Health Resources in Action (HRiA) is a national non-profit public health and medical research organization, located in Boston, whose mission is to help people live healthier lives and build healthy communities through policy, research, prevention and health promotion. UNIVERSAL HEALTH INSURANCE ACCESS EFFORTS IN MASSACHUSETTS: A CASE STUDY Lessons Learned for Public Health Systems across the U.S. January 31, 2014 prepared for: The Centers for Disease Control and Prevention through the Office of Health System Collaboration within the Office of the Associate Director for Policy on behalf of: The National Network of Public Health Institutes Produced by: Contact: Team: Health Resources in Action Brittany Chen, MPH Brittany Chen, MPH 95 Berkeley Street Senior Program Manager Shin-Yi Lao, RN, BSN Boston, MA 02116 [email protected] Yoojin Lee, MPP www.hria.org 617-279-2240 ext. 324 Laurie Stillman, MM Toni Weintraub, MD, MPH Acknowledgements Special thanks to our expert reviewers: From The Centers for Disease From Northeastern University’s Control and Prevention: Institute on Urban Health Research Dr. Frederic Shaw and Practice: Jon Altizer John Auerbach Kristin Golden From The National Network of Atsushi Matsumoto Public Health Institutes: Sarah Gillen Funding for this case study has been provided by the National Network of Public Health Institutes (NNPHI) through a Cooperative Agreement with the Centers for Disease Control and Prevention (CDC - 5U38HM000520-05). NNPHI and Health Resources in Action have collaborated with CDC’s Office of the Associate Director for Policy on this project. The views and opinions of these authors are not necessarily those of CDC or the U.S. Department of Health and Human Services (HHS). Health Resources in Action Introduction Generalizability The federal Patient Protection and Affordable Many of the lessons learned in MA can be applied Care Act (ACA) was largely modeled after the to states across the nation, despite MA’s unique Massachusetts (MA) 2006 landmark health care public health enterprise. In contrast to the county/ reform effort, Chapter 58 of the Acts of 2006 regional infrastructure and state provision of (Chapter 58), entitled An Act Providing Access to clinical public health services in most other states, Affordable, Quality, Accountable Health Care.1–6 MA’s governmental public health system is highly decentralized, with funding and the provision of This case study examines the impact of Chapter local public health services delegated to individual 58 in MA provide lessons learned to states to town and city governments. As a result, with inform their ongoing implementation of the the exception of the largest cities, many public ACA, forecast potential effects on public health health services across the state are contracted practice, and highlight opportunities to improve to area non-profit organizations and community population health outcomes. health centers. Given these distinctions, this case study explores the Background effects of Chapter 58 on non-governmental safety net providers in addition to the public health system. Prior to the passage of Chapter 58 in 2006, the uninsured rate in MA (6.4%) was significantly lower than that of the U.S. as a whole (15.8%) — Methodology a result of numerous reforms over two decades that strengthened MA’s safety net structure, introduced Research was conducted in two phases: a insurance market reform, and expanded health comprehensive review compiled findings from peer- insurance access. While MA’s Chapter 58 built on reviewed and grey literature regarding the effects of these prior efforts through transforming the state’s Chapter 58 on public health practice and population health insurance landscape, expanding affordable health outcomes, and 27 qualitative interviews of 29 insurance options, and impacting the public’s health high-level key informants provided first-hand insight through a variety of other provisions, the federal into the process and impacts of Chapter 58’s passage ACA contains more comprehensive provisions to and implementation, all of which were reported address preventive services, health care cost and anonymously unless specific permission was granted. quality, and other areas. MA has since passed This background research has been documented in additional rounds of legislation addressing these and more detailed reports. The following represents a other issues; however, the lessons presented herein distillation of the research findings and lessons learned. focus primarily on the impact of Chapter 58. For a detailed comparison of Chapter 58 versus the ACA, and for a timeline of MA’s health care reform efforts to date, see Appendices A and B, respectively. A MA CASE STUDY: Lessons Learned for Public Health Systems