On Running a Hospital, Beth Israel Deaconess CEO Paul Levy muses on the collaboration that brings Harvard-affiliated hospitals together and the competition that keeps them apart. In the case of organ transplantation, he argues, separate programs don't make much sense.

"If there are fewer than say, 400, adult liver, kidney, and pancreas transplants in all of Eastern Massachusetts per year, does it make sense to spread them out among six or seven hospitals located within 15 miles of one another?" he asks.

On WBUR's Commonhealth, state Senator Richard T. Moore, co-chair of the legislature's Joint Committee on Health Care Financing, takes Bruce Sprinsteen as his muse. "One step up and two steps back" from his 1997 song "One Step" describes the state's success in insuring more of its residents after passage of the healthcare law two years ago, Moore says, but cost-cutting is a concern.

"If the Patrick administration and the Legislature hope to close the revenue gap and restrain budget growth in years to come, reining in the cost of health care, improving quality and safety, and expanding access to primary care providers needs to be a priority," he writes. "The latest round of state budget cuts suggests that they are not!"

The early returns are in: Businesses and workers both say Massachusetts' new healthcare law mandating near-universal coverage hasn't caused companies to drop or dilute employee-sponsored health insurance.

Researchers writing in today's online edition of Health Affairs were watching for "crowd-out," or the effect state-subsidized insurance would have on whether businesses would continue to offer benefits on their own. The Massachusetts healthcare law, enacted in April 2006, included both a program to pay the bills for low-income residents and to assess an annual penalty of $295 per employee on businesses that decided not to offer insurance.

Results of a spring survey of Massachusetts companies show that 79 percent of businesses with three or more employees are offering insurance, up from 73 percent a year ago. Most employers think the new healthcare law is "good for Massachusetts." Fewer companies -- 29 percent this year compared to 36 percent last -- thought the healthcare law was a financial burden. Compared to employers nationally, Massachusetts companies are less likely to end coverage for their workers or limits who can receive benefits.

There were some complaints, though. Almost half of larger businesses were frustrated by paperwork they must file with the state identifying which workers decline health coverage or company plans allowing them to pay for health insurance with pretax dollars, often through payroll deduction.

Internal medicine and family practice physicians are in critically short supply in Massachusetts, according to a poll of doctors in the state.

The Massachusetts Medical Society today reports in its seventh annual Physician Workforce Survey that the two primary care specialties join 10 other types of medical practice that are experiencing shortages. Oncologists, neurologists, and dermatologists are also on the list of doctors in high demand. The other seven specialties are anesthesiology, emergency medicine, general surgery, neurosurgery, psychiatry, urology, and vascular surgery.

By Kay Lazar, Globe Staff

Massachusetts will receive roughly $10.6 billion dollars from the federal government over the next three years to help keep its landmark health care law and many other health programs afloat.

After months of delicate negotiations, Governor Deval Patrick today outlined details of the long-awaited Medicaid waiver package at a State House news conference.

While Massachusetts did not get everything it had requested, it did get all of the money it expected to receive for this fiscal year, easing anxiety among state leaders who were prepared to make some drastic cuts.

By Matt Viser, Globe Staff

Top state officials today are planning to announce this afternoon that they have come to terms with the federal government on Medicaid waiver, which has huge ramifications for the state budget.

"The state has reached an agreement in principal," according to a source briefed on the plan.

Governor Deval Patrick is planning to announce the terms at 2 p.m. The source said the terms were favorable to the state.

"The agreement is considered a major victory of the Commonwealth and health care reform," said the source, who spoke on the condition of anonymity since the agreement has not been made public.

By Kay Lazar, Globe Staff

Massachusetts spending on Medicaid programs has grown only slightly faster than the state's economy over the past decade, with the biggest growth coming during tough economic times, a new report finds.

Medicaid spending grew at an average annual rate of 7.1 percent, while Massachusetts total personal income grew at an annual rate of 6.2 percent during that period between 1996 and 2007 fiscal years, according to the report from the Massachusetts Medicaid Policy Institute and the Massachusetts Budget and Policy Center.

But the meltdown on Wall Street may force employers to lay off workers or cut health insurance benefits, forcing more residents to seek state-subsidized health care, and that could swell Medicaid spending, said Anya Rader Wallack, executive director of the Institute.

The state's landmark healthcare law is pulling people onto the insurance rolls through new mandates and insurance offerings, but some Massachusetts citizens are still struggling with medical debt, a report released today says.

According to The Access Project, a national health research and advocacy group based in Boston, about 40 percent of the people who came to them for help with their medical debt over the last two years had insurance, but were still unable to pay their bills. Many were unaware of programs put in place to assist them or had difficulty navigating them, said Andrew Cohen, coordinator of the project's Medical Debt Resolution program and co-author of the report.

"This really is a silent tragedy in Massachusetts," he said in an interview. "It's really about medical bills being transformed into medical debt."

The report focuses on 187 people who came for help between September 2006, before the law requiring near-universal coverage was implemented, and April 2008, after it took effect. Most of the people seeking assistance had low incomes; those who qualified were helped to obtain coverage through state-subsidized Commonwealth Care. Others enrolled in non-subsidized insurance plans had trouble paying both insurance premiums and co-payments while dealing with previous medical debt.

While many of the programs' clients weren't aware of programs designed to help them pay their bills, they weren't alone, the report says. People working at hospitals and other healthcare settings contacted by the program didn't always know about them either, the report said.

"While Massachusetts strives to achieve universal coverage, a robust safety net must remain in place to assist people who have unaffordable medical expenses, whether they are uninsured or have inadequate insurance coverage," the report says.

By Kay Lazar, Globe Staff

Business groups today warned that proposed state regulations to define the minimum health insurance coverage each resident must have, or face a tax penalty, would be too costly for some employers and would leave Massachusetts residents with fewer affordable insurance choices.

