Robert Seifert, Principal Associate, Center for Health Law and Economics, Umass Medical School, finds that the poor, the underemployed and the under-educated in Massachusetts are more likely to have intermittent health insurance:

The Division of Health Care Finance and Policy last month released detailed tables from its 2009 Massachusetts Health Insurance Survey, and the news was very encouraging. The survey estimates that 2.7 percent of Massachusetts residents were uninsured when surveyed, statistically unchanged from 2008. This is a remarkable statistic in light of the economic downturn in Massachusetts during 2009.

Twice as many people as were uninsured when surveyed were uninsured during some part of the year, however, and this is worthy of our attention. About 5.5 percent of Massachusetts residents (350,000 people) reported having been without insurance some time in the 12 months prior to the survey. This includes 7.7 percent of adults under age 65, or about 300,000. From the Division’s tables, it appears that someone is more likely to have had a spell of being uninsured if one:

–Is a non-citizen
–Has been in the state less than 5 years
–Has a family income less than 3 times the federal poverty level (about $55,000 for a family of three)
–Has less than a college education
–Is in a family with no full-time workers

In short, some of the same characteristics that are generally understood to be risk factors for being uninsured in the rest of the U.S. seem to be risk factors in Massachusetts for being intermittently insured. Read more…

Robert Seifert, Principal Associate at the Center for Health Law and Economics, UMass Medical School, says national health care reform will impact Massachusetts in unique ways and may set up conflicts between federal and state law:

The vote by the Senate Finance Committee to report out a health care reform bill adds momentum to the drive toward national reform. There are now two bills in the Senate and three in the House that, over the coming months, Congress will work to craft, cobble and cram into a single piece of legislation. It is a challenging task with high stakes: an opportunity for major coverage expansions, insurance reforms, and other key features of these bills may not come again for years.

There is no question that the nation needs reform that expands meaningful health insurance coverage to the tens of millions of people who now go without. There is wide support for reform in Massachusetts, and a hope that the rest of the country can benefit in the way many people have benefited here. But Massachusetts is in a unique position among states, having been out front on this issue, and national reform will affect this state differently from others. Whatever the outcome in Washington, Massachusetts should be allowed to continue on its present path.

My colleagues and I at UMass have been tracking the many provisions of the national bills that would affect features of the Commonwealth’s 2006 health care reform initiative. Some elements of the bills are based directly on the Massachusetts model (all include an individual mandate and a Connector-like “Exchange,” for example) but differ in their details, setting up a potential conflict between federal and state laws. Some key issues worth following as the debate proceeds include:

–Massachusetts would not be eligible to receive most of the additional federal matching funds for Medicaid and CHIP that the Senate Finance bill makes available for newly covered populations because Massachusetts already covers these groups. The House bill would bring Massachusetts an additional $350 million to $450 million per year in federal match.

–The premium subsidies in all of the bills are less generous than in Massachusetts; additionally, all of the bills envision consumers at lower income levels than in Massachusetts having to contribute to premiums. Read more…

There is a three-fold variation in per capita spending on Medicare patients across 300-plus health care markets in the United States, according to the Dartmouth Atlas of Health Care. Lurking in that variation lie important clues to reducing the overuse of unnecessary services, a key to limiting the growth of health care spending. Surgeon-journalist Atul Gawande traveled to McAllen, Texas to investigate those clues and wrote about it in the June 1 New Yorker magazine.

McAllen had the second highest spending per Medicare beneficiary in the country in 2006 – $14,946, behind only Miami. Gawande uses data to dismiss explanations for the excessive spending offered by area physicians – an unhealthy population, better services, the threat of malpractice suits – and points out that in El Paso, a city with similar demographics and public health statistics, spending is half of what it is in McAllen. He argues (and several of the doctors he speaks with agree) that McAllen’s cost disparity is largely the result of a culture of medical practice that overuses intensive, expensive technologies and services.

Dartmouth researchers and others have compellingly argued that, in medicine, more is not necessarily better. Read more…

The Massachusetts health care reform law was enacted 3 years ago this month. Much credit for the law’s passage was given to the balance struck among various interests, and to the concept of “shared responsibility” for financing the expansion of health insurance coverage. Since April of 2006, over 400,000 more people in Massachusetts have health insurance, but there has not yet been a full assessment of whether the goal of shared responsibility is being realized.

Our analysis, being released today by the Blue Cross Blue Shield of Massachusetts Foundation, suggests that it is, at least at this early stage of reform. We took a comprehensive look at who was paying the premiums and other costs of private and public health insurance among employers, consumers, and government in 2005, the year before the law, and in 2007, the first full year after. We also looked at the distribution of spending on uncovered services, since an explicit goal of reform was to see these payments reduced as coverage increased.

Overall, we found that the shares of spending on coverage and uncovered services remained essentially the same between 2005 and 2007: employers and union health plans accounted for about 45 or 46 percent of total spending, government contributed about 30 percent, and individuals the remaining one-quarter. Embedded in these overall findings were some interesting dynamics. Read more…

The Massachusetts unemployment rate reached 6.9 percent in December 2008, up from 5.0 percent in August and 4.3 percent the previous December. An Urban Institute study for the Kaiser Family Foundation found that each percentage point increase in the unemployment rate nationally leads to an increase of 1.1million uninsured and 1 million Medicaid enrollees. In Massachusetts, we can certainly expect that the loss of employer-based insurance that comes with layoffs will lead to increasing numbers eligible for MassHealth and Commonwealth Care. Indeed, if the Commonwealth is to maintain the high level of coverage that it has achieved since the enactment of Chapter 58, growth in these publicly subsidized programs is inevitable.

