“Given the parallels between Massachusetts’ health reform and federal reform, the state’s experience can provide valuable insights into the future of [Patient Protection and Affordable Care Act (PPACA)(P.L. 111-148)] implementation,” according to a brief issued by the Kaiser Family Foundation (Kaiser). The Massachusetts comprehensive health reform, which was signed into law in 2006 by then Governor Mitt Romney, was designed to provide near-universal health insurance coverage for state residents with a plan to promote shared individual, employer, and government responsibility. Kaiser found that Massachusetts succeeded in expanding coverage to nearly all state residents through a series of reforms, including the expansion of public programs and the creation of a health insurance exchange. Kaiser’s brief examined the state’s experience with coverage and access to care over the last six years and ongoing efforts to deal with high health care costs.
According to the brief, Massachusetts experienced an unprecedented drop in the number of uninsured within a year of implementation and continues to retain the lowest rate of uninsured residents in the country. While the state has sustained gains in coverage, the rate of uninsured has continued to climb nationally. Kaiser noted that the gains in coverage since health reform have been most notable for nonelderly adults through the state’s health plans, Commonwealth Care and Commonwealth Choice Health Care Insurance Programs. The subsidized coverage is offered through the Commonwealth Care Health Insurance Program and nonsubsidized coverage is offered through the Commonwealth Choice Health Insurance Program. Employer-sponsored insurance, however, remains the dominant source of coverage for Massachusetts residents, Kaiser noted.
Kaiser reported that between 2006 and 2010, more adults received preventive care services and reported a usual source of care than before health reform. In addition, the number of unnecessary emergency department visits and hospital inpatient stays fell, suggesting improvements in health care delivery. In the same period, fewer adults reported high out-of-pocket spending and unmet needs for care because of costs. The demand for health care, particularly in underserved communities, however, has increased with more residents gaining insurance coverage. According to the brief, the state continues to improve residents’ access to care by increasing primary care recruitment programs, increasing medical school enrollment for students committed to primary care, and creating public-private loan repayment for physicians and nurses who agree to practice in underserved areas.
Massachusetts has utilized broad networks of community partners successfully for outreach and enrollment awarding $11.5 million in grants to community health centers, hospitals, and nonprofits to assist residents in obtaining coverage during the first four years of reform, according to the brief. Although the state did not include additional appropriations for outreach in the 2012 budget, private foundations continue to provide funding for outreach and enrollment programs. Six in ten families have enrolled in public coverage with the assistance of a community-based partner or provider. In addition, early enrollment in Commonwealth Care was jumpstarted by the state automatically enrolling residents who had received uncompensated care at hospitals or community health centers, Kaiser said. Massachusetts has continued to adopt enrollment simplifications and make greater use of technology, which state officials report was critical for keeping pace with applications since health reform.
Affordability continues to be an issue with nearly half of the uninsured reporting having access to employer coverage but not enrolling due to costs, Kaiser said, noting that “[p]er capita health spending is 15 percent higher than the national average and although premium growth has slowed in recent years, the state has the highest individual market premiums in the country.” The state has addressed cost containment through provider payment reform including additional health reform legislation to initiate cost containment and delivery system improvements as well as to create a Special Commission on the Health Care Payment System. In 2009, the Commission released final recommendations on the development of a transparent payment methodology and endorsed a shift away from a fee-for-service system to a global payment system where providers work together to share the responsibility for the patient’s care. Since the recommendation, the Governor and legislature have proposed such cost containment legislation.
Although federal reform was modeled after Massachusetts’ health reform, there are key differences that the state will be required to address including “significant interagency coordination, the potential shifting of existing programs, and the creation of new information technology systems,” Kaiser concluded.