BOSTON — It has been nearly five years since Massachusetts Gov. Mitt Romney signed the state’s landmark health care law amid the political flourish of a fife and drum corps and 300 guests in Boston’s Faneuil Hall. The overhaul is largely seen as a blueprint for the sweeping federal legislation that followed, making the state a political target for critics of President Obama’s efforts.
Brian Rosman, research director for the advocacy group Health Care for All, still has his ticket from Romney’s signing displayed in his downtown office. Obviously, Rosman’s group is pleased that the state has tried to cover as many of the uninsured as possible. But the law passed with support from a wide range of stakeholders.
Massachusetts’ game plan shares several characteristics of the national legislation, but there are differences, including one major distinction: The level of vitriol directed at the federal law doesn’t exist here. Sure, there are criticisms and compromises, disagreements and disappointments — but they come with a distinct lack of the death-panel-type furor that rose up against the law Obama pushed.
Even the fiscally conservative, but nonpartisan, Massachusetts Taxpayers Foundation is on board. President Michael J. Widmer calls the law “a well thought-out piece of legislation” that his group supported because, “we believe in public investments.” Widmer says: “There have been critics from the left and the right … that have not wanted the Massachusetts experiment … to succeed from the outset for different reasons. Most of those critics are either out of state,” or academics or single-payer advocates. “And then, of course, you get the politicians on top of that.”
Yes, the politicians. The Massachusetts plan has been attacked by opponents of the national law, liberal advocates of Canadian-style single-payer insurance for all, and conservative Republicans hoping to derail Romney’s presidential aspirations. For example, former Arkansas Gov. Mike Huckabee, in a February interview with the Associated Press, said Romney should essentially apologize for the law and acknowledge that it “cost more, waiting times were higher, quality of care went down, people were greatly dissatisfied and it ended up having almost the polar opposite effect of what was intended.” We found that there’s not much truth in any of that.
As the 2012 presidential campaign gets under way in just a few months (believe it or not), we expect to see an increasing number of attacks on so-called “RomneyCare.” So as part primer and part preemptive fact-checking, this article is our attempt to set the record straight. We found:
- The major components of the state and federal law are similar, but details vary. The federal law put a greater emphasis on cost-control measures, for instance. Massachusetts is just now tackling that.
- The state law was successful on one big goal: A little more than 98 percent of state residents now have insurance.
- Claims that the law is “bankrupting” the state are greatly exaggerated. Costs rose more quickly than expected in the first few years, but are now in line with what the Massachusetts Taxpayers Foundation had estimated.
- Small-business owners are perhaps the least happy stakeholders. Cheaper health plans for them through the state exchange haven’t materialized, as they hoped.
- Despite claims to the contrary, there’s no clear evidence that the law had an adverse effect on waiting times. In fact, 62 percent of physicians say it didn’t.
- Public support has been high. One poll found that 68.5 percent of nonelderly adults supported the law in 2006; 67 percent still do.
Editor’s note: For this special report, we were able to send Managing Editor Lori Robertson to Massachusetts to conduct research on site. Her travel was made possible by donations from our readers, and is just one of the ways we put your contributions to work.
Here are the major claims we examined, along with our detailed findings.
Blueprint for the Federal Law?
Claim: “It’s not that dissimilar to ObamaCare.” — Republican Rep. Paul Ryan of Wisconsin
Claim: “It was a template. … That work inspired our own health care plan.” — former White House adviser David Axelrod.
There are several similarities between the state and national plans, and there are several differences. When we spoke with Health Care for All’s Brian Rosman, he said that “the template is the same,” for Massachusetts and the nation, but “the details are different.”
Both laws have an individual mandate, requiring persons to have insurance or pay a penalty; subsidies for low-income persons; an expansion of Medicaid; an exchange where individuals can buy insurance; and requirements for employers. But the national law puts a greater emphasis on small businesses by providing tax credits for those who want to offer insurance, and it includes many potential cost-control measures that Massachusetts lawmakers are only now tackling in separate legislation. Yes, those are largely experimental ideas, and as we’ve said before, it’s unclear whether the bundled payments and pilot projects President Obama touts will have a big impact on costs. But the national law included many steps aimed at decreasing the growth in health spending, while the law Romney signed purposefully did not.
