Although Massachusetts has sustained gains in insurance coverage and access to healthcare as a result of its 2006 health reform and coverage expansion, some of the benefits had eroded by the fall of 2008, according to a study by the Urban Institute.
The study is based on interviews conducted in fall 2008 with a representative sample of Massachusetts adults, as well as earlier rounds of interviews from fall 2006 and fall 2007.
“Massachusetts is encountering the same increases in healthcare costs that plague the nation as a whole, as well as inefficiencies in its healthcare delivery system that predate the 2006 reform,” said lead author Sharon Long, a senior fellow at the Urban Institute in Washington, D.C. “The Massachusetts experience shows that major coverage expansions can be undertaken without addressing costs and provider constraints, but these factors, if they are not addressed eventually, can undercut the benefits from gaining insurance coverage by reducing access to care and the affordability of care.”
Massachusetts is addressing the challenges of cost control and delivery-system constraints through new legislation signed by Gov. Deval Patrick in August 2008. Under this legislation, the commonwealth is preparing to reform its delivery system, moving away from fee-for-service to a global payment system that emphasizes care coordination and collaboration.
“Massachusetts once again looks to be in the forefront of designing innovative strategies that will provide guidance to national reform efforts,” said Long and co-author Paul Masi, a research associate at the Urban Institute.
Todd Gilmer and Richard Kronick of the University of California, San Diego project that increases in healthcare costs will result in an increase of at least 6.9 million in the number of uninsured Americans over the three years from 2008 through 2010.
Consistent with a Massachusetts uninsured rate that had declined to an estimated 2.6 percent of all residents in the summer of 2008, sustained improvements in access to care were reflected in the fall 2008 interviews conducted by Long and Masi’s team.
As compared to fall 2006, just prior to the implementation of many key reform elements, Massachusetts adults in fall 2008 were more likely to report that they had a usual source of healthcare and advice and more likely to have had doctor and dental visits in the past 12 months. The gains in coverage and access were strongest for lower-income adults, those with incomes below 300 percent of the federal poverty level, but higher-income adults also realized coverage gains and improved access to doctor care.
However, the researchers also found that, “paradoxically, the increases in healthcare use from fall 2007 to fall 2008 were coupled with indications that some adults were having more difficulty obtaining care in fall 2008 than in fall 2007.” The shares of adults reporting that they did not get some types of needed care increased between fall 2007 and fall 2008, after having decreased in the year prior to that. In fact, as compared to fall 2006, unmet need was lower in fall 2008 only for preventive care screening and prescription drugs; unmet need for other types of care was no longer significantly different from pre-reform levels.
Long and Masi found that about one in five Massachusetts adults said they were told that a doctor’s office or clinic was either not accepting any new patients or not accepting patients with their type of coverage. These problems were much more common among lower-income adults and adults with public coverage than among higher-income adults and adults with private coverage. The authors attribute this to lower provider reimbursement rates and more limited provider networks under the commonwealth's public programs, coupled with increased demand for care from the substantial expansion of public coverage under the 2006 reforms.
In the first year after implementation of the reforms, the financial burden of healthcare on individuals dropped significantly across a number of measures, particularly for lower-income adults. While some of the gains in affordability persisted in fall 2008, the shares of adults reporting problems paying medical bills and problems with medical debt had moved back toward 2006 levels as healthcare costs continued to increase.
By fall 2008, the share of lower-income adults with out-of-pocket spending of 10 percent or more of income was no longer significantly different from pre-reform levels, although higher-income and all residents reported no increase in out-of-pocket costs. Despite this, Massachusetts adults, including low-income adults, were no more likely to report having an unmet need for care due to cost, and the declines in unmet healthcare needs due to cost from 2006 to 2007 were sustained.