But a coalition of consumer organizations said the state's draft plan did not go far enough to protect patients and would leave many with insurance policies that do not adequately cover their needs, especially if they become seriously ill.

The business and consumer groups testified at a public hearing of the Commonwealth Health Insurance Connector Authority, a state board that regulates health insurance coverage. The Connector's draft plans are part of an overhaul of the state's health care system that requires nearly every resident to have health insurance.

By Kay Lazar, Globe Staff

The state was granted another two-week extension today of its Medicaid waiver to keep its pioneering health care law running as officials negotiate with federal regulators over renewing the program.

Federal funding was slated to expire June 30, but the state has received five previous extensions from the federal government.

At stake is roughly $11 billion in federal funds over three years that is used to help subsidize insurance for low-income residents. The state has provided subsidized health care to more than 245,000 residents under its two-year-old law, a higher number than anticipated, and that has stretched funds.

The waiver allows Massachusetts to provide health insurance to some residents with incomes higher than would typically be allowed under traditional Medicaid rules.

The latest extension means Massachusetts' program will be allowed to continue until at least Sept 22.

By Stephen Smith, Globe Staff

Massachusetts has the lowest percentage of residents without health insurance in the nation, according to a US Census Bureau report released this morning that provides evidence that the state's bold experiment to insure nearly everyone is succeeding.

Averaging data from 2006 and 2007, the study found that 7.9 percent of Bay Staters did not have health insurance. From 2004 through 2005, the rate was 10.3 percent.

By comparison, one-quarter of residents lacked health insurance in Texas, the state that fared worst. Nationally, about 15 percent of Americans were uninsured in the 2006-07 period.

The Census report likely understates the effect of the law in Massachusetts requiring virtually every resident to be insured because the law did not go into effect until June 2006 and penalties for not enrolling did not kick in until the end of 2007.

If you wondered what happened to plans for a web site that would show how much insurers pay hospitals for up to 40 procedures they perform, there's an answer in the Boston Business Journal and a response on Charlie Baker's blog, Let's Talk Health Care.

"It’s more difficult to complete than we’ve expected," Katharine London, executive director of the Massachusetts Health Care Quality and Cost Council, tells the BBJ.

The ambitious project, set in motion by the state's two-year old healthcare law, is supposed to help patients see how much having a baby or a bypass will cost, for example, depending on the insurance they have and the hospital they go to. That's especially important for consumers who have to pay a deductible before their coverage kicks in, the BBJ story notes.

So why hasn't it gotten off the ground?

By Kay Lazar, Globe Staff

Hospitals and insurers would be required to pay millions more this fiscal year for the state's landmark health insurance law under a supplemental budget bill being debated this afternoon on Beacon Hill.

Other businesses will also likely have to pay more to help close a $130 million funding gap in the two-year-old law. The administration of Governor Deval Patrick intends to seek regulatory changes that would raise an additional $33 million a year from businesses with more than 10 employees that fail to provide health insurance to their workers.

The administration and consumer groups have argued that it's fair to ask employers to contribute more because people getting subsidized insurance through the law have had their premiums and copayments increased this year.

The House bill would raise $88 million in the fiscal year that began July 1 by: seeking a $33 million assessment on reserve accounts of health insurers; levying a $20 million assessment on hospitals; and shifting $35 million from the state's Medical Security Trust Fund, which is funded by employers to cover insurance for the unemployed.

Wall Street Journal editorial writers sure aren't drinking the Massachusetts healthcare reform Kool-Aid. No sir.

In a withering review, "RomneyCare" gets a going-over because liberals point to the law passed by the state before the former governor hit the presidential hustings as a model for the nation. Mitt is scorned for an op-ed he wrote -- also in the Journal -- proclaiming the plan a success, though he "should know better."

But the big editorial guns come out for Governor Deval Patrick's $129 million tax plan to make up for higher costs from higher enrollment in subsidized Commonwealth Care. More people want coverage because it's free, the editorial reasons. But who pays for it?

"For now, Mr. Patrick wants one-time (yeah, right) charges" on insurers and providers, plus a boost in the pay-or-play tax on businesses for not offering certain amounts of coverage, the editorial says. Make that "pay or pay," it emphasises.

The editorial takes a dim view of this cost-shifting, insisting that people are uninsured because coverage is too expensive, in part because of mandates that insurers in the state cover such expensive procedures as fertility treatments. Spending on those mandates equals 12 percent of premiums. But liberals are still fans, the piece says. Why, you might ask?

"They have to gussy up the state's model because the extravagant claim that led to its creation -- that health care will be less expensive if everyone is covered -- is being relentlessly discredited."

By Kay Lazar, Globe Staff

The state requested another two-week extension today of its Medicaid waiver to keep its landmark health care law running as officials negotiate with federal regulators over renewing the program.

Federal funding was slated to expire June 30, but the state has received two previous extensions, and a third extension would give the state until August 11 to reach an agreement.

At stake is more than $1 billion in federal funds over three years, which would be used to help subsidize insurance for low-income residents. The state has extended health care to more than 350,000 residents under its two-year old law, a higher number than anticipated, and that has stretched funds.

The waiver allows Massachusetts to provide health insurance to some residents with incomes higher than would be allowed under traditional Medicaid rules.

By Kay Lazar, Globe Staff

Patients with autism, eating disorders, substance abuse problems or post traumatic stress disorder would have greater access to treatments under proposed legislation that passed the state Senate today.

The measure differs from a more sweeping version of the "mental health parity" bill that passed the House earlier. That proposal would require insurance plans to cover all mental health disorders the same as physical conditions and would allow any treatments that were medically needed.

Both the Senate and House versions would maintain the current law's requirement that health insurers provide full coverage for nine of the most common psychiatric conditions: schizophrenia; schizoaffective disorder, major depression; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder, panic disorder; delirium and dementia; and affective disorders.

By Kay Lazar, Globe Staff

A hotly-debated ban on drug companies providing gifts and meals to physicians was stripped out of proposed legislation approved by a House committee late today.