Massachusetts has a lower coverage requirement for employers, putting just a $295 per employee “fair share assessment” on businesses that don’t provide insurance. Small businesses may not be very pleased with that — it affects businesses with 11 or more full-time equivalents. But for larger employers, this was a big step back from a state House version of the bill that called for a payroll tax. The national law, meanwhile, has a fine of $2,000 per employee for companies that don’t offer coverage, have more than 50 workers and have at least one who receives a premium credit. (The first 30 workers are excluded.) Subsidies in the Bay State are provided for those earning up to 300 percent of the federal poverty level; national law subsidies go to 400 percent. And in Massachusetts, if your employer offers health insurance, you’re not eligible for a subsidized plan. Not true in the federal law, which allows workers to get subsidies if their premium contributions are above a certain amount.
Tim Murphy, Romney’s secretary of health and human services from 2005 to 2007, says there are many differences between the laws, but acknowledges certain mechanisms are similar. However, “unless you were going to go to single-payer, how many mechanisms really are there to use?”
There also have been plenty of changes made over the last five years. “When the original law was passed, they left a lot of the implemention up to the [state exchange]“, Rosman says.
Unique Problems, Unique State?
Claim: “Our approach was a state plan intended to address problems that were in many ways unique to Massachusetts.” — former Gov. Mitt Romney
Claim: “Different states have different problems.” — Mississippi Gov. Haley Barbour
The general problem of residents going without insurance and facing high health care costs is a nationwide issue, not unique to Massachusetts. But the state had its own circumstances, and unique opportunities, which helped make the health care overhaul a reality and kept stakeholders on board and still supportive of the law. First, there was money: $385 million from the federal government and the risk that those dollars would be taken away.
Massachusetts had some flexibility with that money in the form of a Medicaid waiver that allowed the state to use the federal funds for supplemental payments to safety net hospitals caring for the uninsured. The waiver was due to expire June 30, 2005, and the federal government said the state had to change the way it was spending the money, Murphy, then-state secretary of HHS, explains. In 2005, state officials showed then-U.S. Secretary of Health and Human Services Tommy Thompson a framework of what they wanted to do – essentially reduce the amount the state was spending on uncompensated care and instead give subsidies to the uninsured to buy their own insurance. Thompson extended the waiver for one year, but, Murphy says, told officials they needed to get a law in place.
Murphy, who now is president and CEO of Beacon Health Strategies, says the state’s uncompensated care pool, set up to reimburse hospitals and community health centers for care for the uninsured, was a “poorly designed, poorly administered program” and “a runaway train” with a lack of transparency on where these dollars were going. The philosophy behind the state government’s ideas was to “empower people” by helping them get insurance and financial security, and give the state more oversight on how the money was spent.
“Unquestionably the federal dollars have helped,” Widmer at the Taxpayers Foundation says of the matching funds Massachusetts was able to use. “There were very unique circumstances here, including the politics.”
Rosman, research director at Health Care for All, says back in 2003 the group’s then-executive director, John McDonough, wrote a memo saying that 2006 was the year for reform, citing the expiration of the Medicaid waiver, Romney’s presidential ambitions and Sen. Edward Kennedy’s interest, among other factors. Health Care for All put together a coalition of hospitals, medical advocacy groups, labor unions and community groups to push for a bill. In 2004 Romney’s then-secretary of HHS, Ron Preston, wrote a “white paper” on ways to get to universal coverage.
