Massachusetts' 2006 health reform law provided a model for national reform but there are some differences. The experiences in Massachusetts can provide lessons for New York. Health reform in Massachusetts significantly increased insurance coverage and access to care while improving affordability. Ongoing challenges include continuing increases in health care costs and ensuring access to providers. Addressing rising costs is critical going forward.

1. Getting Ready for Health
Reform in New York:
Lessons from Massachusetts
Sharon K. Long
University of Minnesota
Twenty-first Annual Symposium on
Health Services in New York: Research and Practice
November 3, 2010

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Overview of the Presentation
• How Massachusetts’s 2006 health reform
initiative compare to national reform?
• Can the experiences under health reform in
Massachusetts provide lessons for New York?
• What were the impacts of health reform in
Massachusetts?
• What are the challenges Massachusetts faces
going forward?

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How does Massachusetts’s 2006 health
reform initiative compare to national
reform?
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National reform is modeled on
Massachusetts’s 2006 legislation
• Expansion of eligibility for public programs
• Creation of health insurance exchanges
• Subsidies for low- and moderate- income
individuals
• Expansion of dependent coverage
• Individual mandate
• Requirements for employers
• Standards for covered benefits

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However, there are some are important
differences in national reform
• Expands subsidies to higher income levels (400% FPL versus
300% FPL) but provides lower subsidies for some
• Imposes lower standards for affordability under the individual
mandate
• Provides more generous expansion of dependent coverage
(doesn’t require that child be claimed as dependent for tax
purposes)
• Provides tax credits for small businesses
• Limits penalties for employers who do not offer insurance
coverage to larger firms (>50 workers versus >10 workers)
• Extends some insurance protections to workers in self-
insured plans which are not under the purview of state
regulators

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Can the experiences under health reform
in Massachusetts provide lessons for
New York?
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Overview of Key Changes in Coverage Options
Under Health Reform in Massachusetts
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Pre-Reform Post-Reform
Children
Public coverage < 200% FPL < 300% FPL
Parents
Public coverage < 133% FPL < 300% FPL
Premium support < 200% FPL < 300% FPL
Subsidized coverage -- < 300% FPL
Purchasing pool -- > 300% FPL
Childless Adults
Public coverage -- < 300% FPL
Premium support < 200% FPL < 300% FPL
Subsidized coverage -- < 300% FPL
Purchasing pool -- > 300% FPL
Note: FPL is federal poverty level

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Comparing Insurance Coverage in New York to
Pre-Reform Massachusetts
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New York
2009
Massachusetts
2005
All Residents
Any coverage 89.8% 94.5%
Private coverage 57.3% 66.5%
Public coverage 32.5% 28.0%
Non-elderly Adults
Any coverage 85.7% 90.8%
Private coverage 67.0% 76.4%
Public coverage 18.7% 14.4%
Source: 2006-2009 National Health Interview Survey from Cohen and Martinez (2006) and Cohen, Martinez and Ward
(2010).
Note: Individuals reporting both private and public coverage are assigned to public coverage.

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Comparing recent economic measures
between New York and Massachusetts
• Unemployment rate
– MA – 8.4%; NY – 8.3%
• Average hourly earnings, private non-farm payroll
– MA – $27/hour; NY – $26/hour
• Employees in firms with 50 or more workers
– MA – 74%; NY – 72%
• Private-sector establishments offering health
insurance
– MA – 62%; NY – 59%
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Comparing Coverage Options in New York to
Pre-Reform Massachusetts
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New York
Pre-Reform
Massachusetts
Children
Public coverage < 400% FPL < 200% FPL
Parents
Public coverage < 150% FPL < 133% FPL
Premium support < 250% FPL < 200% FPL
Childless Adults
Public coverage < 100% FPL --
Premium support < 250% FPL < 200% FPL
Note: FPL is federal poverty level

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What were the impacts of health reform
in Massachusetts?
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Data
• Massachusetts Health Reform Survey
– Targets non-elderly adults 18-64
– Conducted every fall from 2006 to 2010 (underway)
– Oversamples of lower-income and uninsured adults
– Telephone interviews, including cell-phones in 2010
– Sample size ~3000
• Funded by Blue Cross Blue Shield of
Massachusetts Foundation
– Additional funding from Commonwealth Fund and
Robert Wood Johnson Foundation in earlier years

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Methods
• Estimate impact of health reform as change over
time from fall 2006
– Pre-post estimates will also capture recession &
health care cost trends
– Consistent findings from studies using national data
• Multivariate regression models control for
demographic characteristics, health and
disability status, socioeconomic status and
region of state
– Estimate linear probability models, controlling for
complex survey design

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Summary of Findings on Impacts
• Increase in insurance coverage, with no crowd
out of private coverage
• Improvements in access to and use of health
care
• Improvements in affordability of health care for
individuals
• Support for health reform remains strong in the
state

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Health insurance coverage, 2006-2009
88%
92%
95% ***
98%***
0%
20%
40%
60%
80%
100%
Currently insured Ever insured over year
2006 2009
Source: 2006-2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
* (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.
Adults more likely to have health insurance under health reform.

