Happy 7th (and last) Birthday, Massachusetts Health Reform

Uninsurance comparison - US-MA 650

Today marks the 7th anniversary of the enactment of Chapter 58, the Massachusetts health reform law. For those of us who have followed our groundbreaking law through formulation, passage, enactment, and implementation, it’s been a long, wonderful journey (our previous birthday posts make an interesting record for the nostalgic: 1st; 2nd , 3rd, 4th, 5th (and 5th anniv. video) and 6th).

It’s also probably the last anniversary where we can take stock of the progress made by Chapter 58. A year from now, the Massachusetts health care coverage landscape will be as influenced by the ACA as it will be by Chapter 58. Obamacare will overtake and subsume Romneycare.

Even though the national law is built on our blueprint, the changes coming on January 1, 2014 will be so substantial that it will not make sense to measure the impact of Chapter 58. There will be no Commonwealth Care program, no state Employer Fair Share or Free Rider surcharge, and a very different MassHealth and Connector.

Chapter 58 was ostensibly all about coverage. The key numbers to remember are 439,000 – the number of newly covered people in the state; and 97% — the percent of people in Massachusetts with health coverage. The Blue Cross Foundation has always been the essential repository for all things 58. Their annotated text of the actual law, along with amendments, is one of the best places to start. Their just-updated, essential chartpack, Health Reform in Massachusetts: Assessing the Results, provides most of the facts and figures one could need to answer how are we doing.

(By the way, the worst place to start would be the Wikipedia entry on Massachusetts Health Care Reform. It’s way out of date, filled with irrelevancies and errors. Does any health policy instructor want to assign their class a project to update the page?)

But although the law successfully boosted coverage, the key question has always been, has it improved health?

A number of studies are approaching this in different ways. These studies are difficult to do in a rigorous way, because one needs to use sophisticated comparisons for control and statistical techniques to isolate just the impact of the health reform law.

One of the most interesting studies is research by Courtemanche and Zapata, two economists (their 2012 paper is here (pdf), an update was published in 2013). They found that reform in Massachusetts led to significant improvements in self-assessed health, and objective health indicators. Improved health was comprehensive, encompassing physical and mental health, functional limitations, joint disorders, and body mass index. They found an increase in reports of “excellent” and “very good” health, and a corresponding decrease in reports of “good,” “fair,” and “poor” health. It was particularly promising finding that there was no substantial difference in short and longer-term trends. These improvements showed an especially strong effect upon minorities, those with low incomes, the near elderly, and women.

Courtemanche - Zapata health status graph

The chart above highlights their findings, which show that between 2001 and 2006, Massachusetts (at the top) and the rest of the US (on the bottom) moved in tandem, with a slight decline in health status. But since 2006, the Massachusetts numbers have improved, while the national experience remained stable.

The journal Inquiry devoted 4 articles in their Winter 2013 issue (gated, unfortunately) to Massachusetts health reform. On a post yesterday, BU economist Austin Frakt summarizes a study by Sharon Long , Karen Stockley, and Kate Nordahl on coverage, access, and cost in 3 charts. Another one of the studies, by researcher Sarah Miller, focuses on the relationship between reform and methods of obtaining regular care, with particular focus on use of emergency room care. Miller found a 5% reduction in the use of emergency room services due to reform – 80% of which relates to the reduction in use for non-emergency services. Patients from wealthier zip codes experienced no reduction in use of ER services, yet patients from poorer zip codes had rates of reduction that were near double the average. In addition, the probability of heavy ER use (3+ times in last year) fell by 1.9% and the probability of reporting non-urgent ER visits fell by 3.8%.

These data were matched by a corresponding increase in preventive services. Children were found to have more checkups and office visits after reform, and there was a slight decrease in the number of patients admitted to emergency services for preventable conditions. She summarized her findings as follows:

I find evidence that the reform increased the use of primary and preventive services. In particular, I find significant increases in office visits and flu shots. I also find that the reform reduced reliance on hospital emergency rooms as a usual source of medical care among survey respondents. Finally, I find that the reform significantly improved self-reported health…. The reform spurred usage of routine and preventive care, resulting in a modest reduction of over-reliance on emergency rooms and an increase in those reporting better health.

These studies join others in making the case that increased coverage in Massachusetts led to real improvements in health. Two years ago, we reported on a study, since updated, that found a decline in Massachusetts hospital admissions for preventable conditions, attributable to our reforms.

Happy 7th birthday, health reform. Many happy returns.
-Brian Rosman and Devon Branin

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