History and Current Landscape
There are primarily 3 payment models for health insurance: “Fee-for-Service”, “Single-Payer (Universal/Medicare for All)”, and “All-Payer”.
Since the 1970s, Maryland has operated an “All-Payer” system, which requires hospitals to charge the same price for each service, thus forcing them to compete with other hospitals on price. This has been proven to not only to increase quality of care provided to patients, but also give hospitals flexibility to invest in care improvement (by providing them predictable revenue streams). Since 2014, it has slowed hospital costs and reduced readmission rates by more than 8% (readmission rate is an important quality measure that shows patient care doesn’t end with a hospital discharge).
In 2018, Maryland expanded the “All-Payer” model to the “Total Cost of Care” model — bringing non-hospital healthcare providers into the mix. Rather than focusing on how hospitals, alone, can deliver efficient and high-quality care, private physician practices, nursing homes and mental healthcare providers will be incentivized to improve how they coordinate care for their patients. This will show other states how to successfully reward quality of care, rather than quantity of care.
As a cancer survivor, someone who works at a healthcare non-profit, someone who previously worked as the Associate Director of External Affairs at the U.S. Department of Health and Human Services and as then Vice-President Biden’s Director of Outreach for the Cancer Moonshot, affordable healthcare is a personal issue.
I want everyone to have access to affordable and high-quality healthcare. That’s why I support building upon the Affordable Care Act.
Thankfully, millions of Marylanders already have private health insurance through their employers. Under the ACA and the ACA health exchanges, private insurance companies often compete under tight regulations, offering a variety of plans for those wanting health coverage. It’s proven to work by lowering premiums and out-of-pocket costs; increasing the number of competitive private insurers; and ensuring there’s no exclusions for pre-existing conditions, no lifetime limits on benefits, and expansions on coverage to folks until the age of 26.
For those who don’t have and/or can’t afford private health insurance, I believe the most efficient solution would be to improve upon our state’s current “Total Cost of Care” model. From increasing Medicaid eligibility to expanding public healthcare supply, there are many cost-effective, tangible, and practical steps to take to make universal coverage a reality in our state.
Medicaid Eligibility Expansion
- Nearly 350,000 Marylanders do not have health insurance, and over 100,000 of these people are not even eligible to receive Medicaid, a federally and state-funded healthcare subsidies program designed to help cover those with financial hardships.
- This significant gap in eligibility is primarily created by state-specific income limits that place extreme caps on how much money a household can make before being rendered ineligible for Medicaid. In Maryland, that income limit is just 138% of the Federal Poverty Level (FPL), which amounts to approximately $17,800 for a one-person household. This income limit is a policy disaster, as hardly any full-time workers in Maryland who earn the state minimum wage of $11.75/hour would be able to qualify for Medicaid, despite making less than $25,000 a year.
- To make matters even worse, undocumented immigrants are technically barred from Medicaid eligibility entirely, because they fail to meet federal immigration status requirements. These flaws in our healthcare system will inevitably continue to lead to needless suffering and increased medical debt.
- Raise Maryland’s Medicaid income limit to 200% of the FPL, which would correspond with approximately $25,800 for a one-person household.
- This would help ensure that nobody slips through the cracks and misses an opportunity for meaningful health coverage, because it would more comprehensively bridge the gap between those who can and cannot afford health insurance.
- Another crucial solution to this problem would be to expand the Emergency Medicaid ‘loophole’ that already enables periodic, selective coverage for undocumented immigrants.
Unlike other policy proposals, this one does not inherently entail additional costs:
- This policy purely expands Medicaid eligibility for those who desire it — instead of automatically enrolling people and increasing spending;
- It will not only help us reduce healthcare costs in the long-term, but the lion’s share of this financial burden will still belong to the federal government.
As Governor, I will work to expand access to the underserved and underinsured by creating a new “Health Enterprise Zones Program” to boost funding for healthcare programs in lower-income communities and majority-minority areas.
