As California undergoes implementation of the federal health care reform legislation over the next four years, the experiences and challenges Massachusetts has faced in its implementation of its own state-run health care reform can serve as a helpful guide.
In 2006, Massachusetts passed it own state health reform law long before the federal law was even conceived. Since its inception, the number of uninsured has fallen by half – from 13 to 7 percent over all. More specifically, the uninsured rate declined from 24 to 13 percent among low-income adults, from 18 to 9 percent among males and from 9 to 6 percent among females. The uninsured rate among young adults fell from 23 to 13 percent. There was also no evidence that subsidized insurance “crowded out” private insurance. In fact, low income people receiving coverage from their employers increased from 38 to 42 percent.
In addition to increased coverage, Massachusetts also saw improvements in access to care. Post-reform, Massachusetts saw an increase in the number of people accessing care, including an increase in preventative care and dental visits. There was also a decline in unmet care because of the cost of physicians, specialists, tests, prescriptions and dental care, particularly among low-income people. Last, out-of-pocket expenses declined substantially as did the percentage of people reporting difficultly paying for medical expenses.
Despite quantitative progress in these areas, Massachusetts continues to struggle with rising costs – health care costs and health insurance rates - as well as a limited supply of primary care physicians (PCPs), as more physicians opt for more lucrative specialty practices. In fact, a recent report has just revealed the number of visits to the emergency room increased 9 percent between 2004 and 2008 primary due to the shortage of PCPs in the state.
So what does this mean for California as it moves forward in enacting the federal health care reform?
It means the state should learn from the challenges Massachusetts faces and work to enact measures that avoid experiencing those same challenges here. What it shouldn’t mean is that California, nor any state for that matter, proceeds as if federal health care reform is a colossal failure because Massachusetts is struggling with some cost-containment, as a recent writer for the Wall Street Journal seems to suggest.
First, recognize that the federal health reform legislation has far more cost control measures included than the original Massachusetts plan. The state has also made moves since the law was enacted to control costs that California may consider adopting such as statewide electronic medical records, uniform billing and coding among health care providers and insurers, and an effort to increase the number of primary health care providers.
Second, analyze where there are similarities between the states and work to avoid falling in the same trap. For example, California also faces a shortage of primary care physicians who are reluctant to see patients on Medicaid (known as Medi-Cal in CA) because of low reimbursement rates. In the federal health care reform, reimbursement rates for physicians caring for Medicaid and Medicare patients have been increased, costing the state virtually nothing. In fact, the federal government will be picking up 96 percent of the tab for Medicaid expansion.
California should also consider leveraging the billions of federal dollars to be invested into the community health clinic system to increase the number of PCPs. And we shouldn’t stop there.
Massachusetts has the costliest medical care in the nation and virtually no competition among health care providers – particularly the academic medical centers and hospitals - or health insurance plans. Thus, when the providers’ costs increase, the health insurance companies pass those costs directly to the health insurance consumer to maintain their profits. As California enacts reform, it must look to ensure that health market competition exists among health care providers and insurers.
I obviously don’t have all the answers to what may or not happen as California enacts health care reform over the next few years. But I do know that ensuring all Californians get the health care they need is a cause we should all be working toward.
Will we hit bumps the road in enacting reform? Yes. Does that mean when we do, we try to overcome those obstacles? Yes, indeed!