Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Tuesday, April 22, 2008

Massachusetts Health Care Reform: Ingenuous… or Ignorant? - Chris Hoedt

In 2006, the Massachusetts Health Care Reform Bill pioneered drastic social changes, in an effort to alleviate the national health care crisis, by attempting to ensure all state residents have medical health insurance. Chapter 58 mandates that all state residents acquire health insurance, privately or through their employer, or face financial penalty (1). Through this plan, the state sought to blaze the trail in creating an effective method of containing health care costs and ensuring a basic level of medical accessibility. Originally, the state estimated that about 400,000 residents were uninsured, 6% of the state population (2,3), while the federal government surveyed this figure to be closer to 650,000 uninsured residents, about 10% of the state population (4). The legislation provides a gradient of partial subsidization of insurance policies for individuals with an adjusted gross income less than 300% the Federal Poverty Level (FPL) and full subsidization for those individuals under 150% FPL; in 2008, 300% FPL is $31,212 for an individual and $63,612 for a family of four (5). The Uncompensated Care Pool (“Free Care Pool”), which previously paid providers for the medical expenses of those who could not afford their care, has been dissolved into the Health Care Safety Net Trust Fund, which serves as an emergency pool of finances for hospitals experience operating hardships and funds the subsidization of premiums for state health insurance programs (6).
Established as a program to facilitate the universal health insurance coverage for all Massachusetts residents, the Commonwealth Connector is composed to two major programs. Commonwealth Care assists qualifying residents, who have a financial income with respect to FPL was previously mentioned, obtain state subsidized insurance policies. Commonwealth Choice assists residents in securing insurance policies that fit their particular needs and have at least the minimum state requirements for coverage; these residents have an income too high to qualify for subsidization. Current estimates by the Commonwealth Connector believe that over 300,000 citizens have obtained health insurance since the implementation of the Chapter 58 legislation (4). Although it would seem that health insurance is no longer a barrier to obtaining care in the state and that medical cost inflation would decrease, hundreds of thousands of underinsured have chosen to pay penalties instead of obtaining insurance (7) and accessibility has not significantly changed (8). More importantly, the stated goal of Chapter 58: to improve health care access and affordability of Massachusetts citizens (9), has be ineffectively implemented as this policy neglects significant social factors affecting health outcomes that may lead to this program’s failure.

Mandates do not produce effective improvements in health outcomes
Forcing all citizens to have health insurance does not mean that people will have better health outcomes. Although studies have shown that patients with health insurance generally have better health outcomes (10), this is in under the context of comparing those who are insured to those uninsured. Mandating health insurance for everyone, especially to those patients in the bottom strata does not guarantee better health outcomes, since they would remain the bottom strata. Moving the bottom line up will likewise shift the quality of care provided and maintain similar health outcomes for these people (11). The Massachusetts mandate does not ensure that those who need health care the most are more likely to obtain effective health treatment and prevention. Many social and behavioral factors are neglected by this mandate, which have enormous correlation to the health outcomes of individuals. Education level, socioeconomic status, and race have been found to be very important predictors of health outcomes for individuals (12). One study found that correcting the education level associated-mortality disparity in our nation could have saved over one million lives; eight times the number predicted to have been saved that same year by medical technology/procedure advancements (13). Improving the education of Commonwealth residents would produce a multitude of benefits, which would include substantially better health outcomes overall. Twenty percent of physicians care for more than 80% of the Black population and this illustrates the necessity for significant social reform in our nation (14). Further contributing to the disparities in providing adequate access to health care services, minority cultures frequently comprise a considerable amount of people uninsured or underinsured in the state. This past year in Massachusetts, Blacks were 1.5 times more likely, and Hispanics more than twice as likely, to be uninsured as compared to Whites (15). These same cultures have been found to be less likely to seek out health care in Massachusetts, even when they have health insurance. Similarly, compared to Whites, medical or dental preventive care check-ups within the last year were obtained by Blacks 1.5 times less frequently and Hispanics over twice less frequently (15). An estimated 90,000 illegal immigrants in the state of Massachusetts are not even considered in the Chapter 58 policy or the survey of those without insurance in the state (16). Programs targeted to provide insurance for minorities and increase their likelihood of seeking preventive care should have been a major focus of Chapter 58 and would have been ingenious. The health insurance mandate of Massachusetts has failed to appropriately address the need for health programs targeted towards minorities and improving education levels, shown to improve the accessibility and affordability of health care.

