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By Sharon K. Long, Karen Stockley, and Heather Dahlen
10.1377/hlthaff.2011.0653
HEALTH AFFAIRS 31,
NO. 2 (2012): 444–451
©2012 Project HOPE—
The People-to-People Health
Foundation, Inc.
doi:
Sharon K. Long (slong@umn
.edu) is a professor in the
Division of Health Policy and
Management, School of Public
Health, at the University of
Minnesota, in Minneapolis.
Karen Stockley is a graduate
student in economics at
Harvard University, in
Cambridge, Massachusetts.
Heather Dahlen is a doctoral
student in applied economics,
with a minor in health
economics, at the University
of Minnesota.
Massachusetts Health Reforms:
Uninsurance Remains Low, SelfReported Health Status Improves
As State Prepares To Tackle Costs
ABSTRACT The Massachusetts health reform initiative enacted into law in
2006 continued to fare well in 2010, with uninsurance rates remaining
quite low and employer-sponsored insurance still strong. Access to health
care also remained strong, and first-time reductions in emergency
department visits and hospital inpatient stays suggested improvements in
the effectiveness of health care delivery in the state. There were also
improvements in self-reported health status. The affordability of health
care, however, remains an issue for many people, as the state, like the
nation, continues to struggle with the problem of rising health care
costs. And although nearly two-thirds of adults continue to support
reform, among nonsupporters there has been a marked shift from a
neutral position toward opposition (17.0 percent opposed to reform in
2006 compared with 26.9 percent in 2010). Taken together,
Massachusetts’s experience under the 2006 reform initiative, which
became the template for the structure of the Affordable Care Act,
highlights the potential gains and the challenges the nation now faces
under federal health reform.
M
assachusetts is in its sixth
year of a reform initiative that
provided the template for the
federal Affordable Care Act of
2010. The Bay State’s health
care reform bill, An Act Providing Access to Affordable, Quality, Accountable Health Care (also
referred to as Chapter 58 of the Acts of 2006, or
simply Chapter 58),1 was passed in 2006, during
the administration of Gov. Mitt Romney (R). Its
components include Medicaid expansion, subsidized private health insurance, a health insurance exchange, insurance market reforms, and
requirements for individuals and employers—all
elements included in federal health reform.2 As
the nation continues a contentious debate on the
potential benefits and costs of federal health reform, Massachusetts’s experience provides an
early indication of potential gains and challenges.
444
H ea lt h A f fai r s
Fe br uary 201 2
In this article we report on health reform in
Massachusetts as of 2010 and build on the findings reported for prior years.3 We focus on working-age adults—the population that was most
likely to be uninsured before health reform in
the state and, consequently, the primary target
group for many elements of the state’s reform
initiative. In 2005 the uninsurance rate for nonelderly adults in Massachusetts was estimated to
be 11.4 percent—well above the rate for children,
which was 3.2 percent.4
Study Data And Methods
Data Our study used data from the Massachusetts Health Reform Survey, which collects information from Massachusetts adults ages 19–
64.5 The survey was first conducted in fall 2006,
just before the implementation of many of the
key elements of reform, and has been conducted
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each fall thereafter. Information is obtained each
year from a new random sample of approximately 3,000 nonelderly adults in the state;
adults in low-income areas of the state and uninsured adults are oversampled.6 The survey,
which is described in more detail elsewhere,7
collects information on insurance status and—
for people in a health plan—characteristics of
coverage, along with measures of access to and
use of care, health care costs and affordability,
and other measures.
The survey is conducted by telephone, and the
sample for 2006–09 was limited to households
with a landline telephone. In 2010 the sample
was modified to include households with landline telephones and households with cell
phones, to capture the growing share of the Massachusetts population residing in households
without a landline phone. In this article we report on estimates using the full 2010 sample. The
landline sample and combined landline and cell
phone sample were quite similar after poststratification reweighting. Consequently, the
inclusion of the cell phone sample for 2010
had little impact on the estimates of changes over
time.
