Massachusetts Health Insurance Reform Research Articles

Diabetes Control During Massachusetts Insurance Reform.

Racial/ethnic disparities in glycemic control-a key diabetes outcome measure-continue to widen, even though the overall prevalence of glycemic control in the US has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a 6-month period; 2) A1C >8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

Engaging Human Rights Norms to Realize Universal Health Care in Massachusetts, USA

Massachusetts is a national leader in health care, consistently ranking in the top five states in the United States. In 2006, however, only 86% of adults aged 19-64 had health insurance. That year, Governor Romney signed into law An Act Providing Access to Affordable, Quality, Accountable Health Care. By 2017, more than 96% of these adults were insured. The 2006 Massachusetts health insurance reform later became the model for the 2010 federal Patient Protection and Affordable Care Act, also known as Obamacare. This article examines, through a human rights lens, the 2006 Massachusetts health insurance reform 10 years after its implementation (2007-2017) to shed light on the effectiveness of this approach in achieving universal health coverage. Drawing on documentary and interview data, and applying international human rights norms, we found that (1) the 2006 Massachusetts health reform replaced a crisis of uninsurance with a crisis of underinsurance; (2) state leaders in health reform propose widely diverging solutions to the increasing health care costs, the inability of many residents to afford needed health care, and the persistence of medical bankruptcies; and (3) health care is recognized as a human right in Massachusetts, but understanding of the substance or potential of the right is limited.

Health Insurance, Fertility, and the Wantedness of Pregnancies: Evidence from Massachusetts

Health insurance reform in Massachusetts lowered the financial cost of both pregnancy (by increased coverage of pregnancy-related medical events) and pregnancy prevention (by increasing access to reliable contraception and family planning). We examine fertility responses for women of childbearing age in Massachusetts and, on net, find no effect from increasing health insurance coverage. This finding, however, masks substantial heterogeneity. For married women aged 20 to 34 – who have high latent fertility and for whom pregnancies are typically wanted – fertility increased by approximately 1 percent. For unmarried women in the same age range – for whom pregnancies are typically unwanted – fertility declined by 10 percent. Fertility rates changed very little for other groups, in part because of low latent fertility or minimal gains in insurance coverage.

HEALTH INSURANCE, FERTILITY, AND THE WANTEDNESS OF PREGNANCIES: EVIDENCE FROM MASSACHUSETTS

Health insurance reform in Massachusetts lowered the cost of both pregnancy (by increased coverage of pregnancy‐related medical events) and pregnancy prevention (by increasing access to reliable contraception). We empirically examine fertility responses and find no overall effect from increased coverage due to the Massachusetts reform. This finding, however, masks substantial heterogeneity. For married women aged 20 to 34—with high latent fertility and pregnancy wantedness—fertility increased by approximately 1%. For unmarried women in the same age range—for whom pregnancies are typically unwanted—fertility declined by 8%. (JEL I13, I18, J13)

The Impact of Massachusetts Health Insurance Reform on Labor Mobility

This paper examines the impact of the Massachusetts Health Insurance reform of 2016 on job mobility and employment exit using administrative data from the Social Security Administration. The Massachusetts reform mandated that every resident have insurance coverage and facilitated this initiative by requiring employers to offer coverage, as well as expanding Medicaid and creating health insurance exchanges with subsidized premiums. These elements provided the basis for the Patient Protection and Affordable Care Act (ACA) passed nationwide in 2010, so the experience of workers in Massachusetts provides evidence for how the ACA may affect labor market efficiency. Of particular interest is the extent to which Massachusetts’ reform reduced “job lock” – the phenomenon in which workers stay with employers to maintain their health insurance coverage, rather than move to a more productive match at another employer (especially a small firm unlikely to offer coverage) or exit employment entirely. The project measures differential effects by age, gender, and firm size, and tries to disentangle the effects of the employer mandate and the individual mandate by identifying individuals who cross state lines between home and work. This paper found that: • Trend analysis and regression estimates indicate that Massachusetts residents were actually less likely to move to new employers after the reform, relative to workers in neighboring states that did not make structural changes to their health insurance markets. • Estimates of whether Massachusetts workers moved from large firms, which likely offered insurance, to small firms is statistically insignificant. • Employment transitions were largely unaffected by the Massachusetts reform, though some select groups saw increases in employment exits that may be consistent with the easing of job lock. The policy implications of this paper are: • On the whole, the evidence that the Massachusetts reform increased mobility across employers or out of employment is weak. • These findings suggest that either job lock does not tie workers to their jobs as much as labor economic theory had suggested, or that the Massachusetts reform, and by extension the ACA, may not ease job lock as much as some previous research had suggested.

