Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.
“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”
Positives & Negatives
The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.
There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare.
—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.
The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.1
The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.
More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).1
One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”
Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.
“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.
Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.