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In the midst of the national health care reform debate, a new report (PDF) says Massachusetts' landmark reform is delivering mixed results.
Over the past three and a half years, more residents have signed up for insurance in the state, but according to the report, more people are having a hard time paying for insurance, and for health care.
We spoke with Carol Pryor, who co-wrote the study being published this week. Pryor is the policy director for The Access Project, a health care advocacy group.
Bob Oakes: Lay out some of the findings: Which group of people is benefiting from the coverage mandate, and why?
Carol Pryor: Well, our report was based on interviews with a number of people who are still struggling with medical bills, and we've worked with these folks over time. I think what we found is that people who qualified for coverage under the state-subsidized Commonwealth Care plans, for many of them the plan has been a remarkable benefit.
It's given them access to a range of services and, for most, probably at a reasonable cost. So it's been an option for thousands of people who didn't have one before.
On the other side, the report finds that people are still struggling to afford health care.
That's right, and there's a couple of groups in particular that we cited. One group is folks earning just over the income limit to qualify for the subsidized plans. While they have access to some of the non-subsidized plans that have been developed in the state, these plans, even though they've brought the price down somewhat, are still pretty unaffordable for a lot of folks earning just over the income limit for the subsidized plans.
And the second group is lower-income workers, who have an offer of insurance through their employers. The way that the state has constructed the plan is that, if you have an offer of insurance from your employer, even if you're income-eligible for the state-subsidized plan, you're not eligible to join, because you have this offer of insurance.
And we know that generally lower-income workers tend to be offered less comprehensive plans and more expensive plans than other workers. So for those lower-income workers whose employer insurance isn't as good as it needs to be, those folks are still struggling quite a bit. That person, while they may not have to pay the penalty for not having insurance, still are not allowed to enter the subsidized plans.
One of the key findings of the report is that people with chronic conditions still face great barriers, especially cost barriers. Explain that.
A plan may have out-of-pocket payments that seem nominally reasonable, or seem reasonable in terms of the co-payments that people have to make when they visit a doctor, or the co-payments for medications.
But if you are a person with limited resources who has to see a doctor frequently, see many specialists and take many medications, these ongoing co-payments can quickly become a problem. We've talked to many people with chronic illnesses who face those problems.
And the report also found that the bureaucracy, the complexity, of the program leads to gaps in coverage.
That's right. Massachusetts has been blessed in a way by having a very robust safety net system, even before health reform. And partly it's a product of our success, as we've added different forms of coverage over the years.
Our health reform program was built on top of this. So the result is that you have a wide variety of programs — they have different rules, they have different start and stop dates — it's created a very complex system. And people can face gaps in coverage moving between programs, and the complexity also makes it difficult for people to really understand what's available to them and how the health system works.
What about human emotion in all of this? There is, as I understand it, still great fear out there about being able to afford medical bills and going into significant debt if you face a big medical problem — despite the fact that this system tries to address those concerns.
Well there's sometimes a perception that people don't want to pay their bills. The folks that we spoke to experienced great anxiety because of the bills that are hanging over them. And one of the things that struck me in this round of interviews was also the fear of the unpredictability of the situation for them, not knowing what was going to happen, not knowing what new bills were coming in. People found this very anxiety-producing and very fearful.
So has this system changed anything in terms of that anxiety, which has been with us for a long time?
For the folks that have access to the subsidized plans, who didn't have insurance before, many expressed a huge relief at not having to worry about this anymore. For the folks that are still faced with these bills — and as I've said, by the latest figures that's one out of five adults — the anxiety is still there.
Massachusetts is being held up as a model for other states and maybe for the federal government in the ongoing health care debate. Based on this report, do you think the Massachusetts system should be followed?
I think we need to look at what's working and what isn't working. When we talk about affordability, we can think about the affordability of the program to the state or the government, but that's different from the affordability to individuals.
So I think that if nationally we're going to use a model that's based on Massachusetts, we have to look not just at coverage, but at real access — at real affordable coverage — and continue to work to increase the affordability of products, bring down costs in the system, so that we can help support more consumers who really are still in need of help.
This program aired on September 2, 2009.
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