This, of course, costs money ¬– money that is scarce in the Commonwealth, as the Governor and Legislature wrestle with outsized budget deficits. But help may be coming from the federal government. Read more…

How is our faltering economy likely to affect the Commonwealth’s recent gains in health care access and coverage? The most direct effect will be a probable decline in employer-sponsored health insurance: since most people get their health coverage through an employer, a drop in employment would mean a loss of coverage. (I should note here that, thus far, major metropolitan areas in Massachusetts have dodged the job losses befalling much of the rest of the country.) This trend would be offset somewhat by the fact that Massachusetts has in place a very strong coverage safety net – MassHealth and Commonwealth Care. These programs, authorized by the federal government under the Commonwealth’s Medicaid demonstration waiver, are designed to be countercyclical – enrollment should rise when economic conditions decline. Governor Patrick’s recent budget cuts maintain eligibility and benefit levels in MassHealth and CommCare, though the increased enrollment that likely will result from contraction in the private sector would put further pressure on the State budget.

Even if the number of uninsured does not grow significantly, though, the number of underinsured might. A real phenomenon with no precise definition, “underinsurance” basically describes a circumstance in which health insurance does not adequately protect a person from prohibitive, potentially catastrophic medical expenses. Read more…

A letter to the editor about Senator Obama’s health care proposals in last Friday’s New York Times concludes, “There is no question that we spend a lot of money on health care in this country. Let’s not rule out the possibility that we are getting our money’s worth.” Sadly, it seems clear that the U.S. health care system overall is in fact not delivering value for our dollars, when compared with other countries or the highest performing states. This is the inescapable conclusion of the latest “National Scorecard on U.S. Health System Performance,” just published by The Commonwealth Fund.

The report scores the U.S. health system on 37 indicators in five areas: healthy lives (measures of mortality, life expectancy and limitations on activity); quality (effectiveness, coordination, safety and patient-centeredness of care); access (coverage and affordability); efficiency (administrative and clinical waste, inappropriate care or setting, readmissions); and equity (racial and ethnic disparities across select measures). Overall, the U.S. scores a 65 compared with a benchmark score of 100 and shows no improvement since the Fund published its first scorecard in 2006. Across the specific indicators, only 35 percent of them showed improvement from the 2006 report to 2008, while scores relative to benchmarks fell for 41 percent of the measures. It’s a discouraging assessment. As the authors put it: “The U.S. health system continues to exhibit suboptimal performance relative to what is achievable and to the resources invested.”

How do we improve? Read more…

Supporters, detractors and agnostics of Massachusetts’s health care reform law have all been noting the second anniversary of the law’s enactment with respective celebration, criticism and, well, agnosticism. This week the Blue Cross Foundation, a central force in the development of health reform policy over the last several years, will host a policy summit titled “Health Reform Turns Two: Monitoring the Impact of Expanded Coverage,” at which Urban Institute researchers, who have provided illuminating analysis from the beginning of this journey, will report their findings on where things stand today. Health care issues are also prominent in national political campaigns, of course, and Massachusetts is often held up as a model of how to – or how not to – do it right.

What is the long view? Can Massachusetts reach and sustain its goal as one of a very few individual states that have enacted broad coverage reforms without national reform soon to follow? And what is the state’s role, as a “laboratory of democracy,” in bringing about national reform? Read more…

The Massachusetts Health Council held a conference today titled “The Road to Affordability: Models to Control Health Care Costs and Improve Quality.” The conference featured representatives from several organizations prominent in the drive for “high value” health care. Cathy Schoen of the Commonwealth Fund reported on the work of Commonwealth’s Commission on a High Performance Health System which, among others things, has published Bending the Curve, a useful set of policy options for achieving savings while improving value in the health care system. Dr. Ronald Paulus of Geisinger Health System, an integrated delivery system (hospitals, group practice and health plan) in central Pennsylvania, spoke of how the system has used data and measurement to drive a transformation in how it delivers care, resulting in savings and better outcomes for its patients. David Pryor of Ascension Health – a large, multi-state hospital system – also spoke of clinical transformation in its improvements in mortality rates, perinatal safety, hospital-acquired pressure ulcers, and other processes. Read more…

I would like to use this visit to the blog to call attention to a new article by Laurence Baker, Elliott Fisher and John Wennberg, published on the Health Affairs website a couple of weeks ago. The authors analyzed hospital use by chronically ill patients in California and found a wide variation of resource use across hospitals treating patients with similar characteristics. The authors suggest that understanding the variation presents an opportunity for significant savings in health care expenditures by reducing resource use at the most resource-intensive hospitals, particularly because there is some evidence (in this study and others) that systems using greater resources actually deliver lower quality care.

This new research reinforces a larger body of work documenting the inefficient overuse of certain services and calling for better alignment of incentives and local delivery system accountability for the cost and quality of care. (I’ve written about some of Fisher’s contributions before here.)

Cost control solutions such as increasing copayments in order to slow premium growth, as the Connector Authority is now considering, address short-term fiscal demands but are unlikely to have a great effect on costs and may hinder access. Read more…