AMA Journal of Ethics^®

Massachusetts’s 2006 comprehensive health reform initiative was the template for the Patient Protection and Affordable Care Act (ACA) of 2010, which is making wide-ranging changes to the health care system nationally. Like the Massachusetts 2006 reform, the ACA utilizes a Medicaid expansion option, subsidies for private insurance, a health insurance marketplace, insurance market reforms, requirements for employers, and an individual coverage mandate, among other things, in an effort to expand health insurance coverage for the nation [1]. There is early evidence of rapid gains in insurance coverage for the nation under the ACA [2-4], echoing the large gains in coverage in Massachusetts following its 2006 reform [5-10]. Subsequently, health insurance coverage in the Commonwealth has remained well above the national average [11-17]. For example, in 2013, 95.4 percent of all Massachusetts residents were estimated to be insured, while only 85.6 percent of residents nationwide were [11].

Health insurance coverage provides a first step toward improving access to and affordability of health care for all, but coverage does not guarantee either access or affordability. This paper examines Massachusetts residents’ satisfaction with their health insurance coverage using the 2013 Massachusetts Health Reform Survey (MHRS) [18]. We find that nonelderly adults in Massachusetts are generally quite satisfied with their coverage, their network of health care practitioners, and the quality of care available with their plans. However, they are less satisfied with the financial protections afforded by their health insurance coverage and often report financial barriers to care and problems paying medical bills. Health care affordability continues to be a challenge for Massachusetts residents, despite near-universal coverage.

Massachusetts Health Reform Survey

The MHRS has been conducted by the Blue Cross Blue Shield of Massachusetts Foundation most years since 2006 to monitor and understand the state’s health care system [19]. Its participants are a stratified random sample of approximately 3,000 adults aged 19 to 64 interviewed by telephone (landline and cell phone) in English and Spanish [18]. The 2013 response rate was 30.4 percent. The MHRS gathers information on health insurance coverage, including the respondent’s assessment of it; health care access and use, including the respondent’s experiences with using it; and health care affordability.

All tabulations based on the MHRS were prepared using weights that adjust for the complex design of the survey, undercoverage, and survey nonresponse. In this text, we focus on estimates that were statistically significant at the five percent level or better.

Results

Massachusetts attained near-universal coverage by the second year after health reform and has maintained it ever since [11-17]. The most recent federal survey data show that 94 percent of nonelderly adults in Massachusetts had health insurance coverage at the time of the survey in 2013, with most of those adults covered all year [11].

In 2013, nearly two-thirds of insured adults in Massachusetts rated their health insurance coverage as very good or excellent in terms of the range of services available, the choice of doctors and other practitioners, the quality of care available, the locations of their doctors and other practitioners, and their ability to gain access to specialist care (see figure 1). Roughly another quarter rated each of those aspects of their plan as good. The remaining adults rated those dimensions of their health plans fair or poor.

Figure 1. Rating of care available under health insurance plan by insured nonelderly adults (ages 19-64) in Massachusetts, fall 2013 [18].

Higher-income adults (defined as those whose family income is at or above 300 percent of the federal poverty level, or FPL) tended to rate their health plans more favorably than did those with lower incomes (see figure 2).

Figure 2. Rating of care available under current health insurance plan by insured nonelderly adults (ages 19-64) in Massachusetts, by family income, fall 2013 [18].

Nearly a quarter (23.2 percent) of the insured adults who had coverage for all of the prior year reported difficulty obtaining health care because of lack of access, including 10.5 percent who reported difficulty finding a general doctor and 9.4 percent who reported difficulty finding a specialist. These problems were more common for lower-income than higher-income adults.

Massachusetts’s health care consumers rated the financial protection against high medical bills provided by their health plans less favorably than the nonfinancial aspects of their care. Only half of insured adults rated their plan’s financial protections as very good or excellent; nearly one in five (17.1 percent) rated their plan’s financial protections as fair or poor (see figure 3). As with the ratings of the nonfinancial aspects of their insurance plans, higher-income adults tended to rate the financial protections under their plan more favorably than lower-income adults did; two of the differences were statistically significant.

Figure 3. Rating of financial protection under current health insurance plan by insured nonelderly adults (ages 19 to 64) in Massachusetts, overall and by family income, fall 2013 [18].

Problems with health care affordability were relatively common among insured adults in Massachusetts: 18.3 percent of insured adults reported expensive medical bills for services not covered by their health plans, and 25.1 percent of those who had coverage all of the prior year had had problems paying medical bills. Notwithstanding these issues, very few (roughly 1 percent) of the adults with coverage all of the prior year went without needed medical care because of costs; however, dental care and prescription drugs were more of a challenge, with 8.7 percent of adults with full-year coverage forgoing needed dental care and 6 percent skipping needed prescription drugs.

Problems with health care affordability were more of an issue for lower-income adults than for higher-income adults. As shown in figure 4, 28.9 percent of lower-income adults who were insured all year were very worried about their ability to pay their medical bills in the future, while only 13.8 percent of their higher-income counterparts were; the differences were statistically significant.

Figure 4. Worry about ability to pay medical bills in the future by insured nonelderly adults (ages 19 to 64) in Massachusetts, overall and by family income, fall 2013 [18].

Conclusions

While near-universal health insurance coverage has become the norm in Massachusetts—almost all of the population is continuously insured—gaps in the available coverage lead to gaps in access to care and problems with affording care for Massachusetts residents, particularly low-income residents. Thus, despite the successes of the 2006 Massachusetts health reform in expanding health insurance coverage, more work is needed to ensure that access to affordable care is part of that coverage. In 2012, Massachusetts enacted a new law to address health care costs, entitled An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation (Chapter 224 of the Acts of 2012). This law establishes a statewide goal of bringing the rate of growth in per-capita health care spending down to the rate of growth of the gross state product. That reduction is to be accomplished by, among other things, encouraging wide adoption of alternative payment methodologies by both public and private payers (including specific targets for Medicaid), supporting the expansion of electronic health records and health information technology, placing new scrutiny on health care market power and price variation (with the potential of penalties for health care entities that exceed cost growth benchmarks), and increasing price transparency for consumers [20]. So far there has been little change in consumers’ assessment of health care affordability under the new law [18].

The need to ensure that access to affordable health care is part of health insurance coverage will be a national issue as well. As in Massachusetts, increased health insurance coverage in the US has not guaranteed access to affordable health care, and there are few provisions in the ACA to change that. Consequently, in March 2015, problems with health care costs were an issue for many American families: 15.1 percent of nonelderly adults with health insurance coverage all year reported problems paying their and their families’ medical bills [21], and medical debt, which is often due to medical bills that arise from cost-sharing provisions under health plans, including deductibles and co-pays, was reported by 24.5 percent of nonelderly adults [22]. With the share of Americans with high-deductible health plans growing and cost-sharing provisions increasing under many health plans [11, 23], affordability issues are likely to continue to be a challenge for many Americans in the absence of stronger cost-containment policies.