Healthcare in Delaware can be improved
By C.D. Casscells, MD (pictured)
Director of the Center for Health Policy
(Originally published on Sunday, December 12, 2021 by Delaware State News.)
For multiple decades the people of Delaware have had limited access to healthcare at an expensive cost, with quality outcomes below the national average. According to a 2019 Health Affairs article published by former secretary of health and social services for the state of Delaware, Kara Odom Walker, MD, "Delaware may continue to be an expensive place for health care due to its market size and limited competition, and additional tools to reduce unnecessary costs and focus on waste may be critical."
How can this be? Delaware is one of the most sophisticated regions of medicine in the world. Delaware is not a remote outpost in Siberia, although many of our problems mimic those of the sparsely populated state of Alaska.
How can Delaware begin to fix this?
Let's start by:
- allowing Delaware citizens and businesses to buy health insurance from our neighboring states (Pennsylvania, New Jersey, Maryland, and Virginia);
- allowing the reciprocity of medical and nursing licenses from our neighboring states;
- decommissioning the Health Resources Board (HRB) and its failed oversight Delaware Health Care Commission (DHCC) and eliminating the Certificate of Public Review (CPR) program once and for all.
According to its own 2020 internal and public polling, the HRB and its CPR program are dysfunctional. By any measure, both the DHCC and the HRB have failed their purpose.
The necessary outcome of these simple measures would be to introduce competition in healthcare for quality, cost, and access to the existing monolithic hospital systems and Highmark, the only insurance carrier in Delaware.
To decline to make these restorative market measures will simply further guarantee the consolidation of our healthcare financing and delivery into a monopoly of Highmark, ChristianaCare, and Bayhealth, with the expectation of the predictable rise in everyone's cost, limitation of access to both rural and underserved inner-city Medicaid populations, and no incentive to have better outcomes.
In short, a failure to act now virtually ensures a deterioration of Delaware's public health.
BACKGROUND: In June 1990, Delaware established the Delaware Health Care Commission (DHCC) to oversee the growth of healthcare services and to solidify the "Triple Aim" goals in healthcare for higher quality outcomes, lower cost, and better access. DHCC had also established the Health Resources Board (HRB) Certificate of Public Review program "to regulate the number of beds in hospitals and nursing homes and essentially prevent excessive purchasing of expensive equipment." However, this has not achieved the Triple Aim goals initially set forth. Instead, anticompetitive monopolistic practices have continued in the health insurance industry and the hospital healthcare delivery system.
The predictable result has been no overall improvement in the quality of outcomes with a generalized deterioration of the metrics of Delaware public health, a consistent increase in cost over the national increase, and no improvement in access to care through the consolidation of hospital services.
When the DHCC was formed, Delaware had multiple health insurers, with a directive to the Insurance Commissioner that there always should be at least three choices in the state for both employers and individuals. However, the inaptly named Affordable Care Act ended that. All of the other major insurance carriers left the state, leaving only Blue Cross Blue Shield of Delaware (BCBSDE), which was chartered here and could not leave, and Delaware's Medicaid partnership with the federal government, which serves only as a broker to companies to manage the state's Medicaid. Self-insured entities were mainly unaffected.
Having violated a semisacred principle of a choice of three major carriers, Delaware promptly declared that we only needed two choices and that the state itself counted as one of the choices. BCBSDE gave itself to Highmark Blue Cross Blue Shields as the last man standing, preserving its charter and improving purchasing power through consolidation.
Why did everyone else leave the Delaware marketplace? Because it was too expensive, and the liability of insuring Delaware's not so healthy population was not likely to be profitable. To include in their network of providers ChristianaCare and Bayhealth systems and their fees schedules were too expensive. And they could not sell their insurance product without including those hospitals.
The HRB, through its duplicative licensing process, the CPR program, served to intimidate out-of-state hospital provider systems from entering the marketplace, which was just fine with the DHCC, whose makeup resembles a healthcare industry lobbying group. Meanwhile, the Insurance Commissioner was incapable of attracting other health insurers to the Delaware market, often remarking that there is nothing they can do to make insurers come to Delaware, which is, of course, the identical response from our legislators.