Massachusetts Healthcare Reform, 10 Years Later

Massachusetts achieved near-universal insurance coverage after enacting its own healthcare reform 10 years ago, but gains in improved access to and affordability of care faded over time.

Four years before the passage of the Affordable Care Act (ACA), Massachusetts’s enacted its own health reform legislation to put the state on the road to near-universal health insurance coverage and make healthcare accessible and affordable (the state’s 2006 Chapter 58 Act Providing Access to Affordable, Quality, Accountable Health Care). How has Massachusetts’s ambitious healthcare reform effort fared 10 years later?

In the September 2016 issue of Health Affairs, Sharon K. Long, PhD, a senior fellow in the Health Policy Center at the Urban Institute in Washington, DC, and colleagues concluded that although there have been sustained gains in coverage in Massachusetts since Chapter 58’s enactment, many vulnerable populations and communities in the state have high uninsurance rates, and among those with coverage, gaps in access and affordability remain.

Long and colleagues provided a status report on health reform in Massachusetts after 10 years, focusing on the state’s ongoing efforts to move from universal coverage to universal access to affordable healthcare. Drawing on many sources, including federal and state surveys, the researchers examined health insurance coverage and access and affordability over time and across population subgroups and geographic areas of Massachusetts.

They found that Massachusetts achieved near-universal insurance coverage within 2 years of the passage of Chapter 58, and the state’s uninsurance rate dropped significantly and remained at or below 5% since 2008. By 2008 Massachusetts had the highest coverage in the nation, well above coverage levels in the remaining states, and has maintained the highest coverage since then.

Although Massachusetts has attained near-universal coverage, gaps persist, especially among nonelderly adults. Among nonelderly adults, uninsurance was particularly high for immigrants, minorities, those with less than a high school education, and those with family income at or below 138% of the federal poverty level. Furthermore, annual premiums for coverage in the state, which long have been among the highest in the country, increased by more than 50% between 2005 and 2014 despite employers’ seeing lower premiums by shifting more of the costs of care to employees. The cost of coverage was the most common reason cited for being uninsured, reported by 54.8% of those uninsured in 2015.

Although expansion of coverage in Massachusetts led to improved access and affordability of care early in the period of reform, the researchers said those gains faded somewhat over time. They report that in 2015 more than one-third of full-year-insured adults reported going without some type of needed care during the prior year, which was attributed in part to difficulty finding providers who would see them and difficulty getting timely appointments.

About 1 in 5 full-year-insured adults reported unmet need for care because of cost; furthermore, 1 in 6 reported problems paying medical bills. More than 20% of insured adults reported medical debt.

“While the sustained increase in coverage is impressive, a key lesson from Massachusetts is that coverage does not guarantee access to health care or affordable health care,” the authors noted. “Difficulty finding healthcare providers, unmet need for care, and difficulty paying medical bills are all too common among adults in Massachusetts who are insured all year.”