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Massachusetts and Health Reform

abstract-medicalIn April of 2006, Massachusetts passed legislation intended to move the state to near-universal health insurance coverage and, concurrently with that expansion, improve access to affordable, high-quality health care. The Massachusetts model, which became the template for the 2010 Patient Protection and Affordable Care Act (PPACA), represented an ambitious effort to transform the health care system in the Bay State. The Urban Institute has conducted numerous studies of Massachusetts’s health reform effort, including work based on the Massachusetts Health Reform Survey (MHRS), the Massachusetts Health Insurance Survey (MHIS), and national surveys. The Urban Institute, along with our partner Social Science Research Solutions/SSRS, conduct the MHRS and the MHIS. The MHRS, which began in 2006, is funded by the Blue Cross Blue Shield of Massachusetts Foundation. Earlier years of the survey were also funded by the Commonwealth Fund and the Robert Wood Johnson Foundation. The MHIS, which began in 2008, is funded by the Massachusetts Division of Health Care Finance and Policy.

Papers | Policy Briefs | Commentary | Research Reports | Methodology Reports

Papers

Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs
Sharon Long, Karen Stockley, Heather Dahlen
Health Affairs: Published online before print, January 2012 

Massachusetts is in its sixth year of a reform initiative that provided the template for the federal Affordable Care Act of 2010. This Health Affairs article reports on the status of health reform in Massachusetts as of 2010, providing an early indication of potential gains and challenges under national reform. 

Have Gender Gaps in Insurance Coverage and Access to Care Narrowed under Health Reform? Findings from Massachusetts
Sharon Long, Karen Stockley, Shanna Shulman
American Economic Review: Volume 101, Issue 3, May 2011

Under its health reform legislation, Massachusetts has achieved near universal insurance coverage, along with significant gains in health care access and affordability. This paper, published in the American Economic Review, examines the impacts of health reform in Massachusetts on differences in coverage, access, and affordability for women and men. We find that both women and men gained under health reform, with the gender gap in insurance coverage narrowed as men's coverage increased relative to that of women. However, the gaps in access and affordability of care have not narrowed—women in Massachusetts continue to report more unmet need for care and problems affording care than men.

Disentangling the Effects of Health Reform in Massachusetts: How Important Are the Special Provisions for Young Adults?
Sharon Long, Alshadye Yemane, Karen Stockley

Massachusetts enacted a comprehensive health care reform bill in 2006 that has moved the state to near universal health insurance coverage. The Massachusetts law included expanded eligibility for public coverage, subsidized insurance coverage, an insurance purchase exchange, market reforms, expanded coverage options for young adults, requirements for employers, and, most controversial, an individual mandate that requires all adults who have access to affordable coverage to obtain health insurance. Although estimates to date have focused on the overall effect of the Massachusetts health reform package, there is substantial policy interest in determining the effects of the different components of the reform effort. In this paper, published in American Economic Review, we focus on disentangling the effects of the special provisions implemented in Massachusetts to expand coverage to young adults.

Sustaining Health Reform in a Recession: An Update on Massachusetts as of Fall 2009
Sharon Long, Karen Stockley

This Health Affairs article provides an update on the progress of health reform in Massachusetts as of fall 2009 using data from surveys of working-aged adults. Massachusetts continues to sustain record high levels of insurance coverage in the midst of the economic recession, with uninsurance at 4.8 percent for non-elderly adults in fall 2009. In addition, the authors find that the gains in access and affordability reported in Massachusetts under the initial years of health reform persisted into fall 2009. However, some barriers to accessing care persist and problems affording care continue to be an issue for some residents..

Massachusetts Health Reform: Employer Coverage from Employee's Perspective
Sharon Long, Karen Stockley

The national health reform debate continues to draw on Massachusetts' 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This Health Affairs article provides an update on employers' responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers' dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms.

Access And Affordability: An Update On Health Reform In Massachusetts, Fall 2008
Sharon Long, Paul Masi

This Health Affairs article Massachusetts continued effort to move forward on comprehensive health reform. Uninsurance is at historically low levels, despite the recent economic downturn. Building on that coverage expansion, there have been improvements in access to care and the affordability of care in the commonwealth. Notwithstanding these successes, some of the early gains under health reform in reducing barriers to care and improving the affordability of care had eroded by Fall 2008, reflecting trends that predate health reform in Massachusetts-constraints on provider capacity and increasing health care costs. Because these are national concerns as well, Massachusetts continues to offer lessons for national health reform efforts.

