Five Questions For Sharon K. Long

Five Questions for... the people behind the Urban Institute research. In traditional interview format, our experts talk about the nature of their work and offer insights on what they've learned.

Urban Institute researcher Sharon Long answers five questions about Massachusetts’s landmark health reform experiment, which aims for near-universal coverage and improved access to affordable health care. In 2006, lawmakers passed a bill that required most adults to get health insurance, expanded Medicaid, provided subsidies for lower-income adults, created a health insurance exchange where residents can buy plans easily, and required employers to offer coverage or pay a fee. Early success has made the state a model for nationwide reform.

1. Massachusetts has the country’s lowest percentage of uninsured residents—an estimated 2.6 percent in summer 2008. How did the state reach near-universal coverage? And what other improvements did you find in your latest evaluation?

Massachusetts had a high percentage of insured residents to start with, so the distance to near-universal coverage wasn’t as great as it will be in other states. Still, Massachusetts’s success is impressive. Insurance coverage is well above that anywhere else in the country. And, as coverage grows, we’re seeing greater access to health care and use of care. By fall 2008, adults were more likely to have a regular source of health care and were more likely to have seen a doctor over the past year. Dental care visits also went up. And preventive care increased across the board, even among those who already had coverage, likely because new standards for insurance require that preventive care be covered without a deductible. Altogether, we find substantial evidence that health care use has improved under the state’s health reform initiative.

Massachusetts was able to get compromises from different constituencies and that brought people together. Support for reform among the key stakeholders has remained strong. Three years out, government, health plans, providers, business, advocates, and the public are all still at the table—that alone is an accomplishment.

2. Massachusetts decided to expand coverage before tackling cost containment, but rising costs are cutting into some early gains in affordability, particularly for low-income people. What does this tell us about adopting the Massachusetts model on a national scale?

In theory, national reform could start the same way reform did in Massachusetts—if we’re willing to live with the deficits. Health care costs are rising faster than inflation from coast to coast, not just in Massachusetts.

Massachusetts’s decision to tackle coverage before cost containment has political advantages. State policymakers would probably argue that expanded coverage means better health care access, which, in turn, improves health, productivity, and quality of life. Once the system is up and running, it’s harder to take back what’s been given. Higher costs may cause some people to drop their coverage, preventing them from getting needed care, which pressures the system to address costs. Keeping the expanded coverage that Massachusetts has achieved is an easier perspective to defend when taking on cost control, though that’s not to say controlling costs will be easy.

I’ve heard cost control described as “round two” in Massachusetts. The first question was “Can you achieve near-universal coverage?” And the Massachusetts example says yes. The second question is “Can you get costs under control?” And we’re waiting to see how Massachusetts will answer that one.

Last year, the state set up a commission to find ways to slow the growth of health care costs. The strategy currently under debate in Massachusetts—a global payment system—would fundamentally change the provider payment system to create more incentives for primary care, care coordination, and more efficient care delivery. Just like national discussions on health care costs, Massachusetts is emphasizing primary care-based medical homes, evidence-based coverage, chronic care management, and health information technology.

3. Your evaluation also found that, despite the overall increase in health care use, more adults had trouble getting some types of care in 2008 than in 2007. What can the state do to address these problems? What does this suggest for national reform efforts?

That’s another lesson for nationwide reform—making sure health care systems are ready to support the uptick in demand that comes with expanded coverage. Provider capacity was a problem in Massachusetts before health reform—just as it is in the nation as a whole. Demand for health care went up in Massachusetts as people gained health insurance coverage, which led to higher levels of unmet need for specialist care and medical tests, treatment, and follow-up care.

Our latest survey also found that, in fall 2008, about one in five Massachusetts adults reported being told that a doctor’s office or clinic wasn’t accepting new patients or wasn’t accepting patients with their type of insurance. Low-income adults and adults in publicly subsidized programs in particular had more difficulty finding a doctor. Since most of the expanded coverage was in publicly subsidized programs, the increased demand for care was concentrated among a subset of providers.

Adding more primary care doctors will help but is likely to be only a partial solution. Massachusetts is also looking at the way providers are paid. By moving away from fee-for-service to a global payment system, the state hopes to put incentives in place for better care coordination and more cost-effective and efficient care delivery.

Difficulty getting a doctor’s appointment may partially explain why there was no change in the percentage of people using hospital emergency departments for nonemergencies. It’s a sign of inefficiency in the health care delivery system. Before reform, Massachusetts had a higher rate of emergency department use than the national average. In fall 2008, 15 percent of adults reported going to the emergency department for nonemergency care and, for more than half of those visits, people reported being unable to get a doctor’s appointment as soon as they needed one. National studies show that emergency department use is a pretty entrenched habit. The hope is better coordinated care and a stronger primary care network will change that behavior.

4. Can and should we follow Massachusetts’s model on a national scale?

There are some elements and lessons we can take from Massachusetts. But let me point out that Massachusetts started out in a very different place from most states. Massachusetts had a high rate of health insurance coverage before reform, and there’s a strong commitment to health reform among political leaders, providers, the health plan industry, and the public. Support for health reform is high among low-income residents who gain the most from health reform, but it’s also high among higher-income people whose taxes help support the subsidies for those low-income residents.

Also, keep in mind this is the third round of health reform in the state since 1988. Before 2006, Massachusetts expanded public coverage and made changes in the health insurance market for private coverage. Those earlier reforms built the foundation for the 2006 initiative. So learning from the Massachusetts example means learning from multiple rounds of reform, not just this last round.

5. Is national health reform different this time around? And what do you make of the concessions industry groups say they are willing to make? For example, cutting $2 trillion in costs over 10 years and eliminating the practice of charging higher premiums to sick people.

It’s encouraging to see the health insurance and health care industries come to the table, though they haven’t released enough details to know how big their concessions really are. It’s easy to talk about cutting back and being more fiscally responsible, but when it comes time to live by a budget, it’s easier said than done. Also, I’d like to see some required enforcement to make sure they follow through with their plans.

Is reform different this time around? For one thing, health care costs are higher now than before. Rising costs are becoming a heavy burden on the economy and the pressure is on to do something now to rein them in.

Also, Massachusetts’s experiment convinced people that reform is possible. We’ve seen one state develop a consensus, pass an initiative, put it in place very quickly, and achieve real success within three years. It’s not a perfect model—there will never be a perfect model—but it’s a model that realized near-universal coverage in a short period. Massachusetts had to navigate many internal debates along the way. The key to national reform is trying to find some middle ground we can all live with and moving forward. The status quo is not the answer.