The overall response rate for the survey in
2010 was 39 percent, which combines the response rates for the landline sample (42 percent)
and the cell phone sample (31 percent).
Although response rates are generally lower
for cell phone samples than landline samples,
cell phone samples capture a part of the population (adults in cell phone–only households)
missed in landline-only surveys. The response
rates for earlier years of the survey ranged from
43 percent to 49 percent.
Methods We compared outcomes for samples
of adults following the implementation of health
reform (2007–10) to outcomes for a similar sample of adults in 2006.8 Any differences between
the baseline period and the follow-up periods
would reflect the effects of Chapter 58 as well
as other factors beyond health reform that
changed during the time period. These factors
include the continuing increase in health care
costs in the state, a national trend that predates
health reform; the economic recession and financial crisis; and the implementation of early
provisions of the Affordable Care Act.
Given those other changes between 2006 and
2010, we cannot attribute trends over time in
Massachusetts solely to the effects of Chapter
58. It is likely that the economic downturn and
the continuing increase in health care costs, in
particular, dampened any gains in coverage and
affordability that might otherwise have been
achieved under health reform in the state.
In this article we report estimates based on
multivariate regression models that controlled
for characteristics of a person and his or her
family and that include dummy variables for
the region of the state in which the person lives.
The latter variables control for characteristics of
the community that are constant over time, such
as location in the state, urban versus rural status,
and the local health care infrastructure. The regression-adjusted estimates controlled for shifts
in the composition of the sample across years. As
indicated above, our data did not allow us to
isolate the impact of reform from that of changes
in other factors during the study period. Estimates from follow-ups conducted in the early
years (2007–08) are less likely to be affected
by those other factors than are estimates from
follow-ups conducted in later years (2009–10).
For ease of comparison across models, we
estimated linear probability models, controlling
for the complex design of the sample using
the survey estimation procedure in the statistical
analysis software Stata, version 11. We pooled
all five years of data (2006–10), tested for
differences in the outcomes relative to 2006
(changes since health reform was implemented), and—for each of the follow-up
years—tested for changes relative to the prior
year. In presenting the results, we obtained regression-adjusted estimates for each year using
the parameter estimates from the regression
models to predict the outcomes that the individuals in the 2010 sample would have had if they
had been observed in each of the preceding
study years.
The simple (unadjusted) differences and regression-adjusted differences were generally
similar. The simple (unadjusted) differences
are provided in the online Appendix,9 along with
an example of the output from the regression
model. The complete set of findings from our
study, including findings for analyses focused
on low-income nonelderly adults, is available
in the full report upon which this article is
based.7
Limitations Because our study relied on data
for Massachusetts alone, we were not able to
isolate the effects of the 2006 health reform initiative in Massachusetts from other factors that
were changing in the state over the same time
period. In addition, data used in the study were
drawn from a population survey and, consequently, were subject to various types of error,
including coverage, sampling, measurement, reporting, and nonresponse errors.
Study Results
Insurance Coverage Health insurance coverage among nonelderly adults in Massachusetts
February 2012
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was at 94.2 percent in 2010, based on the Massachusetts Health Reform Survey (Exhibit 1).