Beyond money and politics, Massachusetts had advantages and disadvantages in its existing health care system. The state had a lower percentage of uninsured and higher percentage of employers offering coverage than the national averages. The National Health Insurance Survey found that 14.8 percent of persons nationwide lacked insurance at the time of the interview in 2006. Massachusetts’ rate was 7.7 percent, the lowest state rate in the country. Seventy percent of employers offered insurance in the state the year before the law was passed, compared with 60 percent nationally. So, in terms of the uninsured, other states have bigger problems than Massachusetts did. Barbour’s Mississippi has an uninsured rate of 17.9 percent.
The bad news for the Bay State: Health spending per capita has been higher than the nationwide average since at least 1992. Even after adjusting for income differences and federal grants received, the state spending per person was 15 percent higher than the U.S. average in 2004, according to the state Division of Health Care Finance and Policy. Massachusetts also had a dysfunctional individual market. In 1996, the state had instituted rules requiring community rating (premiums could only vary by a certain amount based on age, geography and occupation) and guaranteed issue (no discrimination based on preexisting conditions), says MIT economist Jonathan Gruber, who advised both Romney and the Legislature in creating the health care law and is still on the board of the Health Connector, the state’s version of an exchange. Those regulations “destroyed the market,” he says. “You can’t institute those reforms without a mandate,” requiring individuals to have coverage. One of the intentions of the law was to fix what Gruber calls “a deeply broken nongroup insurance market.”
98 Percent Covered
Claim: Massachusetts has done a great job covering the uninsured.
This is undeniably true. The latest number from the state Division of Health Care Finance and Policy: 98.1 percent of Massachusetts residents had health insurance in 2010. The percentages from various surveys differ — the way the questions are asked and the definition of uninsured make a difference — but DHCFP’s statistics show the percent of residents without insurance declining from 7.4 percent in 2004 and 6.4 percent in 2006 to 1.9 percent in 2010. (That compares with national figures of 14.8 percent uninsured in 2006 and 15.4 percent last year.) Specifically, the state has added 401,000 people to the insurance rolls since June 30, 2006, excluding Medicare, leaving about 120,000 still uninsured.
MIT’s Gruber says that while numbers vary, the best estimate is that 60 percent of those previously uninsured have gained coverage. That’s a little less that DHCFP numbers, but any way you look at it, the state has made enormous strides. Sarah Iselin, president of the Blue Cross Blue Shield of Massachusetts Foundation, says the state’s goal was to get “as close to universal coverage as we could.”
Massachusetts Secretary of Health and Human Services Dr. JudyAnn Bigby, a Harvard Medical School graduate and former primary care physician, says that when the state hit 97.4 percent, “I thought we were not going to be able to do better.” She says 98.1 percent is “fairly close to the best we’ll do.”
The state does better in covering children — 99.8 percent of kids are estimated to have insurance. (Nationally, the figure is 92.6 percent.)
Here’s how those 401,000 have gained insurance, since 2006: Individuals buying their own insurance went up by 83,000, MassHealth (Medicaid and Children’s Health Insurance Program) numbers went up by 164,000, and subsidized plans sold through the state exchange went up 154,000, as of June 30, 2010. Private group insurance had grown between 2006 and 2008, but has since declined to the ’06 level, likely because of the recession. (More on employer plans later.)
Michael Doonan is executive director of the nonpartisan Massachusetts Health Policy Forum, which brings health care leaders together for discussions of policy issues, and an assistant professor at Brandeis University. He credits the individual mandate for getting most of the state’s residents on insurance. “Gov. Romney’s leadership made this possible. … But where his argument was the strongest was his support of the individual mandate,” Doonan says. Romney said it was a matter of personal responsibility. (The former governor made that argument last year, as well.) “And that was the lynchpin.” Without the mandate, coverage wouldn’t be close to 98 percent, says Doonan, who also was a member of President Clinton’s Health Care Taskforce.
Those earning up to the federal poverty level get fully subsidized coverage with minimal copays. From 100 percent to 150 percent of the poverty level, there are no premiums if individuals take the cheapest plan, and up to 300 percent of the poverty level (that’s $67,050 for a family of four), there are premiums to be paid along with the subsidies.
