Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate

Context: Much can be learned from Massachusetts's experience implementing health insurance coverage expansions and an individual health insurance mandate. While achieving political consensus on reform is difficult, implementation can be equally or even more challenging.
Methods: The data in this article are based on a case study of Massachusetts, including interviews with key stakeholders, state government, and Commonwealth Health Insurance Connector Authority officials during the first three years of the program and a detailed analysis of primary and secondary documents.
Findings: Coverage expansion and an individual mandate led Massachusetts to define affordability standards, establish a minimum level of insurance coverage, adopt insurance market reforms, and institute incentives and penalties to encourage coverage. Implementation entailed trade-offs between the comprehensiveness of benefits and premium costs, the subsidy levels and affordability, and among the level of mandate penalties, public support, and coverage gains.
Conclusions: National lessons from the Massachusetts experience come not only from the specific decisions made but also from the process of decision making, the need to keep stakeholders engaged, the relationship of decisions to existing programs and regulations, and the interactions among program components.     

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference‐in‐differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.     

The Impact of Near‐Universal Insurance Coverage on Breast and Cervical Cancer Screening: Evidence from Massachusetts

This paper investigates the effect of expansion to near‐universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low‐income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low‐income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low‐income women. Our results suggest that reform was successful in promoting preventive care among targeted populations. Copyright © 2015 John Wiley & Sons, Ltd.     

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

Health insurance reform and retirement: Evidence from the Affordable Care Act

The Affordable Care Act (ACA) has provided millions of Americans with medical insurance but may have led to an increase in retirement among older individuals who are utilizing the newly available coverage options as a substitute for employer‐provided insurance. Using data from the American Community Survey from 2009–2016, this hypothesis is tested by estimating the effect of the premium subsidies and Medicaid expansions of the ACA on retirement transitions for the non‐Medicare eligible cohort of older Americans aged 55–64. Research results indicate a 2% and 8% decrease in labor force participation resulting from the premium subsidies and Medicaid expansions, respectively. Slightly larger estimates are found among a subgroup of adult couples. The study also finds suggestive evidence of crowd‐out of employer‐sponsored insurance by subsidized marketplace plans but finds no such effects from the Medicaid expansions.     

How product standardization affects choice: Evidence from the Massachusetts Health Insurance Exchange

This paper examines the effect of choice architecture on Massachusetts' Health Insurance Exchange. A policy change standardized cost-sharing parameters of plans across insurers and altered information presentation. Post-change, consumers chose more generous plans and different brands, but were not more price-sensitive. We use a discrete choice model that allows the policy to affect how attributes are valued to decompose the policy's effects into a valuation effect and a product availability effect. The brand shifts are largely explained by the availability effect and the generosity shift by the valuation effect. A hypothetical choice experiment replicates our results and explores alternative counterfactuals.     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.Methods. We used 2003–2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.Results. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states—from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.Conclusions. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