The panel also removed requirements that drug and medical device companies report payments they make to doctors for consulting and speaking to other physicians, and that the Department of Public Health post that information on its website. A proposed $5,000 fine per violation was also dropped from the bill, which is expected to be voted on by the full House tomorrow.

Instead, the measure would simply require drug companies to adopt a marketing code of conduct, such as the one the pharmaceutical industry's trade association announced last week while negotiations on the Massachusetts bill were in progress. That voluntary code would ban restaurant meals and trinkets such as mugs and pens bearing the names of drug companies and products, but still allow companies to cater lunches in doctors offices and hospitals, which company salespeople use to promote their products directly to physicians.

By Kay Lazar, Globe Staff

State regulators said today they expect more than a three-fold increase in the number of Massachusetts residents who will appeal penalties in the next year for failing to have state-mandated health insurance.

The Commonwealth Health Insurance Connector Authority set aside $3.3 million -- nearly 10 percent of its $39 million 2009 fiscal year budget, which it finalized today -- for the 8,000 appeals the board expects to process. In the year that ended June 30, there were an estimated 2,000 to 2,500 appeals, the board said.

In a report on the state's new law requiring near-universal health coverage, the BBC asks if Massachusetts can serve as a model for the nation, which lags behind poorer countries in some health measures despite its wealth.

"It is a brave attempt to address gaps in US healthcare without trampling on a core US value: freedom of choice," says the British story, which includes interviews with Massachusetts General Hospital's Dr. David Torchiana, former Health Care For All chief John McDonough, Commonwealth Connector head Jon Kingsdale, and Roxbury minister Reverend Hurmon Hamilton.

"Its survival is very dependent on political will," the story concludes. "All eyes, then, on the presidential elections in November."

A USA Today story also timed to the one-year anniversary of the law's deadline for obtaining coverage focuses on the costs of the effort.

"Some will say it's an overwhelming success story. Others will say it has cost somewhat more than expected, so we can't afford to expand coverage," Drew Altman, president of the non-partisan Kaiser Family Foundation, tells the paper. "The truth is somewhere in the middle."

As the cost of providing near-universal health coverage in Massachusetts climbs, public support and financial backing need to stay strong to keep the insurance program afloat, an influential journal says.

An editorial in the New England Journal of Medicine says the state faces more than just the substantial financial challenges of providing free or partially subsidized coverage to more people than expected. Massachusetts also needs to improve access to care for newly insured people and to find a way to help part-time employees or low-paid workers who can't afford coverage.

"Health care reform in Massachusetts is not a panacea for the many shortcomings of the health care system," Dr. Robert Steinbrook, a national correspondent for the journal, writes. "Massachusetts has made some strides, and given sufficient resources, more can be done."

Employees at more than 1,400 workplaces in Massachusetts – including Wal-Mart, Stop & Shop, and the Commonwealth itself -- received $637 million in healthcare for themselves and their families through publicly funded programs last year, according to a state report released today.

The cost to insure people who worked for companies with 50 or more employees came to $372 million for coverage through three state programs: MassHealth, the state’s Medicaid plan; Commonwealth Care, the subsidized insurance plan created by the 2006 healthcare law; and the Uncompensated Care Pool, which pays hospitals for treating the uninsured. When dependents and non-working spouses are added, the total rises to $637 million, an increase of 14 percent over fiscal 2006 when the estimate was $559 million.

“It shows that the level of public dollars being used to provide coverage to lower-income folks working for large employers is much greater than anybody imagined,” John McDonough, executive director of Health Care For All, said in an interview on his last day as head of the advocacy organization. “It also shows that the number of folks, adults and dependents, is much larger than anybody imagined.”

The report, from the Executive Office of Health and Human Services, said that in Massachusetts, 72 percent of employers offer health insurance to their workers, higher than the national rate of 60 percent. And that rate has held steady here in recent years, while dropping nationally.

By Alice Dembner, Globe staff

Advocates of a government-run healthcare system that insures everyone will hold two events Monday to draw attention to their position.

They plan to discuss shortcomings of Massachusetts’ approach to health reform at a 9 a.m. forum at the Marriott Courtyard in South Boston. And they plan a rally at 4:30 on Boston Common.

The events are being held in conjunction with demonstrations in other cities nationwide in support of a Medicare-for-all, or single-payor health system.

Sponsoring groups include HealthCare-Now!, MassCare and Massachusetts Senior Action Council.

By Alice Dembner, Globe Staff

A state board today updated standards that will be used to decide who faces fines this year for failing to have health insurance (see details below).

The vote came the same day officials and community members gathered to celebrate the second anniversary of the healthcare reform law that has resulted in more than 340,000 people getting insurance so far.

"This is a wonderful, wonderful experiment and it is showing great results," said Governor Deval Patrick at a State House ceremony. "But nothing this ambitious or important comes easy." To sustain the initiative, he said, "our first priority... is to rein in costs."

The state faces a rapidly rising bill to cover insurance subsidies and is searching for ways to reduce expenses and raise additional revenues.

By Alice Dembner, Globe Staff

About 320 Massachusetts adults age 25 to 64 died in 2006 because they lacked health insurance, according to an estimate released today by Families USA, a national healthcare advocacy group based in Washington.

The death toll is a statewide extrapolation of national reports produced by the Institute of Medicine and the Urban Institute, and based on the US Census estimate of the number of uninsured in Massachusetts, which may overcount the total. An IOM report in 2002 found that the uninsured are 25 percent more likely to die prematurely than those with health coverage.

“Massachusetts is likely to have a significant drop [in the death rate] as a result of the healthcare reform legislation being implemented,” said Ron Pollack, executive director of Families USA.

Uninsured people are more likely to delay or forgo needed medical care, according to a number of studies.

The 2002 IOM report estimated that 18,000 adults died nationwide because they didn’t have insurance. A follow-up report by the Urban Institute estimated that 22,000 died in 2006 for the same reason.

