J June 2011 National Reform: What Can We Learn ULY 2010 from Evaluations of Massachusetts? Sharon K. Long*, Karen Stockley^, and Heather Dahlen* KEY FINDINGS *University of Minnesota • Minneapolis, MN • ^Urban Institute • Washington, DC Impact of Massachusetts’ Reform on Non-Elderly Adults INTRODUCTION  There have been strong gains in insurance coverage for non-elderly adults The 2010 Patient Protection and Affordable Care Act under health reform. (ACA) is modeled on Massachusetts’ 2006 landmark  Over time, uninsurance in Massachusetts reform—An Act Providing Access to Affordable, Quality, has been consistently much lower than in Accountable Health Care. As in Massachusetts, national the nation broadly. reform includes public program expansions; the creation of health insurance exchanges; premium and  There is no evidence that the expansion of cost-sharing subsidies; an individual mandate; and public coverage has led to the crowd-out of employer-sponsored coverage. requirements for employers, among other provisions (Henry J. Kaiser Family Foundation, 2010). This brief  There is evidence of gains in access to provides a synthesis of what we know about the and use of care in under reform, although impacts of Massachusetts’ health reform and an not across all measures. assessment of what these findings mean for the ACA  There have been improvements in the and for the evaluation of the ACA’s impacts. affordability of care, particularly as measured by the share of adults forgoing care due to costs, although these MASSACHUSETTS’ REFORM improvements have tended to erode over time. We discuss findings from the range of studies that examine the effects of Massachusetts’ health reform on non-elderly adults, focusing on work that has from 2 to 8 percentage points over the 2007 to 2009 evaluated insurance coverage; health care access and post-reform period.ii use; and the affordability of care. Figure 1 illustrates the gains in insurance coverage for non-elderly adults in Massachusetts relative to the rest COVERAGE of the country over the 2006 to 2009 period, using the Current Population Survey (CPS), the National Health Strong Gains in Coverage Interview Survey (NHIS), and the American Table 1 summarizes the literature on the impacts of Community Survey (ACS).iii As shown in the figure, health reform on health insurance coverage for non- the patterns of uninsurance for Massachusetts are elderly adults in Massachusetts.i Despite the quite similar across the surveys, as are the patterns for differences in data sources and methods, there is the nation as a whole. Moreover, across the surveys general consistency in the core findings across the and over time, uninsurance in Massachusetts is studies. The studies all find gains in insurance consistently much lower than in the nation broadly, coverage for non-elderly adults under health reform, with the rate of uninsurance falling in Massachusetts with estimates of the increase in coverage ranging since 2006 while increasing for the nation as a whole. State Health Access Reform Evaluation, a national program of the Robert Wood Johnson Foundation ® National Reform: What Can We Learn from Evaluations of Massachusetts? Table 1: Summary of Studies Addressing the Impacts of Health Reform on Insurance Coverage for Non-Elderly Adults in Massachusetts* Study Data Source Summary of Key Findingsa Increase in insurance coverage (up 5.6 percentage points in Fall 2007), with Long (2008) in Health Affairsb MHRSc increases in ESI and public/other coverage; Reduction in ever uninsured over the past year Increase in insurance coverage (up 7.9 percentage points in Fall 2008), with Long and Stockley (2009), Urban MHRS increases in ESI and public/other coverage; Reduction in ever uninsured and Institute publicationb always uninsured over the past year Increase in insurance coverage (up 7.7 percentage points in Fall 2009), with Long and Stockley (2010) in Health MHRS increases in ESI and public/other coverage; Reduction in ever uninsured and Affairsb always uninsured over the past year Zhu et al. (2010) in Journal of BRFSS Increase in insurance coveraged General Internal Medicine Tinsley, Andrews, Hawk, and Cohen Insurance coverage increased (up 5 percentage points in 2007/2008), with (2010) in Morbidity and Mortality BRFSS private coverage (ESI and direct purchase) reduced and public coverage Weekly Report increased Increase in insurance coverage (up 2 to 3 percentage points in 2007/2008), Clark et al. (2011) in Health Affairs BRFSS with increase in public/other coverage and no change in ESI coverage Long and Stockley (2011) in Health Increase in insurance coverage (up 2 to 3 percentage points in 2007/2008), NHIS Services Research with increase in public/other coverage and no change in ESI coverage Yelowitz and Cannon (2010), CATO Increase in insurance coverage (up 6.7 percentage points in 2007/2008), with CPS Institute publication an increase in private coverage (ESI