PROVIDENCE – In advance of the show and tell hearing about the consequences to Rhode Island from the repeal of the Affordable Care Act held on Feb. 7, Al Charbonneau, executive director of the Rhode Island Business Group on Health, the advocacy arm of the health insurance industry in Rhode Island, shared with ConvergenceRI a tip about the upcoming RIBGH legislative breakfast, scheduled for March 24.

Do you know what the biggest cause of health cost increases is? Charbonneau asked, in rhetorical fashion.

ConvergenceRI decided to play: “Drug prices?”

Charbonneau shook his head no.

“Growing utilization?”

Once again, Charbonneau shook his head no.

“Investments in health IT systems?”

Charbonneau shook his head no a third time, adding: health IT costs can be depreciated over five years’ time

The reason, Charbonneau answered, was the high administrative overhead at hospitals.

“Really?”

You need to keep an open mind about this and come to the breakfast, Charbonneau urged.

ConvergenceRI walked away, thinking: was the same also true for health insurers?

Pendulum shift
The cause and effect of what happens in health care, and why, is still at the center of an economic debate about who pays, who is at risk, and who profits, both here in Rhode Island and nationally.

There is often a somewhat predictable cast of characters at the table: insurers, hospitals, health agencies, providers and lobbyists, with the conversation centered how the future pie of financial resources gets divvied up, with the goal of reducing costs.

What patients want and need for health care, prevention and wellness, and what communities need to become healthier places to live, is often not on the agenda and not part of the discussion.

Efforts to reform how payments are made, moving from fee-for service to accountable entities, with bundled payments for a continuum of care, may get short-circuited by what happens if and when Obamacare is replaced by Trumpcare.

Here in Rhode Island, the pendulum appears to be shifting, in concert with efforts to respond to the consequences of the new Trump administration.

Newly empowered progressive legislators such as Rep. Aaron Regunberg, seeking to push the boundaries of what can be accomplished in the R.I. General Assembly, are leading the charge for a new law to create earned sick time for all workers in Rhode Island, pushing an economic solution to a health care problem from the ground up, not the top down.

Orchestrated comments
While many other Rhode Islanders were braving the cold rain to attend the rally celebrating the Super Bowl-winning New England Patriots at The Dunk on Feb. 7, including Gov. Gina Raimondo, a small crowd of health care experts were gathered in the Senate Lounge at the State House to listen to testimony offered by the Raimondo team before the joint hearing of the Senate Finance and Health and Human Services committees about the “future of Affordable Care Act in Rhode Island.”

In orchestrated fashion, Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, Kathleen Hittner, R.I. Health Insurance Commissioner, Zack Sherman, director of HealthSource RI, and Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, presented a succinct overview of the accomplishments of Obamacare in Rhode Island:

• More than 100,000 Rhode Islanders gained coverage, dropping the number of uninsured from 12 percent in 2013 to 4.5 percent in 2015.

• About 73,000 Rhode Island adults, ages 19-64, without dependent children and with incomes below 138 percent of the federal poverty level, were now covered through Medicaid expansion.

• The promising early outcomes as a result of the Medicaid expansion included a 12 percent drop in inpatient days, a 6.4 percent drop in ER visits, and a drop of 8.8 percent in the number of people using the ER in lieu of seeing a primary care provider.

• Rhode Island enjoyed relative market stability and avoided steep average premium rate increases seen in other states.

In turn, if the Affordable Care Act were to be repealed and/or replaced, there were many parts of the current health care system that would be at risk:

• There would be a destabilized risk pool for insurers and a loss of insurance coverage for individuals, as well as economic uncertainty for providers and projected economic losses for the state.

• Annual and lifetime coverage for essential health coverage would be at risk, including parity coverage for mental health and behavioral health.

• Some $8 million in federal funds granted to R.I. Department of Health from the Prevention and Public Health Fund would be at risk, including support of diabetes prevention, heart disease and stroke prevention, epidemiology and laboratory capacity, and immunization programs.

Asked and not quite answered
Sen. Josh Miller, chair of the Senate Health and Human Services Committee, interrupted testimony by Dr. Kathleen Hittner to pose a prescient question: if the Affordable Care Act was repealed, would the state be in a position to offer a public option as a health insurance package?

Hittner said that without federal funds, it would not be possible, because there were not enough current state resources to do so.

In response to a similar question by Miller, about the capability of the state to guarantee reproductive health services for women if the Affordable Care Act was repealed, Hittner answered the same way: the state could enact such protections, she said, but there were not enough state resources to provide such services without federal funds.

The unanswered part of both questions was this: what additional state resources would be required to create a public option and to guarantee reproductive health services for women? And, were the state’s elected officials willing to invest resources to do so?

Market competition
When asked if the costs of health insurers to sell products across state lines would lower costs, Hittner cautioned against such products because they would be impossible to regulate; services and plans and networks offered in another state could not be regulated by Rhode Island, offered scant consumer protection.

When asked about the reasons behind UnitedHealthcare’s withdrawal from the Rhode Island exchange and efforts to open the market up to other insurers, Roberts said that the question required a legislative answer; it was not something that could be decided by agencies. Roberts also said that Rhode Island was lucky to have two stable nonprofit insurers, Neighborhood Health Plan and Blue Cross & Blue Shield of Rhode Island, participating fully in the individual market.

Earned sick time for all
Earlier that afternoon, a crowd about three times the size of that attending the Senate hearing gathered on the first floor of the State House in the Bell Room for the official launch of the Earned Sick Days legislation in the R.I. General Assembly.

Under the legislation, “all employees in Rhode Island shall accrue a minimum of one hour of paid sick and safe leave for every 30 hours worked, up to a maximum of 56 hours per year, unless the employer chooses to provide a higher annual limit.” That translates into a full week’s worth of earned paid sick leave.

Sen. Maryellen Goodwin and Rep. Aaron Regunberg, the sponsors of the bill, spoke before a crowd of about 60 supporters, with a bevy of legislative co-sponsors standing behind them.

Georgia Hollister Isman, director of Working Families, spoke first, introducing the thinking behind the “Healthy and Safe Families and Workplaces Act.”

“Earned sick days are an essential and basic protection that every single family needs,” she said. “But 41 percent of working men and women in Rhode Island don’t have access to even one paid sick day.”

Everyone, Isman continued, get sick, whether you have earned sick time or not. “Everyone should be able to take care of themselves and their loved ones without fear of lost income or even fear of a lost job.”

The people in Rhode Island who currently do not have access to earned sick time, Isman said, were disproportionately people of color, low-wage workers, and workers in food service industries, with the risk of spreading disease “to all of us.”

“Without paid sick time, these employees go to work sick, and they send their kids to school sick,” Isman said. “We are here today because this is a problem that we can solve.”

Not revolutionary
Regunberg spoke next, saying that the law to create earned sick time in Rhode Island was not revolutionary, nor should it be controversial.

“All we’re doing is stating a basic, boring truth: everyone gets sick sometime,” he said. “And, when you get sick, or a loved one who you care for is sick, you should be able to take a day off from work to care for yourself or for your loved ones. Yet, this is a fundamental security that many Rhode Islanders have no ability to access.”

Regunberg continued: “We are better than this as a society,” adding: “We can make a concrete difference. There is absolutely no reason to wait to pass this legislation. Let’s do it.”