OP-ED

Did Massachusetts Health Care Reform Hurt Access To Care For the Previously Insured?

In 2006, Governor Mitt Romney signed Chapter 58 of the Acts of 2006 entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” It has been described by many names, including Massachusetts Healthcare Reform (MHR), Romneycare, or simply, as the template for the Affordable Care Act. The goal of the act was straightforward: to ensure near-universal access to health insurance for citizens of the Commonwealth of Massachusetts. The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance, an 8 percent increase over the 86.6% in 2006. By all accounts, the goals of insurance expansion were met.

But the bill has not been without controversy. There have been two main concerns: first, that the bill did too little to control rising healthcare costs. The cost crisis led to the 2012 bill that many refer to as “Mass Health Reform 2.0” – formally called Chapter 224 of the Acts of 2012. Its focus is to curtail healthcare spending, and while reasonable people have reasons for skepticism about the likelihood of success, that’s a topic for another day.

The second concern was that bringing hundreds of thousands of new people on to the health insurance rolls without a commensurate increase in physician supply would overwhelm the state’s supply of physicians. The logic behind the concern was as follows: health insurance expansion created nearly 400,000 newly insured residents. As these folks rushed in to see primary care physicians, all the empty spots filled up, the primary care offices got overwhelmed, and access for everyone else was diminished. Stories of physician shortages abounded: the Massachusetts Medical Society called the shortage of primary care at a “critical level”, citing its own surveys (which were of poor quality). The Wall Street Journal editorial page ran stories entitled “RomneyCare’s bad outcomes keep coming”, citing the same MMS statistics.

So, for a hypothetical 80 year old woman we will call Ms. Jones, who has congestive heart failure, getting into her PCP was harder. She used to see her PCP every 2 months, but after Mass Health Reform, had to wait longer between visits. And, when her breathing worsened one night, instead of getting seen by her PCP the next morning, she had to go to the emergency room and ended up getting admitted. Indeed, people worried that for the most vulnerable patients, those who rely on primary care to stay out of the hospital, Mass Health Reform decreased access, made their lives worse, and led to unnecessary hospitalizations and worse outcomes.

The concerns over insurance expansion without adequate provider expansion, of course, become that much more salient in the context of the Affordable Care Act. If Massachusetts, with its large supply of physicians and a reasonably high insured rate prior to health reform, could suffer broad shortages that hurt vulnerable populations, the rest of the nation is surely in trouble. This was the scenario played out repeatedly in the political debates of 2012 when Mitt Romney was running for the Republican nomination. Not surprisingly, these discussions were generally data-free. We felt that empirical input would be helpful. Whether Massachusetts residents suffered because of the reported shortage of primary care was a serious question that needed to be addressed with real data, and we set out to do so.

To determine if Massachusetts residents were negatively affected, we examined rates of preventable hospitalizations, those that result directly from diminished access to effective primary care, before and after health reform kicked in. We focused on older adults, the Medicare fee-for-service population, who rely on primary care, hypothesizing that if their access to primary was curtailed, they would be susceptible to these preventable admissions. We studied Massachusetts from 2005 through 2010, and used the rest of the New England states as controls. We figured any effect would be particularly pronounced among those over 80 years of age, who might be particularly vulnerable to disruptions. Finally, we thought that the counties within Massachusetts where the insurance uptake was the greatest, and therefore where the biggest surge of new patients to PCPs might occur, would see the biggest negative effects.

The Impact: So What Happened?

So what did we find? Not much. Our study was well powered to detect even small differences – and we found no negative impact of MHR at all. In fact, contrary to our hypothesis, rates of preventable hospitalizations fell somewhat more rapidly in Massachusetts after the reform than it did in control states (see Exhibit 3 of the paper in Health Affairs). The effect was small and whether it was due to the reform or some other factor is unclear. What is clear is that if Massachusetts Health Reform did lead to a negative spillover on the previously insured, it was not substantial enough to have a deleterious effect on their outcomes. In every group we examined, Massachusetts improved as rapidly or even more so as the control states.

So are we done worrying about Massachusetts?

Does this mean that we should table the concerns about MHR having a negative effect on the previously insured? Not quite yet. It is possible that older, vulnerable patients saw their primary care physicians less often, or maybe they had extra visits to the emergency room and received more tests and procedures as a result of having less time with their PCPs. These are ongoing analyses and we expect to have answers soon. However, at least in terms of the bottom line, preventable hospitalizations, the events you’d worry about the most if there was restriction on access to primary care, there was no negative effect.