Who’s still uninsured in Massachusetts? Undocumented immigrants, those who are not eligible for coverage because they have an offer from an employer but the premiums are unaffordable — those individuals are given an affordability waiver — and persons who choose to pay the individual mandate penalty ($1,212 for this tax year). For tax year 2008 (when the penalty was a bit lower than that), 53,000 residents were assessed a penalty for not having insurance (see Table 1).
Those hit with the penalty can file an appeal for hardship reasons. Glen Shor, executive director of the Health Connector, told us his office approved 60 percent of the 8,000 hardship appeals individuals filed between 2007 and 2009.
Huckabee was dead wrong when he said that the law “ended up having almost the polar opposite effect of what was intended.” A major goal — if not the goal — was to reduce the number of uninsured. The state was very successful in that regard. We called and e-mailed the press office for Huckabee’s political action committee several times, asking for back-up for his claims. A spokesman told us he would get back to us, but we have not yet received a response. We will update this article if we do.
The question is: “cost more” than what? We’ll take that to mean, “more than was predicted.”
Unfortunately, there’s no Congressional Budget Office in Massachusetts that can give us a solid look at spending projections specifically attributable to the law. Experts we spoke to said the Taxpayers Foundation was the best source for this, and the foundation says state spending is in line with what it expected.
It certainly takes money to create a subsidy program and expand Medicaid coverage. But is the Massachusetts law “bankrupting” the state? The foundation says no. In May 2009 it put out a report called “The Myth of Uncontrolled Costs,” which concluded that the net added cost to Massachusetts taxpayers was $353 million in 2010, or roughly 1.2 percent of the state budget. (The total cost of “reform spending,” beyond what Massachusetts was already paying for uncompensated care before the law, was $707 million, with federal dollars covering half of that.)
The state Executive Office of Health and Human Services estimated that Massachusetts needed $172 million more from the general fund in 2009 than it spent in 2006 to cover “reform.” But the 2009 budget also used an unspecified number of federal stimulus dollars.
Costs for the subsidies did grow more than was expected at first. More people signed up for subsidized insurance more quickly than officials predicted — there was a point when there was great concern that the state had vastly underestimated the number of the uninsured. Costs “at the beginning rose dramatically and much faster than people assumed,” Widmer of the Taxpayers Foundation says. But enrollment in the subsidized plans leveled off. It reached 176,000 in mid-2008 and is down somewhat, to 154,000, after the state reduced coverage for legal immigrants (illegal immigrants were never covered).
To pay for the law, the state increased the cigarette tax, and had some money coming in through individual and employer penalties. It also continued a safety net surcharge on insurers and hospitals (which had been assessed before the law), and, as mentioned, it spends general funds.
Murphy, Romney’s secretary of HHS, says that the subsidized program “has worked out fairly fine,” and as expected. “I still think that the state sends too much to hospitals and community health centers for people who say that they’re not insured,” he says. But overall, “from a state budgeting perspective, anybody who makes any type of comment that this is busting the bank, this is a runaway train, this is a failure, flat-out doesn’t know what they’re talking about. Simple as that.”
So far, Massachusetts is making the numbers work for the health care overhaul, and the state remains committed. It all comes during a nationwide recession and budget crunch. Massachusetts faced about a $5.6 billion budget gap for 2010, and for 2012, the projected gap is $1.8 billion. The Connector, the state exchange, is being asked to find ways to keep its budget constant next year while facing the prospect of increasing enrollment in the down economy. Glen Shor, the Connector’s executive director, says he thinks it can be done by using “the power of competition” to drive down what insurers charge. Some cuts already have been made in the last few years because of the state’s overall fiscal situation — the Connector cut back on coverage for legal immigrants who have been in the country for less than five years, giving them reduced subsidies, and an increase in payments to providers was scaled back.