This program would build on what Governor O’Malley conducted and work something like Economic Enterprise Zones (where businesses receive subsidies to create jobs and activity in certain areas). While the initial program funding was expired by Governor Hogan, I will revitalize it and provide loan assistance, tax credits and/or assistance in installing health technology with any primary-care practitioner willing to participate, especially those in areas with higher disparities.
Invest more in Community Health Clinics
Community health centers increase the availability of healthcare for all residents — especially those in lower-income and rural communities. These clinics not only provide preventive services (like screenings, pap smears, mammograms) to vulnerable populations that would otherwise not have access to them, but studies have shown that by increasing local access for these patients, hospitals have fewer costly-emergency room visits.
As such, we need to designate more state grants to serve community clinics and need to protect Medicaid reimbursements for these clinics (since Medicaid reimburses clinics on a per visit basis, it frees up clinics to use federal/state grant revenues to increase care for the uninsured rather than use funds to subsidize care for Medicaid patients).
- Enshrine essential healthcare services (like abortion care, contraceptive coverage and gender affirmation treatment) in our State Constitution
All women, girls, and other gender variant people — regardless of their zip code, identity or economic status — should have safe, affordable access to the healthcare they need.
- Direct our federally funded Medicaid to cover all essential healthcare services (like abortion care, contraceptive coverage and gender affirmation treatment)
This will ensure all our residents — especially in our low-income and rural communities — gain coverage for critical health services.
- Require all public schools to have comprehensive sex-ed in health classes
Students must learn about everything from abstinence to contraceptives, to period poverty, to domestic violence, to LGBTQ inclusion, gender identity and reproductive rights.
- Require all public schools to provide free menstrual products in bathrooms
If toilet paper can be free for all students, so should menstrual products. And while most of our school budgets cover these expenses, these products are often kept in the nurse’s offices. We need to, instead, make these available in the restrooms.
- Expand availability of medication abortion
Medication to induce an abortion is generally taken within the first 10 weeks of pregnancy and considered very safe and less expensive than surgical abortion.
As such, we should ensure that pharmacists (who are the most accessible and affordable provider for residents in low-income and rural communities) keep stocks of mifepristone (one of two drugs used for medication abortion) on hand, and can dispense the medication with a prescription.
- Expand lactation accommodations for new mothers
Similar to what they achieved in Baltimore, we must ensure that — statewide — employers provide lactation accommodation for new mothers (i.e. a private lactation space that isn’t a closet, with a lockable door, place to sit, surface to place equipment and a fridge for storing breast milk).
Ease Medical Debt
No one should go bankrupt trying to pay for medical bills.As such, I support efforts to protect hospital patients struggling with medical debt.
One solution is to expand the eligibility for hospital-provided financial assistance — and ensure patients are aware of these programs.
Another solution is to ensure the methods that hospitals use to collect their unpaid debts are not predatory in nature (ex. restrict their ability to pursue liens on a patient’s home or garnish their wages).
There’s often a HUGE stigma in communities of color to address our mental health. Oftentimes, it’s “weak” to share emotions or seek help. Furthermore, we are often so preoccupied with fulfilling our immediate physical needs (like safety, food, shelter, employment) that we don’t prioritize our emotional needs. Ironically, however, we make it more difficult to cope with the demands of daily life if we don’t address what’s happening in our minds and hearts.
Many don’t talk about their mental health because they fear being judged or labeled “crazy” or “weird”. But these labels persist only because people don’t share their challenges enough and don’t use the appropriate language when discussing mental health issues.
That’s why I share my own mental health struggles —and times when I was depressed and felt suicidal. And that’s why I talk about the need to make it easier for all Marylanders to have access to the full spectrum of healthcare services.
That includes investing in more trained mental health professionals — in schools and our criminal justice systems — who can deal with issues ranging from depression, to substance abuse to suicide prevention. It means treating drug use and addiction for what it truly is — not a crime that can be corrected with punishment, but a public health crisis requiring support for those suffering. It means dedicated funding for non-profits and rehab centers that address this issue for those that need help, as well as working with local agencies and leaders to increase access to necessary resources. And it means building supportive and open communities and take care of our neighbors when they are in need.
