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.

References
1. Massachusetts Department of Public Health. Chapter 58 of the Acts of 2006. 12 April 2006. 3 Apr 2008 http://www.mass.gov/legis/laws/seslaw06/sl060058.htm.
2. Commonwealth Connector. Health Care Reform: Overview. 2008. 03 Apr. 2008. http://www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e8 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. http://64.233.169.104/search?q=cache:BxgnyrNyvVEJ:www.mahealthconnector.org/portal/binary/com.epicentric.contentmanagement.servlet.ContentDeliveryServlet/About%252520Us/News%252520and%252520Updates/Current/Week%252520Beginning%252520March%2525209%25252C%2525202008/Facts%252520and%252520Figures%2525203%25252008.doc+health+connector+facts+and+figures&hl=en&ct=clnk&cd=1&gl=us.
5. The Commonwealth of Massachusetts. Health Care Access and Affordability Conference Committee Report. Boston, 2008. 3 Apr. 2008. http://64.233.169.104/search?q=cache:E6-Qynob6kEJ:www.mass.gov/legis/summary.pdf+health+care+access+and+affordability+summary&hl=en&ct=clnk&cd=1&gl=us.
6. Henry J. Kaiser Family Foundation. Massachusetts Health Care Reform Plan: an Update. Washington, D.C.: Kaiser Family Foundation, 2007. 3 Apr. 2008. kff.org/#7494-02.
7. Mahar, Maggie. Massachusetts Health Care Reform : the Canary in the Coal Mine. Health Beat (2007). 23 Oct. 2007. 3 Apr. 2008, http://www.healthbeatblog.org/2007/10/universal-cover.html.
8. Dembner, Alice. Sticker Shock for State Care Plan. The Boston Globe 20 Jan. 2007. 03 Apr. 2008. http://www.boston.com/yourlife/health/other/articles/2007/01/20/sticker_shock_for_state_care_plan/?page=1.
9. Massachusetts Health Care Reform Coalition. FAQs on the New Health Reform Law. 2008. 03 Apr. 2008. http://www.masshealthreform.org/faqs.html.
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. http://www.statemaster.com/graph/peo_est_num_of_ill_imm-people-estimated-number-illegal-immigrants.
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. http://pittsburgh.about.com/od/health/a/flu_shot.htm.
19. Influenza (Flu) Prevention. MayoClinic.Com. 21 Sept. 2007. 3 Apr. 2008. http://www.mayoclinic.com/health/influenza/DS00081/DSECTION=8.
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. http://www.southendfitness.org/membership.htm
22. Massachusetts Health Care Reform Bill Summary. Blue Cross Blue Shield of Massachusetts. BCBS, 2007. 3 Apr. 2008. http://www.masshealthreform.org/faqs.html.
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. http://www.mass.gov/bb/h1/fy2009h1/exec2_09/hbudbrief8.htm
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.

Is insurance the answer? A critique of the efficacy of the individual insurance mandate in promoting positive health outcomes for all – Katie Stone

The latest trend in comprehensive insurance is the individual insurance mandate, a legislative policy which forces individuals to obtain insurance. If they do not comply, they are faced with penalties [1]. As a public health intervention, the individual insurance mandate fails to adequately address the diverse reasons people fail to seek needed medical care, instead choosing to believe that insurance status is a direct predictor of health outcomes. Unfortunately, before insurance status can lead to improved outcomes, access to care must be made more equitable. By addressing problems of affordability, cultural competence, and community infrastructure, access would be expanded and the individual mandate would become a far more effective tool for improving people’s health.


Background
The individual insurance mandate, pioneered in the U.S. by the Commonwealth of Massachusetts (MA), is a legislative decision to confer individual responsibility for obtaining health insurance on residents of the Commonwealth of Massachusetts. Enacted in 2006 as part of Chapter 58 of the Acts of 2006, this mandate requires Massachusetts residents eighteen and older to purchase health insurance and includes provisions to help residents obtain this coverage; should residents fail to purchase insurance, they face penalties on their state income tax [2]. To date, legislators have enacted a series of laws (collectively called the Health Care Reform Acts) that aim to increase the number of insured MA residents (and therefore improve their health status) by loosening income restrictions for Medicaid eligibility and enacting employer mandates which enforce tax penalties on employers who do not offer their employees coverage. While legislators allow that the Acts aim to cover 95%, rather than 100%, of uninsured residents within the next three years, this number will still be hard to achieve, as they may not have fully considered the reasons residents lack insurance. By relying heavily on the health belief model to plan their intervention, which suggests that health care seeking is a rational behavior, legislators miss less rational components, such as cultural considerations, which may factor heavily into the decision making process. Therefore, legislation targeted at reducing uninsurance without improving access may not provide the desired victory in the fight to reduce disparities and increase the health status of the population.