This is similar to the 2010 estimates for Massachusetts from other surveys, including the
American Community Survey (93.6 percent)10
and the National Health Interview Survey
(94.6 percent),11 but it is below the estimate from
the Massachusetts Health Insurance Survey
(97.1 percent).12
Looking back, the 94.2 percent coverage rate
for Massachusetts in 2010 was well above the
86.6 percent estimate for 2006, just before implementation of the key elements of the state’s
health reform initiative, and unchanged from
the 94.5 percent rate estimated for 2009. A comparison of simple (unadjusted) estimates and
regression-adjusted estimates over time for insurance coverage is provided in Appendix
Exhibit 1.9 The simple (unadjusted) estimates
for all of the insurance measures are provided
in Appendix Exhibit 5.9 The high coverage rate
for nonelderly adults in Massachusetts in 2010
compares favorably to an estimated 77.7 percent
coverage rate for nonelderly adults in the nation,
based on the National Health Interview Survey.11
In addition to the strong drop in uninsurance
at the time of the 2010 survey, the share of Massachusetts adults who were ever uninsured during the past year and the share uninsured for
twelve months or more also dropped. By 2010,
12.1 percent of Massachusetts adults had a
period of uninsurance during the prior year—
down from 19.5 percent in 2006—and fewer than
3 percent were long-term uninsured—down from
8.8 percent in 2006 (data not shown).7
Massachusetts’ high level of insurance coverage reflects high levels of employer-sponsored
coverage in the state, which remained strong
in 2010. More than two-thirds of nonelderly
adults (68.0 percent) reported coverage through
an employer. This is significantly higher than the
level in 2006 (64.4 percent), before health reform. In 2010, as in earlier years, there was no
evidence of public coverage “crowding out” employer-sponsored insurance under health reform in Massachusetts.
Access To And Use Of Health Care Chapter
58 was expected to affect access to and use of care
along two paths: by expanding access to health
insurance and by creating a new standard that
health plans must meet to count as coverage
under the individual mandate. The “minimum
creditable coverage” standard includes coverage
for a comprehensive set of services (including
prescription drugs); doctor visits for preventive
care, without a deductible; limits on out-ofpocket spending; and no caps on total benefits
for a particular illness or a single year. Both
paths were expected to lower the costs of health
care to individuals and, thereby, increase access
to and use of care.
In 2010 Massachusetts adults reported sustained gains in health care access and use relative
to 2006 (Exhibit 2; additional measures can be
found in Appendix Exhibit 2; simple [unadjusted] estimates are in Appendix Exhibit 6).9
Exhibit 1
Trends In Health Insurance Coverage For Adults Ages 19–64 In Massachusetts, Fall 2006–Fall 2010
a
a,b
a
a
Any health insurance
Employer-sponsored
Public and other
a
a,c
a
a
a
a
a
a
a,b
a
Uninsured
Percent
a
a
SOURCE Massachusetts Health Reform Survey, 2006–10. NOTES N ¼ 15; 544. Regression-adjusted estimates. See text for discussion
of regression model and predicted values. aSignificantly different from the value in 2006 at the 0.01 level, two-tailed test. bSignificantly different from the value in the previous year at the 0.01 level, two-tailed test. cSignificantly different from the value in
the previous year at the 0.05 level, two-tailed test.
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Exhibit 2
Trends In Usual Source Of Care And Doctor Visits Over The Past Year For Adults Ages 19–64 In Massachusetts, Fall 2006–
Fall 2010
Percent
a,b
a,b
c,d
a
a,d
a
a
b
Has usual source of
care (excluding ED)
a
Had visit to general MD
Had preventive visit
Had specialist visit
c
d
SOURCE Massachusetts Health Reform Survey, 2006–10. NOTES N ¼ 15; 544. Regression-adjusted estimates. See text for discussion
of regression model and predicted values. ED is emergency department. aSignificantly different from the value in 2006 at the 0.01
level, two-tailed test. bSignificantly different from the value in the previous year at the 0.01 level, two-tailed test. cSignificantly different from the value in 2006 at the 0.05 level, two-tailed test. dSignificantly different from the value in the previous year at the 0.05
level, two-tailed test.
