IN THE STATES: Massachusetts Reform Report Card

The results are in!

While there are still kinks to be worked out, the Massachusetts health care reform legislation seems to be achieving many of its goals, according to a study published this week in Health Affairs. The report focuses on a few key successes and a few remaining challenges facing the new program:

Reform Successes—

• Expansion of Coverage: The adult uninsurance rate fell from 13% to 7% in 2007, with 93% of nonelderly adults insured. (The Massachusetts Connector estimates 340,000 people who had been unisured are now covered.) The biggest effect was seen among lower income people who were least able to afford coverage. Uninsurance rates for adults with incomes below 300 percent of poverty fell by nearly half, and rates for adults with incomes below the poverty level fell by two-thirds. A common concern surronding government subsidies of private insurance is that employers would stop providing coverage, but so far, no decrease in employer coverage—the so-called "crowd-out effect"—has been observed.
• Access to Care: After the reform, low-income adults were more likely to have a place to go for care, to have visited a doctor for preventive care, and to have dental care. (This occurred despite a lot of concern about shortage of doctors—more below)
• Cost: Out-of-pocket spending decreased in Massachusetts after reform, particularly on prescription drugs. And fewer people reported having problems paying their medical bills.
• Public Support: 71% of working-age adults supported the reform efforts at the end of 2007. Support was independent of age, gender, income, or geographic region.

Remaining Challenges—

• Shortage of Physicians: The rise in insured adults has not been matched by a rise in doctors. ER visits have remained the same, and reports of trouble finding a physician increased. Both reflect the shortage of primary care physicians.
• Cost of Reform: The state continues to face difficulties with costs (primarily because initial estimates of the number of low-income uninsured residents in Massachusetts were low.) In 2007, the state spent almost $150 million more than expected, according to the article in the Boston Globe.

These results are indeed exciting, and we look forward to watching how reform successes impact the health of citizens. Study author Sharon Long put it best:

Clearly the drop in the uninsured rate is an impressive first-year drop and a significant finding. It's not just the gain in insurance coverage, but access to care and affordability of healthcare for individuals that has improved with insurance coverage. This is a broader change than just expanding coverage.

We know that the cost problems need to be addressed—and the state legislature is addressing them. But overall, we find the Massachusetts experiment encouraging. Not perfect but definitely encouraging. People are getting covered, and the reforms have broad public support. As we mentioned, a big chunk of the cost problems stem from the fact that Massachusetts underestimated its number of uninsured people at the beginning; future spending projections should be more reliable (and less nerve-racking for politicians) now that they have a better grasp of the true numbers.

And many of the problems that Massachusetts is facing are nearly impossible to fix at the state level. On issues like access to primary care, delivery system reform, and quality improvements, states can only go so far on their own. So we hope that Washington steps up, and steps in.