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Bigby: Massachusetts’ Rate of Uninsured Has Fallen Since Reform Passed

As the nation waits with bated breath for the details of a national health care reform bill, a careful look at Massachusetts’ historic efforts to obtain near-universal coverage provides valuable insights into what the nation can achieve. In 2006, Massachusetts enacted a comprehensive reform bill built on the principle that achieving universal health insurance coverage is a “shared responsibility— of government, employers and individuals. Since then, under Gov. Deval Patrick’s (D) leadership, Massachusetts has continued its successful implementation of reform, and the commonwealth now has the lowest rate of uninsured residents in the nation.

The number of people in Massachusetts without health insurance has dropped significantly since last year, according to survey results released recently by the Massachusetts Division of Health Care Finance and Policy.

As part of reform, the state, in partnership with the federal government, expanded eligibility for Medicaid coverage and created a subsidized health plan for residents with incomes of up to 300 percent of federal poverty level. Individuals with incomes between 150 percent and 300 percent of the FPL pay premiums on a sliding scale. Children whose parents earn up to 300 percent of the FPL are covered through the State Children’s Health Insurance Program.

The state requires businesses with 11 or more full-time equivalent employees in Massachusetts to make a fair and reasonable contribution toward coverage for full-time employees or pay a fair share assessment of $295 per year per employee. Employers must also offer full-time and part-time employees a pre-tax, payroll deduction for those who buy individual plans. This allows employees without access to employer-sponsored insurance to take advantage of significantly less expensive individual plans that resulted after Massachusetts merged the nongroup and small-group health insurance markets. Access to affordable plans is key because the law requires adults in Massachusetts who can obtain affordable health insurance to do so.

With these building blocks of reform firmly in place, Massachusetts has the lowest rate of uninsured in the country, 2.6 percent. As of May 2009, more than 428,000 people are newly enrolled in insurance plans; about 190,000 (or 45 percent) of them are enrolled in commercial plans.

As coverage for individuals has increased, the number of uninsured individuals who present to hospitals has declined. The total number of hospital inpatient discharges and outpatient visits billed to the state’s “free care pool— declined by 37 percent in the first six months of fiscal 2008 compared to the same period a year earlier. Individuals who report having a regular source of health care have increased among all racial and ethnic groups since reform was implemented. People also report making more visits for preventive care and dental care and report decreasing financial barriers to care.

But controlling the cost of health care is critical, and the growth in health care expenditures continues to challenge individuals and employers. Massachusetts has always had one of the highest health care costs in the nation. Research from the Dartmouth Atlas Project shows that Massachusetts has nearly the highest rate of Medicare spending in the country because of overuse of expensive medical care and technology without demonstrating better outcomes of care.

The governor and our partners in the Legislature are committed to a multipronged approach to containing costs. The fee-for-service payment system is increasingly viewed as a barrier to effective, coordinated, efficient and high-quality care because it rewards providers to perform more procedures and deliver more services, especially expensive specialty and highly technical care.

In August 2008, Patrick signed into law a bill initiated by Senate President Therese Murray to help contain health care costs and increase transparency. The bill includes several cost-containment initiatives, including promotion of electronic health records systems; implementation of measures to increase the availability and accessibility of primary care and to improve the quality of chronic care; and regulation of pharmaceutical and medical device manufacturing companies’ gifts and consulting fees to health care professionals. The bill also requires a special commission on the health care payment system to review strategies for reforming and restructuring the current health care payment systems and make recommendations for reform to promote incentives for efficient and effective care.Their report is scheduled for release this summer.

In December 2008, the state’s Health Care Quality and Cost Council launched an interactive Web site ( designed to promote transparency for consumers of health care. For example, a patient considering hip replacement surgery, angioplasty or a mammogram can now visit the site to compare cost and/or quality measures for those and other procedures at Massachusetts hospitals.

Massachusetts elected to tackle coverage before cost containment, and so far this strategy has been successful. Expanding subsidized coverage for low-income persons, requiring employers to pay a fair share if they do not provide coverage and the individual mandate are key components of the successful plan. Insuring the uninsured has not contributed to increased health care costs in Massachusetts. Without controlling costs, however, the state cannot reap the benefits of covering almost 98 percent of the population. Individuals will not be able to afford the out-of-pocket costs associated with accessing primary and preventive care and care for chronic conditions.

Achieving affordability requires fundamental changes in the way that we pay for care and in our systems of care to better support primary care, promote coordinated care in integrated delivery systems, reward quality care and not simply the amount of care, and support informed patient choice and shared decision-making. This is the time to finally develop an integrated health care system in the U.S. that is designed to serve the needs of people and to promote healthy Americans.

Dr. JudyAnn Bigby is secretary of the Massachusetts Department of Health and Human Services.

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