INSIDE THE ISSUE

> House Passes Anti-Violence Bill
> Safety Net Relief
> CHIA on Medical Debt
> Harvard/NYT on OB3
> DPH Standing Order
> Long-Term Custodial Care Beds
> Happy Thanksgiving

MONDAY REPORT

A Major Milestone in the Decade-Long Violence Prevention Effort

Nurses, healthcare workers, and hospital representatives across Massachusetts are celebrating a significant milestone in the effort to curb the growing crisis of violence in healthcare. An Act Requiring Healthcare Employers to Develop and Implement Programs to Prevent Workplace Violence (H.4767/S.1718) passed the Massachusetts House of Representatives last Wednesday by a vote of 158-0 and now advances to the State Senate for consideration.

The legislation, developed through cooperation between MHA, the Massachusetts Nurses Association (MNA), and 1199SEIU Massachusetts, represents a unified statewide commitment to addressing violence in hospitals and protecting frontline workers. While the groups had supported similar but separate proposals in previous sessions, this marks the first time that the three organizations proposed and advanced a single, consensus piece of workplace violence legislation.

The bill garnered substantial legislative support prior to its passage, with 68 sponsors. The lead sponsors are Representative John Lawn (D-Watertown) and Senator Joan Lovely (D-Salem). The Massachusetts Association of Behavioral Health Systems, the Organization of Nurse Leaders – New England, the Massachusetts Emergency Nurses Association, and the Massachusetts College of Emergency Physicians have been longtime supporters of advancing workplace violence legislation. Additionally, the Massachusetts District Attorneys Association and Middlesex DA Marian Ryan were critical in consulting and advising on the criminal justice components of the compromise bill.

“This bill represents years of work, hundreds of conversations with healthcare stakeholders and survivors of workplace violence,” Lawn said on the House floor before the vote. “It’s a unified commitment that unequivocally says this violence will not be ignored or tolerated. Every day these workers show up to treat patients with dignity and respect, and face violence for just doing their jobs. Today the House has taken action to care for our healthcare workers, operational staff, security, in treating them with the same respect they offer their patients.”

Every 36 minutes, a worker in a Massachusetts hospital is subject to an act of violence or a threat. Nurses and healthcare workers experience violent incidents at least five times more often than the average private sector worker.

“This legislation is a commitment to every frontline healthcare employee to provide a safer working environment to treat their patients, said MHA President & CEO Steve Walsh. “We are grateful to the House for making this effort a priority and helping us to deliver on the pledge to offer our workers the protections they deserve. Thank you to Speaker Mariano, Chair Michlewitz, and longtime legislative sponsors and advocates Majority Leader Moran and Chair Lawn. Our hospitals are proud to be working in close collaboration with MNA and 1199SEIU to stem the tide of the current workplace violence crisis — especially as our healthcare system remains under significant strain.”

“Our healthcare workforce has endured violence at alarming rates for far too long,” said Katie Murphy, a practicing ICU nurse and MNA president. “This House vote is a powerful acknowledgment of the crisis and an important step toward ensuring every healthcare worker has the protection we need to safely care for our patients.”

“Workplace violence is a very real and serious problem for the entire care team,” said Cari Medina, executive vice president of 1199SEIU. “1199SEIU strongly supports this bill that will directly engage caregivers in developing facility-specific risk assessments and a comprehensive violence prevention program for hospitals.”

The bill requires all hospitals to complete facility-specific risk assessments and implement comprehensive violence prevention programs tailored to those findings; and engage frontline staff in developing assessments and prevention plans, ensuring workforce-informed training, and making written plans available to all employees and labor organizations. The bill strengthens enforcement through DPH licensing requirements, regular reporting, and enhanced job protections for workers, including additional paid leave for employees who are assaulted.

State Comes Through With Safety Net Relief

Last week, just hours before recessing for a six-week holiday break, the Massachusetts House and Senate passed a $2.3 million supplemental appropriations bill and sent it to Governor Healey, who is expected to sign the measure.

The supplemental budget contains the $50 million increase to the assessment on hospitals that MHA and the state crafted in an effort to increase federal matching Medicaid funds to Massachusetts. The Centers for Medicare & Medicaid Services must approve the new assessment.

The “supp” also contains a $50 million transfer from the Commonwealth Care Trust Fund to the Health Safety Net fund in each of Fiscal Years 2026 and 2027. Ultimately, the plan generates $100 million for the Health Safety Net program annually, and $112 million in annual supplemental Medicaid payments to hospitals to support their operations within a turbulent financial environment. Separate from that funding, the budget also provides a little more than $2 billion to the Medicaid program for FY2025, of which $1.5 billion is funded by the federal government. This bill follows another supplemental bill in September that directed $77 million to the Health Safety Net for Fiscal Year 2025 and an additional $122 million to support high public payer hospitals.

The legislature’s and the administration’s commitment to fund the safety net that pays hospitals and health centers for the care provided to those who are uninsured and underinsured demonstrates what MHA called “a remarkable commitment” to ensuring the Massachusetts healthcare system remains viable. But the current safety net system as constructed is simply unable to cover current and future care costs. Even with the relief in the supplemental budget approved last week, the Heath Safety Net deficits are still projected to exceed $225 million and $250 million in FY26 and FY27, respectively – placing further strain on hospitals and health systems. Hospitals alone bear the burden of covering any funding shortfalls.