Implications for the Affordable Care Act:

If older Americans in Massachusetts did not experience clinically meaningful harms as a result of insurance expansion, what does this mean for the 49 other states that are about to expand their pools of the insured over the upcoming years? It is not straightforward to translate the Massachusetts experience to Texas, where a quarter of the population is uninsured and there are fewer primary care physicians per capita. Might insurance expansion there or in Florida have much bigger effects? Maybe. However, our findings suggest that our healthcare system is far more resilient than we think. Static notions of capacity may be inadequate. Massachusetts was able to absorb the newly insured population with little disruption and I suspect many other states will as well.

However, maybe in states like Texas and Florida, where the impact of insurance expansion will be more substantial, we could also think more creatively. Instead of trying to manufacture more primary care physicians, a long and expensive endeavor, we should think harder about how to better use the trained professionals we have. We need to rethink our “scope of practice” rules that limit the ability of well-trained Physician Assistants and Nurse Practitioners from caring for patients. We need to think about how to use health information technology more creatively. Virtual visits and telehealth can make current providers more productive, allowing them to care for more patients by more effectively triaging who can be seen virtually and who needs to be seen in person. Again, reimbursement and regulatory hurdles slow us down, but if state and federal policymakers are smart, we can fix these issues.

Finally, and most importantly, we need to carefully monitor how insurance expansion plays out in the 49 other states and the District of Columbia. We need clear metrics to track not just the impact on the previously uninsured (whether they took up insurance or not) but also on the previously insured. The truth is, while we may split people into the uninsured and the insured, we are all part of the same healthcare system – and what happens to one group likely affects all of us.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.He will serve as a Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation. Submission is open now, and the first issue will be released in late spring 2013.

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13 replies »

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    I appreciate you finding the time and energy to put this content together.
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  2. Great study – I do wonder how it is possible that we increased demand without changing supply and still not did see a significant difference in access among the previously insured. Did the newly insured seek less care?

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  4. This article is so off base that it is hard to know where to begin making corrections or comments. Some of the mistakes are simply indicators of sloppy research and writing, others are examples of total failure to understand Massachusetts’ health care market, and the most critical statements by the author point to complete intellectual dishonesty. So just taking statements in order presented by the author as opposed to order of importance, here goes:

    1. The author of this article begins,

    “The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance…”

    In the category of intellectual dishonesty, if the availability of health-care service to under-65 Massachusetts’ residents was the issue that concerned him, why did the author of the article research and write about over-65 Massachusetts residents? Those of us over 65 in Massachusetts are a group that all have insurance (Medicare) and almost always have had insurance (because healthcare insurance was invented here and Massachusetts has long had – back to when those of us that are today’s over-65 Massachusetts residents were under 65 – the highest rate of insured adults in the country). Could the answer be that access for the group that matters (those under 65) is no different pre and post RomneyCare and that the numbers themselves are bogus?

    2. The author says

    “By all accounts, the goals of insurance expansion were met.”

    This is just typical of some of the sloppiness of this author. By all available sources and subsequent data (see release of 2011 data by state of Massachusetts in January 2013), the goal of RomneyCare was universal coverage and cost containment (see Romney’s November 2005 op-ed piece in the Boston Globe), not “insurance expansion” (that probably was the goal of the insurance companies; I wonder who funds this Harvard guy?).

    RomneyCare failed on both goals stated by former Governor Romney. Everyone agrees that the cost containment objective failed. As the author notes, the state legislature has subsequently fixed prices (albeit weakly and in a way that only affects about 25% of the population). In addition, all state data — including the data released in January 2013 — shows that coverage is not universal and is in fact declining (albeit the state purposely delays releasing this bad data so that the only data we have to look at currently is 18 months old).

    3. The author says,

    “The second concern was that bringing hundreds of thousands of new people on to the health insurance rolls without a commensurate increase in physician supply would overwhelm the state’s supply of physicians. The logic behind the concern was as follows: health insurance expansion created nearly 400,000 newly insured residents. As these folks rushed in to see primary care physicians, all the empty spots filled up, the primary care offices got overwhelmed, and access for everyone else was diminished.”

    Here’s an example of the extent to which the author does not understand the Massachusetts’ healthcare market. You have to understand (this biased author won’t tell you) that the “nearly” 400,000 person increase in insurance coverage in Massachusetts is a net number.

    — One hundred thousand FEWER people are insured via employment after RomneyCare than before. Employer sponsored insurance was the kind of insurance that RomneyCare was supposed to encourage with both carrots (small business coops that were never created) and sticks (tax penalties that employers avoided by offering crappy, expensive insurance that no one “took up”). These RomneyCare ideas totally failed. And these 100,000 people who had access are probably no longer demanding as much healthcare service because they lost their insurance coverage.