Affordability as a Barrier to Access
While failure to account for irrational decision making represents a potentially huge problem with the individual insurance mandate, there are, in addition, rational behaviors which may prove equally problematic. The best example of rational decision-making which could prove counter-productive to the intervention’s intent is that of teenagers and young adults affected by the health care reform laws, who may deem becoming insured unaffordable, even at the supposedly reduced costs offered by the state’s young adult plans. As discussed above, the new laws require residents eighteen and over to have their own insurance. While exceptions exist (young adults are allowed to remain on their parents’ insurance for up to two years after they lose dependent status, or until they are 26 years old), for some teens and young adults, the insurance decision could be as simple as a look at the health belief model.


The health belief model is a theory which attempts to predict how individuals will act when faced with health care decisions. The model has four components: perceived susceptibility, perceived severity, barriers to action, and benefits of action [3]. Using this model, it is possible to understand how a young adult might address the individual insurance mandate. First, teenagers and young adults generally perceive their susceptibility to health problems (that might require visits to the doctor) to be low. Ethier et al. (2003) show that even among teens engaging in high risk behaviors, perceived susceptibility to sexually transmitted diseases was, at most, low. [4] Some participants believed they had no susceptibility at all. Findings such as this one represent not just adolescent beliefs about STDs, but adolescent beliefs about health in general. Therefore, perceived susceptibility related to being uninsured is low, as is perceived severity. Adolescents worry about getting the flu, not getting cancer. Despite the very real possibility that adolescents can have potentially life-altering, expensive conditions, they do not believe it will happen.


Although perceived susceptibility and severity are low for this age bracket, perhaps this intervention could still, according to the health belief model, succeed. To do so, the barriers to obtaining insurance would have to be very low and be far outweighed by the benefits. Unfortunately, this is not likely to be the case for most young adults. The obvious barrier to obtaining insurance is cost. Despite plans to offer lower cost insurance to young adults [2], the fact remains that the cost of any insurance exceeds the cost of no insurance. While tax penalties exist for those who are not insured, the maximum penalty (beginning in 2008) will be equal to half the cost of the lowest Commonwealth Care plan available to a resident [1]. Therefore, for a person, such as a young adult, with low-to-no perceived susceptibility, the cost of obtaining health insurance would not be worthwhile. Therefore, on the basis of the health belief model, it is likely that many young adults will fail to obtain coverage, despite the individual mandate. Despite their uninsured status, this group is likely to remain one of the healthiest groups in the state based on age alone, thus refuting the idea that insurance status is a direct predictor of health outcomes. However, it is impossible to test this hypothesis in the current environment, where access to insurance is tightly linked to cost and ability to pay.


Cultural Competence as a Barrier to Access
Another barrier to obtaining medical care is cultural; mandating insurance does not improve outcomes for people who do not receive needed medical care due to a lack of cultural competence. For example, in her book The Spirit Catches You and You Fall Down, Anne Fadiman (1998) chronicles the story of an epileptic child of first-generation Hmong immigrants [5]. The child’s care is hampered from the very beginning, when the hospital she is taken to has no Hmong interpreter, despite the town’s large and growing Hmong immigrant population. After a series of missteps and misunderstandings which result in catastrophe, the parents, and by extension much of their community, are permanently wary of modern American medicine and no longer visit doctors or hospitals, despite the fact that they are insured by Medicaid. Situations like this one raise the question, then, of whether having insurance is enough to improve health outcomes for underserved immigrant and minority populations. In their review of cultural competency methods and models, Brach and Fraser (2000) define important techniques necessary for providing culturally competent care. These include interpreter services (notably absent in the example above), coordination with traditional healers, and promoting health in a culturally competent way, [6] which will be the focus of the next section.


In their section on culturally competent health promotion, Brach and Fraser (2000), suggest that “public information campaigns can be conducted… in the community. In an attempt to make health-promotion efforts more culturally competent, culture-specific attitudes and values have been incorporated into messages and materials” (pg.187) [6]. In essence, the authors suggest that health-care professionals use advertising theory to “sell” health care to underserved immigrant and minority populations. By doing so, they will not only increase insurance levels in these communities, but may begin to improve outcomes and health status as well. Sadly, the individual insurance mandate fails to adequately address this important issue, as described in the example below.