For example, in 2010 compared to 2006, nonelderly adults were more likely to have a usual
place to go when they were sick or needed advice
about their health (up 4.7 percentage points),
and were more likely to have had a preventive
care visit (up 5.9 percentage points), a specialist
visit (up 3.7 percentage points), multiple doctor
visits (up 5.0 percentage points; Appendix
Exhibit 2),9 and a dental care visit (up 5.0 percentage points; Appendix Exhibit 2).9
After the share of adults reporting a general
doctor visit increased under health reform, between 2009 and 2010 there was a drop (3.5 percentage points) in the share of adults reporting a
general doctor visit—back to the level seen before reform. This pattern, combined with increases in the use of specialists and preventive
care over time, may imply a shift in use toward
other providers for some needs.
During the 2006–10 period there were drops
in the shares of adults reporting a hospital stay
and using the emergency department—the first
shifts in those measures since 2006 (Exhibit 3;
details in Appendix Exhibit 2; simple [unadjusted] estimates in Appendix Exhibit 6).9,13
Notably, the shares of nonelderly adults reporting any emergency department visit, multiple
emergency department visits (defined as three
Exhibit 3
Trends In Hospital And Emergency Department Use For Adults Ages 19–64 In Massachusetts, Fall 2006–Fall 2010
Any ED visit
Percent
a,b
Most recent ED visit
was for nonemergency
conditiond
Any hospital stay
(excluding childbirth)
b,c
Three or more ED visits
a
a
SOURCE Massachusetts Health Reform Survey, 2006–10. NOTES N ¼ 15; 544. Regression-adjusted estimates. See text for discussion
of regression model and predicted values. ED is emergency department. aSignificantly different from the value in 2006 at the 0.05
level, two-tailed test. bSignificantly different from the value in the previous year at the 0.05 level, two-tailed test. cSignificantly different from the value in 2006 at the 0.01 level, two-tailed test. dA condition that the respondent thought could have been treated by a
regular doctor if one had been available.
F eb r u a ry 2 0 1 2
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or more visits during the year), and emergency
department visits for nonemergency conditions
were all lower in 2010 than in 2006. This decline
in emergency department use has also been documented in the state’s analysis of administrative
data.14 In contrast, data for the nation as a whole
show a small increase in emergency department
use by nonelderly adults during this period—
from 20 percent in 2006 to 21 percent in 2010.15
In addition to examining health care use, it is
important to consider barriers to obtaining
needed care. Nonelderly adults in Massachusetts
were less likely to report that they did not get
some of the types of care they needed in 2010,
compared to 2006 (Appendix Exhibit 3; simple
[unadjusted] estimates in Appendix Exhibit 7).9
The share of adults reporting that they did not
get needed care was down for doctor care, medical tests, treatment or follow-up care, and preventive care over this five-year period.
The decline in these measures is consistent
with the increased continuity of coverage for
adults under health reform and with the fact that
more adults were insured than in the year before
health reform. However, we found an overall
increase in unmet need for care in 2010 relative
to 2009 (up by 3.0 percentage points; Appendix
Exhibit 3).9 This erosion in some of the gains
made in earlier years could be related to the
economic climate; however, as shown below,
there was not a comparable increase in reported
unmet need because of costs.
Finally, despite the 2010 gains in access relative to 2006, 22.8 percent of nonelderly adults in
Massachusetts reported that they did not get
needed care in 2010 (Appendix Exhibit 3).9
Affordability Of Health Care The Massachusetts 2006 health reform initiative did not
tackle the high cost of health care in the state.
However, the expansion of health insurance and
the establishment of the minimum creditable
coverage standards were expected to improve
the affordability of health care for consumers.
Consistent with that expectation, there have
been gains in the affordability of care for adults
since 2006, as evident in a lower burden from
out-of-pocket health care spending (excluding
premiums) and less unmet need for care because
of cost (Exhibit 4; additional measures in Appendix Exhibit 4; simple [unadjusted] estimates
in Appendix Exhibit 8).9 The share of nonelderly
adults who reported high levels of out-of-pocket
health care spending (10 percent or more of family income) was lower in 2010 (6.1 percent) than
in 2006 (9.8 percent). Consistent with the lower
burden of out-of-pocket expenses, the share of
adults reporting unmet need for care because of
cost was down in 2010 relative to 2006 for all of
the types of care examined except prescription
drugs and dental care (Appendix Exhibit 4).9
In 2010 the share of adults who reported problems paying medical bills was not significantly
different from 2006, at nearly one in five adults.
