Health care was a clear priority for voters in the 2018 midterm election. The urgency of the issue had much to do with bringing a national blue tide and a decisive blue wave here in Minnesota.
With the governor's office and the Minnesota House now under DFL control, Minnesota Republicans have only a one-vote margin in the Senate to serve as any kind of breakwater.
So what kind of health care reform voyage is ahead for the North Star State during the 91st legislative session that starts in January?
Both parties are responsible for steering the state into treacherous waters on this issue. Democrats must now largely chart a safe course forward. It is a matter of life and death for many. It will require a careful balance of good policy and smart politics.
Medical expertise in government is a plus, and over the years the Legislature has counted nurses and other health professionals among its members. But except for 21 physicians who served Minnesota during its first decade as a territory and state in the mid-19th century, few medical doctors have served in the Legislature.
That is changing. Two physician senators were elected in 2016. Matt Klein is an internist and DFLer from Mendota Heights. Scott Jensen is a family practitioner and Republican from Chaska. In November, two new "doctors in the House" were elected and will join the "doctors caucus" in January.
Both are DFLers who unseated GOP incumbents in suburban swing districts. Rep.-elect Alice Mann is a family practitioner who won her Lakeville/Burnsville district by 5 percentage points. Rep.-elect Kelly Morrison is an OB/GYN who won her tight race in Minnetonka by only 216 out of 20,000 votes cast.
Campaign websites for Mann and Morrison made it clear that health care was a priority. But they didn't woo voters with visions of BernieCare. Each called for "quality affordable health care." Morrison supports a universal buy-in option for MinnesotaCare at what she describes as "market rates."
It is notable that all four physician-legislators are practicing primary care doctors. They will bring a valuable perspective to the Legislature from their continued work in the clinical trenches on behalf of their patients.
Gridlock is not an option this session. The physician-legislators and their colleagues are ready to operate.
A large DFL House majority (75-59) and a narrowly GOP Senate (34-33) will need to work with the new administration of DFL Gov.-elect Tim Walz to write a health reform prescription for Minnesota. What might that look like?
Walz and Lt. Gov.-elect Peggy Flanagan are clear about their ultimate desire for a single-payer system. As a first step, they want to offer the option of buying into MinnesotaCare to all 5.7 million Minnesotans. But their winning progressive populist campaign promises now face the truth and reality of hard policy choices.
The truth is that "free" health care is the most expensive kind. The reality is that the current system is in the stranglehold of managed-care organizations that won't voluntarily give up control. But the Walz administration has to start somewhere. Since the MinnesotaCare buy-in is the plan, let's exam the program.
Currently, MinnesotaCare is a relatively small public plan that covers lower-income people who do not qualify for Medical Assistance (MA). This includes 88,000 people, less than 1/10th of the more than 1 million Minnesotans who are now covered by MA. The $400 million of funding required for MinnesotaCare is dwarfed by the $11 billion in federal and state Medicaid spending each year.
Though more than 50 percent of Minnesota Medicaid funding comes from Washington, a whopping 88 percent of MinnesotaCare depends on federal largesse. The small but significant state share of the cost comes from a 2 percent provider tax and a 1 percent managed-care tax — both scheduled to expire at the end of next year.
It is clear that the MinnesotaCare buy-in option faces major funding challenges.
The other big question is how the public money will flow. MinnesotaCare funds, just like MA dollars, flow from the state Department of Human Services (DHS) to managed-care organizations (MCOs) through bid contracts awarded to UCare, Blue Cross, HealthPartners and others. Expenditures are made monthly and are referred to as PMAP payments (prepaid medical assistance). The MCOs then pay providers — doctors, clinics, etc.
A major provider objection to MinnesotaCare expansion is that public programs pay significantly less for care. This may not be because of inadequate funding from DHS. An example of the uncertainty is in the MCOs' lack of transparency and accountability for the $450 million spent each year through MA on maternity and newborn care. Care for more than 29,000 mother-baby pairs each year would be improved by knowing how (and if) the MCOs spend the public's money.
Expansion of MinnesotaCare seems a simple solution, but the devil is in the details — especially the all-important question of who will pay the large new bills. And can we trust a massive expansion of the public health care system to a state government that, a 2016 Legislative Auditor report said, misspent $200 million on existing health programs while struggling to provide something as basic as auto license tabs?
These challenges are formidable, but they do not mean a meaningful reform compromise is impossible. GOP Senate Majority Leader Paul Gazelka's refusal to support "government-run health care" doesn't mean the GOP will oppose all proposals to provide fiscally responsible universal coverage, at least for catastrophic medical needs. A legislative physician is on call in the narrowly divided Senate.
Sen. Scott Jensen is a principled maverick who has made it clear that he serves his constituents rather than his GOP caucus. He is clearly not afraid to color outside narrow partisan lines. Don't be surprised if Jensen and Republican Sen. Jim Abeler of Anoka (a chiropractor and fellow maverick) convince their GOP colleagues to support carefully crafted, fiscally responsible health care reform measures.
The ideas include progress toward universal insurance coverage using an innovative extension of premium tax credits championed by DFL Sen. Tony Lourey of Kerrick. The subsidies for individual market insurance would be based on income and would be available through the MNsure exchange.
Skyrocketing drug prices might also be addressed with a new drug affordability board as well as a ban on pharmacist gag clauses that prevent disclosure of the lowest possible prices.
One caution: A viable bipartisan health care bill would require that a truce be called in the ongoing culture wars. DFL politicians effectively control the legislative agenda. They can continue to "stand with Planned Parenthood." But if they inject advocacy for abortion or physician-assisted suicide into health care reform efforts, it will be legislatively lethal. These life-and-death issues are incredibly important, but, if dealt with at all, they should be addressed within standalone bills.
Health care sound bites come easy during campaigns, but reality cannot be ignored. Health insurance coverage does not equal health care. Someone has to pay for someone to provide care, and it really matters how payments are made. Transparent innovation will prevail, and eventually more efficient bundled payments will bury fee-for-service in a reformed system.
Health care reform in the 2019 Minnesota Legislature will require expert political navigation by the governor, the House and the Senate. Dangerous partisan currents and sharp economic rocks could easily sink hopes. But I am confident that the new "physician caucus" will play a key role.
I look for them to work across the aisle with colleagues to provide the solutions that University of Texas Prof. Bill Sage describes as the necessary "fracking of health care." It won't be easy. The bold changes that are needed will be opposed by powerful entrenched interests, including drug companies, hospitals, provider groups, plaintiffs' attorneys, managed-care organizations and within the state bureaucracy. But the outcome will be higher-value patient-focused care that preserves choice while protecting every Minnesotan from medical bankruptcy.
Steve Calvin is a Minneapolis physician and medical director of the Minnesota Birth Center.
