Massachusetts health care reform carries lessons for US

Before my oldest daughter was one, she'd had croup many times. One croupy night, my daughter began seriously labored breathing called stridor. On the advice of the nurses' emergency line, we went to the emergency room where our baby was given breathing treatment and sent home the next morning. Shortly before lunch, the phone rang.

It was our doctor, "Hey I got a message this morning that you guys were at the ER for stridor. How is the baby now?"

"Better, fever is down, coughing much better," I told her, grateful she called me.

"I waited until now to call because the report looked fine," she said, "And I saw you didn't leave until nearly 6 a.m. so I hoped you got a few hours of sleep. You guys need anything?"

"Just more sleep, and less croup," I said.

"Take care of you, too," she said, shifting quickly from my daughter's doctor to mine, "Your body is still working for the baby, too, since you're nursing." We chatted about the croup and stridor, overall health for a few minutes and then hung up. My only concern in that moment was taking care of my baby...and me.

I had no concerns that our health insurance premiums would go up, that large portions of the hospital bill wouldn't be covered, or that this would be flagged as a perpetual condition and our coverage would be at risk. The commonwealth protected patients from that. Plus, we were lucky to have 100% employer-provided complete coverage. In fact, I never met a health condition -- not even infertility -- that wasn't covered.

That's because we were fortunate recipients of the health care system in Massachusetts: a very patient oriented, preventive-centric, forward-thinking, comprehensive and inclusive health care system in our experience. Our family health practitioner was networked in with other area doctors and the local hospital.By virtue of treating us all -- with a cooperative network of other more specialized doctors -- she was very tuned in to our family and our health care situation.

However, I knew not every family in Massachusetts was so fortunate. Not everyone had access to employer-provided insurance. Not all employer-provided insurance was perfect. So Massachusetts continued the heath reform process, taking another leap forward into a public program.

As with other health care systems that differ from the general offered in the US, this system has been held up for criticism and negative judgment. But that's largely speculation and conjecture.

Now, Kaiser has released a comprehensive study of the reformed Massachusetts health care system.

So how did it score? Very well, so skeptics and doubters take note: you can reform health care as Massachusetts has and see it succeed even if there is still solid and substantial room for improvement.

I encourage you to read the Kaiser Family Foundation report about consumers' experience with health care in Massachusetts on your own, but I pulled a few key points to share overall results.

In short, the public program has achieved its goal of providing access to health care, quality health care, and protection for those who need it, but those who continue to use employer-sponsored private plans face financial risks.

According to the Kaiser Family Foundation's press release about their recent studies:

As Congress returns from recess and resumes deliberations over comprehensive national health reform, the Kaiser Family Foundation has issued two new reports and an updated fact sheet that examine state-level health reform in Massachusetts and the lessons it offers for policymakers in Washington.

The new reports, Consumers’ Experience in Massachusetts: Lessons For National Health Reform and In Pursuit of Affordable Health Care: On the Ground Lessons from Families in Massachusetts, examine the impact of health reform on the lives of ordinary people in the state. They find that expanded public programs have been an important source of coverage to low and moderate income individuals and have provided protection against high out-of-pocket costs, but also that people with employer-sponsored insurance often continue to face financial challenges if they have significant health care needs.

The Foundation also released an updated version of its fact sheet, Massachusetts Health Care Reform, which describes the basic components of the reform law, examines how many people have gained coverage and discusses cost containment and affordability goals and implementation challenges.

The Foundation released the new and updated reports in conjunction with a Sept. 1 public briefing featuring key players from the Massachusetts reform effort that examined the lessons of the state’s reform law for policymakers in Washington. The new materials and an archived webcast of the briefing are available online.

More health reform-related resources can be found on the Foundation’s health reform gateway page, which serves as a clearinghouse of key information, news and analysis about national health reform efforts."

The Executive Summary in the report PDF boils it down to the bottom line:

In April 2006, Massachusetts enacted a comprehensive health care reform law. Its goal was to move the state towards universal health insurance coverage through a series of reform measures that included an individual mandate for insurance coverage, an expansion of public coverage programs, and the creation of a Connector that sets policies and facilitates access to insurance for state residents. As a possible model for national reform, the Massachusetts reform effort can provide useful lessons for how to make a restructured health care system work for consumers.

