Health Care Reform in
Massachusetts:
The Role of Public Health
John Auerbach, Commissioner
2
Components of Massachusetts Health Care
Reform
• All adults in MA required to purchase health
insurance by 7/1/07 or face a hefty penalty
• All employers with 11 or more employees
required to offer health insurance
• Commonwealth Connector created to “connect”
individuals to insurance by offering affordable,
quality insurance products
• Commonwealth Care Program created as a low-
cost insurance alternative for low-income
families and individuals
3
Five years of Health Care
Reform:
What have we seen in
Massachusetts?
4
5
6
7
A reminder that we are different
% Insured in Texas, US and Massachusetts
505560657075
80859095
100
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Texas Massachusetts Nationwide (States and DC)
8 Massachusetts Division of Health Care Finance and Policy
Most Residents Saw a Doctor in the Past 12 Months
The majority of
children, non-
elderly adults, and
elderly adults in
Massachusetts
had a doctor visit
in the past 12
months, with the
level somewhat
lower for non-
elderly adults. The
2009 estimates are
not significantly
different from the
estimates for 2008.
Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS
88%
94%
85%
94%
88%
92%
85%
94%
0%
20%
40%
60%
80%
100%
Total Population Children (0-18) Non-Elderly Adults
(19-64)
Elderly Adults (65 and
older)
2008 2009
9 Massachusetts Division of Health Care Finance and Policy
Non-Elderly Adults with a Doctor Visit in
Past 12 Months by Insurance Status Compared with
the insured
adults, uninsured
non-elderly adults
were much less
likely to have had
a doctor visit in
the past 12
months. The
2009 estimates
are not
significantly
different from the
estimates for
2008.
Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS
85% 86%
45%
85% 86%
54%
0%
20%
40%
60%
80%
100%
Total Population Insured Uninsured
2008 2009
10 Massachusetts Division of Health Care Finance and Policy
Fewer Residents have a Preventive
Care Visit in Past 12 Months High shares of
both children and
elderly adults had
a preventive care
visit in the past 12
months, while only
73% of non-elderly
adults had a
preventive care
visit. The 2009
estimates are not
significantly
different from the
estimates for 2008.
Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS
78%
89%
73%
86%
78%
88%
73%
87%
0%
20%
40%
60%
80%
100%
Total Population Children (0-18) Non-Elderly Adults
(19-64)
Elderly Adults (65 and
older)
2008 2009
11 Massachusetts Division of Health Care Finance and Policy
Non-Elderly Adults with a Preventive Care Visit
in Past 12 Months by Insurance Status Compared with
the insured
adults, uninsured
non-elderly adults
were much less
likely to have had
a preventive care
visit in the past 12
months. The
2009 estimates
are not
significantly
different from the
estimates for
2008.
Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS
73% 74%
31%
73% 74%
37%
0%
20%
40%
60%
80%
100%
Total Population Insured Uninsured
2008 2009
12
What does this have to do with
improving health?
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14
15
16
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Evidence that reform is improving health
Changes in the first year of implementation
• Flu vaccinations rose 3% (a 7% increase) for 19-
64 year olds at primary care sites as new patients
see primary care doctors – in a year DPH cut
adult public health vaccine doses
• Colonoscopy rates increased 8% (a 15%
increase) among the recommended age group as
newly insured 50+ year olds get referrals for
screening
• And…smoking rates sharply decreased at a rate
not seen in many years (11% of Medicaid adults
used the cessation service)
18
Percent Drop in Smoking PrevalenceMassachusetts, 1998 - 2007
-2.4%
4.3%
1.5%2.0%
3.1%
-1.1%
3.1%
2.2%1.7%
7.9%
-4%
-2%
0%
2%
4%
6%
8%
10%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data Source: Massachusetts Behavioral Risk Factor Surveillance System
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Massachusetts Comparative Public Health
Measures 2006 and 2010
Indicators 2006 (% and rank) 2010
Obesity 20.7 (5) 21.8 (3)
Smoking 18.1 (9) 14.9 (3)
Premature death 6 (rank) 2 (rank)
CV deaths 9 (rank) 7 (rank)
Cholest. check 79.3 (5) 83.9 (1)
Recent dental visit 79.5 (3) 79.3 (2)
Infant Mortality 4.7 (1) 4.8 (1)
Source: america’s health rankings.org
How are Health Care
Reform and Public
Health Connected?
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Three Lessons from Massachusetts
• Public health can help health care
reform to succeed
• Health care reform cannot
substitute for public health
• Public health needs to adapt to
health care reform
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1. Public health can help
health care reform to succeed
We can help with designing
the insurance packages
Attention was/is needed to what is covered
in the insurance packages and what else is
funded
24
Decisions Are Needed on “Preventive”
Services for Insurance Packages
• Will family planning services be covered?
• Will nicotine replacement therapy and
cessation counseling be offered?