Part-time Employment and Health Insurance Reform: What Can Massachusetts Tell Us about the Affordable Care Act?

<p>Experience with health insurance reform in Massachusetts may provide a good forecast of the impact of the Affordable Care Act [ACA] on the growth of part-time employment. Concerns have been expressed that the ACA will lead to growing part-time employment, but it will take several years to observe this effect and whether it is labor demand (firm) or labor supply (worker) initiated. Using state-level data from 1999 to 2012, I treat the 2007 implementation of the new Massachusetts health insurance system as an “experiment” to examine whether it had any differential effect on the growth in part-time employment in the state. A panel estimation including fixed cross-section and period effects reveals that voluntary part-time employment increased in Massachusetts relative to the other states, but reform measures did not have an effect on involuntary part-time employment. The impact of the reform on voluntary part-time employment suggests that some Massachusetts workers found the pre-reform system to be an obstacle to their choice of optimal work hours. The implementation of the ACA, by providing avenues for obtaining health insurance that are not directly tied to employment, may remove this obstacle for workers in other states and make part-time employment a more attractive choice for workers across the U.S.</p>

Member Plan Choice and Migration in Response to Changes in Member Premiums after Massachusetts Health Insurance Reform

In 2006 Massachusetts implemented a substantial reform of its health insurance market that included a new program for uninsured individuals with income between 100% of Federal Poverty (the upper limit for state Medicaid benefits) and 300% of Federal Poverty. Enrollment was compulsory for all citizens because of a mandate. Consumers who enrolled in this program, which offered generous benefits with low copays, received graduated subsidies depending on their income. Five insurers were contracted to underwrite the program, and consumers were able to choose their insurer. Insurers bid annually, and the member contribution was set according to an affordability schedule for the lowest-bidding insurer. Consumers could choose from the range of insurers, but if they chose a plan other than the lowest cost, their contributions reflected the difference. Premiums were changed annually at July 1, and members were eligible to move to a different plan at this date; a number of members migrated each year. This study aims to quantify the effect of this premium-induced switching behavior. Prior studies of member switching behavior have looked at employer plans and estimated the elasticity of response to changes in member contributions. The Massachusetts environment is unique in that there is a mandate (so being uninsured is not an option) and members may choose insurer but not benefit plan. Thus a study of migration in Massachusetts is uniquely able to quantify the effect of price (contribution rates) on member switching behavior. We find elasticity averaging −0.21 for 2013 (the last year of the study) to be somewhat lower (in absolute value) than previous studies of employer populations. Elasticity has also been significantly increasing with time and appeared to have at least doubled over the studied period (i.e., 2008–2013). Prior studies have estimated higher elasticities in the range −0.3 to −0.6. We found that the data contained many outliers in terms of both changes in contributions and percentage of members switching plans. The effect of outliers was moderated by the choice of robust regression models, leading us to question whether other studies may have been affected by outliers, leading to overestimates of the elasticities.

Health insurance reform and part-time work: Evidence from Massachusetts

A concern with requiring employers to provide health insurance to full-time employees is that employers may increase their use of part-time workers to circumvent the mandate. In this paper, we study the effect of the employer mandate in the Massachusetts health insurance reform on part-time work using a difference-in-differences strategy that compares changes in part-time work in Massachusetts after the reform to changes in various control groups. We find strong evidence that the Massachusetts employer mandate increased part-time employment among low-educated workers and some evidence that it increased part-time employment among younger workers. Our estimate of a 1.7 percentage point increase in part-time employment among workers without a college degree suggests that lower-skilled workers may be vulnerable to having their hours cut so that employers do not have to offer them health insurance.