across the U.S. i Health Resources in Action Findings and Lessons Learned With the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, there is much speculation about how national health care reform efforts may impact public health and its organization, delivery, and outcomes at the state and local levels. I. INVESTING IN ENROLLMENT • Facilitating enrollment by training enrollment EFFORTS IS KEY TO SUCCESS specialists and ensuring convenient community MA invested in an array of successful strategies access points; to maximize insurance enrollment among eligible • Streamlining the benefit enrollment processes residents, resulting in a substantial decrease in with an integrated eligibility system, single uninsurance rates (Figure 1). These strategies application form, and automatic enrollment of included: those identified via the uncompensated care • Conducting public education campaigns to pool data; and increase consumer awareness of new benefits and • Infusing a blend of public and private funding employer knowledge of new responsibilities; to support these approaches. • Utilizing community health workers (CHWs) and other trained community-based staff for outreach and navigation to help uninsured populations understand coverage options and connect with primary care providers; FIGURE 1: UNINSURANCE RATES, U.S. VS. MA, ALL AGES 18% MA 15.8% U.S. 16% 15.7% 14% Source: MA CHIA Household 12% Insurance Survey (2006- 10% 2011) and U.S. Census Bureau Current Population 8% 6.4% Survey (CPS) (2006-2011).1 6% 1 Estimates for the Massachusetts 4% rates are from the Center for Health 3.1% Information and Analysis (CHIA). 2% 0% 2006 2007 2008 2009 2010 2011 A MA CASE STUDY: Lessons Learned for Public Health Systems across the U.S. 1 Health Resources in Action II. CONNECTIONS WITH PRIMARY III. EXPANSION OF HEALTH CARE AND PREVENTIVE CARE ARE COVERAGE IS REDUCING DISPARITIES INCREASING While gains in insurance coverage occurred in all Over 90% of MA residents reported having a populations in MA, the most dramatic increases personal health care provider in 2010 and 76% were realized for people of color, a population with reported having had a preventive care visit in the lower insurance rates pre-Chapter 58. As a result, previous year (Figure 2). These indicators suggest post-Chapter 58 reports by white and minority that expansion in insurance coverage led to a adults of having a usual source of care equalized significant increase in access to health care services (91% vs. 90%). However, racial disparities in disease among non-elderly adults. prevalence and mortality persist. FIGURE 2. TRENDS IN USUAL SOURCES OF CARE AND DOCTOR VISITS FOR NON-ELDERLY “ People definitely need access to ADULTS IN MA, 2006 & 2010 health care, but that by itself will 2006 not eliminate the disproportionate 2010 100% burden of illness and premature death…The most important barriers 90.4 80% 85.7 have to do with income and 75.8 60% 72.9 discrimination and racism and 69.9 67.9 access to quality education and 40% jobs with opportunity.” 20% – John Auerbach from Massachusetts reform has lessened some disparities, 0% but gaps remain7 Has Usual Had Preventive Had Dental Source of Care Care Visit in Care Visit in (excluding ER) Past 12 Months Past 12 Months Source: Massachusetts Health Reform Survey, 2006–2010. Percentage changes between 2006 and 2010 are statistically significant. A MA CASE STUDY: Lessons Learned for Public Health Systems across the U.S. 2 Health Resources in Action IV. WHILE SOME HEALTH Preventive screening INDICATORS ARE BEGINNING TO There were modest increases in some preventive SHOW IMPROVEMENT, IT IS TOO EARLY FOR LONG-TERM HEALTH screenings after insurance access expanded; yet there OUTCOMES TO MANIFEST is still room for further growth (Figure 3). Colon cancer screening and flu vaccination rates notably Since Chapter 58 passed in 2006, some health increased post-Chapter 58. Insurance coverage alone indicators have shown improvements. The following does not appear to be sufficient to significantly include highlights of trends for selected preventive improve appropriate utilization of all recommended care, chronic and infectious disease, and hospitalization clinical preventive services; thus, continued public indicators. Additional indicator trends can be found health outreach efforts are vital. in the full literature review. For many health indicators, the full impact of reform will take many years to manifest. Additionally, while the most recent, publicly available data were used for the study’s analyses, there is a time lag in data availability. Finally, for many indicators, it is not possible to completely disentangle the effects of Chapter 58 from other factors, such as concurrent public health programs and campaigns