Families USA produced estimates for each of the states for 2006. The numbers ranged from 30 people in Vermont to 2,700 in Texas.

By Susan Milligan, Globe Staff

Senator Edward M. Kennedy has tapped a former Massachusetts legislator and prominent health care activist to be his chief adviser on health reform, a move Kennedy's office said was aimed at developing a universal health care plan after the presidential election.

John McDonough, a former state House member, was a key player in crafting Massachusetts's mandatory health insurance plan. But McDonough said he will not necessarily advocate such a plan for the nation as a whole.

By Alice Dembner, Globe Staff

Because women generally earn less than men and use more healthcare, they face a greater burden from copayments and deductibles that are part of the state’s health insurance initiative, according to a report from the Center for Women’s Health and Human Rights at Suffolk University.

While acknowledging that the initiative has provided coverage for many women, the report recommends that the state monitor the impact of reform on women.

“The need for a gender analysis at each stage of planning, implementation and evaluation is already apparent if Massachusetts health care reform is to live up to its promise of improving women’s health,” said Susan Sered, a Suffolk sociology professor who wrote the report with the help of her students.

Among the report’s findings:
Out-of-pocket costs for a young women enrolled in the Young Adult Plan could reach $6,000 a year with only modest healthcare needs.

By Alice Dembner, Globe Staff

The state's new subsidized health insurance program will cost "signficantly" more than the $869 million proposed in the governor's FY2009 budget just two months ago, the state's top financial official said today.

The budget gap looms despite steps taken today to hold down state costs -- approval of a tough contract with insurers, and increased premiums and copayments for about half of the 176,000 people enrolled.

"We have closed some of the fiscal gap here, but we have not closed most of it," said Leslie Kirwan, state secretary of administration and finance. She declined to quantify the gap in funding for the Commonwealth Care program, which is at the heart of the state's healthcare reform initiative.

Kirwan said the governor is asking all the powerful players that have supported healthcare reform to contribute to a solution. In the last two weeks, during closed-door meetings, several dozen proposals have been put forward, including raising assessments on insurers, hospitals and businesses.

By Alice Dembner, Globe Staff

Seven community organizations will received a total of $1.1 million in state grants to identify people without health insurance and sign them up in state programs, the administration of Gov. Deval Patrick announced today.

The grants are the second phase of $3.5 million in outreach grants included in the state budget for the year that ends June 30. This phase is designed to help coordinate the work of 45 agencies doing outreach and enrollment, fill gaps in recruitment, and involve colleges and business associations.

The goal is to enroll as many people as possible in Medicaid, Commonwealth Care, or Commonwealth Choice.

Among the agencies getting the new grants are Action for Boston Community Development, Health Care for All and the Latin American Health Institute.

In a sign that Massachusetts' healthcare initiative is succeeding, use of the "free care pool," the fund that pays for hospital care for the uninsured, dropped by 16 percent in the first year of the effort to insure most residents, according to new state figures.

Congress is edging closer to allowing generic versions of advanced biologic drugs, which are made from living organisms instead of chemicals, a development that would have a major impact on consumers as well as on Massachusetts biotechnology companies.

A Massachusetts General Hospital neurologist is studying whether guided meditation administered in the virtual world of Second Life can effectively reduce stress.

A Chestnut Hill synagogue honored a Pittsburgh man who donated a kidney to save the life of Albert Sherman, vice chancellor of the University of Massachusetts Medical School in Worcester.

By Alice Dembner, Globe staff

The board overseeing the state’s health insurance initiative cancelled a meeting today at which it was scheduled to decide whether to raise premiums and copayments for Commonwealth Care, the state-subsidized insurance program.

The proposed hikes are designed in part to reduce the state’s cost for the program – a cost is currently being negotiated with the four insurers who run Commonwealth Care.

In a statement explaining the postponement, board chairwoman Leslie Kirwan said, “The bids we received [from the insurers] were not satisfactory.”

The board is expected to reschedule the meeting next month.

By Alice Dembner, Globe staff

A new report by the Massachusetts Hospital Association tracks the decline in use of the state’s “free care pool” over the last few years, as the state has enrolled more people in Medicaid and a new subsidized insurance plan.

From fiscal year 2006 to 2007, “free care” visits to hospitals dropped by 12 percent, according to the report. The state pays hospitals to care for patients without insurance or who are underinsured, but has been reducing the payments as more people get insured.

“There has clearly been a demonstrated decrease in demand in Uncompensated Care Pool volume and cost between FY06 and FY07, and this is another indicator that health care reform is succeeding,” said Sarah Iselin, commissioner of the state Division of Health Care Finance and Policy, which oversees the pool but was not involved in the report. “As we move forward in FY08, we expect to experience additional decline in demand.”

The drop in visits was uneven, with some major Boston hospitals seeing huge drops, while other hospitals saw increases. The report does not offer an explanation for those differences.

By Alice Dembner, Globe Staff

The state Department of Revenue has posted a video tutorial on its website, to help Massachusetts residents fill out a new tax form on health insurance, Schedule HC.

All residents must complete the form to indicate that they have insurance or to determine whether they are subject to a fine because they don’t. The form is part of the state’s effort to enforce the law, which required all residents to have insurance by Dec. 31 of last year unless they obtained an exemption or can show that insurance met the state's definition of unaffordable.

The fine for being uninsured last year is loss of the personal tax exemption, or $219 for an individual. People who are uninsured in 2008 will face fines of up to $912.

The video can help residents determine if the state considers insurance affordable for them, as well as how to file an appeal of the penalty.

By Alice Dembner, Globe staff

Although many more state residents had health insurance last year than ever before, blacks and Hispanics remain uninsured at a much higher rate, according to data in a new report released today by the state Division of Health Care Finance and Policy.

More than 10 percent of Hispanics and nearly 8 percent of blacks were uninsured in early 2007, compared with about 4.5 percent of whites and Asians. The figures come from a state survey that showed 355,000 people were uninsured. Census figures show a much higher number of uninsured, more than 600,000.