Use of Intensive Care Services and Associated Hospital Mortality After Massachusetts Healthcare Reform*

To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality. Population-based cohort study. Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform. All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission. We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients. Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%). Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.

Physician Payments Under Health Care Reform

This study assesses the impact of major health insurance reform in Massachusetts on the prices of services paid to physicians in the privately insured market. We estimate that the reform caused physician payments to increase at least 10.8 percentage points. This impact occurred while the legislation was materializing but before the final compromised version of the reform was enacted in April 2006. This finding is consistent with prices being set in a forward-looking manner, in anticipation of the reform. Overall, one-sixth of physician service price growth in Massachusetts between 2003 and 2010 was directly attributable to the insurance reform.

The Effect of the Massachusetts Healthcare Reform on Emergency Department Use

Lack of healthcare insurance is considered one of the drivers of the rise in emergency department (ED) use in the United States. Using survey‐based, individual‐level data, we compare ED use after the 2006 Massachusetts health insurance reform with ED use before the reform both in Massachusetts and nearby states. We find that the reform increased the insurance rate significantly by 5.29 percentage points. We do not find a statistically significant effect on ED visits but do not have enough power to rule out potentially relevant effects. It seems that policy makers hoping that insurance reform will dramatically decrease ED overcrowding are likely to be disappointed.

Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis

Massachusetts law requires all residents to maintain a minimum level of health insurance, and rates of uninsurance in that state decreased from 6.4% in 2006 to 1.9% in 2010. The authors of this report assessed whether health insurance expansion was associated with use of mammography and earlier stage at breast cancer diagnosis. By using a prereform/postreform design with a concurrent control (California), mammography rates in the last year were assessed using the Behavioral Risk Factor Surveillance System survey and the diagnosis of stage I (vs II/III/IV) breast cancers based on cancer registry data among women ages 41 to 64. Propensity score analyses were used to compare California women who were most similar to women in Massachusetts with Massachusetts women. Among propensity-weighted cohorts, adjusted mammography rates in Massachusetts were 69.2% in 2006, 69.5% in 2008, and 69.0% in 2010. In California, the rates were 59% in 2006, 60.3% in 2008, and 56.2% in 2010 (P = .89 for interaction by state for 2010 vs 2006). Among propensity-weighted cohorts, adjusted rates of diagnosis with stage I cancers were 52.2% in 2006, 53.5% in 2007, and 52.4% in 2008 in Massachusetts versus 46.4% in 2006, 46.3% in 2007, and 45.7% in 2008 in California (P = .58 for interaction by state for 2010 vs 2006). Health insurance reform in Massachusetts was not associated with increased rates of mammography or earlier stage at diagnosis compared with California, possibly because of insurance and mammography rates that already were high. Additional research is needed to assess the impact of insurance expansions in other populations, especially those with higher uninsurance rates.

Implementation of Massachusetts Health Insurance Reform with Vulnerable Populations in a Safety-Net Setting

This qualitative study examines the experience of racial and ethnic minorities receiving behavioral health care in a safety net setting during the early process of health insurance reform in Massachusetts. Three rounds of interviews were conducted between August 2007 and May 2009, collecting information from patients (n=65) on the experience of health reform and delivery of mental health care. Four categories of enrollees transitioning into health reform emerged over the course of the study that grouped into a typology of experiences with reform: early enrollees, middle enrollees, late enrollees, and multiple switchers. With support, a majority of the sample transitioned smoothly to the new health insurance mechanisms. However, some experienced administrative confusion and disruption in mental health care during the transition. Administrative policies providing special accommodations for individuals with mental health disorders and other vulnerable populations may be important to consider during the transition to health insurance reform.