One example of a failure to “sell” insurance in a culturally competent way involves spoken language. The state’s new mechanism for enrolling uninsured residents in health care, the Commonwealth Connector [7], provides colorful, easy-to-use, interactive tools with information on accessing health insurance – in English. There is one page available in Spanish, but you cannot access any of the tools or other features accessible in English. According to the U.S. Census Bureau (2000), in 2000 18.7% of MA residents spoke a language other than English; of these, only 6.2% were Spanish or Spanish Creole speakers [8]. Although it is important to mention that Latinos are the minority group most likely to be uninsured, with nearly 1/3 uninsured in 1997 [9], this still leaves more than 12% of people, many of whom are from other immigrant groups, with no services easily accessible in their own language. Lu and Matani (2001) show that immigrants have very high rates of uninsurance; among people with incomes below 200% of the federal poverty level (FPL), nationally 58.2% of noncitizen immigrants and 41.6% of naturalized citizens have no insurance [10]. Since services are available only in English and a limited amount of Spanish, the Connector may not reach their target demographic. If, instead, the Commonwealth ran targeted, non-English ad campaigns in areas with high concentrations of underserved (and uninsured) immigrants, they could use the core ideas of advertising theory to “sell” insurance to these groups, which would give these underserved populations a chance at improved access to insurance and perhaps, eventually, better health status.


Unfortunately, even if they are able to reach these populations, insurance alone may not be enough to change health status and promote positive health outcomes. If there is not access to culturally competent care for the newly insured, they may continue to experience delays in care-seeking and, ultimately, poorer health outcomes. For example, one problem that stems from a lack of cultural understanding regards traditional healing methods. For many immigrant groups, traditional healing methods are believed to be effective means of maintaining health and curing disease. In most cases, there is no harm in these traditional beliefs, and in some cases they may help the patient, often through the sense of empowerment gained from being in control of their own care [11]. Should the newly insured visit health care providers and encounter antipathy to their traditional beliefs, they may decide not to come back for further treatment and care; after hearing of these problems, some may choose never to be seen at all. Without physicians actively pursuing cultural competence in these communities, it is highly probable that being insured rather than uninsured will not lead to significantly improved health outcomes. Without insurance information available in many languages, we may never have the opportunity to find out; once this change is made, increasing access to culturally competent care may, as the state hopes, cause the newly insured to have improved health status and outcomes.


Community Infrastructure as a Barrier to Access
While monetary and cultural competence issues are likely to cause the individual insurance mandate to fail at improving health outcomes, arguably the greatest shortcoming of this plan is that it does not address structural and community access issues. Access to care is defined by the Institutes of Medicine as “’the timely use of personal health services to achieve the best possible outcomes’” [12]. It stands to reason, then, that access, and thereby the best possible outcomes, cannot be achieved if “personal health services” (primary care, available appointments, specialty care, etc.) are not readily available. Though access is a problem of far greater magnitude for the uninsured, it is also an important issue for the insured, with 21% of insured people reporting access problems in a 1996 study by the Center for Health Systems Change [11]. Since access has been repeatedly linked to racial, ethnic, and socioeconomic disparities [13], it is likely that many insured people who reported access problems were members of underserved populations, suggesting that while insurance may help improve outcomes for some people, it will be far from achieving this goal for everyone. In addition, focus should be on increasing access to care, especially by increasing availability of primary care.


In the modern era, health care behaviors from the provider standpoint are often driven by reimbursement [14]. This presents a potential problem for residents, newly insured under mandates, whose insurance is provided by Medicaid HMOs (under the MA plan, this would be those newly insured who are insured through Commonwealth Care). Since Medicaid historically reimburses at lower rates than private insurance, and Medicaid HMOs plan to reimburse at approximately the same rates as fee-for-service Medicaid plans [15], there may be a lack of primary care physicians willing to accept Medicaid patients. This will make it much more difficult for these patients, despite insurance, to find a medical home and improve their health outcomes. Since Sox et al. (1998) established that having a regular physician is a more important predictor of health care access than having insurance [16], this problem needs to be solved before improved health outcomes can reasonably be expected from the insurance mandate.