Effective spending on health for residents
Originally it was estimated by former Governor Romney that the average individual insurance premium would cost about $300 per month, but when the plans insurance companies developed were announced, they averaged almost $400 per month (8). Furthermore, in order to create health insurance policies affordable for persons with limited income, insurance companies have cut services covered in policies. Services have been reduced to the state minimum requirements, co-payments have substantially increased with respect to the amount projected by the state government, and deductible levels have more than double on average compared to previously speculated amounts (3). The money spent to obtain a plan, which is already poor coverage, takes almost a 10% proportion of the income for individuals just above the individual qualification maximum of $50,000 (17). This money could have been used on other things that would have improved the lives of those people, possibly more than having low quality health insurance coverage.
Many daily activities and medical treatments, which are very inexpensive, can significantly improve an individual’s health. A flu shot that can cost up to $25 (18) can reduce the likelihood of contracting the influenza virus by 70-90% (19), which afflicts millions of people in the United States each year. Membership at a fitness center has been found to have enormous benefits for a multitude of health issues (20) and can cost as little as $360 annually (21). Food could even be an expenditure some people of Massachusetts can barely afford. For the 2007 tax year, many people, hundreds of thousands just above the $50,000 income max (7), have chosen to spend their money elsewhere than purchasing more costly health insurance, at the penalty of a $4,125 tax exemption loss (22). Most plans cost a significant amount more than the penalty and thus this mandate is forcing these persons to make a choice of the least worst result.

Effective allocation of resources by the Commonwealth
The money and time dedicated to funding this program has proven ineffective in its first year compared to projected results and has caused a large number of physicians to sign an open letter to everyone in the United States giving Chapter 58 a “failing grade” (23). Without the support of hospitals and physicians, it is politically unfeasible for this mandate to take root and succeed at improving access and quality of health care. These resources should have been dedicated towards other programs that would have produced more effective outcomes and had more health care provider support. Furthermore, resentment is growing, because of an exceptional miscalculation in the finances necessary to fund this program. In order to account for misjudged numbers of uninsured and underinsured individuals, Governor Patrick has requested an additional $200 million for the $700 million budgeted to this reform plan for the 2009 fiscal year (4). This money will be acquired by cutting funding to other projects, increasing taxes, and increasing the cost of health insurance policies (24). With regard to previous estimates, the state found there were about 40,000 residents of Massachusetts that would be required to purchase more comprehensive plans for the 2009 fiscal year health insurance policy coverage requirement increase (4). Yet, recent predictions estimate there are about 200,000 residents that this minimum coverage policy will affect (3). Furthermore, hundreds of thousands of residents have chosen to not adhere to the mandate in the last year, causing a lack of funding that was expected for state health insurance subsidized plans (4). Based on the significant lack of adherence to the mandate and underestimation of how many residents the increase in policy requirements would affect, the support for the mandate is diminishing (25). Recently, the state legislature approved an additional 3.5 million dollar campaign to promote awareness of the mandate (26); less than 25% of the population believe this mandate helps them in any way and many people are completely unaware of the policy changes: 26% of people 18-35 years of age, 21% with an income less than $25,000, and 22% of the uninsured (25). It is a significant problem that about 25% of residents have not heard of the mandate, since the aforementioned groups (persons 18-35 years of age, with an income less than $25,000, and/or uninsured) are the targeted demographic of residents this policy seeks to affect. Many administrative, financial, and promotional errors would have been prevented if more subgroup targeting had been implemented in the plans for Chapter 58.
Programs created by the state to promote funding for health care interventions of these target demographics would have been more effective to improve overall accessibility and affordability to health care. These demographics are generally those people that cost the health care system the most money (15). Often these persons have worse health and lack finances to pay for preventive care and comprehensive health insurance (14). Programs targeting their care would provide the best direct intervention methods of containing overall costs, because better health for these people mean less costs to the system. Furthermore, the loss of the “free care pool,” before having a significant majority of those uninsured in compliance with the new policy, creates financial strain on many hospitals. A more effective program that should have been implemented would target providing preventive care for those who cannot afford it and/or subsidizing health care for those persons making too much money to qualify for Medicaid assistance.
One year after the implementation of the Massachusetts Health Care Reform plan, most of the nation has withdrawn their original support and confidence in Chapter 58. Further contributing to the dwindling political feasibility are the many physicians of the state who have come together to express their concern for the plan. They hold a universal belief that the plan will make health outcomes worse in the state (23). A significant lack of social and behavioral health perspective in to effective measures of improving health care accessibility and affordability could prove to be extremely costly to the state of Massachusetts.

