Project HCAD: resource file and topic overview

Mass Health

Access, Cost, and Quality of the Massachusetts State Health Program: A Model for the Nation?

Few issues are as controversial or as pressing in terms of national policy than healthcare, which was and continues to be a prominent election issue and matter of public debate and scrutiny. Technological and pharmaceutical advancements and innovation have created a wealth of opportunities for improved quality of life and quality of care for many nations and individuals, but paying for this care -- and determining how much care should be paid for -- remains a complex and divisive issue throughout the developed world. Innovation is not cheap and neither is the use of many newer medical technologies, and aging populations that require greater levels and longer periods of care are also placing a strain on many healthcare systems.

The United States is one of the only developed nations that lacks an implemented comprehensive national healthcare system of some sort, leaving many individuals without adequate access to care and contributing, according to some analysts, to skyrocketing costs of healthcare in the country (Heslop 2010). There is no question that the United States' healthcare system lags behind most of the developed world's in terms of effectiveness and efficiency; according to the 2000 World Health Organization's rankings of national healthcare across a variety of factors, the United States came in 37th (just behind Costa Rica and ahead of Slovenia) (WHO 2000). This is despite the fact that the U.S. spends more per capita and in terms of GDP on healthcare than any other country in the G8 and beyond (Heslop 2010).

Much has been made of the politicians and the political philosophy surrounding the issue of healthcare provision and how much it should be a matter of public policy, or even if it should be a matter of public policy at all. Extreme libertarian theories on one end of the spectrum assert that government should not involve itself in the workings or financing of the healthcare industry beyond the barest regulations preventing unsafe practices or fraud, while those on the other side of this spectrum call for a completely non-profit healthcare system administered wholly by the government in a fully socialized plan. Most United States citizens fall somewhere in the middle of this spectrum, but the debate remains.

The lack of federal policy addressing these issues prior to the major legislation pass in 2010 (which does not take full effect until 2014 and which still does not create a unified national healthcare plan) has required the individual states to develop their own healthcare systems, including independent and varied ways of using federal funds through the Medicare program. Whether or not state solutions are in keeping with the philosophies of democracy and federalism upon which the United States is ostensibly built is a moot point, but the efficacy of the various healthcare programs in certain progressive states if of pressing interest both for other states and the nation as a whole. Massachusetts has one of the most comprehensive and progressive health programs in the country, and understanding the cost, access, and quality features of this program could provide a model for the rest of the nation in terms of both certain solutions and certain pitfalls in the healthcare situation.

The following pages will examine certain of the technical aspects of Massachusetts' health plan following the reform enacted in 2006, eschewing the more often encountered political arguments in favor of a practical examination of what actually works in terms of providing affordable access to quality care. Massachusetts has not been entirely successful in this goal, and there are certain inefficiencies in its program that warrant careful inspection, but overall the state seems to have developed a system that is able to provide access to appropriate levels of care without the major negative effects of governmental involvement in healthcare provision warned about by conservatives and libertarians, and without the major wealth redistribution that had been predicted, as well. The healthcare system has remained largely privatized and market-controlled, yet the increased coordination, regulation, and limited degree of competition offered by the state government has increased overall efficiency, access, and quality.

Summary of Plan and Proposal

Major healthcare reform in Massachusetts became a topic of serious conversation amongst the state's legislature and various interest groups beginning in 2004, and a ballot initiative for November of 2006 was well underway when legislation was crafted and signed into law earlier in the year (Shi & Singh 2011). Rising healthcare costs in the state and especially the high cost of running emergency departments, which were required by federal law to serve all individuals in need yet which were funded from state money, were cited as specific concerns in the push for action (Shi & Singh 2011). The reform bill passed almost unanimously.

The broad details of the Massachusetts healthcare reform plan were relatively simple and did not have a substantial initial impact, if any, on those who were already insured through their employers or directly by for-profit insurance companies or those who qualified for Medicare (Shi & Singh 2011; OECD 2008). Medicaid coverage was expanded to include children and families earning up to 300% of the federal poverty level, individuals were mandated to purchase insurance with monetary penalties for non-compliance, and employers had to make substantial contributions towards employees' health policies or make contributions to the government, which set up a subsidized health insurance program as well as a regulated health insurance exchange (OECD 2008). These provisions were meant to reduce the number of uninsured and overall healthcare costs in the state.

Current Status

The healthcare program in Massachusetts is still in effect very much in the way it was first enacted five years ago, with minor adjustments to technical details having been made in 2006 and again in 2007 (Shi & Sing 2011; Maxwell et al. 2011; Chen et al. 2011). The individual insurance coverage mandate is still in place, now with much steeper penalties than it used to be, and employer responsibilities have also increased slightly with broad support from individual employers and business associations in the state (Gabel et al. 2008; Shi & Singh 2011). Analyses of the healthcare reform's effects have not been so consistently optimistic, however, with several problems and specific failures noted in the plan's implementation.

The number of Massachusetts residents that remain uninsured after the passage of the healthcare reform is still approximately around five percent according to most measures and predictions, and is significantly higher in certain demographics (Chen et al. 2011; Maxwell et al. 2011). As reducing the number of uninsured in the state was one of the primary goals of the program, this fairly insignificant reduction (an estimated six to even percent of the state's citizens were uninsured prior to the passing of the reform legislation) is often cited as evidence of the failure of the health insurance mandate and the offering of subsidized or even free health insurance (Shi & Singh 2011; Maxwell et al. 2011). The number of emergency department visits has also not changed appreciably compared to national averages following the healthcare reform, again suggesting a failure in one of the main stated goals of the program (Chen et al. 2011). Coverage is still more widely provided, however, and despite ongoing issues the program appears to be favored by most businesses and Massachusetts residents.