The survey also showed that cost is a growing barrier to getting health care. Eighty-six percent of the uninsured said cost was an impediment, up from 79 percent in a 2006 survey. For those with insurance, 37 percent said cost of care was a problem, compared to 32 percent in 2006.

The report also includes the first data from a survey of employers conducted in early 2007. It found no change in the percent of employers offering health insurance since 2001 -- about 72 percent.

The report, titled “Health Care in Massachusetts: Key Indicators,” is designed to monitor changes in insurance, state-paid care at hospitals and health centers, health status of residents and financial performance of healthcare institutions.

More than 250 Massachusetts doctors give the state's healthcare law a failing grade in an open letter released today.

Physicians for a National Health Progam, which favors a single-payer system of healthcare, contends that requiring almost all individuals to buy health insurance harms poor people, enriches insurance companies, and costs the state more than it can afford. Most but not all of the doctors who signed the letter are members of the group.

“It’s to tell people outside of Massachusetts, ‘Do something better than what we have done here,’ ” Dr. David Himmelstein, a primary care doctor at Cambridge Hospital and a member of the group, said in an interview. “The presidential candidates should be proposing something better.”

The full text of the letter follows:

By Alice Dembner, Globe Staff

The penalties for Massachusetts residents who do not obtain health insurance this year have been set too low to encourage people to buy insurance, a member of an influential state panel said today.

"The mandate has to be enforced," said Jonathan Gruber, a director of the Commonwealth Health Insurance Connector, which oversees implementation of the state’s health insurance initiative. “We need to think beyond what looks mean and do what’s right.”

Last week, the Patrick administration proposed a schedule of penalties starting at $17.50 a month for those at the lowest incomes and climbing to $76 a month for those with at least moderate incomes. They based the schedule on state law that requires every adult to have insurance or pay a penalty of up to half the cost of the least-expensive insurance premium.

The penalties will be finalized after a public comment period that ends Tuesday. They will be imposed in 2009 when individuals file their 2008 tax returns.

By Alice Dembner, Globe Staff

New federal rules restricting eligibility for the Medicaid health insurance program will not affect Massachusetts immediately, but could make it harder in coming years for the state to assist children and families with moderate incomes who are covered as part of Massachusetts’ health insurance initiative, state officials said today.

With the federal government’s permission, the state in 2006 expanded Medicaid coverage of children and insurance subsidies for families with incomes up to three times the federal poverty level – or about $62,000 for a family of four. But the Bush administration, which pays for at least half the cost of Medicaid nationwide, is barring some other states from similar expansions, saying Medicaid needs to focus on the lowest-income families.

"We expect to maintain the expansions," which cover thousands of patients, said Thomas Dehner, the state’s Medicaid director. "But our overall program is all up for discussion" because the state must renew federal approval for the expansions this summer.

On Running a Hospital, Paul Levy reminds us that the state Public Health Council will meet Wednesday to vote on allowing in-store medical clinics. CVS Corp. wants to open 20 to 30 MinuteClinics in Boston-area stores to treat minor illnesses. State health officials have developed new regulations for the primary care venues, which are designed to treat such common illnesses as bladder infections or poison ivy.

Beth Israel Deaconess CEO Levy is squarely behind the clinics.

“I hope that the members of the Public Health Council will approve the regulations at its meeting on January 9,” he writes. “Were they to turn them down, I fear that they would send a clear signal that Massachusetts is not a friendly place for new health care delivery concepts that offer convenience to the public and the potential to alleviate crowding of Emergency Rooms and other higher acuity sites of care.”

By Alice Dembner, Globe Staff

The Patrick administration’s launch today of an initiative to “make Massachusetts a healthier place to live and work” – as Dr. JudyAnn Bigby put it – was met with faint praise and some pointed criticism because of the broad goals and lack of specifics.

Bigby, the state secretary of health and human services, stood in for the governor at the State House announcement, and laid out the Healthy Massachusetts Compact -- an agreement among major state agencies to improve access to healthcare, enhance healthcare quality and contain costs and promote wellness. (See below for complete compact.)

Senator Richard T. Moore, co-chairman of the Legislature’s Committee on Health Care Financing, applauded the goals, but challenged the administration to put the full weight of state government and the state budget behind them.

“Governor Patrick would do well to convert this compact into an Executive
Order to give these goals and objectives the true force of law,” Moore said in a statement (pasted below). “Other governors have convened health care task forces and issued sweeping policy statements, but they have not resulted in real health care reform.”

By Alice Dembner, Globe Staff

Governor Deval Patrick is expected to announce Wednesday that he is launching a major effort to tackle healthcare problems -- including soaring costs and the elusive goal of quality -- through a coordinated approach across state government.

The state “compact” on health will bring together agencies overseeing prisons, law enforcement, finance and insurance with healthcare behemoths insuring millions of state residents and workers, according to three individuals who have been briefed on the plans but requested anonymity because they were asked to keep the information confidential until Wednesday.

The administration declined to comment in advance of the announcement.

By Alice Dembner, Globe staff

A total of 46 people have already applied for waivers of the $219 penalty that the state will impose on adults who don’t have insurance as of Dec. 31, officials said today.

Nineteen were approved, and the rest were denied because the individuals were eligible for state-subsidized insurance or didn’t provide documentation that insurance was unaffordable for them. One is appealing the decision.

Anyone seeking a waiver can apply now through the Commonwealth Health Insurance Connector website. Criteria include facing financial hardships or having income too low to make insurance affordable. The state has posted a chart of insurance premiums it considers affordable for people at various income levels.

Residents can also apply for the waiver on their FY07 state tax return, which state officials said may be easier for many people. The form will contain the affordability chart and a place to attest that you didn’t get insurance because the state says it isn’t affordable. People with a particular financial hardship can also apply for a waiver through the tax form.