And if the premium tax credits – that were the focus of the recent longest-ever shutdown of the federal government – do indeed expire as scheduled on December 31, it is estimated that not only will premiums rise but that more pressure would be put on the safety net. Also, beginning in 2027, Medicaid work requirements in the One Big Beautiful Bill (OB3) will begin to take effect, which – according to both state and private studies – could lead 300,000 Massachusetts residents losing coverage. The Massachusetts Taxpayers Foundation estimates the OB3 changes alone will increase Health Safety Net demand by $510 million which would mean funding shortfalls exceeding $850 million by FY2028.

Deductibles & Co-Pays Driving People into Medical Debt

A research brief that the Center for Health Information and Analysis (CHIA) released last week shows that 12.7% of Massachusetts residents carry “medical debt,” which CHIA defines as a bill paid over time, “including bills on a credit card, through personal loans, or bill paying arrangements with hospitals or other providers.”

While families who were not continuously covered over a 12-month period incur debt, CHIA found that “health insurance coverage does not fully protect Massachusetts families from medical debt.” According to the research brief, approximately half of insured residents (53.4%) reported that care not covered by their health insurance contributed to their medical debt. Insured residents incur debt mainly through the deductibles, co-insurance, and co-pays in their plans. CHIA found that deductibles (71.5%) and co-pays or co-insurance (64.7%) were the most common sources of bills leading to medical debt for those insured.

Increases in high-deductible health plans (HDHPs) is also contributing to the debt problem. Among residents with commercial insurance those currently enrolled in an HDHP were more likely to report medical debt (17.0%) than those not currently enrolled in an HDHP (13.0%), according to CHIA.

Medical debt affects certain populations more than others. “Black residents and residents with family incomes between 139 to 500 percent of [the Federal Poverty Level] had higher rates of medical debt, were more likely to have $2,000 or more in medical debt, and were more likely to have held medical debt for more than a year,” according to CHIA.

“As CHIA’s report shows, the weight of medical debt is being felt by far too many Massachusetts residents – particularly those from historically marginalized populations who often have fewer care options in the first place,” said Dan McHale, MHA’s senior vice president of healthcare finance & policy. “It is especially troubling to see the outsized role that high-deductible health plans and increased cost-sharing are playing. These factors go hand-in-hand with the authorization denials that result in patients having to pay out-of-pocket or go without, potentially ending up sicker and with even higher medical expenses. Our hospitals and health systems appreciate the statewide focus on this issue, especially as we work to bend the cost curve for patients through primary care investments, administrative simplification, and affordable prescription drugs.”

More Evidence Shows How OB3 Will Harm Hospitals

“With 80% of the US population residing in urban areas, the closure of urban hospitals may have an equally or even more profound population-level impact than the closure of rural hospitals,” the Harvard researchers wrote. “This is particularly true for safety-net hospitals in Medicaid expansion states, where Medicaid patients represent 24% of patient revenues. Additionally, nearly 1 in 4 hospitals are already characterized as financially distressed, operating with razor-thin margins and at risk for bankruptcy. Hospitals with a high share of revenue from Medicaid patients are at higher risk for financial distress than those with a low proportion of revenue from Medicaid. Further reductions in Medicaid reimbursement and the growing burden of providing uncompensated care to the uninsured may tip financially distressed hospitals further toward closure, bankruptcy, or conversion to non-hospital facilities.”

The Healthcare Quality and Outcomes Lab at T.H Chan released a data blog on the issue while the New York Times used the data and interviews with healthcare leaders to draft an article. Among those the Times interviewed was UMass Memorial Health President & CEO Eric Dickson, M.D., a member of MHA’s Board of Trustees, who said, “Anybody who thinks that they are not going to be impacted by this is crazy. I don’t care who you are, your premiums are going to go up. And when you end up in an emergency department — and everyone’s going to end up in an emergency department eventually — they will wait longer.”

DPH Standing Order on the Flu Vaccine

DPH has issued a new standing order for local boards of health to administer influenza vaccine in Massachusetts to all eligible persons.

According to the order, “Qualified local board of health personnel means: an individual who is affiliated with a local board of health by reason of employment, or contract, or other relationship such as a volunteer subject to the control of the applicable local board of health for purposes of administering influenza vaccinations.”

The action is yet another example of the state’s ongoing effort to not only stress the importance of vaccines but to make them easily accessible.

Complex Patients Wait to Get into a Skilled Nursing Facility

MHA’s most recent survey to determine how many patients remain stuck in acute care hospitals unable to transfer to post-acute care for a variety of reasons – ranging from workforce shortages to conservatorship issues to insurance red tape – has revealed some disturbing trends.

In September, on any given day, there were 387 patients waiting for a bed in a skilled nursing facility for both short-term rehab beds and long-term care custodial beds. And 49% of those 387 patients have been waiting for 30 days or more. The 49% number is one of the highest numbers MHA has recorded in recent years. (A long-term custodial care bed is one designed for extended use for individuals who need someone to help them with their activities of daily living – bathing, dressing, eating, etc.)

Of the 387, 160 have been waiting for a long-term custodial care bed for more than 30 days. And of those 160, 127 have been identified as having a dementia care diagnosis.

The long-term care bed need and the number of patients who have dementia diagnoses is significant, especially since September’s MHA reporting is temporarily missing data from some hospitals due to their reformatting the way they gather and report information.

The effort to ease care transitions is complex and ongoing, from building the post-acute workforce, to streamlining processes for guardianship and healthcare proxies, improving transportation options, and reducing insurance administrative barriers.

Happy Thanksgiving

MHA wishes you and yours a healthy and happy Thanksgiving. We extend special gratitude to the commonwealth’s committed frontline healthcare workers, many of whom remain on the job even as the rest of the nation pauses. Our offices will be closed on Thursday and Friday.

John LoDico, Editor