Universal Health Insurance and Health Care Access for Homeless Persons

Objectives. We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.Methods. We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.Results. Unmet health care needs were reported by 17% of participants. Compared with Toronto''s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.Conclusions. Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.Homeless people are among the most marginalized groups in society, and large numbers of homeless individuals are found in the United States, Canada, and throughout the world.^1,2 Although the majority of homeless people are men, women and parents with children represent substantial segments of the homeless population.³ Homeless people suffer from many serious threats to their health, including an increased risk of all-cause mortality.⁴ Common medical conditions in this population include epilepsy, chronic obstructive pulmonary disease, hypertension, diabetes, and musculoskeletal disorders.⁵ Substance abuse, mental illness, and related comorbidities are also highly prevalent.⁵Despite high levels of morbidity and mortality, homeless people face numerous financial and nonfinancial barriers to obtaining needed health services.^6,7 A 1996 nationwide survey of homeless people across the United States found that 57% were uninsured, and lack of health insurance was associated with significantly lower odds of using ambulatory health care.⁷ Nonfinancial barriers have also been described. Competing priorities such as securing adequate food and shelter may lead to delays in seeking health care.⁸ Lack of transportation to health visits, long waiting times in clinics, and feelings of being stigmatized by health care professionals are also obstacles frequently reported by homeless people.^6,9 Lack of appropriate health care for homeless people may contribute to deterioration in health status, prolonged homelessness, and even death.^10,11Most studies of unmet needs for care among homeless individuals have been conducted in the United States.^6,7,12 Unmet needs for medical care in the past year were reported by 25% of respondents in a nationwide survey of homeless people in the United States and were somewhat more common among homeless families than among single homeless persons (27% vs 24%, respectively).^7,13 Studies conducted in various US urban centers have found even higher rates of unmet needs for care. Among homeless people living in urban encampments in Los Angeles, California, 41% felt there was a time in the past 6 months when they had needed to go to a doctor but did not.¹² A study of homeless women in Los Angeles County in 1997 found that 37% of participants had unmet needs for health care in the past 60 days.⁶ In a survey of low-income adults in Baltimore, Maryland, 57% of whom were homeless, 51% reported having difficulty accessing health care services.¹⁴ A recent study conducted in Birmingham, Alabama, found that the prevalence of unmet needs for care among homeless people rose from 32% in 1995 to 54% in 2005.¹⁵ This overall pattern suggests inadequacy of the US health care safety net for low-income and uninsured individuals.¹⁵Canada has a publicly funded system of universal health insurance that consists of single-payer plans administered by each province. All medically necessary physician services and hospital-based care are fully covered with no copayments. However, the extent to which such a system meets the needs of severely disadvantaged individuals has not been well defined.^16,17 Our objectives were to determine the prevalence of unmet needs for health care among homeless single men, single women, and women with dependent children within Canada''s universal health insurance system and to identify individual characteristics associated with having unmet needs.     

How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care

The Patient Protection and Affordable Care Act (ACA) will expand coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The key to this expansion is the essential health benefit provision in the ACA that requires coverage of mental health and substance use disorder services at parity with general medical benefits. Other ACA provisions that should improve access to treatment include requirements on network adequacy, dependent coverage up to age 26, preventive services, and prohibitions on annual and lifetime limits and preexisting exclusions. The ACA offers states flexibility in expanding Medicaid (primarily to childless adults, not generally eligible previously) to cover supportive services needed by those with significant behavioral health conditions in addition to basic benefits at parity. Through these various new requirements, the ACA in conjunction with Mental Health Parity and Addiction Equity Act (MHPAEA) will expand coverage of behavioral health care by historic proportions.     

Improvements in Health Status after Massachusetts Health Care Reform

Context

Massachusetts enacted health care reform in 2006 to expand insurance coverage and improve access to health care. The objective of our study was to compare trends in health status and the use of ambulatory health services before and after the implementation of health reform in Massachusetts relative to that in other New England states.

Methods

We used a quasi-experimental design with data from the Behavioral Risk Factor Surveillance System from 2001 to 2011 to compare trends associated with health reform in Massachusetts relative to that in other New England states. We compared self-reported health and the use of preventive services using multivariate logistic regression with difference-in-differences analysis to account for temporal trends. We estimated predicted probabilities and changes in these probabilities to gauge the differential effects between Massachusetts and other New England states. Finally, we conducted subgroup analysis to assess the differential changes by income and race/ethnicity.

Findings

The sample included 345,211 adults aged eighteen to sixty-four. In comparing the periods before and after health care reform relative to those in other New England states, we found that Massachusetts residents reported greater improvements in general health (1.7%), physical health (1.3%), and mental health (1.5%). Massachusetts residents also reported significant relative increases in rates of Pap screening (2.3%), colonoscopy (5.5%), and cholesterol testing (1.4%). Adults in Massachusetts households that earned up to 300% of the federal poverty level gained more in health status than did those above that level, with differential changes ranging from 0.2% to 1.3%. Relative gains in health status were comparable among white, black, and Hispanic residents in Massachusetts.

Conclusions

Health care reform in Massachusetts was associated with improved health status and the greater use of some preventive services relative to those in other New England states, particularly among low-income households. These findings may stem from expanded insurance coverage as well as innovations in health care delivery that accelerated after health reform.     