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Type of health insurance coverage,
2006-2009
66%
22%
68% ***
27%***
0%
20%
40%
60%
80%
100%
Employer-sponsored insurance Public and other coverage
2006 2009
Source: 2006-2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
* (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.
Employer-sponsored insurance coverage increased under health reform.

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Employers’ insurance offer and
employees’ take-up, 2005-2009
70%
78%76%
80%
0%
20%
40%
60%
80%
100%
Employers offering coverage Employees taking up coverage
2005 2009
Source: 2006-2009 Massachusetts Division of Health Care Finance and Policy Employer Survey
Employers more likely to offer health insurance coverage to workers
and workers more likely to take-up coverage under health reform.

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Type of health insurance coverage,
2006-2009
4,333
40
705
4,374
90
1,008
0
1,000
2,000
3,000
4,000
5,000
Private group Individual purchase Public
Thousands
2006 2009
Source: 2006-2009 Massachusetts Division of Health Care Finance and Policy enrollment data from health plans and
programs.
No evidence of public coverage crowding out of employer-sponsored
insurance coverage under health reform.

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Health care access and use, 2006-2009
86%
80%
70% 68%
89%**
86%***
78%***
75%***
0%
20%
40%
60%
80%
100%
Usual source of care Any doctor visit Preventive care visit Dental care visit
2006 2009
Source: 2006-2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two tailed test
Adults more likely to have a regular health care provider and to have had
health care visits over the prior year under health reform

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Unmet need for care, 2006-2009
24.9%
7.7%
9.1%
7.9%
6.8%
19.0%***
5.3%** 5.7%*** 5.7%**
4.9%**
0%
5%
10%
15%
20%
25%
30%
Any unmet need
for health care
Doctor care Medical tests,
treatment, or
follow up care
Prescription drugs Preventive care
screening
2006 2009
Source: 2006-2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test
Adults less likely to have unmet need for any reason under health reform

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Health care costs and affordability for
individuals, 2006-2009
9.5%
19.1% 19.5%
16.3%
4.4%***
19.1%
20.3%
11.7%***
0%
10%
20%
30%
OOP health care
costs=>10% of family
income
Problems paying
medical bills
Medical debt Unmet need because of
cost
2006 2009
Source: 2006-2009 Massachusetts Health Reform Survey
Note: Regression-adjusted estimates
*(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test
Improvements in affordability of care under health reform despite
increasing health care costs and economic recession

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Residents support for health reform,
2006-2008
61%
52%
69%
58%
0%
20%
40%
60%
80%
100%
Support for health reform Support for the individual mandate
2006 2008
Source: Blendon et al. (2008)
Support for health reform among Massachusetts residents has remained
strong

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Physicians support health reform, 2008
70%
75%
13%
7%
17% 18%
0%
20%
40%
60%
80%
100%
Support for the health reform law Support for continuing with reform
For Against Neither for nor against/Don't know
Source: SteeleFisher et al. (2009)
Support for health reform among Massachusetts physicians is strong

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What are the challenges Massachusetts
faces going forward?
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Challenges in Massachusetts prior to
health reform
• Uninsurance, particularly among non-
elderly adults
• Provider shortages in some areas,
particularly for primary care and
populations with public coverage
• High and rapidly rising health care costs
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Reform addressed uninsurance, but
access and, especially, costs remain issues
• Health insurance coverage does not guarantee
access to care
– 1 in 5 adults reported unmet need for care
– 1 in 5 adults reported difficulty finding a doctor that
would see them
• Health care costs continue to threaten gains
under health reform
– 1 in 5 adults reported problems paying medical bills
– Cost remains major reason for continued uninsurance

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Addressing continued increases in costs of
care is “harder than expanding coverage”
• Passed 2006 legislation with knowledge that
would need to address costs in future legislative
efforts--“Round II” of health reform
• Considerable consensus in the state on the need
to address continued escalating costs
• Less consensus as to how to address rising
health care costs

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Massachusetts must also address differences
under national reform
• Many new rules and regulations that affect state
• Examples:
– Under current provisions, some Massachusetts
residents will face both federal and state penalties
under the individual mandate if they do not obtain
coverage
– Under current provisions, some Massachusetts
employers will face both federal and state penalties for
not offering coverage to their workers
– May need to change structure of the exchanges

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Contact information
Sharon K. Long
University of Minnesota
slong@umn.edu
612-624-4802
©2002-2009 Regents of the University of Minnesota. All rights reserved.
The University of Minnesota is an Equal Opportunity Employer