Tracking the Impacts of Health Reform: Lessons from Massachusetts

Sharon K. LongUniversity of Minnesota

Measuring the State-Level Impact of Health Reform

2011 Minnesota Health Services Research Conference

March 1, 2011

www.shadac.org 2

Health reform in Massachusetts

• Legislation passed in April 2006, with implementation beginning in July 2006

• Major goals:

– Extend comprehensive insurance coverage to all Massachusetts residents

– Improve access, affordability, and quality of health care

• Became the foundation for the 2010 national health reform legislation

www.shadac.org 3

Elements of Massachusetts health reform

• Expanded eligibility for public programs• Created health insurance exchanges• Provided subsidies for low- and moderate-

income individuals• Expanded dependent coverage • Individual mandate• Requirements for employers• Standards for covered benefits

www.shadac.org

Key changes in coverage options under health reform in Massachusetts

4

Pre-Reform Post-Reform

Children

Public coverage < 200% FPL < 300% FPL

Parents

Public coverage < 133% FPL < 300% FPL

Premium support < 200% FPL < 300% FPL

Subsidized coverage -- < 300% FPL

Exchange -- > 300% FPL

Childless Adults

Public coverage -- < 300% FPL

Premium support < 200% FPL < 300% FPL

Subsidized coverage -- < 300% FPL

Exchange -- > 300% FPL

Note: FPL is federal poverty level

www.shadac.org 5

Stakeholders began planning for an impact evaluation in May 2006

• Reviewed available data sources– National surveys

• MA sample size too small• Survey content too narrow• Data available too late for policy/program purposes

– Existing state data (survey and administrative data)• Available outcomes relatively narrow• Stakeholder concerns about access to state data

• Decided to invest in a new state survey– Funded by BCBSMA Foundation, with support from

Commonwealth Fund and RWJF

www.shadac.org 6

Data

• Massachusetts Health Reform Survey– Sample of non-elderly adults 18-64 years old– Baseline survey in 2006, follow-ups 2007 to 2010

(underway)– Oversamples of the lower-income and uninsured adults

who were targeted by reform– Telephone interviews, with cell-phones added in 2010– Sample size ~3000 each year

www.shadac.org 7

Outcome measures

• Health insurance status—current, prior year• Availability of/adequacy of employer sponsored

insurance• Access to care/barriers to obtaining care• Use of health care services• Affordability of health care services and medical

debt• Attitudes toward health reform and, particularly,

the individual mandate

www.shadac.org 8

Methods

• Estimate impact of health reform as change over time from fall 2006– Pre-post estimates will also capture recession &

health care cost trends– Consistent findings from studies using national data to

estimate difference-in-differences models that compare changes in MA to other states

• Multivariate regression models control for demographic characteristics, health and disability status, socioeconomic status and region of state

www.shadac.org 9

Health insurance coverage, 2006-2009

Currently insured Ever insured over year0%

20%

40%

60%

80%

100%88%

92%95% *** 98%***

2006 2009

Source: 2006-2009 Massachusetts Health Reform SurveyNote: Regression-adjusted estimates* (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.

Adults more likely to have health insurance under health reform.

www.shadac.org 10

Type of health insurance coverage, 2006-2009

Employer-sponsored insurance Public and other coverage0%

20%

40%

60%

80%

100%

66%

22%

68% ***

27%***

2006 2009

Source: 2006-2009 Massachusetts Health Reform SurveyNote: Regression-adjusted estimates* (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.

Employer-sponsored insurance coverage increased under health reform.

www.shadac.org 11

Employers’ insurance offer and employees’ take-up, 2005-2009

Employers offering coverage Employees taking up coverage0%

20%

40%

60%

80%

100%

70%78%76%

80%

2005 2009

Source: 2006-2009 Massachusetts Division of Health Care Finance and Policy Employer Survey

Employers more likely to offer health insurance coverage to workers and workers more likely to take-up coverage under health reform.

www.shadac.org 12

Health care access and use, 2006-2009

Usual source of care Any doctor visit Preventive care visit Dental care visit0%

20%

40%

60%

80%

100%

86%80%

70% 68%

89%**86%***

78%***75%***

2006 2009

Source: 2006-2009 Massachusetts Health Reform SurveyNote: Regression-adjusted estimates*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two tailed test

Adults more likely to have a regular health care provider and to have had health care visits over the prior year under health reform

www.shadac.org 13

Unmet need for care, 2006-2009

Any unmet need for health care

Doctor care Medical tests, treatment, or fol-

low up care

Prescription drugs

Preventive care screening

0%

5%

10%

15%

20%

25%

30%

24.9%

7.7%9.1%

7.9%6.8%

19.0%***

5.3%** 5.7%*** 5.7%**4.9%**

2006 2009

Source: 2006-2009 Massachusetts Health Reform SurveyNote: Regression-adjusted estimates*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test

Adults less likely to have unmet need for any reason under health reform

www.shadac.org 14

Health care costs and affordability for individuals, 2006-2009

OOP health care costs=>10% of family

income

Problems paying med-ical bills

Medical debt Unmet need because of cost

0%

10%

20%

30%

9.5%

19.1% 19.5%

16.3%

4.4%***

19.1%20.3%

11.7%***

2006 2009

Source: 2006-2009 Massachusetts Health Reform SurveyNote: Regression-adjusted estimates*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test

Improvements in affordability of care under health reform despite increasing health care costs and economic recession

www.shadac.org

Additions to the state survey in anticipation of national health reform

• Provider capacity/barriers to care• After hours care/emergency care use• Health care costs/medical debt• Medical home/care coordination• Experiences navigating health programs

and the health care system• Employers’ response to reform/quality of

employer-sponsored insurance coverage

15