Access-to-care problems are resurfacing in Mass.

Major reforms in 2006 shrank the uninsured population, but some initial gains in reducing care barriers and boosting affordability have eroded, according to a survey.

By — Posted June 29, 2009

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Massachusetts' Commonwealth Connector health reforms have reduced the state's uninsured population to less than 3% of residents, the lowest among all states. But a recent survey found an uptick last fall in adults reporting difficulty accessing certain types of care.

The outcome of the Massachusetts health system reforms has national implications. Democrats in Congress have offered or are drafting health reform bills based on many of the state-adopted principles, including a health insurance exchange, subsidized private health insurance for low-and moderate-income residents, a requirement for individuals to have health insurance, and a mandate for employers to offer health insurance to their employees or else contribute to a health care fund.

The Connector reforms, adopted in 2006, have expanded access to health care coverage appreciably. More than 428,000 non-elderly adults bought public or private coverage between June 30, 2006, and Dec. 31, 2008. The state's percentage of uninsured residents decreased from 6.4% in 2006 to 2.6% in 2008, according to a May report by the Massachusetts Division of Health Care Finance and Policy. Nearly a third of the gains were from workers signing up for employer-sponsored insurance in response to the individual mandate.

To help people afford coverage, the state's insurance exchange offers subsidized coverage to those earning 300% of the poverty level or less through participating private plans. People earning 150% of poverty or less are eligible for virtually free insurance. Residents with incomes higher than 300% of poverty have access to unsubsidized insurance through the private plans.

"I do think that after three years, I would no longer describe this as an experiment," said Jon Kingsdale, PhD, executive director of the Connector Authority, the organization implementing the health system reforms. "This is definitely working."

Massachusetts Medical Society President Mario Motta, MD, said the reforms are still a work in progress but that they have successfully reduced the state's uninsured population.

The program also has improved access to health care for some residents. For example, more non-elderly adults -- especially lower-income adults -- reported in fall 2008 than in the year before that they had a usual source of care and that they visited a physician in the last 12 months, according to a survey of more than 4,000 adults published in the May 28 online edition of Health Affairs link.

But not all care access gains have held, the report found. The percentage of non-elderly adults who reported that they did not get needed care from specialists in the last 12 months dipped from 7.1% in fall 2006 to 4% in fall 2007, but then bounced back up to 7% in fall 2008. The survey revealed less significant but similar trends for those having access problems for physician care, medical tests and follow-up care.

The recent uptick in access issues may be due to increased demand for follow-up care from the newly insured that is not being matched by available doctors, according to the article's authors. Most of those surveyed who reported problems said they were told by physicians they were not accepting new patients or patients with their type of coverage.

Some initial gains in affordability also appear to have eroded. Lower-income residents and those with public coverage reported more access difficulties than higher-income people, which may be due to lower payment rates or the more limited physician networks of the four health plans serving Medicaid enrollees, the authors wrote.

The state's reforms also have not produced a decrease in emergency department visits for non-emergency conditions, the article found. Of all the non-elderly adults in the state who said in fall 2008 that they had visited an ED in the last year, the percentage who said the visit was for a condition that could have been treated in a physician's office was just over 15%, roughly the same as in 2006.

ED usage can be reduced over time, said Georgia Maheras, private markets policy manager for the patient advocacy organization Health Care For All. "Suddenly giving someone that piece of plastic isn't going to change their behavior right away."

Kingsdale surmised that Massachusetts residents often rely on emergency departments when they can't access physicians, such as after normal business hours. Many people believed the reforms would reduce the rate of ED visits. "I was not among them," he said.

Dr. Motta said the state continues to experience shortages of physicians who can see patients regularly. Many doctors in the state spend most of their week doing research but see patients only once a week. Alternative practice hours among regularly practicing doctors also may help increase access. "Physicians need to try to figure out how to make themselves more available," Dr. Motta said. The state also needs more primary care and certain specialty doctors and to pay primary care physicians better, he added.

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Overall access up in Mass.

Massachusetts comprehensive health reforms, adopted in 2006, have helped increase overall access to physician services for adults age 18 to 64. Visits to specialists, however, dipped in the year following adoption.

Has a usual source of careAny physician visit in the last 12 monthsAny visit to a specialist in the last 12 months
Fall 200686.4%80.0%50.6%
Fall 200788.7%81.5%48.4%
Fall 200891.3%83.9%53.2%

Note: Excludes emergency department care.

Source: "Access and Affordability: An Update on Health Reform in Massachusetts, Fall 2008," Health Affairs, May 28 link

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