• Will the role of CHWs be considered?
• Will substance abuse and mental health
treatment be covered?
• What services will be offered with “first
dollar” coverage? No copays, deductibles.
We can measure the
impact of reform on
health
26
Demonstrate the access to care is good
for one’s health
• Support the inclusion of
public health and other
useful fields in HIT
systems
• Utilize BRFSS and other
traditional approaches –
add optional questions
• Prepare periodic reports
on the impact on health
54 55
84
43
57
63
85
46
30
40
50
60
70
80
90
PSA test past
year, men age 50-
64
Colonoscopy or
sigmoidoscopy
past five years, all
respondents age
50-64
Mammography in
past two years,
women 40-64
Flu Vaccine in
Past Year, 50-64
%
January 2006-June 2007 July 2007-December 2008
27
The latest: News from the 2010 Survey
• 91% of Mass residents say they have a personal
health care provider
• The percentage who had a routine check-up
increased signficantly in 2010 (80% vs. 76%)
• The percentage who had a dentist visit increased
from 2008 (81% vs. 78%)
• Only 7% say they could not see a doctor because of
cost
• Access was an issue for the disabled, Latinos, 18-
24 year olds, the least educated and the lowest
income
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We can fill important gaps
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Some services are better addressed with
public health funding
• Public health programs can reach the populations that are not linked to reform (in Massachusetts, perhaps 125,000 adults) – Family planning sites serve may serve as primary care providers for the uninsured
• We can provide services less expensively (vaccine purchases)
30
2. Health care reform
cannot substitute for public
health
Public Health Prevention Needs to be a Priority
It can reduce the cost of reform by
actively promoting good health using proven approaches
32
Example: To address overweight epidemic and
resulting chronic disease risk
With over 60% of
adults and 30% of
children overweight
a statewide
comprehensive
effort needed
Prevalence of Diabetes in Massachusetts, 1994-2005
4.1 3.84.7 4.3
3.8
4.95.8 5.6 5.8 6.2
5.66.4
0
1
2
3
4
5
6
7
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Perc
en
t
Overall
Source: Massachusetts Behavioral Risk Factor Surveillance System (BRFSS);
1994-2005. Note: Estimates have been age-adjusted to 2000 US standard
population
33
Mass in Motion Campaign Includes
• Statewide regulations: Menu labeling of fast foods
• Schools: mandated BMI testing of all students
• Worksites: Employee wellness programs
• Cities and towns: Community-wide mobilization grants
There are dangers if
reform is thought to
substitute for public
health
F
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35
Example #1 – Unwisely cutting public health
may lead to reduced access
Faulty assumptions
may be made about
what is covered by
insurance
(examples: loss of
access to nicotine
replacement therapy
and childhood
immunization funds)
36
Example #2 – People still fall through the
cracks
Certain populations
won’t or can’t use
insurance (example:
adolescents access
to family planning
services; the
uninsured continuing
needs)
37
Example #3 – There are barriers built into
insurance coverage
We may see new unintended barriers to
access (co-pays and deductibles create
barriers for some previous/current clients of
public health)
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3. Public Health needs to
adapt to health care reform
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We need to do more to show that
prevention works
• More data are needed on to demonstrate the cost-savings associated with prevention
• More emphasis is needed on the short-term (2 year) return on investment
• Example: emerging Mass. data shows a dramatic drop in heart attacks within first year of Medicaid nicotine replacement coverage
40
We Need to Reassess our Service Models
at the State and Federal Levels
• We may need to adapt some of our
programs to the new conditions (not
ones that assume the target population is
mostly uninsured)
We need to show that
public health is good at
cost-savings (while
improving quality)
42
*Hospitals must report hospital
associated infections and serious
reportable events
*Hospitals are prohibited from
charging for services needed to
treat a serious reportable
event/medical error
In order to prevent hospital associated infections
and serious medical mistakes
43
In order to prevent costs of construction of
unneeded or duplicative services
Changes to the Determination of Need
process - broadening its scope to include
ambulatory surgery, large outpatient
capital projects and beds added to
hospital satellites
44
We need to be a part of payment reform
• Learning more about the process and
the opportunities
• Learning the language (ACOs, medical
loss ratio, global payments, ROI)
• Making the case
• Clarifying our priorities and specifying
our requests
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Payment Reform: conceptualizing 3
areas where prevention occurs
1. Clinical preventive measures
2. Community health
The grey zone (sometimes ties
to clinical and sometimes
ties to community via a non
clinical CHW, patient
navigator, pt. trainings and
education
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So…What can we expect?
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Conclusions
• Health care reform will benefit from a close
partnership with public health
• But there is no substitute for a healthy and
robust public health system - Caution
should be taken in assuming that reform
has taken over public health functions
• Public health needs to adapt and grow to
ensure the success of health care reform
& address the new conditions
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