The connector will decide the cases, with the help of a panel of independent lawyers. Anyone who disagrees with the state decision can appeal in Superior Court.

By Alice Dembner, Globe Staff

Holding down increases in health insurance premiums to 5 percent next year is a near-impossible task that could endanger the financial solvency of insurers, according to a group of Massachusetts insurance companies.

The Massachusetts Association of Health Plans delivered a letter today to the Commonwealth Health Insurance Connector saying that insurers’ hands are tied by rising health costs and constraints imposed by the state.

“Unless we address what is driving health care spending, setting a five percent premium target is essentially asking carriers to offer coverage at a loss,” said the letter, signed by the association’s president Dr. Marylou Buyse.

The letter urged the state to call hearings on ways to hold down medical costs, reiterating a strategy the insurers endorsed last week. The group speaks for all the state’s major insurers, except Blue Cross Blue Shield.

By Alice Dembner, Globe Staff

Nearly 300,000 people have obtained health insurance through the state's landmark initiative over the last 18 months, officials announced today, putting Massachusetts closer to the goal of covering nearly all residents.

The total surged in the last month as people rushed to sign up before year's end when a penalty kicks in, and officials predicted that thousands more would meet the deadline. Under the initiative, all residents must get insurance, unless the state determines it is unaffordable for them.

"Massachusetts is proving that healthcare reform can work on the state level," Lieutenant Governor Tim Murray said today at a State House event to announce the results. "Together, we've achieved what no other state has tried."

The state initiative is being closely watched across the nation, as other states consider how to move forward in the absence of any federal solution to the growing millions of uninsured people. In addition, nearly every candidate for president is proposing a national insurance effort and members of Congress are pushing their own plans.

Massachusetts officials said yesterday that they don't know how many people remain uninsured here. Estimates of the total without coverage last year ranged from the US Census's 657,000 to the state's 395,000. Based on those figures, the progress represents coverage for nearly one-half to three-quarters of the uninsured.

By Alice Dembner, Globe Staff

Concerned that rising costs could jeopardize Massachusetts' landmark health insurance initiative, a state panel voted yesterday to press insurers to hold premium increases to 5 percent next year for unsubsidized plans sold through the state. The panel also instructed insurers to curb premiums without shifting significantly more costs to consumers.

The steps by the Commonwealth Health Insurance Connector could directly affect tens of thousands of people, and the panel hopes it will nudge similar changes in the larger insurance market. Connector officials and healthcare analysts agree that neither the state nor individuals will be able to afford coverage without aggressive price control.

"We've got to do something about cost and we've got to do it now," Dolores Mitchell, a member of the connector board, said after yesterday's meeting.

Without the limit, connector staff estimated that premiums for the Commonwealth Choice insurance would increase between 4 and 14 percent depending on the coverage an individual chooses. Mitchell and some other board members said even 5 percent might be too high an increase.

By Alice Dembner, Globe Staff

The largest insurer of patients in the state's new subsidized coverage plan faces sanctions and a possible investigation by the attorney general for attempting to poach patients from other insurers.

Boston Medical Center sowed confusion when it sent a letter a month ago to 2,600 patients that wrongly implied they could only get care at BMC if they signed up for the hospital's insurance plan, called HealthNet. "To continue getting your care at Boston Medical Center, now is the time to switch..." the letter said.

The content of the letter and the direct approach to patients enrolled with other insurers violated HealthNet's state contract, according to the Commonwealth Health Insurance Connector, which oversees the state plan.

Both Boston Medical Center and the state are now recontacting patients to ensure they have accurate information about access to care and their choice of health insurers, which also include Network Health, Neighborhood Health Plan and Fallon Community Health Plan.

By Alice Dembner, Globe Staff

Some 518 moderate or large Massachusetts companies -- out of tens of thousands -- will pay the state a small penalty rather than offer health insurance to some of their workers, the state announced today.

State officials and business leaders called the small number of penalty payers a positive sign for the state's effort to ensure that every resident has coverage. But healthcare advocates said it reflects the weak requirement for business participation set by the administration of former Governor Mitt Romney.

Either way, the state will collect only about $5 million in penalties, far less than the $24 million budgeted, which could result in another budget shortfall for healthcare reform.

Lawmakers authorized the penalty -- of up to $295 per employee per year -- to help subsidize state insurance for low-income state residents and to spread financial responsibility for the coverage initiative among individuals, government and businesses.

By Alice Dembner, Globe Staff

Health insurance premiums for non-subsidized insurance offered through the state are on a pace to rise between 4 and 14 percent by July, according to the Commonwealth Health Insurance Connector.

The high end of that rate is unacceptable, connector board members said yesterday as they discussed ways to keep Commonwealth Choice insurance more affordable.

The connector is preparing to ask for bids from insurers for plans that might win the connector’s seal of approval for the fiscal year beginning July 1. One option under consideration is asking insurers to offer plans that keep the rate of increase to a set amount, perhaps in the 5 to 7 percent range. Another is pushing the plans to make adjustments, such as restricting access to specific hospitals or specialists or increasing copayments, in order to keep premiums down.

The board will decide among the options at its next meeting, Dec. 4.

By Alice Dembner, Globe Staff

Tuesday is the deadline to sign up for state-subsidized health insurance in order to avoid a tax penalty next year. In addition, people seeking to buy special discounted insurance aimed at 19- to 26-year-olds must also make their purchase by Nov. 23.

However, people seeking to buy private insurance have several more days to do so and still avoid the penalty.

All Massachusetts residents are required to have insurance by Dec. 31, if the state deems that coverage affordable. Those not insured will face the loss of their personal exemption – about $219 -- when they file their 2007 state tax return.

By Alice Dembner, Globe Staff

The state appears to be catching up with the volume of calls from people seeking help enrolling or navigating the Commonwealth Care subsidized insurance program.

