Ten years after Massachusetts passed health reform legislation intended to push the state toward near-universal insurance coverage, significant gains in coverage have been made. But a new study from Health Affairs finds that gaps in access and affordability persist.
Statewide uninsurance rates dropped from 7.7 percent in 2006 to 3 percent in 2008, while the national insurance rate stayed essentially the same. By 2015, uninsurance rates in the state were down to 2.5 percent, compared to 9.1 percent nationwide.
But the study's authors maintain that coverage doesn't necessarily mean easy access or affordable care. Difficulty finding providers, unmet need for care and difficulty paying medical bills are all common problems among insured adults in the state.
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Gaps in coverage are especially common among non-elderly adults, the research found. Overall, the uninsurance rate for that group was 5 percent in 2014, compared to less than 2 percent for children and less than 1 percent for elderly adults. Uninsurance was particularly high for non-elderly adult immigrants, minorities, those with less than a high school education and those with family income at or below 138 percent of the federal poverty level.
The cost of coverage was the most commonly cited reason for being uninsured, reported by 54.8 percent of uninsured residents in 2015. Only one in 10 of the state's uninsured population reported not needing or wanting health insurance.
When it comes to access and affordability, the situation improved during the early period of reform, but those gains faded somewhat over time, the authors found. In 2015, more than one-third of full-year-insured adults reported going with some type of needed care during the prior year, including dental care or prescription drugs. Some of that unmet need reflected difficulty finding providers who would see them, as well as challenges in securing timely appointments.
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The unmet need for care due to cost was reported by about one in five adults, and one in six said they had difficulty paying medical bills. Medical debt was reported by 20 percent of the state's insured adults, which the authors say could reflect increasing consumer cost sharing in Massachusetts, which rose by 4.9 percent in the commercial market in 2014.
To address the remaining gaps in coverage, the authors point to MassHealth, the state's Medicaid/children's health insurance program, and the Health Connector, the state's health insurance exchange. Using data on the variation in uninsurance rates across the state, and the characteristics of the remaining uninsured, those groups have targeted outreach and enrollment efforts to populations and areas of the state with higher uninsurance rates. In early November 2015, for example, with the start of the 2016 open enrollment period, the Health Connector opened four new walk-in enrollment centers in communities pegged as having high uninsurance rates, expanding in-person assistance in those communities.
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As far as access and affordability gaps are concerned, a series of laws on the Massachusetts books already partially address the issue, particularly the creation of the Health Policy Commission, a quasi-governmental body tasked with monitoring the healthcare system's efforts to reduce the growth of costs. Central to the state's strategy is the shift from fee-for-service reimbursement to a value-based model, integrated delivery models and a greater emphasis on consumer engagement.
Those changes have mostly been led by private sector initiatives, the authors said, but payment and delivery system reform is moving to the public sector; Massachusetts is expanding alternative payment methods under MassHealth, and is currently supporting delivery system reforms, including the development of accountable care organizations that will be paid based on value instead of volume.
Twitter: @JELagasse