and direct purchase) Long, Stockley and Yemane (2009) in Insurance coverage increased (up 6.6 percentage points in 2007), with CPS American Economic Review increases in ESI and public/other coverage Massachusetts Division of Health Insurance coverage in the state increased by 8 percent (410,000 persons) Care Finance and Policy (2010) Administrative between June 2006 and March 2010, with gains in both public and private Health Care in Massachusetts: Key Data group coverage Indicators *Notes: MHRS is Massachusetts Health Reform Survey; BRFSS is Behavioral Risk Factor Surveillance System; NHIS is National Health Interview Survey; CPS is Current Population Survey; ESI is employer-sponsored insurance a Findings are based on regression-adjusted estimates unless otherwise noted. b The research based on the MHRS is updated each year as another round of data becomes available. c Studies using the MHRS, which provides data for Massachusetts only, have relied on pre-post comparisons. In contrast, studies using other data sources have generally taken advantage of the availability of data for other states to use the stronger difference-in-differences model to assess the impacts of health reform in Massachusetts. d Point estimate not available. SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 2 National Reform: What Can We Learn from Evaluations of Massachusetts? Figure 1. Trends in Uninsurance in the United States and Massachusetts for Non-Elderly Adults, 2006-2009 25 22.3 United States 20.2 20.3 21.2 19.6 20 19.8 20.6 19.8 19.4 19.7 Percent Uninsured 15 13.6 Massachusetts 10 8.2 10.2 7.3 5.9 7.0 5.5 5.9 5 5.2 4.2 0 2006 2007 2008 2009 CPS - United States ACS - United States NHIS - United States CPS - Massachusetts ACS - Massachusetts NHIS - Massachusetts reduction in ESI coverage in the state. Administrative No Evidence of Crowd-Out data from the Massachusetts Division of Health Care Beyond the impact on insurance coverage overall, Finance and Policy provides further support for this an important issue in assessing the implications of conclusion (2010). Moreover, employers indicated health reform on insurance coverage is the extent that they were more likely to offer coverage to their to which expansions of public coverage substitute workers in 2009 than they were in 2005 (76% versus for or ―crowd out‖ existing employer-sponsored 70%), and data on total enrollment in private group coverage. If individuals give up their employer- plans in the state indicate an increase of 28,000 people sponsored coverage to enroll in public coverage, between 2006 and 2010. (DHCFP 2009 the net gain in overall insurance coverage from the Massachusetts Employer Survey, data drawn from all public expansion will be lowered. MA employers). As shown in Table 1, studies focusing on changes in employer-sponsored insurance (ESI) coverage under ACCESS TO AND USE OF HEALTH CARE health reform using the MHRS (Long 2008, Long and Stockley 2009, Long and Stockley 2010) and the CPS Some Gains, Still Room for (Long, Stockley, and Yemane 2009) find increased Improvement ESI coverage, while work using the NHIS (Long and The expansion of health insurance coverage in Stockley 2011) finds no change in ESI coverage under Massachusetts was expected to provide better reform. Thus, there is no evidence that the expansion access to health care providers and increased use of public coverage in Massachusetts has led to a of care for those who gained coverage, as these SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 3 National Reform: What Can We Learn from Evaluations of Massachusetts? individuals would face lower costs for using on the individual’s experiences over the prior year services. Moreover, Massachusetts created new (unlike measures of current insurance coverage). standards (―minimum creditable coverage‖ As a result, we have less timely information on standards) for the benefits that a health plan must changes in access to and use of health care under cover in order for the plan to count as coverage health reform than we do on insurance coverage. under the individual mandate.iv These new standards apply both to those obtaining coverage Overall, the findings from studies using the MHRS under health reform and to those who were are consistent with the expected lag in observing previously insured—and with more benefits changes in health care access and use under health covered, access to and use of care was expected to reform: there were few improvements in access to improve for both groups. care or increases in health care use in 2007 (Long 2008), the first year after reform began, with Table 2 summarizes the findings from research greater gains observed in subsequent years (Long that has examined access to and use of care by and Masi 2009, Long and Stockley 2010). By 2009, non-elderly adults under health reform in there were increases in the share of non-elderly Massachusetts. There has been less work on this adults