Between 4 and 5 percent of calls went unanswered in the last two weeks of October, still above the state’s goal of 3 percent, but far better than in recent weeks, according to the Commonwealth Health Insurance Connector. The state added operators and sent more calls to an overflow center in Georgia.

Nearly half of all calls were “abandoned” earlier in October, meaning that people grew tired of waiting and hung up before an operator could help them. Weekly call volume reached a high of nearly 22,000 in mid-October before falling off substantially as the month wore on.

The call center has periodically had trouble keeping up with the calls since April, but state officials say they hope they have the problem solved.

Call volume is driven in part by increasing enrollment. As of Nov. 1, nearly 133,000 people had enrolled in Commonwealth Care. That’s almost as many as the state expected to sign up by next summer.

By Alice Dembner, Globe Staff

Massachusetts made history last March by requiring all residents to obtain health insurance that includes coverage of prescription drugs. Now, it's finding that making such coverage affordable is an even more heroic task.

The goal is to ease the sticker shock for more than 160,000 people who currently have health insurance that doesn't cover drugs and will have to upgrade their coverage by January 2009 when the drug requirement takes effect. In addition, about 30 percent of people who bought non-subsidized insurance through the connector this year have chosen coverage that excludes prescription drugs.

Today, members of the board overseeing the insurance requirement rejected a proposal that could have cut insurance premiums a few dollars a month by imposing a $1,000 deductible for any non-generic drugs.

Although the board of the Commonwealth Health Insurance Connector did not formally vote on the proposal, several members noted that it offered little savings on the monthly premium while potentially leaving people without adequate coverage.

“A deductible of $1,000 is pretty extreme,” said Celia Wcislo, a board member and assistant division director of labor union 1199 SEIU. “It’s a catastrophic plan; it doesn’t solve the problem.”

The board directed its staff to look for other ways to cut costs of prescription drug coverage, but the board is running out of time. Individuals buying insurance through employers may have to make adjustments in their coverage as early as January 2008 to meet the requirement for January 2009. And health insurers must still design actual policies that meet the new standard. The connector has set a November deadline to tell insurers what kind of coverage will meet state standards.

By Alice Dembner, Globe Staff

Another 12,000 people signed up for state-subsidized health insurance in September, pushing the total to 127,000, state officials said today. And the state this month is sending out notices to about 45,000 people it believes are eligible, but who haven’t yet enrolled.

Of the total enrolled, about 79,000 are getting full subsidies, far more than the 60,000 the state expected.

All that growth could put unexpected pressure on the state budget, a point made at today’s meeting of the Commonwealth Health Insurance Connector by board member Richard Lord, president of Associated Industries of Massachusetts.

Leslie Kirwan, chairman of the connector's board and state secretary of administration and finance, acknowledged that the state hadn’t budgeted for that success. “We’re still evaluating the impact,” she said.

Alice Dembner, Globe Staff

The board of the Commonwealth Health Insurance Connector Authority is finally back up to speed with the appointment of Ian Duncan to fill the seat reserved for an insurance actuary.

Duncan, who runs a healthcare management consulting firm called Solucia in Farmington, Ct., attended his first meeting today and jumped right into a lively and complex discussion of a prescription drug benefit. The connector is overseeing implementation of the state’s new near-universal health insurance law.

Duncan replaces Bruce Butler, an actuary who resigned because of potential conflicts of interest between his private consulting business and the connector’s work.

State officials apparently had to reach out to Connecticut to find an actuary who didn’t have business connections with insurers working in Massachusetts.

In a 30-year career in healthcare management, Duncan has also worked for Aetna Life and Casualty and PricewaterhouseCoopers. He has recently specialized in evaluating disease management programs.

By Alice Dembner, Globe Staff

In the first week of a 6-week filing period, only four Massachusetts companies fessed up to not providing health insurance for their full-time workers, according to figures from the administration of Governor Deval Patrick.

The state’s universal health insurance law requires companies with 11 or more employees to offer insurance or pay a fee of up to $295 per employee per year. To enforce this provision, companies must report by Nov. 15 whether they paid for insurance for at least one-quarter of their full-time workers or offered to pay at least one-third of an individual’s premium in the last year. Firms that don’t meet either of these tests must pay the fee.

From Monday through the end of business Thursday, about 860 companies with 11 or more employees filed. But only four said they would be subject to the fee. At least partial payment of the fee is due by Nov. 15.

State officials said they had no idea how many companies are required to file. But US Census figures from 2005 suggest there may be as many as 40,000 Massachusetts companies with 11 or more workers.

By Alice Dembner, Globe Staff

Enrolling virtually every eligible uninsured person in the state’s subsidized insurance program is one of the goals the Commonwealth Health Insurance Connector today set for itself in the coming year.

As of Sept. 1, the total enrolled was just over 115,000.

The difficulty in meeting the new goal is that no one really knows how many state residents meet the income and other requirements for the Commonwealth Care program.
Last year’s estimates were between 140,000 and 210,000.

Another goal is signing up 35,000 people for the Commonwealth Choice program, which offers unsubsidized insurance including some stripped down plans, through the Connector.

This program is aimed at people with mid-level incomes or higher – and estimates suggested there were between 160,000 and 230,000 people without insurance last year in this income group.

The Connector is figuring that most of those people are going to get insurance through their jobs or directly from insurance brokers or companies.

By Alice Dembner, Globe Staff

Restrictions imposed by the Bush administration on a program that provides health insurance for more than 90,000 children in Massachusetts are "dumb" and should be revoked by President Bush or overturned by Congress, Governor Deval Patrick said this morning.

Patrick said the new rules for the State Children's Health Insurance Program would deny health insurance to thousands of children and hurt the state's effort to provide coverage for all its residents.

"It's a step in the wrong direction and has to be prevented," Patrick said at a news conference at the Martha Eliot Health Center in Jamaica Plain.

Another 10,000 people signed up for the state's subsidized insurance plan last month, bringing the total to 115,418, the Commonwealth Health Insurance Connector announced today.