The basic form of the Massachusetts healthcare system is quite similar to healthcare in most of the United States; despite rhetoric to the contrary, there is little of the plan that compares to the compensation schemes or overall payment provisions of more socialized plans such as those of the Canada or Great Britain (WHO 2000; Heslop 2010; Shi & Singh 2011). This continued privatization has allowed premiums in the state to soar, and average premiums in Massachusetts are now among the highest in the country, while total healthcare costs in the state remain comparable if not somewhat lower (Shi & Singh 2011; Maxwell et al. 2011).

Access

Access to care was a major factor in the policy discussions leading up to the healthcare reform in Massachusetts, specifically due to the perception that a large proportion of emergency department visits were prompted by a lack of access to preventative and other non-emergency care (Chen et al. 2011). The lack of insurance and the level of underinsurance in a significant portion of the population, exacerbated by the shortcomings of Medicare coverage, were other limiting factors perceived in the pre-reform healthcare system in Massachusetts that the legislation attempted to directly address (OECD 2008; Shi & Singh 2011). Though the proportion of uninsured has only dropped slightly, there are other signs that the overall equality and comprehensiveness of access to quality medical care in Massachusetts has increased as a result of the healthcare reforms passed in the state.

Access to care as measured both by insurance levels and resultant non-emergency medical visits has greatly improved amongst minority groups, especially Hispanics, since Massachusetts' healthcare reform legislation went into effect (Maxwell et al. 2011). Hispanics as a group are still more likely to be uninsured than their non-Hispanic white counterparts in the state, yet the percentage Hispanics that acquired insurance after the legislation was passed was more than twice that of non-Hispanic whites (Maxwell et al. 2011). The Hispanic population is also a fairly reliable predictor of certain economic demographics, and the increased access seen here directly correlates to increased access for those between the income levels necessary to receive Medicare benefits and those that made purchasing private insurance truly affordable.

The affordability of insurance and of care has been a major cause of the improved access experienced under the Massachusetts healthcare reforms, but maintaining adequate levels of medical professionals has also been a key part of the legislation's success. The incremental building on the private insurance system that already existed in the state and the lack of any radical change in the payment systems or compensation levels of physicians and other medical professionals and institutions is in large part responsible for the lack of disruption in levels of medical service. Though predictions of long waits for doctors abounded in the run-up to the actual implementation of this legislation, this has not been evidenced at all in the actual provision of service in Massachusetts (Wilson 2008; Steinbrook 2008; Chen et al. 2011). Overall, access to care has not been dramatically improved by the legislation, but there have been incremental improvements and no significant movements in the other direction.

Costs

A key element of measuring the effectiveness of the new healthcare program in Massachusetts is examining the costs of providing healthcare both before and after the reform s went into effect. Estimating these costs is also, of course, one of the more controversial and disputed elements of this and any other healthcare legislation, and numbers are not at all agreed upon by different measurements and analysts. Even within the first year, it became clear that certain cost estimates were too low, however, and they have unquestionably ballooned since then (Wilson 2008). Cost remains Massachusetts biggest healthcare hurdle.

In provisions similar to what were ultimately included in the federal healthcare reform legislation, Massachusetts set requirements for insurance providers that mandated coverage for individuals with pre-existing conditions at comparable premium rates to individuals without such conditions, without setting any overall premium caps. This led to rapid increases in premium rates for insurance carriers throughout the state, though most premiums are still considered affordable at rates between approximately seven and ten percent of household income, on average (Steinbrook 2008). The affordability achieved despite the increase in premium rates is a function both of the marketplace established by the legislation, which provides easily comparable plans offered by competing insurers, and of the level of government spending that has been appropriated to pay for care or subsidize insurance premiums, which enhances capitation payments overall, providing more cost-effective care and payment plans for physicians and consumers (Steinbrook 2008; Gabel et al. 2008).

Employer contributions to the healthcare system are a major source of revenue for the government-run healthcare options and subsidies, and yet these, too, are considered highly affordable by the employers that pay them (Gabel et al. 2008; Wilson 2008). Current costs for employers that do not offer insurance to their employees are approximately $300 annually per employee at the high end, and most business groups have advocated even higher contributions (Gabel et al. 2008). These funds are used to offer low-cost insurance options to those that cannot afford to purchase private insurance but do not qualify for Medicare.

Quality Assurance

Again, the changes that were wrought via the Massachusetts healthcare reform legislation were primarily in the mandates for insurance possession and the setting up of both a regulated insurance marketplace and a low-cost public insurance option similar in some ways to Medicare (as well as an expansion of Medicare coverage itself). The provision of care itself was not greatly affected, and even the direct compensation methods for physicians and medical institutions was not greatly changed, and thus quality assurance was not a major focus or concern of the legislation (Shi & Singh 2011). This is not to suggest that the quality of care provided has not been considered worthy of study, of course, and there have been numerous attempts to ascertain a change in care quality following the implementation of the healthcare reforms, but the results have been generally inconclusive (Chen et al. 2011; Wilson 2008; Steinbrook 2008). As with access to care, there does not seem to have been any significant change in the quality of care prompted by the legislation.