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.
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The 2010 national health reform legislation—the Patient Protection and Affordable Care Act (PPACA)—is modeled on Massachusetts' 2006 landmark reform effort. As in Massachusetts, national reform includes expansions of public programs, the creation of health insurance exchanges, subsidies for low- and moderate-income individuals, an individual mandate, and requirements for employers, among other provisions. Given the strong parallels between Massachusetts' health reform initiative and national health reform, the experiences in the Bay State provide insights into the potential effects of PPACA.
Massachusetts' health reform initiative, entitled An Act Providing Access to Affordable, Quality, Accountable Health Care (Chapter 58 of the Acts of 2006), aimed to make comprehensive insurance coverage available and affordable for residents as a first step toward improving access, use, affordability, and quality of health care in the state. The evidence suggests that Massachusetts has made significant progress toward each of these goals in the years since the reforms were implemented:
- In 2008, 96 percent or more of the state's residents were estimated to have health insurance—well above the 85 percent in the nation as a whole.1, 2 Insurance coverage in Massachusetts remained at a historical high in 2009, despite the economic recession.3
- The gains in coverage in the state reflect gains in employer-sponsored insurance as well as the expansion of public coverage. There is no evidence that public coverage "crowded out" employer-sponsored coverage in the state.3, 4 As was true prior to health reform, the majority of Massachusetts residents—both adults and children—continue to obtain insurance through their employers under health reform.
- Gains in insurance coverage were reported across every population group examined, including young adults, who are more likely than older adults to forgo insurance coverage.5
- Compliance with the individual mandate is high, with the Massachusetts Department of Revenue reporting that of the roughly 3.5 million adult filers in tax year 2008, only about 45,000 (about 1 percent) were assessed a penalty for failing to obtain insurance when affordable coverage was available to them.6
- Access to and use of health care in the state improved under health reform, with more adults reporting visits to doctors and other health care providers and fewer adults reporting going without needed health care in fall 2009 than prior to health reform. There is evidence of particularly strong gains in the use of preventive care and prescription drugs, benefits specified under the state's new minimum creditable coverage (MCC) requirements, which outline the key benefits and cost-sharing provisions that must be included in a health insurance plan if it is to satisfy the state's individual mandate for health insurance coverage. In addition, adults in Massachusetts were more likely to rate the quality of the health care they received as very good or excellent under health reform.3
- The burden of health care costs was reduced under health reform, particularly for lower-income residents. Out-of-pocket spending on health care was reduced and fewer adults reported going without needed care because of costs under health reform, despite the recession.3 The gains were particularly strong for lower-income adults, who are more likely to lack the financial resources to pay for care, and adults with chronic health conditions, who are more likely to use health care.7
- Many racial and ethnic disparities in health insurance coverage, access to and use of health care, and health care affordability have been reduced or eliminated in the state under health reform.7
In addition, support for health reform was quite strong among Massachusetts residents when the legislation passed in 2006 and continues at high levels: More than two-thirds of adults in the Bay State support health reform.3, 8 Furthermore, support for reform is widespread across the state, including men and women, younger and older adults, and higher- and lower-income adults.7
Support for health reform is also high among providers in Massachusetts. The majority (70 percent) of practicing physicians in Massachusetts support health reform and most (75 percent) want reform to continue.9
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