Had the planners of this intervention looked at health insurance and health status through the lens of the transtheoretical model, they might have planned a somewhat different solution. The transtheoretical model suggests that there are stages in the process of behavior change, and that you must overcome each step in order to proceed to the next one [17]. When using this model to address the problems of insurance and health care utilization, one can see that for the behavior change of seeking needed medical care, an uninsured person could conceivably make it through all the stages up to preparation, the stage at which they would likely need to obtain insurance (in preparation for seeking health care from a provider). However, if they were then unable to find a doctor willing to accept their insurance, or if the waiting time for an appointment was too long, these people might never get to the “action” stage where they actually see the provider and address their health needs. To take the reality into account, steps must be taken to improve accessibility of providers and appointments, especially in rural (which have a high prevalence of inadequate structural resources [18]) and other underserved areas. Once structural access is improved, the newly insured can move through the transtheoretical model beyond preparation, to action and maintenance. Only at this point is it likely that becoming insured will lead to improved health status.


Conclusion
Massachusetts has recently pioneered the individual insurance mandate, a plan they hope will improve the overall health status of their residents. Unfortunately, that dream is unlikely to become a reality without modifications both to the plan and to the state’s health care infrastructure. Ultimately, the nation should go to a system of national health care under which all systems have equal access to equal health care. Since that is not a possibility currently on the horizon, Massachusetts should work on improving access to health care in the domains of affordability, cultural competence, and structural access, thereby eliminating barriers to care-seeking behavior and solidifying the link between insurance status and health status. Once these access issues are resolved, the individual insurance mandate may indeed become an excellent tool for improving the health of the Commonwealth.


REFERENCES
1. Massachusetts Department of Health Care Finance and Policy (MDHCFP). Draft TIR 07-18: Individual mandate penalties for tax year 2008. 2008. http://www.mass.gov/?pageID=dorterminal&L=4&L0=Home&L1=Individuals+and+Families&L2=Personal+Income+Tax&L3=Health+Care+Reform+Information&sid=Ador&b=terminalcontent&f=dor_rul_reg_tir_tir_07_18_draft&csid=Ador.
2. McDonough, J.E., et al. The Third Wave Of Massachusetts Health Care Access Reform. Health Affairs, 2006; 25(6): 420-431.
3. Strecher, V. and I. Rosenstock. The health belief model (p. 113 - 116). In: Baum, A, ed. Cambridge Handbook of Psychology, Health, and Medicine. Cambridge: Cambridge University Press, 1997.
4. Ethier, K.A., et al. Adolescent women underestimate their susceptibility to sexually transmitted infections. Sex Transm Infect, 2003; 79(5): 408-411.
5. Fadiman, A. The Spirit Catches You and You Fall Down: A Hmong child, her American doctors, and the collision of two cultures. United States: Farrar, Strauss, and Giroux, 1998.
6. Brach, C. and I. Fraser. Can Cultural Competency Reduce Racial And Ethnic Health Disparities? A Review And Conceptual Model. Med Care Res Rev, 2000; 57(suppl 1): 181-217.
7. Commonwealth Connector. Commonwealth Connector: You need insurance. The state's health connector can help. Boston: Commonwealth Connector. www.mahealthconnector.org.
8. United States Census Bureau. Langauge Spoken at Home: 2000. Census 2000 Summary File -- Sample data 2000 [cited; Available from: http://fastfacts.census.gov/servlet/QTTable?-geo_id=04000US25&-qr_name=DEC_2000_SF3_U_QTP16&-ds_name=DEC_2000_SF3_U.
9. Brown, E., et al. Racial and ethnic disparities in access to health insurance and health care, in Policy Research Reports. 2000, UCLA Center for Health Policy Research: Los Angeles, CA.
10. Ku, L. and S. Matani. Left Out: Immigrants' Access To Health Care And Insurance. Health Affairs, 2001; 20(1): 247-256.
11. Lewith, G. Complementary and alternative medicine: an educational, additudinal, and research challenge. Med Jour Aust, 2000; 172(3): 102-103.
12. Andrulis, D.P. Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health. Ann Intern Med, 1998; 129(5): 412-416.
13. Ibrahim, S.A., S.B. Thomas, and M.J. Fine. Achieving Health Equity: An Incremental Journey. Am J Public Health, 2003; 93(10): 1619-1621.
14. Armour, B.S., et al. The effect of explicit financial incentives on physician behavior. Arch Intern Med, 2001; 161(10): 1261-1266.
15. Holahan, J., et al. Medicaid managed care in thirteen states. Health Affairs, 1998; 17(3): 43-63.
16. Sox, C.M., et al. Insurance or a regular physician: which is the most powerful predictor of health care? Am J Public Health, 1998; 88(3): 364-370.
17. Edberg, M. Essentials of health behavior: Social and behavioral theory in public health. Boston: Jones and Bartlett Publishers, 2007.
18. Hayward, R.A., et al. Regular source of ambulatory care and access to health services. Am J Public Health, 1991; 81(4): 434-438.