Tuesday, January 31, 2012

The Truth about Massachusetts Health Reform

If your view of Massachusetts health reform came from the Republican presidential debates you'd think the program is a catastrophe. That's baloney.

A recent article in Health Affairs shows it's a measured success, a work in progress.

An ongoing annual survey of 3,000 randomly selected households shows that uninsurance among nonelderly adults - the group most vulnerable to being uninsured - is steady at 94-95%, the highest insurance rate in the nation.  Emergency room visits for nonemergency conditions has declined. From 2006, when the reform went into effect, to 2010, self reported "excellent" health status improved from 59.7% to 64. There's been no drop in the rate at which employers offer insurance to employees. Two thirds of the population continue to support the program, though political bashing of "Obamacare" and "Romneycare" has led to an increase of those who are opposed to it from 17% to 27%.

As I see it, the key lesson from Massachusetts health reform is the process by which it launched and is currently handled. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Those leading the reform process decided to defer the most challenging aspects of reform - (1) cost containment and (2) delivery system reform, until almost everyone in the state was insured. The agenda for Massachusetts has now shifted to those two issues.

In 2012, Governor Patrick, a Democrat, is using the same process that Governor Romney, a Republican, used in 2006 - orchestrating broad stakeholder participation, and using the bully pulpit of the state house. Instead of bashing insurers for the health cost trend the Governor is directing insurers to drive hard bargains. This repositions the insurer from being the enemy of the public to being the agent of the public. The fact that more than 90% of the Massachusetts insurance market consists of locally based not-for-profits makes this a viable strategy for the state.

I'm deeply skeptical about the readiness of the U.S. to come to grips with health costs, but I'm guardedly optimistic about Massachusetts. This year rates in the small group market are going up by only 1.8% (see here and here). Fee-for-service is diminishing - 1.2 million folks (20% of the insurance market) are already in programs with global budgets. And from conversation with friends who practice in different hospitals and medical groups I know that the medical community is working on reengineering clinical systems to produce equal or better results at a lower cost.

If the Supreme Court finds the Accountable Care Act constitutional and it becomes clear that the law will stand, it will be easier for other states to do the kind of long term work with messy and difficult problems that Massachusetts is doing. Hysterical tantrums about "Obamacare" are getting tiresome!

(If you're interested in Mitt Romney's role in launching the Massachusetts reform process, see this excellent New Yorker article.)


Dennis Byron said...

"Truth" in the context of your headline is over the top. A few peoples' "opinion about" Massachusetts health reform would be a better way to title your post.

As you know the article is based on Blue Cross of Massachusetts research, which was looking for a certain outcome. Blue Cross and the contractors that did the research for them will not release the underlying data so it's hard to tell how "truthful" the data is. It is a fact that the BC data strongly contradicts the state of Massachusetts' own research in some areas (e.g., ESI, ER usage) as well as Mass Medical Society research (which to be fair, could also be biased).

But whatever the problems with the data (it's 18-months old, its self-reporting approach is highly suspect as a research tool, the methodology of "adjustment" is not explained, and so forth), the article itself and the BC report from which the article claim are clearly just opinion.

You conclude based on this opinion that "Those leading the reform process decided to defer the most challenging aspects of reform - (1) cost containment and (2) delivery system reform, until almost everyone in the state was insured."

I am not sure how you reached that conclusion based on the data but a purposeful choice of deferral of cost control and delivery methodology is not what "those leading the reform" promised between 2004-2006 in the run-up to the passage of RomneyCare. See the Romney op-ed in the Globe in November 2004 ( http://www.boston.com/news/globe/editorial_opinion/oped/articles/2004/11/21/my_plan_for_massachusetts_health_insurance_reform/ ) and his presentation to the Medicaid Commission in January 2006. In the op-ed, Romney began by promising

"What it will do is restrain the growth in healthcare costs and change how we provide healthcare for those who receive it at taxpayer expense."

Didn't happen as we now know.

Jim Sabin said...

Hi Dennis

Thanks for the comment. I visited your blog and see that you spend a lot of time in the weeds of data reporting. You're obviously well informed.

Re your question about the strategy of deferring attention to cost until the challenge of getting most Massachusetts folks covered by insurance - I've been told that by several people who were close to the political process that culminated in the 2006 legislation. In retrospect I think that was a wise political tactic, since cost containment is where painful choices will ultimately have to be made.



Dennis Byron said...

So just to be clear, you agree with my comment that when you said "those leading the reform" in your initial post, you really meant to say "several (unnamed) people who were close to the political process," whatever that means.

On one hand, there is the hard printed evidence of the one person most involved in leading the so-called reform. On the other hand, there is revisionist history by politicians (of both parties) and wonks, scrambling to explain the failure of their ideas.

Which should I consider accurate or -- to use an ethics term -- "the truth?"

Jim Sabin said...

Hi Dennis -

I think we'll have to agree to disagree on this. I believe what I heard from my sources. Governor Romney's statement was what a political leader had to say. No strong steps were taken to contain costs at the time. What's happening now may not work, but it's a real effort. If it fails we'll have to declare the Massachusetts reform process a failure. But I'm guardedly optimistic that we'll see some real progress over time.

But when candidates for office declare the Massachusetts effort to be a failure, chalk it up to running for office, not to truth.