Before you write off these folks, note that a recent survey of doctors by the Massachusetts Medical Society found that a growing number of doctors support the idea of a single-payer system. More than 40 percent, up from 34 percent last year. So do a lot of folks at Occupy Boston.
OVERVIEW: While the Massachusetts health reform law of 2006, widely regarded as the model for the new federal health law, reduced the uninsured population in the state, it did so at the cost of rapidly rising underinsurance, increased health care premiums, and a financial crisis among the state’s safety-net hospitals and community health centers. And the financial burden of the reform has fallen disproportionately on lower-middle-class families.
Those are some of the findings in a new, exhaustively documented report on the outcomes of the Massachusetts reform law released by Mass-Care and Massachusetts Physicians for a National Health Program. The report draws on hundreds of sources, including academic studies, government statistics and scientific surveys, in the first compilation of its kind.
EXECUTIVE SUMMARY
The Massachusetts Health Reform Law of 2006 expanded Medicaid coverage for the poor and made available publicly subsidized private health insurance for additional low-income residents of the state. It also mandated that all but the poorest uninsured residents either purchase private health insurance or pay a substantial fine (up to $1,212 in 2011). Smaller fines (up to $295 per employee) were also levied on employers who fail to offer insurance.
Four years after full implementation of the law, Massachusetts has not achieved universal coverage, although one-half to two-thirds of the previously uninsured now have some type of insurance policy. Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care. The reform did not lead to a sustained increase in employer-sponsored coverage, but did slow declining employer coverage. Instead of dropping coverage, employers in Massachusetts have increased cost sharing, shifting costs on to employees, leading to rapidly rising underinsurance after health reform. The use of high-deductible plans more than tripled for residents with private insurance, and good insurance coverage at small businesses all but disappeared over a few short years after reform.
Reform has had a positive impact on access to care in the state, but this impact has affected a modest share of residents, and for some patients has been negative. For example, some low-income patients who previously received completely free care under the state’s prior free care program faced new co-payments and premiums after becoming insured, which impeded their access to care. Reform has not reduced the burden of medical bills and medical bankruptcy on Massachusetts’ families.
The growth of residents with insurance coverage has exacerbated a primary care shortage in Massachusetts by increasing wait times for appointments and decreasing the portion of physicians accepting new patients, creating access problems even for those with coverage. Reform did not reverse growing use of the state’s emergency departments for care, despite expectations that expanding insurance coverage would reroute patients through primary care offices. There is no evidence as of yet that expanding insurance coverage has had an impact on health outcomes or disparities in health outcomes. Reform has also created a financial crisis for safety net providers that specialize in care for low-income communities and the uninsured, by shifting resources away from safety net providers while patient demand for safety net care has actually increased.
The public cost of reform has been high, exceeding $800 million in fiscal 2009 for a state with a total budget of $32.5 billion. However, federal taxpayers paid for the bulk of the law’s public expenses. The state has made a broad range of cuts to the original law in order to its keep costs down, cutting back coverage for over 30,000 documented immigrants, curtailing some benefits, increasing cost sharing, and increasing the share of enrollees required to pay premiums. Substantial funds from the federal stimulus bill were also used to sustain the reform law, but this was a short-term fix only.
Public payments account for only a portion of the reform law’s costs. A central premise of the law was that the state, employers, and individuals would all have to sacrifice financially to approach the goal of universal coverage. This premise of “shared responsibility” for the costs of the reform was in many ways disingenuous. Although employers, individuals, state and federal government have shared the burden of increased costs roughly equally, this overlooks the fact that governments pass on their spending to taxpayers, and employers pass on their costs to employees. The actual burden of health reform was regressive, with increased spending after health reform falling disproportionately on lower-middle income residents.
The reform failed to “bend the cost curve” in Massachusetts because it contained no significant cost-control provisions. Health care costs in Massachusetts are higher than in any other state in the nation, and reform has been found to accelerate the rising costs of employer-sponsored health care. There is general agreement that the Massachusetts reform is itself not sustainable without effective cost control.
Massachusetts enjoyed favorable circumstances at the outset of reform, such as previously high levels of spending on health care for the poor, high personal incomes, and relatively low rates of uninsurance. Without controlling costs, national reform will run up against the same difficulties as Massachusetts: growth in public insurance coverage will prove unsustainable and will accompany the rapid erosion of private insurance benefits, while modest gains in access to care will be threatened in the short term by unsustainably high costs that are increasingly shifted on to patients.
While Massachusetts health reform has enjoyed support from a majority of residents in the state, that support has declined since national health reform instigated a broader debate over alternatives to the Massachusetts plan. Moreover, while residents support the Massachusetts reform law over no change at all, they have expressed increasing skepticism that the law is working for vulnerable communities, and more residents report that the law is hurting them than helping them.
We believe that the data in this report should give pause to those concerned with national health care reform. Although not without its successes, the Massachusetts reform has not addressed the fundamental deficiencies in the health care system – treating symptoms rather than causes – and even its modest successes are unsustainable for the state and Massachusetts residents.
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A study of cancer patients and their doctors in the Annals of Internal Medicine a year later found that many doctors didn’t quite tell patients the truth about their prognosis. Doctors were up front about their patients’ estimated survival 37 percent of the time; refused to give any estimate 23 percent of the time; and told patients something else 40 percent of the time. Around 70 percent of the discrepant estimates were overly optimistic.
But the health care system doesn’t operate in the real world and often that scan doesn’t represent the best care. And, even insured pateints are in for huge copays and deductibles.