Create a Caregivers Program
While we help our seniors age-in-place — and support our residents who have a disability — it’s also important to assist their caregivers and reduce the burden of family care.
I believe we should model a program in Maryland that is similar to the Kupuna Caregivers Program in Hawaii, in which the state helps offset some of the various costs associated with long-term caregivers (many of whom are women who are forced to leave the workforce to care for their family members).
In Maryland, I would ensure residents who work 40 hours or more a week outside the home — and who serve as the primary caregivers — are eligible to enroll and eligible to receive $50-$100 per day to help cover some of the costs associated with hiring at-home direct care staff.
In doing so, we will not only help reduce the burdens of family care, but we will also help increase the number of in-home caregivers.
Reduce the cost of prescription drugs
Not only are drug prices out of control, but they disproportionately affect low-income and minority communities.
As such, I will work with our newly created, independent Prescription Drug Affordability Board — to see what specific legislative efforts we can support.
Clean Drinking Water
The issues faced by residents in Flint, Michigan may have generated national attention (rightly so), but are closer to home than we may appreciate.
Maryland was one of the top 5 states with the fewest policies protecting residents from unhealthy levels of nitrate in water from private wells. As such, there have been unhealthy levels of nitrate in drinking water in the Eastern Shore, resulting in some residents facing health problems. Nitrate pollution also disproportionately affects minority, low-income families, demonstrated by the fact that Wicomico and Worcester Counties have higher proportions of people living in poverty than the state average.
Unfortunately, neither boiling nor chemical disinfectants can remove nitrates from drinking water. With most Eastern Shore residents relying on private wells for drinking water, we need to set stricter safe drinking water standards and testing for private wells. Currently, water from Maryland private wells are only required to be tested at the time they are constructed, and the state does not offer financial assistance for well water testing or notify private well owners when there is known contaminated groundwater nearby. In fact, Maryland was one of the top five states with the fewest policies protecting residents from nitrates in private well drinking water. This is unacceptable and must be addressed!
Assist our Veterans
Currently, the primary option to help veterans who are facing mental health issues or contemplating suicide is the VA’s 24-hour Veterans Crisis Line. In my opinion, however, this is not a sincere way to help our veterans, nor is it a long-term solution.
Instead of telling them to call the crisis line and then find a way to get to the hospital, we should take the responsibility and meet them where they are. Similar to a new program started in LA, we should require local law enforcement who respond to emergency calls or check on veterans who have missed therapy appointments to dispatch not only officers, but also social workers. I have addressed investing more in mental health professionals in the Criminal Justice section.
Improve In-Home Care
Home based services provide opportunities for Medicaid participants to receive services at home. It’s an issue I actually currently work on in my day job at the National Kidney Foundation. This especially helps those who are immunocompromised, seniors and those with disabilities who physically can’t leave their homes, and those in rural communities who can’t get to a more formal setting. We must protect and expand funding for these programs.
We must encourage healthy eating. Typically, those living in low-income neighborhoods lack access to fresh produce; they live too far away from full-service groceries; they’re poorly served by public transit; and what they have is limited to what smaller convenience stores carry.
Furthermore, living in a food desert can also lead to other challenges like high rates of obesity, diabetes and heart conditions, which are compounded by the fact that many underserved neighborhoods lack recreational opportunities and have poor air quality.
We should offer grants, loans and tax incentives to grocers willing to open stores in underserved and impoverished areas.
We must also increase awareness and education of the federal SNAP program and local organizations like the Maryland Food Bank.
Paid Family/Medical Leave
Maryland currently has no laws requiring employers to provide this. But another key part of employee well-being is ensuring all workers have paid leave. This ensures that should there be a personal or family emergency, they do not risk getting fired or becoming forced to choose between their emergency and their source of income.