How Have Employers Responded to Health Reform in Massachusetts? Employee's Views at the End of One Year
Sharon Long, Paul Masi

In April 2006, Massachusetts passed legislation intended to move the state to near-universal coverage within three years, with key components of the reform effort targeting the role of employers. Based on surveys of working-age adults in the state in 2006 and 2007, this Health Affairs paper examines employers’ responses to health reform as reported by their employees. At roughly the end of the first year under health reform, employers in Massachusetts had made few changes in the insurance coverage they offered their workers. Long and Masi find no evidence that employers have dropped coverage, tightened eligibility for coverage, or changed the scope of benefits, network of providers or quality of care available under the health plans. Nor is their evidence that employers have shifted a greater share of the cost of health care onto their workers in response to health reform.

On the Road to Universal Coverage: Impacts of Reform in Massachusetts at One Year
Sharon Long

In April 2006, Massachusetts passed legislation intended to move the state to almost universal coverage within three years and, in conjunction with that expansion, to improve access to affordable, high-quality health care. This Health Affairs article reports that in roughly the first year under reform, uninsurance among working-age adults was reduced by almost half among those surveyed, dropping from 13% in Fall 2006 to 7% in Fall 2007. At the same time, access to care improved and the share of adults with high out-of-pocket costs and problems paying medical bills dropped. Despite higher than anticipated costs, most residents of the state continued to support reform.

MassHealth Succeeds in Expanding Coverage for Adults
Sharon Long, Stephen Zuckerman

This study provides the first rigorous evaluation of the impacts of MassHealth, Massachusetts?s ambitious effort in the late 1990s to expand coverage to the entire low-income population. We find clear evidence that MassHealth led to an expansion of insurance coverage relative to what was happening to similar populations in comparison states. While current budget shortfalls have forced many states, including Massachusetts, to scale back their expansion efforts, the current economic downturn is not permanent. Understanding the impacts of the expansion efforts in Massachusetts adds to the base of knowledge that will be critical for guiding states when the economy recovers and the resources needed for expansion again become available.

Are Adults Benefiting From State Coverage Expansions?
Sharon Long, Stephen Zuckerman, John Graves

This paper reports on findings from an evaluation of insurance coverage expansions in California, Massachusetts, New Jersey and Wisconsin. Overall, parents in Wisconsin and parents and childless adults in Massachusetts experienced the largest expansions in public coverage, with little offsetting reductions in private coverage. By contrast, coverage expansions for parents in California and New Jersey led to increased enrollment in publicly sponsored programs, but often with a corresponding drop in private coverage. With constraints on resources curtailing state coverage efforts, the study finds evidence that cuts in public coverage will likely put more adults at risk of becoming uninsured.

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Policy Briefs

What Is the Evidence on Health Reform in Massachusetts and How Might the Lessons from Massachusetts Apply to National Health Reform?
Sharon Long

The Patient Protection and Affordable Care Act (PPACA) is in many ways patterned after the Massachusetts 2006 reforms. These reforms provided for an expansion of public programs, income related subsidies, health insurance exchanges, and an individual mandate. This paper reviews the evidence from Massachusetts and shows that there was a substantial increase in coverage, little crowding out of employer-sponsored insurance, high levels of compliance with individual mandate, improvement to access and use of health care services, and reduced financial burdens from health reform. The paper concludes by considering issues of provider capacity and health care costs that were not directly a focus of the legislation and but now being addressed..

Massachusetts Health Reform in 2008: Who are the Remaining Uninsured Adults?
Sharon Long, Lokendra Phadera, Victoria Lynch

This policy brief uses the Integrated Public Use Microdata Series (IPUMS)‐USA file of the 2008 American Community Survey (ACS) to identify the characteristics of the remaining uninsured population in Massachusetts following the state’s 2006 health reforms..

The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use, and Affordability for Women in Massachusetts
Sharon Long, Karen Stockley, Shanna Shulman

This policy brief examines the progress women have made in under health reform in Massachusetts. The authors find that women achieved significant gains in coverage, access, use, and affordability under health reform, although gains in affordability were more limited. Gains were particularly strong for vulnerable subgroups of women, including lower-income women and racial/ethnic minority women.

Emergency Department Visits in Massachusetts: Who Uses Emergency Care and Why?
Sharon Long, Karen Stockley

Massachusetts residents are frequent users of emergency department (ED) care, with high levels of use continuing despite significant improvements in access to care as a result of the state's 2006 health reform initiative. In an effort to better understand ED use in Massachusetts, this policy brief looks at ED use among working-age adults, focusing on reported reasons for using the ED and barriers to obtaining needed health care among ED users. Findings show adult ED users in Massachusetts are a sicker, more disabled, and more chronically ill population and report more difficulties obtaining care in the community and more unmet need for care than other adults in the state. Potential strategies for addressing preventable ED use include efforts targeted to specific care settings and particular population groups.