reporting that they had a usual source of topic than on insurance coverage, reflecting the health care; increases in the shares reporting more limited data sources available for examining outpatient visits and the use of prescription drugs; access to and use of care overall and within and decreases in the shares reporting having individual states. Research on the impacts of foregone needed health care.v Studies based on the health reform on health care access and use is also BRFSS and NHIS also provide evidence of some limited by the expected lag in the impact of the gains in access to and use of care under health expansion of insurance coverage on the reform, although the findings are not entirely individual’s health care access and use and the consistent across the studies. For example, in nature of the access and use questions included in work using the BRFSS, Tinsley et al. (2010) report the surveys. The survey questions generally focus an increase in the share of non-elderly adults with a Table 2: Summary of Studies Addressing the Impacts of Health reform on Access to and Use of Care for Non-Elderly Adults in Massachusetts* Study Data Source Summary of Key Findingsa Increase in share with usual source of care; Increases in some types of Long (2008) in Health Affairsb MHRS outpatient visits; No change in share taking prescription drugs or emergency department use; Reductions in unmet need for care Increase in share with usual source of care; Increases in some types of Long and Masi (2009) in Health MHRS outpatient visits and share taking prescription drugs; No change in Affairsb emergency department use; Some reductions in unmet need for care Increase in share with usual source of care, outpatient visits, and taking Long and Stockley (2010) in Health MHRS prescription drugs; No change in inpatient use or emergency department Affairsb use; Reductions in unmet need for all types of care No change in receipt of mammogram or Pap smear; Increase in receipt of Clark et al. (2011) in Health Affairs BRFSS colonoscopy; Increase in cholesterol screening for women but not men Tinsley, Andrews, Hawk, and Cohen Increase in share with a personal health care provider; Increase in share (2010) in Morbidity and Mortality BRFSS with a routine checkup Weekly Report Zhu et al. (2010) in Journal of BRFSS No change in share with a personal health care provider General Internal Medicine No changes for most measures, with the exception of increases in delayed Long and Stockley (2011) in Health NHIS getting needed care because couldn't get an appointment and in likelihood of Services Research a visit to a nurse practitioner, physician assistant, or midwife *Notes: MHRS is Massachusetts Health Reform Survey; BRFSS is Behavioral Risk Factor Surveillance System; NHIS is National Health Interview Survey a Findings are based on regression-adjusted estimates unless otherwise noted. b The research based on the MHRS is updated each year as another round of data becomes available. SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 4 National Reform: What Can We Learn from Evaluations of Massachusetts? personal health care provider under health reform Table 3 summarizes the findings from studies that in Massachusetts, while Zhu et al. (2010) report no have looked at the impacts of health reform on change in that measure. affordability of care for non-elderly adults in Massachusetts. This work has relied on the Despite the gains in access to care under health MHRS, the BRFSS and the NHIS. reform in Massachusetts, it is important to note that the analyses reveal some persistent problems As with the studies focusing on insurance coverage with access to health care that have continued and health care access and use, the findings from under health reform. According to survey these studies are generally consistent. All show responses, roughly one in five non-elderly adults in improvements in the affordability of care for non- Massachusetts did not get some type of needed elderly adults, particularly in terms of reductions in the care in the past 12 months (Long and Stockley share of adults going without needed care because of 2010); more than one in four adults did not have a costs—the one measure available across all three data doctor visit in the past 12 months for a routine sets. Findings from studies using the MHRS, which check-up (Tinsley et al. 2010); more than one in provides a broader set of measures on affordability of ten women went without a recent Pap smear (ages care, suggests that there were stronger gains in the 18 to 64) or mammogram (ages 40-64) (Clark et al. affordability of care for individuals in the early period 2011); and more than one in three adults ages 50 to after health reform (Long 2008), with those gains 64 went without a recent colonoscopy (Clark et al. eroded over time (Long and Masi 2009, Long and 2011). Stockley 2010). As with access to care, it is important to note that AFFORDABILITY