"Survey says..." by Jarrett T. Barrios

Almost everyone has an opinion about health reform in Massachusetts: some say it’s expensive, some say it’s cumbersome, many say it’s not perfect. But we all should all be saying this now: it’s working.

Data released today by the journal Health Affairs documents dramatic effects of health reform on the lives of Massachusetts residents, including a massive reduction of nearly 50 percent in the state’s rate of uninsured residents. The Urban Institute, a Washington DC-based nonprofit, nonpartisan policy research center, conducted two 3000-person surveys detailing Massachusetts’s residents’ experiences with health care. The first survey was taken in the Fall of 2006, before the implementation of the health reform law; the second was conducted in the Fall of 2007, one year after the first reforms were put in place. The Urban Institute will conduct a third survey in the Fall of 2008.

The 2006 baseline survey found that 13 percent of working-age adults (those aged 18-65) did not have health insurance. The 2007 survey found that that number dropped to 7.1 percent. The drop is more dramatic for low income residents:

from 24 percent to 13 percent. Even more encouraging, the survey, which was commissioned by the Blue Cross Blue Shield of Massachusetts Foundation and funded by the Foundation, the Commonwealth Fund, and the Robert Wood Johnson Foundation, found that the law is doing more than just putting an insurance card in people’s pockets. It’s also increasing access to care.

The survey found statistically significant reductions in unmet health care needs among adults earning within 300 percent of the federal poverty level (approximately $32,000 for a single person and $62,000 for a family of four): in 2006, 27 percent of low income adults reported that cost issues had prevented them from seeking needed care; in 2007, that number had dropped to 17 percent. In short, the new coverage options made care more affordable for more people.

Meanwhile, the rate of low income adults accessing dental care improved 10 percentage points between the two survey periods, from 49 percent to 59 percent. And 70 percent of low income adults saw a doctor for a preventative care visit in 2007 as compared with 65 percent who reported accessing preventative care in the 2006 survey. This signals the removal of financial barriers to essential types of care. But it also shows that we are on the cusp of moving toward more comprehensive care for all residents. If we maintain and deepen reform, this could be a profound change for the health care system – one that promises to move Massachusetts toward health equity.

Medical debt is also declining. Adults across all income levels reported paying fewer out of pockets health care-related costs in 2007 than in 2006. Perhaps most significant, there was a nine percent drop in low income adults reporting spending more than $500 in medical costs in 2007 (37 percent) as compared with 2006 (48 percent).

The survey also found that this law, unlike health coverage expansions in other states, is not tempting employers to drop their insurance plans and send employees to the state for health care needs. In fact, more low income adults reported receiving health insurance through their employers in 2007 (42 percent) than in 2006 (38 percent). This goes against national trends, which have seen steady declines across the country in employer-sponsored coverage.

What is most notable about all this is that these changes — all statistically significant — have occurred in just one year’s time. No other state can make the same claim. Studies looking at the drop in uninsurance among low income populations in Minnesota, Oregon, Tennessee, and Wisconsin show nothing close to the nearly 50 percent drop for adults earning within 300 percent of the federal poverty level, let alone the drop by two-thirds for people earning within 150 percent of the federal poverty level. (See “Are Adults Benefiting From State Coverage Expansions?,” and “Insuring Low-Income Adults: Does Public Coverage Crowd-Out Private?.") Additionally, those other programs were studied three to 10 years into their expansions of health coverage. The state that has come closest to matching Massachusetts’s gains is Wisconsin, which saw a 40 percent drop in its rate of uninsurance. But Wisconsin took three years to reach that goal.

So much of the recent public conversation around the state’s innovative health law has focused on rising costs. That is as it should be when so many of our public resources are now going toward paying for reform. But let’s keep the costs in context. First, we are paying for our success. The original law called for near-universal coverage to be completed over a three-year period. It now appears as if the state has come very close to that goal in just one year.

Second, the state stood to lose $1.2 billion in federal funding if it did not reform its care delivery system for low income residents. Yes, the state is spending a lot of money on health reform today, but imagine what it would be like had the state forfeited $1.2 billion over three years but still had to meet its Medicaid obligations.

The Massachusetts health reform law is not perfect. Not by any stretch. But there is no denying that it has created measurable social change. There’s a lot to be done to preserve, monitor, and adjust health reform in Massachusetts: plans must be kept affordable to consumers; costs must be contained; quality and access must be assured; and the system needs sustainable funding. Let’s keep the conversation going.

Jarrett T. Barrios is president of the Blue Cross Blue Shield of Massachusetts Foundation.