Health Reform in Massachusetts: An Update on Insurance Coverage and Support for Reform as of Fall 2008
Sharon Long, Karen Stockley

Massachusetts began an ambitious push toward near universal health insurance coverage in 2006. This policy brief provides an update of the impacts of health reform in Massachusetts on insurance coverage as of Fall 2008 for working-age adults, the primary target population of the reform initiative, along with an update on support for health reform in the state. Findings demonstrate that the state has achieved its goal of near universal health insurance coverage and that state residents continue to show strong support for health reform, even in the face of increasing program costs and the recession that began in December 2007. Given the success of the coverage expansion, Massachusetts policymakers are turning to the next phase of health reform – reigning in health care costs.

Access to and Affordability of Care in Massachusetts as of Fall 2008: Geographic and Racial/Ethnic Differences
Sharon Long, Paul Masi

Massachusetts continues to move forward on comprehensive health reform, with improvements in coverage, access to care and the affordability of care in the state. This policy brief provides a supplement to a recent Health Affairs article on health reform in Massachusetts, examining geographic and racial/ethnic differences in access to care and affordability of care across the commonwealth in Fall 2008.

Who Gained the Most Under Health Reform in Massachusetts?
Sharon Long

We know that health insurance coverage rose dramatically in the past year in Massachusetts. This study examines what the effect has been on specific populations, finding that the greatest gains in insurance coverage were reported by lower-income adults, younger adults and those in minority groups. Further, the reductions in uninsurance tended to be largest for subgroups that started out with higher levels of uninsurance.

Impact of Health Reform on Underinsurance in Massachusetts: Do the Insured Have Adequate Protection?
Sharon Long

Although health insurance coverage rose dramatically in the past year in Massachusetts, some questioned whether health reforms simply moved people from being uninsured to underinsured. This study explores whether requiring individuals to have health insurance has forced some people, particularly those with modest incomes, into plans that offer little financial protection. The findings suggest, however, that health reform in Massachusetts is both providing new coverage for many of those who were previously uninsured and improving the quality of coverage for those with insurance coverage.

Estimates of Health Insurance Coverage in Massachusetts from the Massachusetts Health Insurance Survey: An Update for 2010
Sharon Long, Lokendra Phadera

Massachusetts, which enacted a landmark health care reform bill in April 2006, is now beginning the fifth year of its ambitious health reform initiative, with evidence of strong and continuing gains in insurance coverage. This policy brief, which is based on the 2008-2010 Massachusetts Health Insurance Survey (MHIS), shows uninsurance in Massachusetts continuing at historically low levels.

Estimates of the Uninsurance Rate in Massachusetts from Survey Data: Why Are They So Different?
Sharon Long, Stephen Zuckerman, Timothy Triplett, Allison Cook, Kate Nordahl, Tracy Siegrist, Cindy Wacks

Researchers from the Urban Institute and the State of Massachusetts explored why existing surveys generate very different estimates of the uninsurance rate in Massachusetts. The surveys they examined are the Current Population Survey (CPS), the Behavioral Risk Factor Surveillance System (BRFSS), the Massachusetts Health Insurance Survey, and the Massachusetts Health Reform Survey (MHRS). This brief described how estimates may vary because of differences in the wording of the insurance questions asked in the surveys, differences in question placement and context within the survey, differences in survey design and fielding strategies, differences in accounting for missing data and other data preparation, and differences in survey fielding time frames. The analysis concludes that there has been no single survey in Massachusetts that is clearly superior across all of these important dimensions.

Barriers to Obtaining Health Care among Insured Massachusetts Residents
Sharon Long, Lokendra Phadera

Although Massachusetts' 2006 health reform initiative led to significant gains in insurance coverage and improvements in access to health care, barriers to obtaining care still exist for some Massachusetts residents, including difficulties finding providers who will see them and high health care costs. This policy brief uses the 2008 and 2009 Massachusetts Health Insurance Survey (MHIS) to examine reported difficulties in obtaining health care for insured residents in the state, focusing on difficulties related to access to providers and unmet need for care because of health care costs.

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Commentary

A Comment on "The Massachusetts Health Plan - Much Pain, Little Gain"
Sharon Long

The Cato Institute recently released a study of health reform in Massachusetts by Aaron Yelowitz and Michael F. Cannon, entitled "The Massachusetts Health Plan: Much Pain, Little Gain." That study reports fewer gains in health insurance coverage and higher costs than have been reported by earlier studies. As the Urban Institute has done a substantial amount of research on health reform in Massachusetts, we have received a number of requests to reconcile the findings on health insurance coverage from the Cato study with the findings from earlier work. This paper is a response to those requests.

