Amy Lischko: Mass. Health Law Not What It Was Meant To Be

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. Amy Lischko, DSc, was the commissioner of the Division of Health Care Finance and Policy and director of health policy under Gov. Mitt Romney. She's currently an associate professor at Tufts University School of Medicine.

As I look back on the years since the reform passed, I’m conflicted. Gov. Mitt Romney's administration, of which I was a part, developed an innovative, state-based solution to address some of the pressing market failures endemic to Massachusetts. I am mostly pleased with the progress Massachusetts has made on the access front, albeit concerned about the growing number of people relying on Medicaid for health care coverage.

Gov. Romney’s framework was simple: require personal responsibility from people, convert money being spent on expensive hospital care to insurance subsidies, and establish an insurance exchange for transparency and distribution of insurance. But the act that passed was only a framework — a mere 60 pages long — and the defining details would unfold via implementation. Nine months later, a new governor, Deval Patrick, was sworn in.

Here are five things I would have done differently on implementation:

1) Defined more flexible standards for insurance

The Massachusetts Health Connector’s decision to mandate prescription drug coverage and limit out-of-pocket cost sharing and deductibles as “minimum creditable coverage” stymied attempts at moving towards consumer-driven health care. When care is "free" to the patient, they may get more care than they need and they don't have an incentive to shop for low-cost, high-quality providers.

2) Moved quickly towards transparency

Does anyone remember the Health Care Quality and Cost Council? They were charged with providing transparency around quality and cost information. Transparency was never a priority of Gov. Patrick's administration. Are we surprised that price variation between hospitals for the same procedures remains a significant problem when we have done nothing over the last decade to improve it?

"The act that passed was only a framework -- a mere 60 pages long -- and the defining details would unfold via implementation. Nine months later, a new governor, Deval Patrick, was sworn in."

Amy Lischko

3) Leveraged the Health Connector for innovation

The Health Connector chose to adopt a paternalistic view of health insurance instead of developing decision-support tools to help consumers choose plans that best meet their needs. It began with adopting an Olympic medal value hierarchy for the various plan types, fostering a misperception among consumers that a “Gold” plan is better than “Bronze” plan. Fully 10 years later we still find little decision support and limited choice of value-based plans available on the Connector.

4) Supported small businesses

Small businesses have been virtually ignored. What happened to the idea of employers giving employees a set amount of money for health insurance, and letting them buy the insurance on their own? The two-year moratorium on the passage of new mandated benefits only seemed to fuel the Legislature to pass another 14 coverage mandates over just eight years. Why do we maintain two different standards for insurance coverage — one that applies to small group and individual market purchasers of fully-insured plans — and a separate standard for everyone else?

5) Truly reformed the uncompensated care pool

Aside from a euphemistic name change from “free care pool” to “safety net care,” very little was done to reform this “safety-net” program — which pays for care for those without insurance or with inadequate insurance. In 2006 there were 447,000 users, a number reduced to 262,000 by 2008 but steadily grew to 336,000 in 2013.* After removing 250,000 people off the Medicaid roles this year, I suspect the number of safety net care users for 2016 will be close to where we began in 2006.

*The numbers for 2014 and 2015 are artificially low, as reported, because of the state’s decision to enroll in Medicaid those for whom the Connector could not accurately determine eligibility.

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