On top of the health care overhaul is the state’s Medicaid spending, the vast majority of which would exist with or without the law. It has gone from $7 billion in 2006 to $9.3 billion in 2010, according to the Taxpayers Foundation. The foundation estimates that about $487 million of the 2010 Medicaid budget, about 5.2 percent, was for expansions under the health care law. (All those figures are before federal reimbursements.)
Widmer says rising Medicaid costs are a major problem regardless of the new law. Gov. Deval Patrick’s administration “has got a major effort in 2012 to keep Medicaid [at] level funding. Do I think it’s possible? No, I don’t. Do I think it’s realistic? No, I don’t.”
And costs for the overhaul plan will also grow. Most people are insured at this point — and there are some on public insurance who might come off once the economy recovers. But there’s still medical inflation. “That’s the larger issue of cost control,” Widmer says. That’s an issue the state didn’t address in the health care law, and is now tackling.
What Happened to Premiums?
Claim: Premium costs increased.
One of the main claims Republicans make about the federal law is that it will drive up premiums. (In fact, as we’ve often noted, the Congressional Budget Office predicts the federal law won’t have a significant impact on premiums for most people.) But what has actually happened in Massachusetts?
The truth about premiums is that they’ve gone down for those who buy their own insurance (in what had been the so-called “individual market’), and the health care law is given credit for several reasons. And while premiums have gone up for large employers who buy coverage for their workers (the so-called “large group market”), there’s no clear evidence that the law was the cause. As we mentioned, the law attempted little cost control, and Massachusetts premiums, and those nationwide, have been rising for years before the law was passed. The law has had one clearly negative impact on small businesses who bought coverage in the “small group” market. Their premiums have risen faster than before, a small part of which can be attributed to the law’s workings. This has been a major disappointment because small businesses had been hoping for a decrease.
Let’s start with the individual and small group markets: After the law was passed, the state merged these markets, which benefited individual rates and hurt small business rates. It’s simply a matter of a less-healthy risk pool getting a boost from a more well-rounded risk pool. “The worst risk pool is the individual risk pool all by itself,” explains Brandeis’ Doonan. If you add the small group market to that, it’s “better for individuals and worse for small business.”
How much did that raise premiums? It’s not clear. One prediction, cited in a report conducted for the state Division of Insurance, estimated a 1.0 percent to 1.5 percent impact, but there’s not good information on what exactly the impact turned out to be. Jon B. Hurst, president of the Retailers Association of Massachusetts, told us: “It was a factor.” But, “I don’t know that there’s any one major silver bullet” for increasing premium costs.
That report for the Division of Insurance did find that a higher percentage of individuals in the merged market were dropping coverage after a major medical expense than had done so previously – this “adverse selection” drove up costs by an estimated 0.5 percent to 1.5 percent. A 2010 state law instituted open enrollment periods, which the study had suggested as a way to avoid this problem.
The individual market, meanwhile — the one MIT’s Gruber had called “deeply broken” — saw a major drop in premiums, as much as a 40 percent decline, according to some figures. The individual market itself more than doubled in size, says Gruber. Young, healthy people came into the market and bought less generous (hence, cheaper) plans than the sicker individuals who had been in that guaranteed issue market. “The typical nongroup market in the country has people buying really crappy products,” Gruber says. But in Massachusetts, the opposite was true — the sick were buying good products. With the health care law and the individual mandate, “people were buying down,” says Gruber, “not buying up.”
Premiums would show a smaller drop if adjusted for the less generous average policy, he says. But however you want to look at it, premiums went down. Let’s compare what people in the pre-merger individual market spent per person per month for a premium in 2006 and what those in the post-merger market spent in 2008. Those numbers went from $437 to $360, an 18 percent decrease. (See page 103 of this Division of Health Care Finance and Policy report.)
