Bad Medicine

The Patrick administration likes the notion of universal health coverage. It just doesn’t want to pay for it.

BOSTON MEDICAL CENTER was formed in 1996 from the merger of Boston City Hospital, the first publicly owned municipal hospital in the nation, and its private South End neighbor, Boston University Medical Center. To preserve BCH’s long-standing mission to serve the poor, lawmakers wrote that obligation into legislation that created the new quasi-public hospital. Boston Medical Center, the statute stipulates, must “consistently provide excellent and accessible health care services to all in need of care, regardless of status or ability to pay.” The state, in turn, must compensate BMC for treating a disproportionate share of low-income patients by paying “rates that equal the financial requirements of providing care to recipients of medical assistance.”

BMC has kept its part of the bargain. Seventy percent of its patients are poor, elderly, disabled, or members of ethnic and racial minorities. More than 50 percent rely on free care, Medicaid, or state-subsidized insurance plans like Commonwealth Care. Many live in Boston’s most impoverished neighborhoods, and more than 30 percent speak a primary language other than English.

The commonwealth has failed to uphold its end of the deal. The state that has been so successful in expanding insurance coverage — Massachusetts has the lowest number of uninsured residents in the nation — has been caught flat-footed by a struggling economy and skyrocketing healthcare costs. The Patrick administration has chosen to help fund the expenses incurred by new enrollees in Medicaid and Commonwealth Care by cutting payments to the very hospitals that care for those patients. It turns out that expanding insurance coverage is not the same as actually paying for it.

That is not how it was supposed to work. The state had planned to pay for expanded insurance coverage in part by eliminating millions of dollars in supplemental payments to safety-net hospitals, which provide free care to the uninsured. With fewer uninsured, the thinking went, there would be less need for those payments. Medicaid reimbursement rates would rise to help those hospitals care for the newly insured. Instead, the Patrick administration is phasing out those supplemental payments — at the same time it is reneging on its promise to boost Medicaid rates. (BMC is not alone in the resulting financial crisis. Cambridge Health Alliance, the second-largest safety-net provider in Massachusetts, needs a buyer or a deep-pocketed partner to stay afloat.)

Medicaid, one of the largest line items in the state budget, is a politically tempting place to cut. Unlike other areas of the budget — local aid, education, and public safety — healthcare for the poor does not have a vociferous constituency mobilized to express its dismay at the polls. And the state’s plea of poverty doesn’t play when, under the new national healthcare law, Massachusetts is slated to receive a $2.3 billion boost in federal Medicaid funds over the next 10 years.

For the state to argue that it cannot continue to pay for healthcare costs is to duck its own failure at curbing those costs. The governor and lawmakers have yet to act on a report, issued more than 14 months ago by a special commission, that urged an overhaul of how hospitals and doctors are paid. Demanding that BMC simply cut its way to solvency is as glib as promising that every government budget can be balanced by eliminating “waste, fraud, and abuse.” Of course programs should be reviewed for inefficiencies, but there is no getting around reality: It is more expensive to treat the patients who come to BMC.

  • sri

    It seems a shame that the Brigham and Mass general doesn’t step up to absorb some of the difficulty of caring for the poor.

  • Michael

    Why is it a shame? The state isn’t living up to its deal with the BMC and is showing why health care isn’t as cut-and-dry as everyone likes to make it out to be.