The share was lower in 2007 relative to 2006.
However, there was no sustained improvement
in problems paying medical bills, and the levels
in 2008, 2009, and 2010 were not significantly
different from that in 2006.
Health Status Health insurance coverage
and improved access to care are interim goals
of the 2006 reform initiative; the ultimate goal
is improved health for the population in Massa-
Exhibit 4
Trends In Health Care Affordability For Adults Ages 19–64 In Massachusetts, Fall 2006–Fall 2010
a
b
Percent
a
a
a
c
a
a
a
SOURCE Massachusetts Health Reform Survey, 2006–10. NOTES N ¼ 15; 544. Regression-adjusted estimates. See text for discussion
of regression model and predicted values. aSignificantly different from the value in 2006 at the 0.01 level, two-tailed test. bSignificantly different from the value in 2006 at the 0.05 level, two-tailed test cSignificantly different from the value in the previous year
at the 0.05 level, two-tailed test. dBecause of the way in which income information is collected in the survey, the measure of spending
relative to family income cannot be constructed for adults with family income above 500 percent of the federal poverty level.
448
H ea lt h A f fai r s
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chusetts. The survey used for this study had a
single question about health status: “In general,
would you say that your health is excellent, very
good, good, fair, or poor?” Although selfreported health status has limitations, it is often
used as a proxy for clinical measures of health
when such measures are not available, as was the
case here. We found strong and sustained gains
in the share of nonelderly adults in Massachusetts who reported their health as very good or
excellent, with an increase from 59.7 percent in
2006 to 64.9 percent in 2010 (data not shown).7
The Role Of Employers A core element of the
success of health reform in Massachusetts has
been the strong role of employer-sponsored coverage in the state. In 2010, 91.3 percent of workers were employed by a firm that offered coverage to any workers at the firm (although not
necessarily to the worker in our sample; some
workers were not eligible for coverage because
they had not been employed long enough or
worked too few hours), and 82.6 percent were
employed by a firm that offered coverage to them
(data not shown).7
In addition, employees continued to view the
scope of that coverage quite favorably. Workers
were more likely to rate their employersponsored insurance plans as very good or excellent in 2010 than they were in 2006, based on
the range of services offered and their choice of
doctors and other providers. They also were no
more likely in 2010 to report problems with expensive medical bills or doctor’s charges that
were not covered by their plan (data not shown).
There is, however, reason to be concerned
about employer-sponsored insurance premiums
because health care costs in the state continue to
rise. Data from the Insurance Component of the
Medical Expenditure Panel Survey, a national
survey of employers, indicate that in 2006 the
average employee contribution toward premiums in Massachusetts was $1,011 for single coverage and $3,128 for family coverage. By 2010 the
average employee contribution had increased to
$1,200 for single coverage and $3,444 for family
coverage, although the change in the employee
contribution for family coverage was not statistically significant.16 Health care costs in Massachusetts, as in the rest of the country, continue
to grow faster than wages and inflation.17
Support For Reform Massachusetts began
health reform with strong support among residents of the state, including support from
69.0 percent of nonelderly adults. Support for
health reform in 2010, although down a bit, remained high, at 65.6 percent of those adults.
However, among those who did not support reform, there has been a marked shift away from a
neutral position toward opposition to reform:
from 17.0 percent opposed to reform in 2006
to 26.9 percent in 2010 (data not shown).7
Discussion
As states begin the challenging process of redesigning their health care systems in response
to the Affordable Care Act, the experience in
Massachusetts offers an optimistic prognosis
of potential gains. The Bay State’s 2006 health
reform initiative has continued to fare well despite a severe economic downturn and the continued escalation of health care costs in the state.
