Neil Osterweil

November 19, 2013

BOSTON — With several years of health reform under its belt, Massachusetts has seen significant reductions in healthcare disparities and inequities, and now has the smallest percentage of uninsured residents of all 50 states, says John Auerbach, MBA, former Commissioner of Public Health for the Commonwealth of Massachusetts.

The Bay State's experience with health reform, including a mandate that all eligible residents buy insurance or pay a tax penalty, began in 2006 when then-Governor Mitt Romney signed An Act Providing Access to Affordable, Quality, Accountable Health Care. The Act, also known as Romneycare, became the model for President Obama's Affordable Care Act.

In his failed campaign to unseat President Obama, Romney called for repeal of the Act and tried to distance himself from the very law that he helped coax into existence.

Yet the Massachusetts experience with health reform so far holds promise for what the United States, as a whole, may be able to achieve in the coming years, said Mr. Auerbach, director of the Institute on Urban Health Research, at Northeastern University in Boston.

Mr. Auerbach reported on the impact of health reform in the Bay State in a presentation here at the American Public Health Association 141st Annual Meeting.

The percentage of uninsured people in Massachusetts declined from approximately 6% before the law was enacted to an estimated 2% in 2013, he said.

"We've seen that there is a connection between access to health insurance and improved health. Much of the discussion focuses on costs and utilization, but we're seeing improvement in a number of different areas," Mr. Auerbach told Medscape Medical News. "I'm hopeful that as insurance expands in other parts of country, we'll see similar outcomes that people who have symptoms from chronic diseases will see a significant reduction in those symptoms as a result of improved access to healthcare."

Racial Disparities Dwindle

According to the Henry J. Kaiser Family Foundation, in 2010 — the most recent year for which US data were available — 4% of Massachusetts residents did not have health insurance compared with 16% for the country as a whole. In Texas, nearly 1 in 4 residents had no health insurance in 2010 (an uninsured rate of 24%).

One measure of how successful reform has been in Massachusetts is the increase in the number of working people who were not eligible for Medicaid, but qualified for subsidized insurance under the state's Commonwealth Care Program. After the law, 175,000 of the 400,000 previously uninsured people signed on to subsidized plans offered by both for-profit and not-for-profit insurers.

"That's a good sign that healthcare reform is disproportionately helpful to people with low incomes, and that will be true particularly for those states that are implementing the Medicaid expansion," Mr. Auerbach said.

Additionally, among nonelderly residents, the percentage of uninsured Hispanics declined from nearly 25% in 2005, to about 12% in 2006. Similarly, the percentage of uninsured blacks shrank from a high of about 14% in 2006, to about 5% in 2010, approaching parity with white residents.

The percentage of racial and ethnic minority residents who reported having a regular source of care increased from 84% in the autumn of 2006 to 91% by the autumn of 2009, and the percentage who had a doctor visit for any reason also increased from 71% to 84% over the same period.

There was also evidence to show that having insurance for the first time improved access to care, suggested by figures that 86% of insured residents reported having a doctor and seeing that doctor within the last 12 months. In contrast, only 54% of the uninsured had seen a doctor within the previous year.

Chronic Disease Care Increases

The percentage of nonelderly adults with unmet healthcare needs in the previous year also declined following the implementation of health reform. For example, in 2006, 30% of all adults in the state with a chronic condition reported having a healthcare need that had not been met, compared with 23% in 2009.

After health reform, patients with diabetes were also significantly more likely to receive recommended care, including an annual eye exam, an annual foot exam for numbness, a flu shot, and twice-yearly hemoglobin checks.

From 2005 to 2006, 12% of diabetic Bay Staters received the recommended care compared with 19.6% from 2007 to 2009.

Health reform has also taken some of the strain off family budgets for people making up to 500% of the Federal Poverty Level, currently $117,750 for a family of 4. The percentage of families who shelled out for out-of-pocket expenses of 5% or more in 2006 was 23%, compared with 18% in 2009. The percentage of those who paid out more than 10% of their income for health expenses dropped from 10% to 6% over the same period.

Massachusetts has also recently implemented payment reform laws designed to contain medical costs. The law, which was passed in 2012, created new agencies to monitor and enforce benchmarks for cost growth, and fosters alternative payment methods to move away from fee-for-service care. The law was also designed to increase the transparency of medical costs, expand the primary care workforce, and address problems with medical practice, Mr. Auerbach noted.

Representative Carolyn Dykema, a Democrat from Massachusetts' 8th Middlesex District, who was first elected in 2008 and was not involved in the healthcare reform law, told Medscape Medical News that in her state at least, healthcare reform is working as intended.

"The best kind of healthcare is the kind that helps keep people healthy in addition to caring for them when they're sick," she said. "The changes we've made give almost every citizen access to the care they need, when they need it, regardless of age, zip code, or health status. For families, this new sense of health security will contribute to more stable communities, more productive workplaces, and an even more vibrant Massachusetts."

This study was supported by Northeastern University. Prof. Auerbach and Rep. Dykema report no relevant financial relationships.

American Public Health Association 141st Annual Meeting: Abstract 276235. Presented November 5, 2013.

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