Academic journal article Inquiry

Coverage, Access, and Affordability under Health Reform: Learning from the Massachusetts Model

Academic journal article Inquiry

Coverage, Access, and Affordability under Health Reform: Learning from the Massachusetts Model

Article excerpt

While the impacts of the Affordable Care Act will vary across the states given their different circumstances, Massachusetts' 2006 reform initiative, the template for national reform, provides a preview of the potential gains in insurance coverage, access to and use of care, and health care affordability for the rest of the nation. Under reform, uninsurance in Massachusetts dropped by more than 50%, due, in part, to an increase in employer-sponsored coverage. Gains in health care access and affordability were widespread, including a 28% decline in unmet need for doctor care and a 38% decline in high out-of-pocket costs.

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In April 2006, Massachusetts passed a comprehensive health reform bill, An Act Providing Access To Affordable, Quality, Accountable Health Care (Chapter 58 of the Acts of 2006), that sought to move the state to near universal coverage. That legislation provided the template for the 2010 federal Affordable Care Act (ACA). Massachusetts' reform initiative, like the ACA, includes, among other changes: an expansion of publicly subsidized coverage for low- and moderate-income people; the creation of health insurance exchanges for individuals and small businesses; insurance market reforms; a mandate that individuals obtain insurance coverage if affordable coverage is available; and a requirement that employers contribute toward health insurance premiums for their workers or face a penalty. (1) Given the parallels with the Massachusetts legislation, the experience under reform in Massachusetts provides a preview of the potential implications of the ACA for the rest of the nation. While the impacts of the ACA will vary across the states given the complexity of their health care systems and policies in place prior to reform and the differences in their choices under the new law, the findings for Massachusetts are a confirmation that major gains in coverage and health care access are possible.

To provide an assessment of the potential trajectory of the nation under the ACA based on the Massachusetts example, this paper summarizes the evidence of the impacts of Massachusetts' health reform effort on insurance coverage, access to and use of care, and health care affordability for individuals since 2006. Our primary focus is on the findings based on the Massachusetts Health Reform Survey (MHRS), a comprehensive survey of nonelderly adults in Massachusetts that has provided the core assessment of the state's reform effort to date (see, most recently, Long, Stockley, and Dahlen 2012a,b). We supplement that overview with findings from studies that have used other data sources and methods as a check on the MHRS results, with a focus on studies that rely on stronger evaluation designs than the pre/post model that is possible with the MHRS. We end with a summary of some of the key challenges that Massachusetts has faced under health reform, the state's strategies in addressing those challenges, and the prognosis for the ACA based on the Massachusetts case study.

Comparison of Massachusetts Reform and the ACA

As noted previously, there are many similarities between Massachusetts' health reform and the ACA. Both include a requirement for individuals to obtain health insurance if affordable insurance is available to them, although the ACA requires this of all people while the Massachusetts law only requires it of adults. Both require employers above a certain size to offer coverage to their employees or face penalties, although the specifics of the requirements and penalties vary. Both expand Medicaid coverage and subsidize coverage for low-income populations to help make insurance more affordable, although the specifics here vary as well. Insurance market reforms, including guaranteed issue and modified community rating, which had been implemented previously in Massachusetts in the mid-1990s, are also critical to the ACA.

While there are broad similarities in the structure of health reform in Massachusetts and the ACA, few--if any--states, including Massachusetts, are implementing the ACA under political and economic conditions as favorable as those facing Massachusetts in 2006. …

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