Health Care Reform in

Massachusetts:

The Role of Public Health

John Auerbach, Commissioner

2

Components of Massachusetts Health Care

Reform

• All adults in MA required to purchase health

insurance by 7/1/07 or face a hefty penalty

• All employers with 11 or more employees

required to offer health insurance

• Commonwealth Connector created to “connect”

individuals to insurance by offering affordable,

quality insurance products

• Commonwealth Care Program created as a low-

cost insurance alternative for low-income

families and individuals

3

Five years of Health Care

Reform:

What have we seen in

Massachusetts?

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5

6

7

A reminder that we are different

% Insured in Texas, US and Massachusetts

505560657075

80859095

100

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Texas Massachusetts Nationwide (States and DC)

8 Massachusetts Division of Health Care Finance and Policy

Most Residents Saw a Doctor in the Past 12 Months

The majority of

children, non-

elderly adults, and

elderly adults in

Massachusetts

had a doctor visit

in the past 12

months, with the

level somewhat

lower for non-

elderly adults. The

2009 estimates are

not significantly

different from the

estimates for 2008.

Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS

88%

94%

85%

94%

88%

92%

85%

94%

0%

20%

40%

60%

80%

100%

Total Population Children (0-18) Non-Elderly Adults

(19-64)

Elderly Adults (65 and

older)

2008 2009

9 Massachusetts Division of Health Care Finance and Policy

Non-Elderly Adults with a Doctor Visit in

Past 12 Months by Insurance Status Compared with

the insured

adults, uninsured

non-elderly adults

were much less

likely to have had

a doctor visit in

the past 12

months. The

2009 estimates

are not

significantly

different from the

estimates for

2008.

Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS

85% 86%

45%

85% 86%

54%

0%

20%

40%

60%

80%

100%

Total Population Insured Uninsured

2008 2009

10 Massachusetts Division of Health Care Finance and Policy

Fewer Residents have a Preventive

Care Visit in Past 12 Months High shares of

both children and

elderly adults had

a preventive care

visit in the past 12

months, while only

73% of non-elderly

adults had a

preventive care

visit. The 2009

estimates are not

significantly

different from the

estimates for 2008.

Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS

78%

89%

73%

86%

78%

88%

73%

87%

0%

20%

40%

60%

80%

100%

Total Population Children (0-18) Non-Elderly Adults

(19-64)

Elderly Adults (65 and

older)

2008 2009

11 Massachusetts Division of Health Care Finance and Policy

Non-Elderly Adults with a Preventive Care Visit

in Past 12 Months by Insurance Status Compared with

the insured

adults, uninsured

non-elderly adults

were much less

likely to have had

a preventive care

visit in the past 12

months. The

2009 estimates

are not

significantly

different from the

estimates for

2008.

Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS

73% 74%

31%

73% 74%

37%

0%

20%

40%

60%

80%

100%

Total Population Insured Uninsured

2008 2009

12

What does this have to do with

improving health?

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14

15

16

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Evidence that reform is improving health

Changes in the first year of implementation

• Flu vaccinations rose 3% (a 7% increase) for 19-

64 year olds at primary care sites as new patients

see primary care doctors – in a year DPH cut

adult public health vaccine doses

• Colonoscopy rates increased 8% (a 15%

increase) among the recommended age group as

newly insured 50+ year olds get referrals for

screening

• And…smoking rates sharply decreased at a rate

not seen in many years (11% of Medicaid adults

used the cessation service)

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Percent Drop in Smoking PrevalenceMassachusetts, 1998 - 2007

-2.4%

4.3%

1.5%2.0%

3.1%

-1.1%

3.1%

2.2%1.7%

7.9%

-4%

-2%

0%

2%

4%

6%

8%

10%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Data Source: Massachusetts Behavioral Risk Factor Surveillance System

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Massachusetts Comparative Public Health

Measures 2006 and 2010

Indicators 2006 (% and rank) 2010

Obesity 20.7 (5) 21.8 (3)

Smoking 18.1 (9) 14.9 (3)

Premature death 6 (rank) 2 (rank)

CV deaths 9 (rank) 7 (rank)

Cholest. check 79.3 (5) 83.9 (1)

Recent dental visit 79.5 (3) 79.3 (2)

Infant Mortality 4.7 (1) 4.8 (1)

Source: america’s health rankings.org

How are Health Care

Reform and Public

Health Connected?