OF HEALTH CARE affordability of care continues to be an issue for some adults in Massachusetts. For example, Health Care Costs are Less of a Barrier several of the studies report unmet need for health While Massachusetts’ 2006 health reform initiative did care due to costs for more than one in ten non- not tackle the high cost of health care in the state, the elderly adults in the state (Long and Stockley 2010, expansion of health insurance coverage and the Long and Stockley 2011), with higher levels for establishment of the minimum creditable standards some subgroups of adults (Clark et al. 2011). were expected to improve the affordability of health Long and Stockley (2010) also report roughly one care for individuals. in five non-elderly adults with high out-of-pocket health care costs, problems paying medical bills, Table 3: Summary of Studies Addressing the Impacts of Health Reform on the Affordability of Care for Non-Elderly Adults in Massachusetts* Study Data Source Summary of Key Findings a Long (2008) in Reductions in OOP spending, problems paying medical bills and medical debt, Health Affairsb MHRS and unmet need due to costs Long and Masi (2009), in Health Reductions in OOP spending and unmet need due to costs; No change in Affairsb MHRS problems paying medical bills and medical debt Long and Stockley (2010) in Health Reductions in OOP spending and unmet need due to costs; No change in Affairsb MHRS problems paying medical bills and medical debt Clark et al. (2011) in Health Affairs BRFSS Reduction in unmet need due to costs Zhu et al. (2010) in Journal of General Internal Medicine BRFSS Reduction in unmet need due to costs Long and Stockley (2011) in Health Some evidence of reductions in unmet need for care and delays in getting care Services Research NHIS because of costs *Notes: MHRS is Massachusetts Health Reform Survey; BRFSS is Behavioral Risk Factor Surveillance Survey; NHIS is National Health Interview Survey; OOP is out-of-pocket. a Findings are based on regression-adjusted estimates unless otherwise noted. b The research based on the MHRS is updated each year as another round of data becomes available. SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 5 National Reform: What Can We Learn from Evaluations of Massachusetts? and problems with medical debt. system across the nation in order to keep health care affordable. LESSONS FOR NATIONAL REFORM National Data Sources are Limited for State Applications Complex Reforms Can Be Carried out Quickly and Effectively Finally, efforts to evaluate the impacts of health reform in Massachusetts have highlighted the Massachusetts has shown that a complex health limitations of current national data sources for reform initiative, including the deployment of a assessing the impacts of national reform across the strong outreach and enrollment system (Dorn, Hill states. For national surveys, state sample sizes are and Hogan 2009), can be implemented quickly and often small, the range of issues addressed in the effectively (Raymond 2007, 2011). The net result surveys are often limited, and there are often lags in has been significant gains in health insurance data availability that affect the timeliness of efforts to coverage and access to health care for the state’s assess the impacts of health reform. There are a residents. number of strategies that would increase the value of existing surveys for evaluating national reform, The Gains of Reform Can be Sustained including investing in state representative samples and in a Weak Economy larger state sample sizes, expanding survey content to More recently, Massachusetts has shown that, while address issues of particular relevance under health difficult, sustaining the gains of health reform in a reform, and releasing data more quickly and in more severe recession is possible. Uninsurance in the state accessible formats.vii For administrative data sources, remains at historically low levels and employer- there is a need for more uniform data collection sponsored insurance remains strong despite the severe efforts across the state to provide consistent data for economic recession that began in December 2007 and Medicaid, CHIP, and exchange-based coverage. continues to affect the state’s economy. Consistent data in these areas will help to insure comparability across states and over time. Efforts to improve survey and administrative data are underway Increased Coverage Does Not at a number of federal and state agencies and, to the Necessarily Equal Improved Access, extent they are successful, offer the prospect for more Costs timely and in-depth tracking of the impacts of health Massachusetts’ reform effort has also demonstrated reform in the future than has been possible for that universal health coverage does not guarantee Massachusetts using national survey data.viii universal access to health care, nor does it slow the growth of health care costs. While Massachusetts has i The