The uninsurance rate in the state remained low
in 2010, and employer-sponsored insurance remained strong. There are no signs that employers in Massachusetts have responded to reform
by dropping coverage for their workers or scaling back the scope of the coverage that is offered.
Perhaps not surprising—given that Massachusetts has maintained near-universal coverage for
the past three years—access to health care in the
community is better than it was in 2006. In 2010
there were reductions in emergency department
use, including reductions in multiple visits and
visits for nonemergency conditions; there were
also reductions in inpatient hospital stays. These
declines are suggestive of important improvements in the effectiveness of the delivery of
health care in the state. Analyses of other administrative data sources are needed to assess the
implications of these changes in more depth.
Despite these important achievements, gaps
in access to care continue for some nonelderly
adults in the state. Nearly one in four of these
adults reported unmet need for care, often because of health care costs. Consistent with that
finding, Massachusetts continues to struggle
with escalating health care costs, reflecting the
decision to defer addressing costs in the 2006
legislation so as not to hold up the expansion in
coverage.
A 2011 proposal by Gov. Deval Patrick (D)
would make a number of changes to address
costs, including encouraging integrated care
networks and a move away from fee-for-service
payments to alternative payment methods.18
There have also been efforts by providers and
insurers to address costs in the state.19
Going forward, the success of health reform
under the Affordable Care Act in Massachusetts,
and in other states, will depend on the ability of
policy makers and stakeholders to come together
to take on the considerable challenge of reining
in health care costs. Massachusetts has the opportunity to lead the way here, as the state did in
the push toward universal coverage. The pre2010 status quo is not a sustainable option for
Massachusetts or the nation.
Febr uary 201 2
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Just as Massachusetts’s 2006 health reform
legislation provided the template for the Affordable Care Act, so the state’s experience under
that legislation provides an example of the potential gains under federal health reform. Of
course, the trajectory of policy and health reform
will vary across the states, given the wide
differences in their political, economic, and cultural environments and the wide range in the
different states’ starting points.
Massachusetts’s 2006 reform effort was built
on many years of incremental reforms, with bipartisan political support, strong commitment
to reform across stakeholders, and a strong ecoThis work was funded by the Blue Cross
Blue Shield of Massachusetts
Foundation. Earlier years of the study
were also supported by the
nomic environment. Few—if any—states, including Massachusetts, are starting to implement the
Affordable Care Act in such favorable conditions.
What’s more, polls indicate that support for, and
opposition to, federal health reform remain relatively equal nationally (41 percent and 43 percent, respectively) and that both sides are highly
partisan as well.20 It is likely that the path to nearuniversal coverage nationally will be slower and
bumpier than it was for Massachusetts in 2006.
Yet the findings for Massachusetts are a
reminder that major gains in coverage and associated benefits are possible. ▪
Commonwealth Fund and the Robert
Wood Johnson Foundation. The survey
was conducted by Social Science
Research Solutions, under the direction
of David Dutwin, with support from Tim
Triplett at the Urban Institute.
[Published online January 25, 2012.]
NOTES
1 For a detailed summary of the
legislation, see Blue Cross Blue
Shield of Massachusetts Foundation.
Massachusetts health care reform
bill summary [Internet]. Boston
(MA): The Foundation; 2006 [cited
2012 Jan 13]. Available from: http://
www.bcbsmafoundation.org/
foundationroot/en_US/documents/
MassHCReformLawSummary.pdf
2 Although the Affordable Care Act
draws on Massachusetts’s reform
initiative, there are important
differences. See Seifert RW,
Cohen AP (University of Massachusetts Medical School, Charlestown,
MA). Re-forming reform: what the
Patient Protection and Affordable
Care Act means for Massachusetts
[Internet]. Boston (MA): Blue Cross
Blue Shield of Massachusetts Foundation; 2010 [cited 2012 Jan 13].