The bulk of the enrollees in the Commonwealth Care program are getting full subsidies, but more than 22,000 are required to pay small premiums.

In addition, 7,164 people now have insurance through a separate, unsubsidized program, called Commonwealth Choice. Seventy percent of those people have chosen plans offered with lower than market premiums, most of which have coverage limits or high deductibles.

By Liz Kowalczyk, Globe Staff

The number of Massachusetts residents without health insurance dropped to 355,000 this year, down from 395,000 last year, according to a newly-released state survey. The overall uninsured rate fell to 5.7 percent, from 6.4 percent.

Massachusetts officials said the drop indicates that the state's new mandatory insurance law is beginning to work.

"This is a clear indication that health reform is succeeding, '' said JudyAnn Bigby, state secretary of Health and Human Services. "Even in the early phase of the law's implementation, these findings confirm our success in reducing the number of uninsured people across the entire Commonwealth.''

The Center for Survey Research at UMass-Boston called 4,000 homes between January and June of this year.

On Running a Hospital, Beth Israel Deaconess Medical Center CEO Paul Levy compares the participation of other Harvard teaching hospitals in the search for a new chief of OB/Gyn at his hospital to asking Toyota, Honda, General Motors and Chrysler to sit in on Ford's hiring process for a new division manager.

"What would be odd elsewhere is the norm here at the Harvard hospitals," he writes about the search to replace Dr. Benjamin Sachs, who is leaving to become dean at Tulane Medical School. "The Harvard medical system has an odd assortment of customs and norms. One of (the) oddities surrounds the search for a chief of any of the clinical departments at BIDMC, MGH, Brigham and Women's, Children's Hospital, and the other Harvard affiliates."

On WBUR's CommonHealth, Lynn Community Health Center's Lori Abrams Berry asks what happened to the idea of medical home as the state's new healthcare law gets implemented.

"No one should ever be auto-assigned away from an existing primary care relationship," she writes about people who did not choose a plan. "That is not what healthcare reform is all about."

By Alice Dembner, Globe Staff

The Boston Public Health Commission today launched an effort to help the uninsured -- and particularly Latinos -- sign up for new health coverage.

Multilingual staff at the commission will be available all day Thursday at its 1010 Massachusetts Ave. offices to aid individuals and also to train healthcare providers in the enrollment process. In addition, the commission will host enrollment days from 9 to 11 every Wednesday this year at Boston Public School family resource centers in Roxbury, Roslindale, Dorchester and East Boston.

Barbara Ferrer, the commission’s new executive director, announced the initiative at the Dominican Festival in Jamaica Plain, saying in Spanish that she wants to “knock down any barriers that stand between residents and the doctor’s office.”

In Boston, fewer Latinos have insurance than any other ethnic or racial group, according to the commission.

By Alice Dembner, Globe Staff

Nancy Turnbull, an insurance expert who helped shape Massachusetts’ landmark health coverage initiative, is joining the board overseeing implementation of the experiment.

Attorney General Martha Coakley today appointed Turnbull to the unpaid board of the Commonwealth Health Insurance Connector.

Turnbull, who advocated for the full insurance coverage as president of the Blue Cross Blue Shield of Massachusetts Foundation, recently stepped down from that post to become an associate dean for educational programs at the Harvard School of Public Health.

On Nature Network Boston, M. William Lensch, a scientist at Children's Hospital Boston and the Harvard Stem Cell Institute, writes a mournful entry about the gap created when researchers must depend on small foundation grants now that government funding of science -- which helps pay for a sponsoring institution's overhead -- is shrinking. It's a new version of the "valley of death" between academic research and commercialization of a discovery.

"With private grants ... you might be paying for all your own reagents but you are not paying your share for the bench space you have, the light shining down on it, or the salary of who sweeps the floor around it relative to someone with the same amount of grant support from the NIH," he writes. "Dig? Here’s where the Valley of Death comes in."

On WBUR's CommonHealth, John E. McDonough of Health Care For All outlines the predicament facing Massachusetts as it expands access to coverage while costs rise. He questions the objectives of the state Quality and Cost Council, created by the healthcare law.

"The set of goals embraces a popular hypothesis in health policy -- that if we just get quality right, given the documented amount of clinical waste in our system, that’s the magic pill to cure our cost disease. Wouldn’t it be luverly?" he writes. "What if this hypothesis is wrong? What if we do everything quality-wise and costs still rise at destructive, unsustainable rates? Are we willing to consider "R" word - regulation?"

A report out today flags some of the big issues that could hamstring Massachusetts’ health insurance initiative – affordability, affordability, affordability.

The issue brief from the nonpartisan Center for Studying Health System Change is based on interviews with 25 observers – employers, state officials, insurers and advocates – done in January and updated in June.

The cost of insurance could keep both small employers and individuals from buying, the report asserts, leaving the results far short of universal coverage.

"Places like sandwich shops and auto repair companies are not embracing the reform," the report says, quoting an unnamed insurance broker.

In addition, rising costs could make the initiative unaffordable for the state, particularly if the economy sours, the report points out. And it questions whether the agency set up to implement the effort – the Commonwealth Health Insurance Connector – will add significant administrative costs to the total.

"At what point do the costs to the state getting one additional individual insured outweigh the benefits?" the report asks.

By Elizabeth Cooney, Globe Correspondent

Just when the new healthcare law in Massachusetts is expected to send more people to doctors’ offices, the state’s shortage of primary care physicians continues to be critical, according to a physician workforce study released today.

For the second year in a row, family practice and internal medicine doctors are harder to find, both for patients seeking appointments and for hospitals and group practices trying to recruit them, according to the sixth annual survey conducted by the Massachusetts Medical Society.

"Supply and demand are both going in the wrong direction," Dr. B. Dale Magee, the society’s president, said in an interview. "With the new healthcare reform law, we anticipate that the demand for physician services is going to increase, not only across the board, but especially for primary care physicians."