focus here is on the findings for the overall population. A number initiated a number of strategies to improve access to of the studies also examine the impacts of reform on important subgroups care,vi the state deferred addressing health care costs of the population, including lower-income adults, younger adults, adults as part of the 2006 legislation in order to avoid a delay with chronic conditions, men and women, and racial/ethnic minorities, among others. in expanding coverage. Currently, there is broad ii Differences in the precise point estimates likely reflect differences in data consensus in the state about the need to control sources and methods as well as differences in the specific pre- and post- health care costs, and there is much discussion about reform time periods used in the studies. In particular, post-reform time potential strategies for doing so. A recent proposal by periods ranged from estimates for the first year after implementation began (2007) to estimates following the implementation of nearly all of the Massachusetts Governor Deval Patrick would put a core elements of reform (2009). number of strategies into place, such as the promotion iii Although the ACS does not provide data on insurance coverage for the of integrated care networks and a move away from pre-reform period in Massachusetts, the sample sizes in that survey are fee-for-service payments toward alternative payment much larger than those of the CPS or NHIS, providing more precise state estimates than are possible from the other surveys. methods (Patrick 2011). There have been efforts in iv For more information on the minimum creditable coverage standards, this direction by providers and insurers in the state as see www.mahealthconnector.org. v The MHRS provides the strongest data source for looking at the time well (Chernew et al. 2011). With escalating health care path of changes in health care access and use in the state as it combines a costs a serious problem in every state, there is a clear relatively large sample size for Massachusetts, a fairly comprehensive set of need for strong federal leadership to address the access and use measures, and a more timely data release. systematic problems with the health care payment vi These include primary care physician recruitment programs through the state’s Primary Care Office and a public-private program to repay loans for providers at community health centers. SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 6 National Reform: What Can We Learn from Evaluations of Massachusetts? vii Currently, access to the state identifiers in the NHIS and MEPS and colleagues at the UCLA Center for Health Policy Research requires that the work be done in a Research Data Center. (www.healthpolicy.ucla.edu ), who are focusing on state and local viii population surveys, and Kathleen Call and colleagues at SHADAC Another strategy that could support improved evaluations of the (www.shadac.org/contentsurvey-resources), who are focusing on state impact of national health reform is greater coordination across state- health insurance surveys. sponsored surveys. We are aware of two such efforts: Richard Brown REFERENCES Henry J. Kaiser Family Foundation. Focus on Health Implementation. Boston: The Blue Cross Blue Shield of Reform: Summary of New Health Reform Law Massachusetts Foundation; 2007. Available from: [Internet]. Menlo Park (CA): The Foundation; 2010 http://masshealthpolicyforum.brandeis.edu/publicatio [updated 2010 Mar 26; cited 2010 Apr 6]. Publication ns/pdfs/31- No.: 8061. Available from: May07/MassHealthCareReformProgess%20Report.pdf http://www.kff.org/healthreform/upload/8061.pdf. Raymond A. 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Available from: Health Systems and Payments.‖ February 17, 2011. http://www.cato.org/pub_display.php?pub_id=11115. Available from: Zhu J, P. Brawarsky, S. Lipsitz, H. Huskamp, JS Haas. http://www.mass.gov/Agov3/docs/Legislation/Paym ―Massachusetts Health Reform and Disparities in entReformFillingLetter.pdf Coverage, Access and Health Status.‖ Journal of General Raymond A. The 2006 Massachusetts Health Care Reform Internal Medicine, 2010 25:12 pp. 1356-1362. Law: Progress and Challenges after One Year of ABOUT SHARE The State Health Access Reform Evaluation (SHARE) is a Robert Wood Johnson Foundation (RWJF) program that supports rigorous research on health reform issues, specifically as they relate to the state implementation of the Affordable Care Act (ACA). The program operates out of the State Health Access Data Assistance Center (SHADAC), an RWJF-funded research center in the Division of Health Policy and Management, School of Public Health, University of Minnesota. Information is available at www.statereformevaluation.org. State Health Access Data Assistance Center 2221 University Avenue, Suite 345 Minneapolis, MN 55414 Phone (612) 624-4802 SHARE STATE HEALTH ACCESS REFORM EVALUATION WWW.SHADAC.ORG/SHARE 7