Available from: http://masshealth
policyforum.brandeis.edu/forums/
Documents/IssueBrief_Report
FINAL.pdf
3 See, for example, Long SK, Stockley
K. Sustaining health reform in a recession: an update on Massachusetts
as of fall 2009. Health Aff (Millwood). 2010;29(6):1234–41.
4 Cook A, Holahan J. Health insurance
coverage and the uninsured in
Massachusetts: an update based on
2005 Current Population Survey
data [Internet]. Washington (DC):
Urban Institute; 2007 Aug [cited
2012 Jan 13]. Available from: http://
bluecrossfoundation.org/~/media/
Files/Publications/Policy%20
Publications/070800HealthIns
CovAndUninsInMassAnUpdate
Cook.pdf
5 Early rounds of the Massachusetts
Health Reform Survey included
eighteen-year-olds. That was
changed in 2010 to make the defi-
450
H e a lt h A f fai r s
F e b r u a ry 2 0 1 2
6
7
8
9
10
11
12
nition of adult consistent with that
used by the Massachusetts Division
of Health Care Finance and Policy in
the Massachusetts Health Insurance
Survey.
The survey is limited to nonelderly
adults residing in the community.
The sample size in 2008 was somewhat larger—3,868—to support
oversamples based on geography
and race or ethnicity in that year.
Long SK, Stockley K, Dahlen H.
Health reform in Massachusetts as of
fall 2010: getting ready for the Affordable Care Act and addressing
affordability. Boston (MA): Blue
Cross Blue Shield of Massachusetts
Foundation; 2012.
The fall 2006 survey was fielded as
Commonwealth Care, the statesponsored health insurance program for uninsured adults who meet
income and other eligibility requirements, was beginning; however, enrollment started slowly.
To access the Appendix, click on the
Appendix link in the box to the right
of the article online.
Authors’ tabulations based on the
2010 American Community Survey.
See King M, Ruggles S, Alexander J,
Flood S, Genadek K, Schroeder M,
et al. Integrated public use microdata
series, American Community Survey
[machine-readable database]. Minneapolis (MN): University of Minnesota; 2010.
Cohen RA, Ward BW, Schiller JS.
Health insurance coverage: early release of estimates from the National
Health Interview Survey, 2010 [Internet]. Hyattsville (MD): National
Center for Health Statistics; 2011 Jun
[cited 2012 Jan 13]. Available from:
http://www.cdc.gov/nchs/data/
nhis/earlyrelease/insur201106.pdf
Massachusetts Division of Health
31:2
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13
14
15
16
Care Finance and Policy. Health insurance coverage in Massachusetts:
results from the 2008–2010 Massachusetts Health Insurance Surveys
[Internet]. Boston (MA): The Division; 2010 Dec [cited 2012 Jan 13].
Available from: http://www.mass
.gov/eohhs/docs/dhcfp/r/pubs/10/
mhis-report-12-2010.pdf
In addition to the 2006 reform initiatives, Massachusetts has invested
in strategies directly designed to reduce emergency department use,
such as an emergency department
diversion program supported by a
$4.5 million grant from the Centers
for Medicare and Medicaid Services.
Eccleston S. Challenges in coordination of health care services
[Internet]. Boston (MA): Massachusetts Division of Health Care Finance and Policy; 2011 Jun 30 [cited
2012 Jan 13]. Available from: http://
www.mass.gov/eohhs/docs/dhcfp/
cost-trend-docs/cost-trends-docs2011/eccleston-stacey-june-30.pdf
Authors’ tabulations based on the
2006–10 National Health Interview
Surveys. See Minnesota Population
Center and State Health Access Data
Assistance Center. Integrated Health
Interview Series: version 4.0 [machine-readable database]. Minneapolis (MN): University of Minnesota; 2011.
