The Register Citizen (Torrington, CT)
Unexpected events shaped state’s health policy
Looking back, the eight years of health policy under Gov. Dannel P. Malloy’s administration resembles an obstacle course.
Many of the Malloy administration’s health care policies and budget decisions were reactions to events outside of the governor’s control, circumstances that took hold before he took office, or conditions handed down from the federal government.
His legacy in health policy, and the challenges Gov.-elect Ned Lamont will inherit, can be assessed in terms of Malloy’s handling of these challenges.
The outgoing governor’s two terms nearly dovetailed with the rollout of the Affordable Care Act, the federal health care law that expanded insurance coverage to millions of Americans and boosted federal funds for health care programs.
Connecticut’s early decision to expand Medicaid under Obamacare to more than
200,000 poor adults has had a positive effect on that population’s health, the state’s uninsured rate, and the program’s per-person costs.
But it also created a new set of regulations and funding mechanisms for Connecticut to navigate, and Malloy’s enthusiastic embrace of the law’s federal funding provisions often put him at odds with providers.
Malloy inherited a state in fiscal disarray, making his promise to maintain the state’s social safety net hard to keep as tackling a daunting budget deficit became the priority. While he may have prevented some fiscal pain for future generations, social services and health spending were sometimes victims in his fight against the state’s budget demons.
The Malloy years coincided with a dizzying rise in the numbers of people addicted to opioids — both prescribed drugs, like Oxycontin, and illegal drugs, like the deadly heroin mixin fentanyl — in an epidemic that doesn’t seem to be slowing.
A year into Malloy’s first term, the shooting that
killed 20 young children and six adults at Sandy Hook Elementary School pushed the state’s mental health delivery system into sharp focus, forcing a reconciliation with how the system failed to prevent that shooting and what needed to be fixed.
Medicaid expansion, a vulnerable safety net
Malloy came into office as Connecticut undertook an ambitious effort to bring thousands of people into the state’s Medicaid pool, making it one of the first in the country to voluntarily expand Medicaid coverage after the passage of the Affordable Care Act.
The expansion, enacted under Gov. M. Jodi Rell in 2010, meant more than 200,000 adults without minor children were able to enroll in Medicaid and access health insurance for the first time.
As a candidate and then throughout his years as governor, Malloy pledged to support the social safety net that came with the expansion.
He honored that promise for the most part, advocates said.
While other states made severe cuts to their Medicaid programs, HUSKY grew dramatically, from
covering around 457,529 people in June 2010 to more than 800,000 people today — about one in five Connecticut residents.
Under Malloy, the Department of Social Services has prioritized getting Medicaid-insured residents primary care providers, supporting intensive care management programs for those with high needs, and delivering long-term care in people’s homes or communities rather than in nursing homes.
Malloy altered the Medicaid system in 2012 by dispensing with the companies handling the state’s Medicaid benefits and switching to a system where the state pays hospitals and doctors directly.
Fighting the opioid epidemic
An event outside of Malloy’s control was the opioid epidemic. Deaths from drug overdoses nearly tripled over six years of Malloy’s time in office, from 357 in 2012 to 1,038 in 2017.
Fentanyl drives the state’s drug epidemic; of those 1,038 deaths, 677 involved the synthetic opioid drug, which is 30 to 50 times more powerful than heroin.
Using a combination of local, state and federal resources, Connecticut has pushed prevention education and medication-assisted treatment.
Those and other efforts — like expanding access to the overdose reversal drug naloxone, restrictions on the prescribing of opioids, and a program connecting recovery coaches to people in emergency rooms — earned Connecticut a ‘B’ grade from the National Safety Council when it evaluated what states are doing to protect their residents from opioid overdoses.
In 2016, Malloy convened experts from Yale Schools of Medicine and Public Health to create a threeyear plan to address opioid overdoses in the state, while a statewide public awareness campaign, Change the Script, pushes messages related to addiction prevention, treatment, and recovery.
Lt. Gov. Nancy Wyman said strengthening opioid prescribing laws was another important tool in the state’s fight against opioid addiction.
Malloy pushed for new laws limiting initial opioid prescriptions for acute pain in most cases and that helped prescribers identify patients who might be misusing drugs. Opioid prescriptions dropped from just over 2.6 million in 2015 to almost 2.2 million in 2017, according to state data.
But that hasn’t made the situation the Lamont administration will inherit any less of a crisis: 2017 data from the Centers for Disease Control and Prevention showed that Connecticut’s increase in overdose deaths that year was around 10 percent, the second highest increase in New England.
Reversing his predecessor’s stance against medical marijuana, Malloy favored making Connecticut the 17th state to legalize it for the chronically ill.
Five years after Rell vetoed a medical marijuana bill approved by the Legislature, Malloy supported and signed legislation allowing patients with debilitating diseases like cancer, Parkinson’s, and post-traumatic stress disorder to buy it. The law also created a licensing process for dispensaries and growers.
While potential patients and medical marijuana advocates cheered the program and its later expansion, the medical community was skeptical, said Matthew Katz, CEO of the Connecticut State Medical Society.
“The problem was that there was no evidence that it was medically effective — there was no research,” Katz said.
But the program has proven popular. Under the oversight of the Department of Consumer Protection and a board of medical professionals it has expanded to cover more than 30,500 registered patients with one of 31 approved conditions.
New priorities after Sandy Hook
In the aftermath of the deadly shooting at Sandy Hook Elementary School in Newtown, and with an addiction crisis taking lives across the state, the cuts to behavioral health services were hard to swallow, said Patricia Rehmer, who led the Department of Mental Health and Addiction Services from 2009 to 2015.
But, she conceded, those services made up a large chunk of the state budget and were an understandable place to look when the numbers weren’t adding up.
“In government, when you’re running a state agency, especially in human services, where do you cut?” Rehmer asked. “There’s no good place to cut.”
The Sandy Hook shooting in 2012 forced the state to reckon with children’s behavioral and mental health services on several levels.
In the weeks after the shooting, the administration reversed its plans to cut more than $7 million in funding from mental health and addiction programs that had been approved the previous fiscal year.
Malloy and Wyman prioritized behavioral health over the following years, supporting the expansion of programs that serve people with serious mental illnesses and a system for pediatricians to consult by phone with child psychiatrists. New laws changed how insurance companies cover mental health services.
“With the help of the lieutenant governor, (Malloy) always saw behavioral health as really a part of overall health,” Rehmer said. “He made sure that I had a seat at the table when they were talking about health care reform.”
Rehmer said she remembers speculation in the days after Sandy Hook that the closing of a nearby state hospital might have contributed to the circumstances around the shooting.
Malloy’s insistence that institutionalizing those with mental illness isn’t the answer was a relief, she said.
“Gov. Malloy was great in terms of saying, ‘people deserve to live in the community, we don’t want to keep people institutionalized,’ ” she said.
Instead, Malloy doubled down on crafting housing policy to better serve those with mental health issues, like supportive group homes.