What does the Massachusetts experience tell us about the prospects for success of national health reform? That’s the subject of an ongoing debate that relies heavily on research published in Health Affairs by Urban Institute researchers.
The pessimistic view on Massachusetts. In a column in today’s Washington Post, Robert Samuelson cites a June 2010 Health Affairs article by Sharon Long and Karen Stockley of the Urban Institute for the proposition that access to care has increased, but only slightly, in the aftermath of Massachusetts’ landmark 2006 reform, which in many respects provided a model for the Patient Protection and Affordable Care Act, recently passed by Congress:
People have more access to treatment, though changes are small. In 2006, 87 percent of the non-elderly had a “usual source of care,” presumably a doctor or clinic, Long and Stockley note in the journal Health Affairs. By 2009, that was 89.9 percent. In 2006, 70.9 percent received “preventive care”; in 2009, that was 77.7 percent. Out-of-pocket costs were less burdensome.
But much didn’t change. Emergency rooms remain as crowded as ever; about a third of the non-elderly go at least once a year, and half their visits involve “non-emergency conditions.”
Samuelson says improvements in health stemming from the Massachusetts reforms most probably lie in the future, since many of the newly covered Bay Staters were young and healthy. Finally, and most damningly in Samuelson’s eyes, health costs continue to soar in Massachusetts, and he sees no evidence that the Affordable Care Act will perform any better in restraining costs. “The lesson from Massachusetts is that genuine cost control is avoided because it’s so politically difficult. It means curbing the incomes of doctors, hospitals and other providers. They object,” says Samuelson.
The optimistic view on Massachusetts. Over at his blog CitizenCohn, the New Republic‘s Jonathan Cohn responds with a post titled “The Bum Rap On Massachusetts Health Reform.” “Samuelson has consulted the right source. The Urban Institute’s surveys are the best data we have on how reform in Massachusetts is going,” Cohn says. But he cites a 2009 Health Affairs article by Long and Stockley to argue that Samuelson is unfairly minimizing the benefits of the Massachusetts reforms:
[T]he number of working-age adults reporting that they skipped care because of high costs fell from 17 percent to 11 percent in the first two years after the law took effect. The gap was even more dramatic among those eligible for subsidized insurance through the Connector–that is, people making less than three times the poverty line, or around $66,000 per year for a family of four. Among those people, the proportion skipping care because of cost fell from 27 percent to 17 percent. And that’s despite a rough leveling-off in the second year, most likely due to the fact that the recession meant lots of people were out of work and counting their pennies. When the economy rebounds, the number should decline even more.
Cohn continues: “Samuelson may disagree, but that’s a pretty substantial improvement in access, particularly during a time of overall economic hardship. And while it’s true people don’t seem to be much healthier than they were, that’s entirely unsurprising: To the extent access improves health, in ways that we can measure, it’s going to take the form of people benefiting five or ten years from now because of care they get today.”
Cohn also argues that the Affordable Care Act contains cost-control mechanisms not present in the Massachusetts reforms, such as an independent board to restrain Medicare spending, a tax on high-end health plans, and a host of delivery-system reforms. “Is it enough? No. Future lawmakers will probably have to see which parts of cost control work and then double down on them. And that’s assuming they don’t repeal the less popular elements, as many skeptics fear,” Cohn acknowledges.
The optimistic view, Part 2. Igor Volsky also contributes to the debate from the Wonk Room at Think Progress, the blog of the Center for American Progress Action Fund. He notes the failure of the American Medical Association to convince Congress to override deficit concerns and permanently scrap the sustainable growth rate mechanism for physician payment. The influence of ever-growing health costs and deficits “has contributed to the diminished clout of the AMA and has encouraged other providers to adopt the kind of outcome-based reimbursement systems that Samuelson believes are so politically infeasible,” Volsky says.
Volsky also finds reason for optimisim in the example of Geisinger Health System, a physician-driven system and a leader in delivery and payment reform. In a June 2010 interview with Health Affairs Editor in Chief Susan Dentzer, Geisinger CEO Glenn Steele estimated that its advanced medical home model for the care of chronically ill Medicare patients has lowered projected spending by up to 7 percent, Volsky notes. He concludes: “Samuelson is undoubtedly right about the political challenges to controlling health care spending but he’s underestimating the extent to which economic necessity shapes reality for politicians and providers.”