This is why I am in strong favor of creating a Paid Family Leave Insurance Fund for all businesses to guarantee all workers up to 12 weeks of partial wage replacement should they need to take a leave for personal or familial reasons.
We need to treat drug use and addiction for what it truly is — not a crime that can be corrected with punishment, but a public health crisis requiring support for those suffering.
Criminalizing opioid addiction disproportionately affects low-income communities, indigenous communities, and communities of color. We can move past the scourge of drug use in our communities across Maryland, but we need to do it through support for those most in need, rather than pushing those in need to have to hide their problem.
While we should not legalize scheduled drugs (like cocaine, heroin and meth), we need to decriminalize the possession of them for personal use. Instead of criminally penalizing these individuals, we must send them to rehab centers to address the addiction directly.
This will allow drug users to get out of the shadows and seek help.
And as outlined in my Criminal Justice policy memo, I support dedicated funding for non-profits and rehab centers that address this issue for those that need help; as well as working with local agencies and leaders to increase access to necessary resources.
As we move forward, we must learn from our mistakes that brought us to the opioid crisis. We need to build supportive and open communities and take care of our neighbors when they are in need. This starts by having government institutional structures that can provide these resources and set that example — something I fully intend on building out as Governor.
Support for Nursing Homes and Assisted Living Facilities
Currently, there are no requirements for direct care staff in these facilities to be appropriately licensed and trained as Nursing Assistants; and the resident-to-staff ratios are unreasonably high.
Not only have these issues proven to decrease the quality of care provided to the residents of these facilities, but they have also provided extra stress and strain on the staff. We need to do better and reform the system in which we take care of our nursing home community.
The most effective and tangible solution to resolving some of these issues is by reforming the “Oversight Committee on Quality of Care in Nursing Home and Assisted Living Facilities”.
This committee was established in 2018, but needs better oversight. It only meets once every three months and has typically had issues drawing a quorum. This is why I would amend the Committee’s mandate to establish transparency requirements, regular meeting requirements, and annual progress reporting to the Governor’s Office.
Increase access to Childcare
To tangibly improve access to childcare for parents and families, we must first understand that many of the privately run childcare providers are women-owned businesses.
As such, by partnering with these practices when it comes to implementing Universal Pre-K (i.e. instead of building new classrooms, partner with childcare providers to use their existing rooms); expanding the Childcare Credential Program (which provide tax incentives to those providers who comply with regulations that keep our children safe); and providing these providers better financial security through my “Maryland Now Plan”, we can finally bring immediate results to parents and children across our state.
Increase Access to Tele-Health
Tele-health not only helps healthcare providers maintain a healthier work/life balance, but it removes many of the barriers that typically cause patients (especially those living in more rural and underserved areas) to be unable to receive healthcare — such as distance from providers, access to transportation, the time between visits, and availability of providers.
A recent NIH study also found that increased telemedicine resulted in fewer hospital admissions, re-admissions and savings over inpatient care costs for hospitals, providers and patients, alike.
As such, one tangible and specific way we can increase access to Tele-health is to include audio-only phone calls as part of telemedicine.
Currently, telemedicine does not include an audio-only conversation between a health care provider and a patient (instead relying on both audio and visual). By removing these restrictions, patients in rural areas and those with insufficient broadband access can still receive proper care and attention.
Invest more in Clinical Research
Clinical research improves the ability of healthcare professionals to treat patients with the highest standards of care. Medical research also brings money into the economy and brings medical positions into the job market.
As such, increasing investments — and public awareness — into clinical trials will not only improve the job market for healthcare professionals, but also provide better treatment options for patients who need medical care.
Increase awareness of Advanced Directives
This “end-of-life” policy makes it easier for patients to discuss what procedures they would want to be done in case they become unable to provide consent.
In 2016, Medicare was expanded to provide reimbursement to pay doctors for providing end-of-life counseling — which empowers individual patients to make decisions about their own lives, and costs the system less. But we should make these forms more accessible to patients and easier to complete (i.e. make these advanced directives electronically available).