1. Massachusetts Department of Public Health. Chapter 58 of the Acts of 2006. 12 April 2006. 3 Apr 2008
2. Commonwealth Connector. Health Care Reform: Overview. 2008. 03 Apr. 2008. 8a23468a2dbef6f47d7468a0c?fiShown=default.
3. Raymond, Alan G. The 2006 Massachusetts Health Care Reform Law: Progress and Challenges After One Year of Implementation. BCBSMA Foundation, MA Medicaid Policy Institute, MA Health Policy Forum. Boston, 2007.
4. Commonwealth Connector. Health Connector Facts and Figures. Boston, 2008. 3 Apr. 2008.
5. The Commonwealth of Massachusetts. Health Care Access and Affordability Conference Committee Report. Boston, 2008. 3 Apr. 2008.
6. Henry J. Kaiser Family Foundation. Massachusetts Health Care Reform Plan: an Update. Washington, D.C.: Kaiser Family Foundation, 2007. 3 Apr. 2008.
7. Mahar, Maggie. Massachusetts Health Care Reform : the Canary in the Coal Mine. Health Beat (2007). 23 Oct. 2007. 3 Apr. 2008,
8. Dembner, Alice. Sticker Shock for State Care Plan. The Boston Globe 20 Jan. 2007. 03 Apr. 2008.
9. Massachusetts Health Care Reform Coalition. FAQs on the New Health Reform Law. 2008. 03 Apr. 2008.
10. McWilliams, Michael J., MD. Health of Previously Uninsured Adults After Acquiring Medicare Coverage. The Journal of the American Medical Association.298(24), (2007):2886-2894.
11. Garson, Arthur, MD, MPH, and David Blumenthal, MD, MPP. State-Federal Partnerships for Access to Care. Journal of the American Medical Association ns 297 (2007): 1112-1115.
12. Wharam, J. Frank, MB, BCh, BAO and Norman Daniels, Ph.D. Toward Evidence-Based Policy Making and Standardized Assessment of Health Policy Reform. Journal of the American Medical Association ns 298 (2007): 676-679.
13. Woolf, Steven, MD, MPH, and et al. Giving Everyone the Health of the Educated: an Examination of Whether Social Change Would Save More Lives Than Medical Advances. American Journal of Public Health os 97 (2007): 679-683.
14. Lurie, Nicole, MD, MSPH, and Tamara Dubowitz, MSC, SM, SCD. Health Disparities and Access to Health. Journal of the American Medical Association ns 297 (2008): 1118-1121.
15. Coombs, Alice. Dealing with Disparities: One of the Real Measures of Success. MA Medical Society. Boston: CommonHealth, 2007.
16. Estimated Number of Illegal Immigrants (Most Recent) by State. StateMaster.Com. 2000. US Citizenship and Immigration Services. 03 Apr. 2008.
17. Holahan, John, and Linda Blumberg. Massachusetts Health Care Reform: A Look At the Issues. Health Affairs 10 (2006): w423-w443.
18. Powell, Kimberly, and Albrecht Powell. Where to Get a Flu Shot in Pittsburgh. About.Com: Pittsburg (2007). 3 Apr. 2008.
19. Influenza (Flu) Prevention. MayoClinic.Com. 21 Sept. 2007. 3 Apr. 2008.
20. Atlantis E., Chow et. al. An effective exercise-based intervention for improving mental health and quality of life measures: A randomized controlled trial. (2004) Preventive Medicine, 39 (2), pp. 424-434.
21. South End Fitness Center. Membership. 3 Apr. 2008.
22. Massachusetts Health Care Reform Bill Summary. Blue Cross Blue Shield of Massachusetts. BCBS, 2007. 3 Apr. 2008.
23. Physicians for a National Health Program. Doctors Give Massachusetts Health Reform a Failing Grade - Poor Early Outcomes Raise Red Flags, Only Private Insurers Profit. 14 Jan. 2008.
24. Luddy, Katie. FY09 House 2 Budget Recommendation: Issues in Brief. Health Care Reform.
25. Harvard School of Public Health, Kaiser Family Foundation, BCBSMA. Massachusetts Health Reform Tracking Survey. Menio Park, CA: Kff.Org, 2007.
26. Dembner, Alice. Healthy Advice: Outreach Workers Making Sure People Know of New Law. The Boston Globe 7 July 2007.

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