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Research Reports

Reconciling the Massachusetts and Federal Individual Mandates for Health Insurance: A Comparison of Policy Options
Linda J. Blumberg, Lisa Clemans-Cope

The 2006 Massachusetts health reform law increased insurance coverage and improved access to care for residents, in part due to the law’s individual mandate. An individual mandate is also a component of the federal Patient Protection and Affordable Care Act (ACA), though its design differs from Massachusetts’ mandate in many ways. The implementation of the federal mandate in 2014 raises complex questions about the interaction of the two requirements. We analyze three basic policy options available to the state, assessing their implications for residents and each policy option’s ability to satisfy core policy objectives.

Massachusetts under the Affordable Care Act: Employer-Related Issues and Policy Options
Fredric Blavin, Linda J. Blumberg, Matthew Buettgens, Jeremy Roth

Using the Health Insurance Policy Simulation Model, this report analyzes four policy options for assessing employers who do not provide affordable health insurance to their workers as Massachusetts brings its health reform law into compliance with the Affordable Care Act (ACA). Overall coverage and costs are similar across all options, but replacing the state's Fair Share Contribution (FSC) requirement with the ACA assessment would eliminate a source of state revenue. Similarly, maintaining the FSC for small employers only would raise one-fifth as much revenue as leaving the current assessment in place.

Health Reform in Massachusetts as of Fall 2010: Getting Ready for the Affordable Care Act & Addressing Affordability
Sharon K. Long, Karen Stockley, Heather Dahlen

Five years after the enactment of Massachusetts health reform initiative, gains in insurance coverage and access to care have been sustained. This report provides an update on trends in the Bay State since fall 2006, just prior to the implementation of the state's health reform initiative, along with a more in-depth overview of the circumstances of working-age adults in 2010, as the state begins implementation of the Affordable Care Act.

Health Reform in Massachusetts: An Update as of Fall 2009
Sharon Long, Karen Stockley

This report provides a comprehensive update on the status of health reform in Massachusetts as of fall 2009. The report examines the overall impact of reform on non-elderly adults; the impacts on vulnerable population subgroups of adults; impacts on racial/ethnic disparities; the status of the remaining uninsured adults in the state; an assessment of the adequacy of coverage under health reform; and support for reform over time. The authors find that Massachusetts has made significant progress in accomplishing the goals of the legislation, although some challenges with respect to the cost of health care remain. A chartbook of key findings was also released as a supplement to the full report.

Getting Ready for Reform: Insurance Coverage and Access to and Use of Care in Massachusetts in Fall 2006
Sharon Long, Mindy Cohen

In April 2006, Massachusetts enacted a health care reform bill that seeks to move the state to (almost) universal coverage through a combination of Medicaid expansions, subsidized private health insurance coverage, and insurance reforms. As part of an evaluation of the impacts of the state's reform effort, we conducted a baseline survey of 3010 adults aged 18 to 64 years old in Massachusetts. The survey was conducted by ICR/International Communications Research between October 16, 2006, and January 7, 2007, using a Computer Assisted Telephone (CATI) interviewing system. This report provides a detailed overview of the Massachusetts population in Fall 2006

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Methodology Reports

The Massachusetts Health Reform Survey
Sharon Long

In April 2006, Massachusetts enacted a health care reform bill that seeks to move the state to (almost) universal coverage through a combination of Medicaid expansions, subsidized private health insurance coverage, and insurance reforms. As part of an evaluation of the impacts of the state's reform effort, we conducted surveys of adults aged 18 to 64 years old in Massachusetts. This document provides an overview of the survey approach and the survey instruments.

2008 Massachusetts Health Insurance Survey: Methodology Report
Sharon Long, Timothy Triplett, David Dutwin, Susan Sherr

The Massachusetts Health Insurance Survey (MHIS) collects information on health insurance coverage and access to and use of health care for the non-institutionalized population in Massachusetts. It is funded by the Massachusetts Division of Health Care Finance and Policy (DHCFP) and is conducted by the Urban Institute, along with its subcontractor, Social Science Research Solutions (SSRS). This report provides information about the methods used to collect and analyze the MHIS.

Massachusetts Health Insurance Survey Methodology Report: 2008, 2009, and 2010
Timothy Triplett, Sharon Long, David Dutwin, Susan Sherr

The Urban Institute, along Sharon Long at the University of Minnesota and Social Science Research Solutions, conducts the Massachusetts Health Insurance Survey (MHIS) for the Massachusetts Division of Health Care Finance and Policy (DHCFP). This report provides information about the methods used to collect and analyze the MHIS.

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