As for employer plans, the information is a little fuzzy. Premiums have gone up, but they had been going up in Massachusetts, since before the law was passed. Did the law cause an increase? One study published in 2010 in the Forum for Health Economics & Policy calculated that the health care law had pushed up employer-sponsored, single-coverage premiums by 6 percent over two years, based on the fact that the cost of Massachusetts premiums rose faster than premiums in the U.S. overall (by 2.2 percentage points), and that the cost of the state’s premiums hadn’t risen as much as the country’s in the two previous years. The study also calculated only a 1.5 percent increase for family plans. The authors noted that the study has limitations.
Gruber told us he doesn’t see the changes in Massachusetts employer premiums as statistically meaningful. “We cannot rule out that they found what they did purely by chance,” he says of that study, which used Medical Expenditure Panel Survey data.
The evidence is conflicting: Massachusetts premiums rose faster than premiums in the U.S. overall. But the same data show that 19 states had larger increases, including the nearby states of Vermont and New Hampshire, Gruber says. “Statistically, there is no evidence that MA is particularly different than the other states.”
The Role of Businesses
Claim: The law was bad for businesses.
It depends on which business you ask. In a 2008 poll published in Health Affairs, 52 percent of employers said they believed the health care law had been “good for Massachusetts” and 77 percent said all employers have some responsibility to offer insurance to employees. For large businesses, the law didn’t change much about how their insurance systems operate. For small businesses, there’s general disappointment that the law hasn’t done more to help them, to make insurance more affordable — but there’s also not a clear sense that this was a major goal of the final legislation.
Let’s start with big business: Employer-sponsored insurance actually increased under the law. Any fears that may have existed about companies dropping employees and sending them to state subsidized care have turned out to be unfounded.
As we mentioned, Massachusetts started off with a high percentage of employers offering insurance — 70 percent in 2005 — and that has gone up to 76 percent in 2009, according to the state Division of Health Care Finance and Policy. That’s 7 percentage points higher than the national figure. And more employees are accepting covering when offered. Seventy-eight percent of eligible employees were enrolled in insurance plans in 2005; that inched up to 80 percent in 2009.
In its 2009 report, the Taxpayers Foundation estimates that the increased cost for employers “for newly insured employees and dependents is at least $750 million,” adding that the figure is “more than double the $350 million increase in state spending under health reform.” Despite the big number, Widmer says there’s “very little outcry” from employers who have been supportive of the law. “That piece is one of the most unknown, ignored elements of health reform, and yet one of the key building blocks,” he says of the business community’s role. “It’s sort of a culture in Massachusetts, competitively,” he says. Businesses see offering coverage as a way to attract employees. “Health care is part of what your compensation is.”
Brandeis’ Doonan explains that because the state now requires individuals to have coverage, employer-sponsored insurance becomes “a more important benefit.” Employers offer coverage, Doonan says, because “they want to retain the best employees.” Also, Tim Murphy, secretary of HHS under Romney, says the legislation put into place anti-discrimination laws so employers couldn’t contribute less to lower-income workers in an effort to get them to drop insurance.
Claim: Ok, but small businesses aren’t happy.
It’s true that the small-business community is not pleased. The reason is that the tough small group insurance market hasn’t become more affordable for these employers, as was hoped. Iselin, who was commissioner of the Division of Health Care Finance and Policy from March 2007 until November 2009, says that helping small businesses wasn’t a main focus of the law. “There was a recognition that we needed to be thinking about it,” she says. “There were clearly provisions in the law that set the Connector up to begin to kind of, you know, step into that space. It was by no means the emphasis [or] the focus of the final law.”
Jon B. Hurst, president of the Retailers Association of Massachusetts, says that “small business was essentially not at the table” during negotiation of the law. But still, “we thought that the Connector … was going to be a positive thing for small businesses. … There was a feeling that there would be really robust marketplaces created for small business,” with lots of insurers and “real savings,” he says. “That hasn’t happened.”
Brian Rosman at Health Care for All also says it’s been a disappointment that the small-business offerings from the Connector haven’t attracted more interest. Small businesses are still insuring workers, he says, but “I had hoped that the Connector would bring them cheaper, more efficient coverage.”