Data were obtained using the following selection criteria: (1) Premiums and Contributions of Plans of
Employees Enrolled at PrivateSector Establishments; (2) Single,
Employee-plus-one, and Family
Plans Separately; (3) All Provider
Types Combined; (4) Average Total
Employee Contribution; (5) Specific
States; (7) Massachusetts; and
(8) All Firms. Information obtained
from: Agency for Healthcare Re-
search and Quality. Medical
Expenditure Panel Survey/Insurance
Component data tables. In:
MEPSnet/IC Trend Query system
[Internet]. Rockville (MD): AHRQ;
[last updated 2011 Jul 13; cited 2012
Jan 20]. Available from: http://
meps.ahrq.gov/mepsweb/data_
stats/MEPSnetIC.jsp
17 Massachusetts Division of Health
Care Finance and Policy. Massachusetts health care cost trends: trends
in health expenditures [Internet].
Boston (MA): The Division; 2011 Jun
[cited 2012 Jan 13]. Available from:
http://www.mass.gov/eohhs/docs/
dhcfp/cost-trend-docs/cost-trendsdocs-2011/health-expendituresreport.pdf
18 Patrick DL. An Act Improving the
Quality of Health Care and Controlling Costs by Reforming Health
Systems and Payments: text of filing
letter [Internet]. Boston (MA): Office of the Governor; 2011 Feb 17
[cited 2012 Jan 13]. Available from:
http://www.mass.gov/governor/
legislationeexecorder/legislation/
health-care-system-and-paymentreform.html
19 Chernew M, Mechanic R, Landon B,
Safran D. Private-payer innovation
in Massachusetts: the “Alternative
Quality Contract.” Health Aff (Millwood). 2011;30(1):51–61.
20 See, for example, Kaiser Family
Foundation. Kaiser health tracking
poll—December 2011 [Internet].
Menlo Park (CA): KFF; [cited 2012
Jan 13]. Available from: http://
www.kff.org/kaiserpolls/8265.cfm
ABOUT THE AUTHORS: SHARON K. LONG, KAREN STOCKLEY
HEATHER DAHLEN
Sharon K. Long is a
professor at the
University of
Minnesota.
In this month’s Health Affairs,
Sharon Long, Karen Stockley, and
Heather Dahlen report on the
status of the Massachusetts health
reform initiative four years after it
was enacted into law in 2006. The
authors cite a number of favorable
trends—for example, uninsurance
rates that remained low—but note
that affordability of health care
remains a critical issue and that
political opposition to the reforms
has increased.
Long, a professor in the Division
of Health Policy and Management
at the University of Minnesota, has
earned national recognition for her
work evaluating the impact of
health reform in Massachusetts.
Key findings from that research
have been regularly reported in
Health Affairs.
As of February 2012, Long will be
a senior fellow at the Urban
Institute, where she will focus on
evaluating the impact of the
Affordable Care Act across the
states and where she had served for
many years before moving to the
University of Minnesota in 2010.
She received her doctorate in
economics from the University of
North Carolina at Chapel Hill.
Karen Stockley is a
graduate student in
economics at
Harvard University.
Stockley is a graduate student in
economics at Harvard University.
She was formerly a research
associate at the Urban Institute
Health Policy Center, where she
studied how health reform in
Massachusetts affected different
populations within the state. She
was awarded the National Science
Foundation Graduate Research
&
Fellowship, 2011–14. She has a
bachelor’s degree in economics
from the University of Notre Dame.
Heather Dahlen is a
doctoral student in
applied economics
at the University of
Minnesota.
Dahlen is a doctoral student in
applied economics, with a minor in
health economics, at the University
of Minnesota. She has been a
research assistant to Long in the
university’s State Health Access
Data Assistance Center. Dahlen
develops statistical code and
performs data analyses using
nationally representative health
data and helps health economists
format and implement their
research projects. She earned a
master’s degree in applied
economics from San Diego State
University.
February 2012
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