Commentary by Zackary Berger MD PhD, PGY-3, Health Care Policy Section Editor
As Massachusetts’ Secretary of Health and Human Services, JudyAnn Bigby, MD, is charged with overseeing the health-care program which covers nearly all of the Commonwealth’s residents (nearly 98%) while costing more than anyone expected (about 800 million dollars in 2008). On February 4th, Dr. Bigby spoke at NYU’s Medicine Grand Rounds, where she summarized the approach and accomplishments of Title 58, the health care legislation passed in 2006. The program had several goals: improving access, reforming the insurance market, and (it was hoped) improving outcomes. Bigby gave clear and convincing evidence for the first two goals, while the jury is still out on the third.
Title 58 kept the private insurance (employer-based) market, subsidizing the purchase of insurance by lower-income residents. In addition, Medicaid was expanded to cover anyone whose income was less than three times of the Federal poverty level. Massachusetts also reformed health insurance by merging the individual and small-group insurance markets, outlawing the denial of insurance based on pre-existing conditions, and (most importantly) creating the Massachusetts Health Connector, an agency providing a floor of affordable coverage – “minimal creditable coverage” – through which individuals can meet the state-imposed mandate for health insurance and avoid tax penalties ($900 in 2008).
The results as Bigby presented them are hard to dispute. The percentage of uninsured in the Commonwealth in 2000 was 5.9%; this figure underestimated the number of uninsured among subpopulations undersampled by surveys: people without landlines, immigrants, and those who don’t speak English. In any case, 2007 figures showed that the 97.4% of the population was insured, representing a significant improvement in coverage.
With widespread coverage comes greater access. Bigby said that the state was prepared for the increasing demand for primary care services: “Massachusetts has two and a half times per capita more primary care doctors” than other states. (She thus implied disagreement with some groups, like the Massachusetts Medical Society, who have found that the success of the Massachusetts program in guaranteeing access uncovered the shortage of primary care providers.) In 2008, 88% of residents reported having a primary care provider. This is down from 92% in 2007; however, the percentages of Hispanics and African-Americans reporting a primary care provider increased, from 70% and 82% in 2002, respectively, to 81% and 88% in 2007. Similarly, the proportion of Massachusetts residents reporting unmet healthcare needs, and unmet needs due to cost, has decreased – for example, the percentage of Massachusetts residents reporting the latter has decreased from 27% in 2006 in 17% in 2007.
Bigby also detailed her department’s implementation of pay for performance. Like other such programs across the country, Title 58 increased Medicaid payments to hospitals contingent on hospital adherence to standards designed to improve quality of care and patient safety, in part through decreasing health-care disparities. While hospitals’ adherence to these standards are understandably increasing, any improved outcomes are as yet unshown.
The speaker cited as a chief example of disparities the difference between races in rates of coronary artery bypass surgery, which remains even after clinical differences are accounted for. One question is whether such disparities are real; a questioner pointed out the possibility of confounding by indication, since academic medical centers (which serve more African-Americans and Hispanics) hew more closely to published guidelines in use of CABG. Another difficulty has been pointed out by the current literature: pay for performance might actually increase disparities, by perversely decreasing pay to doctors in minority communities and encouraging providers to avoid patients who might lower quality scores.
Given the obvious successes of the Massachusetts program in improving access, can it be applied on a national scale? While Bigby pointed out two unique aspects of the Commonwealth’s health care landscape – the generous Medicaid benefits the state provides and the high proportion of employer-based insurance – she said that an individual mandate would be important in guaranteeing universal coverage, as would reform of health care insurance. In awaiting the Obama Administration’s next moves, Bigby’s talk, and the Massachusetts experience, provided much to think about.