Murphy, meanwhile, calls the lack of opportunity for small businesses “a big failure.” He and others, such as Joshua Archambault at the Pioneer Institute — a think tank that says it espouses “policy solutions based on free market principles” and “limited and accountable government” — say the Connector hasn’t focused enough on small businesses. “It is the group that we and a few others have identified as really being left out of reform as it’s been implemented,” Archambault, program manager for the Institute’s health care initiative, says. The Pioneer Institute, which did not take a position on the law, has published a report suggesting ways to make the small business market better. “We view our role again as somewhat of a mirror as saying … here’s why our choice model didn’t work. And in other states, as you implement the federal law, then you should be very aware of where, you know, our policymakers got it wrong,” he says.
Glen Shor of the Connector counters that getting more options for small businesses is a “major focus” right now. “We are very committed to using the tools at our disposal to make it easier for small businesses to find and choose affordale coverage. … It’s taken us a little bit longer to sort of perfect our model on that,” he says, explaining that the Connector has had to work very closely with health carriers and others.
For individuals using the Connector’s site to shop for insurance, there are seven insurance carriers selling plans and 34,000 people buying them. For small businesses, there are three carriers and 4,000 employees and dependents who have purchased plans in what’s called Business Express, a program that allows employers to pick one plan for all of their employees. “We want to and need to have more health plan options,” Shor acknowledges.
Hurst says the problem with the Connector plans is that they’re not a better deal. “It would be a lot more helpful if there was a real discount” — if it was like group buying and the premiums were closer to what’s offered through the subsidized program, Commonwealth Care. “Most small businesses would give their eyeteeth to be able to buy the CommCare plans.”
Small-business premiums have continued to go up — Hurst says his members have seen annual increases averaging 15 percent — and that trend was negatively affected at least somewhat by the merging of the small and nongroup markets in 2007. The merger caused an increase for small-business premiums but a drop for plans in the individual market.
The Connector has a pilot program that allowed small businesses to set up coverage and allow their employees to choose from different carriers, a system that Murphy says was more what the Romney administration envisioned. But as a pilot program, it was limited to a small number of businesses, and is closed to new enrollment, Shor says.
The national law could have more of an impact. Hurst says there was more of an emphasis in the federal law on small business (such as subsidies and only assessing a fee on non-insurance-offering employers with more than 50 workers). “We’ll see what the exchanges are … will they be more than what our Connector is?” he says.
And in Massachusetts, it’s still a work in progress. The state passed a law last year to allow small businesses to develop purchasing cooperatives. Hurst says it’s just now going into the pilot phase.
Long Waits, Worse Care?
Claim: …”waiting times were higher, quality of care went down.” — Huckabee
Most experts we spoke to said there wasn’t good data on how the law may have affected wait times. Iselin, with the BCBS of Massachusetts Foundation, called this claim one of the most misinformed or unsubstantiated she’s encountered.
Those who claim the law caused longer waiting times frequently cite annual surveys by the Massachusetts Medical Society. Its 2010 survey did find that the average wait time for internal medicine had gone up by six days since 2005 — to 53 days. But results were mixed — the average wait for family medicine went down by 15 days from the year before to 29 days. Wait times for other specialties were down too, since 2005, including those for cardiology, gastroenterology and orthopedic surgery.
Furthermore, the society’s surveys had been reporting longer wait times and physician shortages since well before the law was signed in 2006. In 2005, the society said this was a “continued” problem.
The medical society doesn’t explicitly attribute changes in wait times to the law. It also criticizes a study focusing only on the Boston area, saying it “cannot be considered determinative” and is based on interviews with only 71 practices. That limited study by Merritt Hawkins & Associates only surveyed 71 physicians in five different specialties in Boston. It did so by having someone call and pose as a new patient looking for an appointment for a non-emergency. The study compared Boston with other cities where the data was also limited. Only three orthopedic surgery offices were contacted in Detroit, for instance.
