contracts include a perk for mandatory overtime — double pay during those hours — and hospital administrators believe the contract language allows them to mandate overtime, despite what state law says, labor officials said.

“In some places, [overtime] is being mandated, because one of the carveouts is it’s covered in a collective bargaining agreement,” said John Brady, a retired registered nurse and vice president for AFT Connecticut. “They’re using that as a loophole for the law.”

Nurses at Dayton’s facility typically work 12-hour shifts, but some are mandated to work another four hours of overtime on top of that, she said.

“It’s one thing when you’re like, ‘OK, I have 12 hours of this.’ But then, with two hours to go before your shift is over and you’re mentally spent, you’re being told you have to stay for another four hours,” she said.

“These nurses are fatigued. And that’s when mistakes happen for anybody, because we’re human. We’re human beings. We require sleep and rest.”

Labor officials are calling on the General Assembly to address mandatory overtime by closing the loophole caused by some collective bargaining agreements. A bill expanding restrictions on hospitals’ ability to mandate overtime was voted out of the Public Health Committee last year but was not ultimately called in the House or Senate.

Mandated staffing ratios or required levels of staffing should also be addressed this year, Dayton said.

“Nobody goes into health care to do any harm. That is ingrained in us from day one of education — do no harm,” she said. “But for every patient that gets added on, the risk of a poor outcome for that patient goes up astronomically.”

California has mandated staffing ratios, and Dayton said she hopes Connecticut legislators look to that state when crafting a local law.

Labor leaders have also called for policies that promote recruitment and retention, such as student loan forgiveness.

“A lot of people are turned away from nursing school because there are not enough nurse educators to teach them,” Brady said. “If someone wants to become a nurse educator at one of our universities, they go back to school to get their master’s degree in nursing education, and they come out with student loans … and then the pay is no more than what they could make at the bedside. I know nurses who have started down that road and realized they just couldn’t take on that debt without some way of paying it off and being compensated.”

The staffing situation is also dire in the long-term care industry, both in nursing homes and home care. 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.

Lawmakers have indicated they are prepared to tackle the workforce in the coming session.

Elder care

In 2021, legislators voted to require a minimum of three direct care staffing hours in nursing homes (time that a nurse or certified nursing assistant spends directly with a resident per day).

Now, advocates are calling for enforcement of those new standards and penalties for those who flout the law.

Mairead Painter, the state’s long term care ombudswoman, is asking the General Assembly to draft a bill that would allow nursing homes to be fined if they fall below the minimum staffing level and to be fined if they misrepresent their staffing levels. She also has asked for nursing homes to be fined if administrators fail to post staffing levels as required.

Facilities that fall below the minimum staffing requirement should be closed to new admissions until they can provide adequate staffing, Painter said.

“If they can’t staff to a level where they can meet the care needs of individuals already in the home, we don’t feel they should be able to admit other individuals, which would just further impact that ability,” she said.

Painter recommended that lawmakers also raise the mandatory minimum hours of direct care to 4.1 this year. A bill that would have done that was introduced in 2021 but did not succeed.

“That’s been a national minimum recommendation for about 10 years,” Painter said. “We still see that as the gold standard.”

Nursing home officials have said that while they support the 4.1-hour minimum, challenges with recruitment and retention of workers make that goal exceedingly difficult. The state’s Office of Fiscal Analysis has also estimated such a standard would cost hundreds of millions of dollars.

Painter is also asking lawmakers to require skilled nursing facilities to provide plain-language summaries of their annual expenses and for the state’s Department of Social Services to post spreadsheets with each facility and a breakdown of their costs — measures meant to enhance transparency.

Mental health

Lawmakers passed sweeping legislation in 2022 that addressed children’s mental health, including license reciprocity for out-of-state providers, funding for school programs and the creation of a working group to study recruitment and retention strategies.

Advocates hope the General Assembly will consider bills this year that take broader aim at mental health resources for adults.