In partnership with the Kaiser Family Foundation, researchers from The Access Project conducted in-depth interviews with fifteen Massachusetts consumers, as well as with several key participants in the health reform effort, to better understand the impact of the Massachusetts health system reform on consumers. The study focused particularly on people’s ability to afford and access needed care. The following key findings emerged from the research:

• Public programs have increased access and provided affordable insurance coverage options for low-income individuals. The expansion of the Massachusetts Medicaid program and the creation of Commonwealth Care, a program that subsidizes coverage for adults under 300% FPL, have reduced the uninsured rate for low income residents and allowed many people to gain access to affordable coverage and obtain care.
• However, some people are still struggling to afford coverage and care. Low-income workers with access to employer-sponsored coverage, as well as moderate-income individuals without access to employer sponsored coverage, are both ineligible for state subsidized insurance. Coverage options for these individuals often remain unaffordable.
• People with chronic conditions still face greater cost barriers to care. While nominal co-payments may be affordable for people who need care only occasionally, lower income people who need ongoing care may quickly find the out-of-pocket costs unaffordable.

• System complexities can lead to gaps in coverage. With the multitude of programs offered by Massachusetts, all with varying eligibility and programmatic rules, residents with fluctuating incomes and employment statuses can fall through the cracks. These individuals, and others who are ineligible for existing programs, still rely on a health safety net program to obtain services and aid in paying for needed care.
• Fear of incurring unaffordable medical bills and medical debt remains a barrier to accessing needed health care. Unaffordable medical bills and pre-existing medical debt still create anxiety and cause many to delay or forgo needed services.

These findings provide important lessons with respect to national health reform. Public programs can serve as an important foundation for health reform that can provide low-income individuals access to consistent, continuous and affordable care. The quality of employer-sponsored coverage, in terms of the comprehensiveness of the benefits and the affordability of coverage, matters for individuals with this coverage, especially for those chronic conditions or other significant health care needs. A health safety net is necessary for people who are not covered under public or private programs, for those who are underinsured, and for those who are between programs and coverage. Lastly, ongoing monitoring of access and affordability will be important to understand how the cost of insurance affects families’ ability to access care.

In the end, residents of Massachusetts have seen improvement, although there's more work to do. As we prepare to resume the health care reform debate, all eyes need to turn from the application of the Bismarck method of health care in Switzerland to the public program in Massachusetts. one advantage of being a late adopter is benefiting from the lessons learned by those who went before you.

Comments

[Liz]

Interesting findings, thanks for sharing.

I work for a non-profit in the Boston area, and most of the staff I supervise are part-time. Some of them have enough hours to be eligible for health insurance through our employer, but because they are part-time their premiums are pro-rated and outrageously expensive. As the report says, they are caught in a catch-22 - they don't qualify for public programs because they do have access to employer-based insurance, but the premiums eat up almost their entire pay checks! There has to be a better way.

[Donna]

Thank you for this post, Julie.

As I read this, I keep wondering why we are trying so hard to protect our insurance industry -- or why anyone is so satisfied with the status quo. I really do feel like I must live on a separate planet from those who don't want the system fixed.

[Julie Pippert]

Liz, you're welcome, thanks for reading.

I agree it's still not there. But it could be worse: you could be in Texas. I pay $5000 out of pocket annually before insurance kicks in, and that's ON TOP OF my monthly premiums, which are high (I'd be intrigued to compare a Bostonian's idea of high and my idea of high now in TX, because let me tell you about culture and sticker shock even five years after moving here!).

There does have to be a better way.

But I look back fondly on how good I had it in MA especially compared to here in TX. The crazy thing is...people here are fighting like lions to keep what they have, and many are surprised when I tell them it's different (and better!) elsewhere. I think people lack a basis of comparison -- which I admit opened my eyes wide on this issue. By that, I mean I don't think they realize how badly they have it!

[Julie Pippert]

Donna, I wonder the same thing. I feel the same way, too. Especially here in TX, where, as I said above, people just don't seem to know it's different and better than here, and here needs loads of improvement for better health care.

[auto insurance companies]

This is a nice story about health insurance which is once in a blue moon in these days. Never understand how it could be screwed up that badly all across America that parents are worried to take their children to hospital for worry of the costs and coverage problems. Is this America or some third world country which can not provide for its sick and needy?