The Impact of the Macroeconomy on Health Insurance Coverage: Evidence from the Great Recession

This paper investigates the impact of the macroeconomy on the health insurance coverage of Americans using panel data from the Survey of Income and Program Participation for 2004–2010, a period that includes the Great Recession of 2007–2009. We find that a one percentage point increase in the state unemployment rate is associated with a 1.67 percentage point (2.12%) reduction in the probability that men have health insurance; this effect is strongest among college‐educated, white, and older (50–64 years old) men. For women and children, health insurance coverage is not significantly correlated with the unemployment rate, which may be the result of public health insurance acting as a social safety net. Compared with the previous recession, the health insurance coverage of men is more sensitive to the unemployment rate, which may be due to the nature of the Great Recession. Copyright © 2013 John Wiley & Sons, Ltd.     

Health Care Coverage and the Health Care Industry

Objectives. We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.Methods. We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.Results. Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI] = 2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI = 3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR] = 1.5; 95% CI = 1.0, 2.4).Conclusions. Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.For complex socioeconomic reasons, private health insurance, typically provided by an employer, is “the dominant mechanism for paying for health services” in the United States.^1(p79) According to the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, analyses of data from the Current Population Survey (CPS) show that, in 2006, 54% of the US civilian, noninstitutionalized population had employer-sponsored health insurance; 5% had private, nongroup health insurance; and 26% had public health insurance coverage. Approximately 46 million US residents (16% of the population) are currently uninsured.² Numerous studies have shown that, relative to people with health insurance, uninsured people receive less preventive care, are diagnosed at more advanced disease stages, and, once diagnosed, tend to receive less therapeutic care and have higher mortality rates.^3–8Although national uninsurance trends are well-documented, the rate of uninsurance within the health care workforce has received scant attention. Given that health care employment rates are increasing at a more rapid pace than overall employment rates, this lack of attention is especially worrisome. According to the Bureau of Labor Statistics, nearly half of the 30 occupations in which employment opportunities are growing fastest are health care occupations. For example, whereas the Bureau of Labor Statistics projects that overall employment will increase about 10% from 2006 to 2016, employment opportunities for personal and home care aides are projected to increase nearly 51%, and opportunities for physical therapist assistants are expected to increase by a third. The Bureau of Labor Statistics also projects that, by 2016, new job opportunities for registered nurses will increase by approximately 24% (approximately 587 000 new jobs).⁹Although the overall employment outlook for health care workers is promising, what is less clear is to what degree employment in health care is associated with health insurance coverage. A 2001 General Accounting Office report suggested that one fourth of nursing home aides and one third of home health care aides were uninsured.¹⁰ The Kaiser Family Foundation reported that the uninsured rate among workers in the health and social services industry was 23% in 2007.¹¹ On the basis of a review of the literature in the health and human services occupations, Ebenstein concluded that the health insurance plans offered to direct care workers in the developmental disabilities field are “inferior … with less coverage and more out-of-pocket expenses” and that fewer direct care workers “are able to afford health coverage even if they are eligible.”^12(p132)Taking a more comprehensive look at the US health care workforce, Himmelstein and Woolhandler¹³ used 1991 CPS data to estimate uninsurance rates among physicians and other health care personnel. They reported that, overall, 9% of health care workers were uninsured, along with more than 20% of nursing home workers. Examining CPS data from 1988 to 1998, Case et al. found that uninsurance rates among all health care workers rose from 8% to 12%, that rates increased more for health care workers than for workers in other industries, and that rates differed according to occupation and place of employment.¹⁴ For example, occupation-specific uninsurance rates were 23.8% among health aides, 14.5% among licensed practical nurses, and 5% among registered nurses, whereas place-specific rates were 20% among nursing home workers, 8.7% among medical office workers, and 8.2% among hospital workers.¹⁵In their studies, Himmelstein and Woolhandler¹³ and Case et al.¹⁴ used national-level data to estimate uninsurance trends among health care workers. However, these trends were not adjusted for health care workers'' social, demographic, or economic characteristics, which would have helped explain variation across categories or over time. Moreover, with the growth of the health care workforce, estimates from these older studies probably do not reflect the current situation. As a result, the picture of uninsurance as it pertains to the health care workforce lacks the precision and currentness necessary for sound policy decisions. In an effort to expand knowledge in this area, produce more up-to-date estimates, and provide support for possible policy decisions, we used data from the National Health Interview Survey (NHIS) to examine uninsurance among workers in the health care industry.