THE URBAN INSTITUTE

On the Road to Universal Coverage: Impacts of Health Reform in Massachusetts at One Year

Sharon K. Long

Urban Institute

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Outline of the Presentation

• Overview of Legislation

• Data and Methods

• Findings:

– Insurance coverage

– Access to health care

– Affordability of health care

– Support for health reform

– The remaining uninsured

• Limitations

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Massachusetts Health Reform• Legislation passed in April 2006

• Many parts, including:

– Medicaid (MassHealth) expansions

– CommCare--new program that provides income-related subsidies for private coverage

– Commonwealth Choice-new purchasing arrangement

– More restrictions on care under the safety net

– Insurance market reforms

– Requirements for employers

– Individual mandate

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Timeline for implementation

• MassHealth expansion July 2006

• CommCare to adults <100% FPL in October 2006

• CommCare to adults <300% FPL in January 2007

• Commonwealth Choice in May 2007

• Individual mandate with small penalty in 2008 (based on coverage December 31, 2007), larger penalty goes into effect in 2009

• Minimum creditable coverage enforced in 2009

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Data and Methods

• Data: Massachusetts Health Reform Survey

– Fielded in Fall 2006, Fall 2007 & Fall 2008 (planned)

– Telephone interviews with sample of adults 18 to 64

– Sample sizes ~3000 in each year

• Methods: Estimate impact of health reform as changes over time using a “pre-post” comparison

– IMPACT = Fall 2007 – Fall 2006

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Uninsurance for working-age adults reduced by almost half in Massachusetts

13%

7%

0%

5%

10%

15%

20%

25%

30%

All Adults

Fall 2006

Fall 2007

Impact on insurance coverage

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Drop in uninsurance larger for low-income adults

24%

13%

5%

3%

0%

5%

10%

15%

20%

25%

30%

Low-income Adults Higher-income Adults

Fall 2006

Fall 2007

Impact on insurance coverage

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No evidence of crowd-out of ESI for low-income adults

38%42%

39%

45%

0%

10%

20%

30%

40%

50%

60%

Employer-sponsored insurance Other insurance

Fall 2006

Fall 2007

Impact on insurance coverage

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Low-income adults more likely to have a regular health care provider and to have had health care visits over the prior year

80% 83%

65%70%

49%

59%

0%

20%

40%

60%

80%

100%

Usual source of care Doctor visit forpreventive care

Dental visit

Fall 2006

Fall 2007

Impact on access to care

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Both low-income and higher-income adults less likely to have any unmet need for health care over the prior year

36%

30%

19%

15%

0%

10%

20%

30%

40%

Low-income Adults Higher-income Adults

Fall 2006

Fall 2007

Impact on access to care

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Both low-income and higher-income adults less likely to have unmet need for health care over the prior year because of cost of care

27%

17%

10%

7%

0%

10%

20%

30%

40%

Low-income Adults Higher-income Adults

Fall 2006

Fall 2007

Impact on affordability of care

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Drop in out-of-pocket health care costs over the prior year for low-income adults

48%

37%33%

24%

12%8%

0%

10%

20%

30%

40%

50%

60%

$500 or more $1000 or more $3000 or more

Fall 2006

Fall 2007

Impact on affordability of care

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Drop in problems paying medical bills and medical debt over the prior year for low-income adults

32%

24%27%

23%

0%

10%

20%

30%

40%

50%

Problems payingmedical bills

Paying medical bills offover time

Fall 2006

Fall 2007

Impact on affordability of care

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Most working-age adults in Massachusetts support health reform

68% 71%

0%

20%

40%

60%

80%

100%

All Adults

Fall 2006

Fall 2007

Support for health reform

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Support for health reform remained high across both low-income and higher-income adults

70% 73%67%

70%

0%

20%

40%

60%

80%

100%

Low-income Adults Higher-income Adults

Fall 2006

Fall 2007

Support for health reform

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However, support was lower among adults who remained uninsured in Fall 2007

69% 73%

63%

44%

0%

20%

40%

60%

80%

100%

Insured Adults Uninsured Adults

Fall 2006

Fall 2007

Support for health reform

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• The remaining uninsured may be difficult to convince to obtain

coverage

– Many are young, male, healthy, and low-income

– Most are working (68%), but few have access to ESI (11%)

– Most reported cost of coverage as reason not insured

– Sizable minority (32%) reported they were not aware of individual mandate in Fall 2007

Expanding insurance coverage

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Study Limitations

• One set of estimates of the impacts of reform

– Will be important to compare to other surveys as data become available

• Estimates are of early impacts of reform

– Another round of the survey will be fielded in Fall 2008

• “Pre-post” evaluation design

– Additional studies are being conducted using other data sources and methods

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Summary: Early Impacts of Health Reform

in Massachusetts• Uninsurance among working-age adults reduced by

almost half • Access to care has improved

– More likely to have usual source of care– More likely to have health care visits– Less likely to have unmet need for care

• Health care is more affordable– Out-of-pocket health care costs are down– Problems paying medical bills and medical debt are down

• Support for health reform among Massachusetts residents remains high