    — A little more than 200,000 people went on Medicaid after RomneyCare. They were more or less always qualified for Medicaid before RomneyCare. This group always had access to medical services and received its care through the Massachusetts uncompensated care pool, which although not insurance basically served (and still serves–remember we did not reach universal coverage) the same purpose. This was really no change except that for the first three years of RomneyCare (as with Obamacare for the rest of the United States) the Federal government paid for the coverage rather than state taxes that fund the uncompensated care pool.

    — A little more than 200,000 people got actual RomneyCare, free or highly subsidized health insurance plans available AFTER the person applies for Medicaid and is turned down.. Many in this group already accessed physicians at their own cost (and now they could get free insurance; what a deal) or were among the 100,000 noted above that lost their employer sponsored insurance. So only part of this third group is actually creating new demand in Massachusetts (while the other group theoretically caused decreased demand).

    After you do all the math, you find that only about 1% of the Massachusetts population was accessing healthcare “for the first time” post RomneyCare as opposed to pre RomneyCare. The math is statistically insignificant so there actually could be no change or a negative change. But realizing this, the Harvard expert instead studied people like me on Medicare. What a joke.

    (Oh by the way this intellectually corrupt Harvard expert only looked at Medicare Fee for Service – FFS — recipients in Massachusetts, but that’s just another example of sloppy research. And the author only looked at those Massachusetts Medicare FFS residents over 80 who went into the hospital. That’s less than a tenth of a percent of Massachusetts population. What deceit to claim such research has any meaning at all.)

  5. Massachusetts continues to be an interesting case study to watch but it’s such an outlier compared to the nation, hard to know how much to discount for its advantages.

  6. Great study – I do wonder how it is possible that we increased demand without changing supply and still not did see a significant difference in access among the previously insured. Did the newly insured seek less care? As a physician-in-training whose job is largely to care for the under-insured it seemed that we were seeing the same patients as before, only more of the care was compensated.

  7. I fall into the camp of someone who trumpeted the MMS data and believed the conventional wisdom. Your study is great–makes superb assumptions (MCR, over 80 as potential to be harmed by less access).

    The blog post is right on in terms of scope of practice.

    You’ve convinced me otherwise.

    I wish my red state governor would accept MCD expansion so as to have this solvable problem. Not giving the uninsured access leaves us at square one.

  8. The point about reforming the scope of practice rules for NP’s and PA’s is an important one as is the potential to use physician resources more productively through greater use of health IT and telemedicine.

    I would add that for people with chronic conditions, when the doctor wants to see them every two or three or six months or whatever is often arbitrary. The supply of doctors and the number of open slots in the appointment book that need to be filled can play a role in scheduling. For several years, I saw a specialist every six months and had good checkups every time. I finally asked him if I could safely stretch the visits to once a year. He said I could but if I didn’t bring it up, I would still be going every six months.

    Regarding congestive heart failure patients specifically, I’m told that Essentia Health in Minnesota has a very effective program that uses NP’s, social workers and health information technology to closely monitor patients’ weight and provide counseling as needed that proved extremely effective in sharply reducing hospital ER visits and inpatient admissions. It costs about $1,500 per year per patient and saves a lot of money vs. a less intensive management approach. If this is so successful, why hasn’t it been more broadly replicated? Is it because too many doctors and hospitals in too many places say that’s not the way we do it here? If so, shame on them.

  9. Our study was well powered to detect even small differences – and we found no negative impact of MHR at all. In fact, contrary to our hypothesis, rates of preventable hospitalizations fell somewhat more rapidly in Massachusetts after the reform than it did in control states.

    I’m sure a physician shortage will be found in some places, but this may reflect the biggest reality. I bet everyone reading this post can think of someone or some couple for whom “going to the doctor” has more to do with lifestyle than medicine. Those trips may be an embedded habit, like going to church or monitoring the odometer to keep up with the next scheduled trip for scheduled car maintenance. But the best habits for good health mean fewer trips to the doctor, not more. (And how many offices have patients on the schedule six months or a year out, not to fix problems but in an effort to discover some? It’s called “well visits” or “screening” for this or that.)

    If health care costs are to be brought down discretionary visits need to go first. The medical-industrial complex is a bubble. The smaller it gets the better off we will all be. Same goes for prescription drugs. The goal should be how few we can use, not now many. ( I read somewhere that in Finland empty hospital beds are not considered a problem. The fewer people are in the hospital the better the health of the community. Strange notion, no?)

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