Sustaining Health Reform in a
Recession: An Update on
Massachusetts as of Fall 2009
Sharon K. Long
Karen Stockley
Urban Institute
June 27, 2010
AcademyHealth Annual Research Meeting
This work was funded by the Blue Cross Blue Shield of Massachusetts Foundation.
Why is Massachusetts Important?
• National reform is modeled on Massachusetts’
2006 health reform initiative
– Expansion of public program
– Creation
C ti off h
health
lth iinsurance exchanges
h
– Subsidies for low- and moderate-income individuals
– Individual mandate
– Requirements for employers
• Massachusetts’ experience provides lessons for
national reform
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F
Focus
off the
h Presentation
P
i
• Update on impacts of health reform on insurance
coverage, access to and use of health care
coverage
care, and
health care costs and affordability between fall
2006 and fall 2009
• Examine changes between fall 2008 and fall 2009,
when
h th
the effects
ff t off the
th recession
i have
h
been
b
mostt
severe
• Lessons from Massachusetts
• Challenges for Massachusetts
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Unemployment in Massachusetts
and the US, 2005-2010
15%
10%
MA
US
5%
0%
2005
2006
2007
2008
2009
2010
Source: Massachusetts Executive Office of Labor and Workforce Development (EOLWD); Unemployment as of March of each year.
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Data
• M
Massachusetts
h
tt Health
H lth R
Reform
f
S
Survey
– Pre-reform survey--fall 2006
– Post-reform surveys--fall 2007, 2008 and 2009
– Telephone interviews with samples of adults 18 to 64
• Oversamples of lower-income and uninsured adults
– Questions on insurance coverage;
g access, use, and
affordability of care; support for health reform
– Sample sizes 3000+ in each year
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Methods
• Estimate impact of health reform as change over
time from fall 2006
– Pre-post estimates will also capture recession & health
care cost trends
• Multivariate regression models control for
demographic characteristics
characteristics, health and disabilit
disability
status, socioeconomic status and region of state
– Estimate linear probability models, controlling for
complex survey design
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Health insurance coverage, 2006-2009
 Adults more likely to have health insurance coverage under health
reform
100%
93%
***
96%
***
95%
***
2006
88%
2007
80%
69% 71%
***
**
66%
2008
68%
2009
60%
40%
24%
21% **
25% 27%
***
***
20%
0%
Any insurance coverage
ESI coverage
Public or other coverage
Source: 2006
2006-2009
2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
•(**) (***) Significantly different from fall 2006 at .10 (.05) (.01) level, two-tailed test.
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Health insurance coverage, 2008-2009
 Health insurance coverage continued at high level despite the
recession
100%
96%
95%
2008
2009
80%
71%
68% +
60%
40%
25%
27%
20%
0%
Any insurance coverage
ESI coverage
Public or other coverage
Source: 2006
2006-2009
2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
+ (++) (+++) Significantly different from fall 2008 at .10 (.05) (.01) level, two-tailed test.
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Health care access and use, 2006-2009
 Adults more likely to have a regular health care provider and to have
had health care visits over the p
prior year
y
100%
86%
90% **
2006
86% ***
80%
78% ***
80%
70%
75% ***
2009
68%
60%
40%
20%
0%
Usual source of care
Any doctor visit
Preventive care visit
Dental care visit
Source: 2006
2006-2009
2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
•(**) (***) Significantly different from fall 2006 at .10 (.05) (.01) level, two-tailed test.
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Unmet need for care
for any reason, 2006-2009
 Adults less likely to have unmet need for any reason
reason, due in part to
gains over the last year
30%
25%
2006
2009
20%
20%***
10%
0%
9%
8%
5%**
8%
6%***
7%
6%**
5%**
0%
Any unmet need
for health care
Doctor care
Medical tests,
treatment or
follow-up care
Preventive care
screening
Prescription
drugs
Source: 2006
2006-2009
2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
•(**) (***) Significantly different from fall 2006 at .10 (.05) (.01) level, two-tailed test.
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Health care costs and affordability, 2006-2009
 Improvements in affordability of care despite increasing health
care costs and economic recession
30%
2006
2009
19%
20%
19%
20%
20%
16%
12%***
10%
10%
4%***
0%
OOP health care
costs => 10% of
family income
Problems paying
medical bills
Medical debt
Unmet need
because of costs
Source: 2006
2006-2009
2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
•(**) (***) Significantly different from fall 2006 at .10 (.05) (.01) level, two-tailed test.
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Support for health reform, 2006-2009
 Strong support for health reform continues in Massachusetts
100%
2006
80%
68%
71%
72%
67%
2007
2008
60%
2009
40%
20%
0%
2006
2007
2008
2009
Source: 2006-2009 Massachusetts Health Reform Survey
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Lessons from Massachusetts
• Disparate policymakers and stakeholders can
come together
g
& stay
y together
g
to support
pp
health reform
• Complex health reform initiative can be
implemented quickly and effectively
• Health reform is a dynamic process that
requires adjustments over time
• Sustaining health reform in a recession is
possible
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Challenges for Massachusetts
• Health insurance coverage does not guarantee
access to care
– 1 in 5 adults reported unmet need for care
– 1 in 5 adults reported difficulty finding a doctor who
would see them
• Rising health care costs continue to threaten
gains under health reform
– 1 in 5 adults reported problems paying medical bills
– Cost remains major reason for continued
uninsurance
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Addressing Those Challenges
• Massachusetts has implemented a variety of
strategies to improve access to primary care
• Massachusetts has made less progress
addressing escalating health care costs
– Deferred issue in 2006 so as to not delay the
expansion
i iin coverage
– Currently there is broad consensus about the need
to address costs and much discussion about how
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