Massachusetts Health Reform Celebrates Success, Faces Costs

By Krisberg, Kim

State cuts adult uninsurance rates in half JUST TWO short years after sweeping health care reforms took root in Massachusetts, the numbers of uninsured, working-age adults have been cut nearly in half. The dramatic change is one of many successful notches on the New England state’s road to universal health care.

Officially passed in April 2006, Massachusetts’ health care reform relies on all parties – residents, employers, insurance providers, policy-makers – to do their share in making affordable health care coverage a reality. Because of its efforts, the state has become a health reform laboratory, with advocates on all sides of the debate watching as Massachusetts charters new territory and works to overcome familiar financial obstacles.

“The results so far show the tremendous progress we’ve made,” said Brian Rosman, research director at Boston-based Health Care for All, an advocacy organization that worked to pass the state’s landmark health reform law and now helps consumers navigate and enroll in the new system. “We’re far from being finished… but while other states are seeing increasing numbers of uninsured, we’re one of the few where (uninsurance) is going down.”

Created with input from diverse stakeholders, Massachusetts health reform expanded the state’s Medicaid program, offered qualified residents financial assistance to purchase insurance, created a new state agency to connect residents with affordable plans and – perhaps the most talked-about change – required all residents with access to affordable coverage to enroll in a plan or incur financial penalties. For employers with more than 10 employees, the law requires that those who do not make a “fair and reasonable” contribution toward worker health coverage, pay up to $295 per employee per year into a state fund. A look at current coverage rates shows the plan is working: In just the first year of reform, Massachusetts’ uninsurance rate among working-age adults fell from 13 percent to 7 percent, resulting in a nearly 93 percent coverage rate among nonelderly adult residents, according to a study published in the June 3 issue of Health Affairs.

Among adults with incomes below 300 percent of the poverty level, the study found uninsurance dropped by almost 11 percentage points, and among adults at less than 100 percent of the poverty level – those eligible for fully subsidized coverage – uninsurance rates dropped by more than two-thirds. Beyond boosting insurance coverage, Massachusetts health reform improved access to health services as well: Low-income residents are now more likely to have had a preventive health care visit as well as a dental care visit. Levels of unmet care due to costs dropped for both low- and high-income adults across a range of health services, including specialist care, medical tests, prescription drugs and dental care. Health reform, however, has yet to make a significant dent in nonemergency use of emergency departments, which remains at 24 percent among low-income adults, the study reported.

And while there was worry that expanding eligibility for subsidized coverage would have a “crowd-out” effect – in which employers drop coverage or employees reject coverage in favor of public assistance – there is “no evidence” of such a trend, the Health Affairs study found. In fact, employer coverage for low- income adults increased by five percentage points between 2006 and 2007.

Doctor shortages, costs are challenges

Despite its successes, Massachusetts health reform is facing a number of challenging bumps in the road, namely health care costs and physician shortages.

In a way, Massachusetts health reform has been a victim of its own success, said Christine Barber, a senior policy analyst at Community Catalyst, a sister agency of Health Care for AU. With more residents than predicted enrolling in Commonwealth Care – the state’s subsidized insurance plan for adults not offered employer coverage and who don’t qualify for Medicaid – state spending projections have outstripped original funding estimates. In addition, the state is collecting less from employers who choose not to offer coverage than was hoped. Still, Barber said, it’s not surprising that the program will have to change and adapt as the state moves into new territory, and cost control will likely dominate policy discussions. However, as fewer residents seek free care, more are able to manage chronic diseases and more healthy people are added to the coverage pool, costs should begin to drop, she told The Nation’s Health.

“People want coverage, but it’s certainly not an inexpensive task,” Barber said.

According to Rosman at Health Care for All, projecting future costs for new health care programs is generally problematic and the current funding issues are not “signs of fundamental flaws in the program.” The slope of people signing up for coverage was steeper than predicted, Rosman told The Nation’s Health, however estimates were revised early into the fiscal year and Massachusetts is now expected to hit its benchmarks in terms of spending. As of late June, the Massachusetts House and Senate had passed tax legislation that included a $1 increase in the cigarette tax, which if signed into law, Rosman said will have a “two-fer” effect: increasing state revenue and reducing tobacco use, which lowers health care costs in the long-term. The state is also in negotiations with the Centers for Medicare and Medicaid Services to reauthorize its Medicaid expansion waiver, which expired June 30.

“Frankly, we’re seeing how important federal support is because states can’t do this alone,” Rosman said.

Investment in traditional public health endeavors and primary care workers is also crucial to keeping the state’s health costs down, he noted. Among the “real challenges with national implications” stemming from Massachusetts health reform is not simply cost, Rosman said, but a shortage of primary care providers. While Rosman and his colleagues hear from residents who are finally receiving treatment for a longneglected condition, they are also hearing from community health centers that have had to close their doors to new patients, “which totally goes against the grain that these institutions believe in,” Rosman said. In turn, Rosman and fellow advocates are pushing for an “aggressive” reordering of insurance payment structures that reward primary care and provide financial incentives to those entering the primary care field.

Supporting public health activities, such as tobacco cessation and water fluoridation, will also be critical to health reform’s success and to controlling the program’s costs, Rosman said. And in fact, funding for public health promotion in Massachusetts has increased over the past year, showing that “policy-makers understand that public health is important to support as part of this effort,” said Massachusetts Department of Public Health Commissioner John Auerbach, MBA.

Though Massachusetts’ health reform is young, Auerbach said the department can already cite positive changes in state health indicators. For example, there was a dramatic increase in vaccination coverage during the last flu season. For the first time in the state’s history, more than half of adults ages 18 to 64 were vaccinated against flu, with the growth rate almost entirely among people who received the shot in a primary care setting, said Auerbach, who attributed the increase to health reform. Auerbach also attributed 2007′s increase in the state colonoscopy rate to health reform, as such screenings are almost always performed in a primary care setting.

“From a public health perspective, it’s quite beneficial for people to have comprehensive health insurance,” Auerbach told The Nation’s Health. “It prevents spread of infectious disease, promotes early screening and detects chronic diseases so that people can change their behaviors.”

Massachusetts public health workers will continue to evaluate and contribute to health reform’s successes, Auerbach said. The department has added health reform-specific questions to its Behavioral Risk Factor Surveillance System and has adapted its data systems to look for areas of health outcome change. On the promotion side, Auerbach said the department is making significant progress in antitobacco activities – in part due to a $4 million increase in tobacco control funds – and is initiating a major campaign to reduce obesity and encourage exercise and healthy eating to prevent diabetes. One of the public health department’s top priorities is successful implementation of health care reform, Auerbach noted.

“We consider ourselves very lucky to be able to observe these challenges and work quickly to address them,” he said.

For more information on Massachusetts health care reform, visit www.hcfama.org or www.mahealthconnector.org.

– Kim Krisberg

Physician assistant Dominique Entzminger, right, examines Marie Jeudy at a Massachusetts health center in April 2006. Health reform adopted that month in the state requires that all residents have some form of health insurance.

Legislative and community leaders join with Massachusetts Gov. Deval Patrick in April to celebrate the two-year anniversary of the state’s landmark health reform initiative. “From a public health perspective, it’s quite beneficial for people to have comprehensive health insurance. It prevents spread of infectious disease, promotes early screening and detects chronic diseases so that people can change their behaviors.”

– John Auerbach

Copyright American Public Health Association Aug 2008

(c) 2008 Nation’s Health, The. Provided by ProQuest LLC. All rights Reserved.