Some Unfinished Work for Massachusetts Health Reform

Carol Pryor, policy director of The Access Project, a Boston-based non-profit, writes that three years after health care reform in Massachusetts, cost remains a barrier to both coverage and care for many people:

A report just released by the Blue Cross Blue Shield of Massachusetts Foundation contains continued good news about Massachusetts health reform – in the fall of 2008, only four percent of state residents were uninsured. The low uninsurance rate reflects gains in both employer-sponsored and public coverage, with most of the gains concentrated among lower-income adults.

The decrease in the number of state residents without insurance is a tremendous achievement that deserves celebration. However, the work of constraining ever-increasing health care costs remains, not just to sustain the reforms we have implemented, but also to expand assistance to the many Massachusetts residents still struggling with the costs of health care. In the fall of 2008, one Massachusetts adult in five had debt resulting from medical bills, and about one in ten (11%) did not get needed care because of cost. The Access Project, with funding from the Kaiser Family Foundation, conducted research to learn more about what lies beneath these figures. We interviewed people with medical debt accrued both prior to and after the implementation of reform, as well as key stakeholders in the reform initiative.

Increased access to insurance for those previously uninsured has been extremely beneficial. We spoke with many enrolled in the subsidized Commonwealth Care plans who felt they were able to access health care without fear for the first time. Don, for example, accrued medical debt when he was uninsured. Now, covered by a Commonwealth Care plan, he said, “I’ve had two physicals since then, and an eye examination. It’s a great peace of mind to know now that I do have insurance.”

However, certain groups have benefited less from our healthcare reforms. We identified two groups in particular who are still having difficulty paying for health care. The first includes some lower-income workers covered by employer-sponsored health insurance. These workers, since they have access to other insurance, are not eligible for Commonwealth Care. However, although they have incomes similar to people covered by Commonwealth Care, they do not have the same protections. Unlike Commonwealth Care plans, employer-sponsored plans can have high deductibles and out-of-pocket costs, and premiums are not based on income. Michael, for example, who earns about $27,000 a year, has a chronic condition that has required two surgeries. Despite having employer-sponsored insurance, over several years he has accrued medical debts that exceed his annual income. His current insurance has a $5,000 deductible and 10 percent co-insurance. For his most recent hospitalization, even with help from the Health Safety Net, he expects to accrue an additional $5,000 to $15,000 in medical debt.

The second group includes people earning just over the eligibility limit for Commonwealth Care plans (300% federal poverty level) who do not have access to other insurance. While the non-subsidized Commonwealth Choice plans cost less than similar plans prior to reform, they are still unaffordable for people at this income level, especially when deductibles and out-of-pocket costs are taken into account. And while some in this group are eligible for assistance through the Health Safety Net, the help may not be sufficient. Mark, for example, found the Commonwealth Choice plans unaffordable. Although he and his wife qualify for the Health Safety Net, they have a $10,000 deductible that they will not be able to pay if they are unlucky enough to get sick.

In addition to cost barriers to coverage and care, we identified one other barrier. The sheer complexity of the reform programs, built on top of an already existing multiplicity of programs, makes navigating our health system extremely difficult. The result is that many consumers are unaware of programs that can help them cover the cost of care, or they experience gaps as they try to move between programs for which they are eligible. A survey of outreach workers identified the biggest barriers their clients experienced in getting and keeping health insurance as general confusion about paperwork (78%) and general confusion about systems and programs (50%). A description by an outreach worker of the problems facing people moving between the Medical Security Program and Commonwealth Care provides a vivid illustration of how extremely complicated the system can be.

The state is now engaged in a serious discussion about how to rein in health care costs. The discussion sometimes assumes that we have achieved everything we aimed for in coverage expansions and now need to keep costs down so we can sustain it. This is certainly true, but we also need to reduce costs to ensure that everyone in the state has access to affordable coverage. This work is part of the unfinished business of Massachusetts health reform. It includes providing better protections and more affordable options for lower-income workers and for moderate income people without access to state subsidized plans, as well as streamlining our system so people don’t continue to fall through the cracks.

(The Access Project report is entitled Consumers’ Experience in Massachusetts: Lessons for National Health Reform.)