The 2010 medical society survey was based on a much larger sample. It called 885 practices throughout the state and then weighted the responses to ensure geographic representation. Its data on physician shortages came from surveys returned by 995 physicians and about 150 other medical professionals.
So, there’s far too little data to support a conclusion that the law caused longer wait times. The medical society is concerned about doctor shortages, but notes in a document about the law that this is a long-standing issue: “Primary care shortages continue in Massachusetts, but they predate health reform by many years, and mirror shortages in many other areas of the country.” Since the health care law, the number of insured individuals has gone up substantially.
Bigby, the state’s health secretary, notes that Massachusetts has more doctors per capita, including primary care doctors, than any other state. That’s according to the Association of American Medical Colleges. Even so, the state is taking steps aimed at increasing access to primary care further. These include creating a loan repayment program for doctors agreeing to work in community health centers, and regulations for limited service clinics, as well as a new payment demonstration project “to recognize the need to answer e-mail, telephone calls, that sort of thing, which they can’t bill for now,” Bigby says.
Regardless of waiting times, however, access to care and use of care overall have actually gone up, according to the Urban Institute’s Sharon K. Long, a professor at the University of Minnesota’s School of Public Health. She has conducted surveys since Massachusetts passed the law. Her June 2010 report found that:
Long, June 2010: Access to and use of health care in the state improved under health reform, with more adults reporting visits to doctors and other health care providers and fewer adults reporting going without needed health care in fall 2009 than prior to health reform. There is evidence of particularly strong gains in the use of preventive care and prescription drugs, benefits specified under the state’s new minimum creditable coverage (MCC) requirements, which outline the key benefits and cost-sharing provisions that must be included in a health insurance plan if it is to satisfy the state’s individual mandate for health insurance coverage. In addition, adults in Massachusetts were more likely to rate the quality of the health care they received as very good or excellent under health reform.
She also found that physician capacity was a continuing problem, with “about one in five adults report[ing] problems finding a doctor who would see them in fall 2009 — either because the provider was not taking new patients or the provider was not taking patients with their type of insurance coverage.” She told us she didn’t have a pre-reform statistic with which to compare that.
Nevertheless, with more people covered by insurance, more people visiting doctors and fewer people saying they are going without needed care, we conclude that Huckabee’s claim that “quality of care went down” is contradicted by the available evidence.
Plenty of Satisfaction
Claim: “… people were greatly dissatisfied.” — Huckabee
Claim: “Massachusetts has a state health insurance program that they’re happy with.” — Barbour
Score one for Haley Barbour. The state’s health care efforts haven’t been plagued by claims about grandma’s life-support, as we saw on the federal level. For now, public support and physician support are both high in the state.
Surveys by the Urban Institute and the BCBS of Massachusetts Foundation found that 67 percent of nonelderly adults in the state supported the health care law in the fall of 2009; in the fall of 2006, a few months after it was passed, 68.5 percent supported it. Another 2009 survey by the Harvard School of Public Health and the Boston Globe found 59 percent of state residents supported it, which was also similar to the poll’s 2006 number, 61 percent. In 2009, 28 percent opposed it and 13 percent weren’t sure. Support was much higher among Democrats and Independents than Republicans. Those are the most recent surveys we found.
Among practicing physicians, 70 percent supported the law in a fall 2009 survey, also from Harvard. That poll, published in the New England Journal of Medicine, also found that 60 percent of physicians said the law didn’t have much of an impact on how long patients wait to get an appointment (and 2 percent said there was a positive impact). Eighty-five percent said the law either had not much impact or a positive impact on the quality of care patients receive.
Bills haven’t been filed to repeal the individual mandate, says Rosman with Health Care for All. And there was no taxpayer revolt when the state asked residents to confirm their insurance status on their tax returns. “We were totally expecting a big issue,” particularly from libertarians, he says. “I expected people to write on their tax return, ‘Go to hell.’ ” Instead, more than 98 percent of tax filers complied.
– by Lori Robertson
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