“The legislature did a great thing last session, putting [a lot of money] into kids’ mental health. That was sorely needed,” said Thomas Burr, public policy and affiliates relations manager with the National Alliance on Mental Health in Connecticut. “But in the meantime, the adults didn’t necessarily get a huge amount of investment, and that system is also very much gridlocked.”

Advocates are calling on the state this year to support the continued rollout of a “robust and comprehensive” 988 Crisis Response system, including expanding respite programs that fill gaps in services.

They are asking for the creation of peer-run respite centers, which provide short-term, overnight support in a home-like environment such as a residence, with trained workers on hand. The programs are voluntary.

The centers would offer an outlet for people experiencing a mental health crisis but would allow them to avoid hospitalization, officials with NAMI Connecticut said.

In 2019, the legislature passed a bill that required insurance companies to submit annual reports detailing their coverage of mental health and substance abuse services. The measure was meant to increase transparency and put pressure on companies to comply with mandates that bar them from placing greater restrictions on mental health services than medical care.

Since then, the state has received data from the companies that is difficult to analyze and understand, advocates said.

“The first report was basically a data dump of raw data. It didn’t shed light on much of anything,” Burr said.

Advocates are hoping to change that by pushing for a bill that would require insurance companies to submit data in a specific format that is easier to understand. The legislature could also consider funding for a position dedicated to sorting and analyzing that data, they said.

Coverage for small businesses

Insurance companies this year sought an average rate increase of 20% on fully insured individual health plans for 2023. They also asked for a 15% average hike for small group policies, those offered to businesses with 50 or fewer workers.

The state approved a 13% average increase for individual plans and 8% for small group plans.

But while many people who purchase individual plans through Connecticut’s health insurance exchange qualify for financial assistance to offset the cost of monthly premiums, small businesses do not.

“The small businesses are the ones that really get the short end of the stick,” Ted Doolittle, the state’s health care advocate, told the CT Mirror. “They don’t have the protection of the subsidies that the individual folks do.”

Advocates are asking lawmakers to tackle affordability for small businesses in the upcoming session.

“They are really struggling to get health care coverage at an affordable price for both the employer and the employee,” said Chris DiPentima, president and CEO of the Connecticut Business and Industry Association. “When we hear from our members right now, there are three things at the top of their mind: the workforce crisis … and then right behind that are the cost of energy and the cost of health care.

“Most employers we talked to pay at least 70% of the cost of the health insurance, and some are paying up to 100%. The rising cost of health care is really smacking the employer.”

In 2020, the state began requiring hospitals, medical practices and insurance companies to report their annual increases in health care costs. The state Office of Health Strategy comes up with annual benchmarks for the rising cost of care, and the reporting mechanism shows which entities are exceeding that benchmark.

Advocates are calling on the General Assembly to create incentives for companies to stay at or below those benchmarks going forward. The current law does not penalize or incentivize companies to remain below the benchmarks, other than to expose where their costs stand.

“We would prefer to incentivize those folks who are able to get to a level that’s desirable, whether it’s keeping their increases to single digits or having no increases for the year,” DiPentima said. “Tax credits are things we could look at.”

He also suggested exploring whether any health care mandates that drive up costs could be removed. Connecticut could also consider allowing association health plans, where small businesses are grouped together to appear like one large business for insurance purposes, so they have more leveraging power and a larger pool to spread risk.

At least 14 states have authorized association health plans.

“It’ll allow associations to pool their membership together to have them leverage their interests so they’re getting a better bang for their health care,” DiPentima said.

The session runs through June 7.

Jenna is CT Mirror’s Health Reporter, focusing on health access, affordability, quality, equity and disparities, social determinants of health, health system planning, infrastructure, processes, information systems, and other health policy. Before joining CT Mirror Jenna was a reporter at The Hartford Courant for 10 years, where she consistently won statewide and regional awards. Jenna has a Master of Science degree in Interactive Media from Quinnipiac University and a Bachelor or Arts degree in Journalism from Grand Valley State University.