Less than two years after Massachusetts' 2006 reform law was implemented, 2.6 percent of residents were uninsured—the lowest proportion ever recorded in an American state. The state's individual mandate alone does not explain this result, since it is not enforced against adults with incomes at or below 150 percent FPL or children. During a multi-day site visit, researchers identified several factors contributing to Massachusetts' high enrollment, including an intensive marketing campaign; use of data to establish subsidy eligibility for newly-insured residents; an integrated eligibility system serving multiple subsidy programs with a single application; and healthcare provider/community-based organization-driven application assistance.
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By the summer of 2008—less than two years after Massachusetts’ health care reform law became effective—only 2.6 percent of Massachusetts residents were uninsured (Long, Cook and Stockley 2008). This was the lowest proportion ever recorded in an American state.
The state’s gains in coverage were particularly large for adults with incomes low enough to qualify for subsidies – that is, at or below 300 percent of the federal poverty level (FPL). For them, the percentage without coverage dropped from 23.8 percent in 2006 to just 7.6 percent in 2008 (Long and Stockley 2009).
How did the state accomplish this result? The usual explanations are insufficient. The state mandates insur-ance coverage for adults, but the mandate does not apply to children and is not enforced against adults with in-comes below 150 percent FPL. These two groups represent nearly half of the increase in coverage since 2006, as we discuss below.
The state provides hefty subsidies for uninsured residents with low incomes, but other states have taken similar steps without achieving remotely comparable participation by eligible households (Maine School of Public Service Institute for Health Policy 2006). To borrow the familiar “Field of Dreams” cliché, other states built systems of health coverage subsidies, but the uninsured didn’t come. How did Massachusetts get them to come?
Based on state administrative data, a review of existing studies, a site visit to Boston in July 2009, and follow-up interviews, this report explains the innovative adminis-trative strategies that caused an unprecedented proportion of eligible, low-income residents to participate in Massachusetts’ subsidized health coverage programs.
National policymakers structuring health reform legisla-tion have already learned much from Massachusetts’ groundbreaking efforts. Key features of both Massachusetts reform and proposed national legislation include generous subsidies for uninsured residents with incomes too high to qualify for Medicaid but too low to afford coverage on their own, an individual mandate to purchase coverage whenever it is affordable, and a health insurance “exchange” in which consumers can choose from among competing plans.
But none of these well-known policies, either alone or in combination, would have yielded the state’s ex-traordinary results placing the low-income uninsured into subsidized health coverage. Innovative outreach and enrollment strategies, which this paper describes for the first time to a national audience, also played a central role. For future reforms at either the national or state level to accomplish the basic objective of enrolling the low-income uninsured into health insurance, it will be important to incorporate these additional lessons from Massachusetts into the design of coverage expansion.
This study was completed under a grant from the Robert Wood Johnson Foundation’s State Health Access Reform Evaluation (SHARE) initiative.
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