Advocates for Evidence-Based Health Policy Speakers
How Massachusetts Can Inform the Nation
Massachusetts serves as an experimental guide for a nation seeking to implement dramatic health care reforms.
In November 2009, the Urban Institute conducted a site visit and a series of interviews of key stake holders to analyze the health system reform in Massachusetts. As of 2009, only 2.6 percent of Massachusetts’ residents were uninsured. Many assume that this level of participation is due to the new individual mandate; however, the majority of newly-insured residents are not subject to the mandate due to their low income. In addition, the availability of new premium-free health care benefits in many other state and national programs has not produced such high participation in the past. For example, only 60 percent of children eligible for CHIP are actually enrolled and receiving benefits. This analysis focuses on the methods by which Massachusetts reached such high participation in its varying health care programs since the 2006 reform.
To summarize, the Massachusetts health care reform of 2006 implemented a mandate on all adults to have health insurance and a mandate on employers to contribute to employee health plans, with a monetary penalty for noncompliance. The following are the government-funded programs that help to pay for health care of Massachusetts residents. Health Safety Net reimburses hospitals and community health centers for uncompensated care. Medicaid insures the state’s lowest-income adults. MassHealth insures children of parents earning up to 300 percent of the Federal Poverty Level (FPL). Commonwealth Care Health Insurance Program provides subsidies for adults earning up to 300 percent of the FPL to purchase health care coverage. Medical Security Program insures laid-off workers with income up to 400 percent of the FPL.
The analysis found that with so many intertwining programs working together to cover the state’s residents, the streamlining of the application and enrollment process, as well as readily available public information, especially through local community representatives, have made participation in the health programs so successful.
For example, the state used existing databases on residents who received uncompensated care, including their demographics and income, to automatically enroll them in any program they were eligible for at the time the reform legislation passed. This process alone has registered nearly 100,000 residents for new coverage since the 2006 reform, approximately one-quarter of all newly insured residents.
For those not already in the state database, the application process was streamlined. There was one application for every program except the Medical Security Program, available online and submitted online, which was processed by one agency. Through a computerized process, rather than through staff manpower, it was determined for which, if any, program the applicant was eligible. Of note, more than half of the time, this application was filled out by employees of community-based organizations (CBO) or hospitals who are specifically trained to help residents through the process. Massachusetts’ reform provided clinics and hospitals a financial incentive to assist residents in correctly filling out these forms because then those clinics and hospitals could be reimbursed for services. Grant money from the state was made available to help fund these community employees.
These CBO employees were useful in assisting residents in the application process and in distributing information about programs. CBO employees were residents of the communities in which they worked. They delivered the message of upcoming benefits and penalties in a culturally appropriate manner, which was key to gaining the trust of the state’s diverse population.
Commentary
The lessons learned from Massachusetts can be applied to the recently passed national health reform (PPACA), especially with such vast expansion of state Medicaid programs. In order to have the intention of the policy to actually reach its intended audience, the application process in many states needs to be more streamlined. Applicants need to be able to not only fill out the application online but also submit it online. Moreover, states should strive to use existing databases, such as tax returns, which are available for 86.3 percent of uninsured Americans, to automatically enroll their residents in appropriate health care programs. Finally, federal policy should go beyond the regional information and assistance centers to give funding to the states that can financially support trained representatives at the local level, a tool shown to be most useful in Massachusetts.
Kaiser Family Foundation. Massachusetts Health Care Reform: Three Years Later. Sep 2009. #7777-02.
by
Lisa Maurer, MD
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