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Three Lessons from Massachusetts

• Public health can help health care

reform to succeed

• Health care reform cannot

substitute for public health

• Public health needs to adapt to

health care reform

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1. Public health can help

health care reform to succeed

We can help with designing

the insurance packages

Attention was/is needed to what is covered

in the insurance packages and what else is

funded

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Decisions Are Needed on “Preventive”

Services for Insurance Packages

• Will family planning services be covered?

• Will nicotine replacement therapy and

cessation counseling be offered?

• Will the role of CHWs be considered?

• Will substance abuse and mental health

treatment be covered?

• What services will be offered with “first

dollar” coverage? No copays, deductibles.

We can measure the

impact of reform on

health

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Demonstrate the access to care is good

for one’s health

• Support the inclusion of

public health and other

useful fields in HIT

systems

• Utilize BRFSS and other

traditional approaches –

add optional questions

• Prepare periodic reports

on the impact on health

54 55

84

43

57

63

85

46

30

40

50

60

70

80

90

PSA test past

year, men age 50-

64

Colonoscopy or

sigmoidoscopy

past five years, all

respondents age

50-64

Mammography in

past two years,

women 40-64

Flu Vaccine in

Past Year, 50-64

%

January 2006-June 2007 July 2007-December 2008

27

The latest: News from the 2010 Survey

• 91% of Mass residents say they have a personal

health care provider

• The percentage who had a routine check-up

increased signficantly in 2010 (80% vs. 76%)

• The percentage who had a dentist visit increased

from 2008 (81% vs. 78%)

• Only 7% say they could not see a doctor because of

cost

• Access was an issue for the disabled, Latinos, 18-

24 year olds, the least educated and the lowest

income

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We can fill important gaps

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Some services are better addressed with

public health funding

• Public health programs can reach the populations that are not linked to reform (in Massachusetts, perhaps 125,000 adults) – Family planning sites serve may serve as primary care providers for the uninsured

• We can provide services less expensively (vaccine purchases)

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2. Health care reform

cannot substitute for public

health

Public Health Prevention Needs to be a Priority

It can reduce the cost of reform by

actively promoting good health using proven approaches

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Example: To address overweight epidemic and

resulting chronic disease risk

With over 60% of

adults and 30% of

children overweight

a statewide

comprehensive

effort needed

Prevalence of Diabetes in Massachusetts, 1994-2005

4.1 3.84.7 4.3

3.8

4.95.8 5.6 5.8 6.2

5.66.4

0

1

2

3

4

5

6

7

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Perc

en

t

Overall

Source: Massachusetts Behavioral Risk Factor Surveillance System (BRFSS);

1994-2005. Note: Estimates have been age-adjusted to 2000 US standard

population

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Mass in Motion Campaign Includes

• Statewide regulations: Menu labeling of fast foods

• Schools: mandated BMI testing of all students

• Worksites: Employee wellness programs

• Cities and towns: Community-wide mobilization grants

There are dangers if

reform is thought to

substitute for public

health

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Example #1 – Unwisely cutting public health

may lead to reduced access

Faulty assumptions

may be made about

what is covered by

insurance

(examples: loss of

access to nicotine

replacement therapy

and childhood

immunization funds)

36

Example #2 – People still fall through the

cracks

Certain populations

won’t or can’t use

insurance (example:

adolescents access

to family planning

services; the

uninsured continuing

needs)

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Example #3 – There are barriers built into

insurance coverage

We may see new unintended barriers to

access (co-pays and deductibles create

barriers for some previous/current clients of

public health)

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3. Public Health needs to

adapt to health care reform

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We need to do more to show that

prevention works

• More data are needed on to demonstrate the cost-savings associated with prevention

• More emphasis is needed on the short-term (2 year) return on investment

• Example: emerging Mass. data shows a dramatic drop in heart attacks within first year of Medicaid nicotine replacement coverage

40

We Need to Reassess our Service Models

at the State and Federal Levels

• We may need to adapt some of our

programs to the new conditions (not

ones that assume the target population is

mostly uninsured)

We need to show that

public health is good at

cost-savings (while

improving quality)

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*Hospitals must report hospital

associated infections and serious

reportable events

*Hospitals are prohibited from

charging for services needed to

treat a serious reportable

event/medical error

In order to prevent hospital associated infections

and serious medical mistakes

43

In order to prevent costs of construction of

unneeded or duplicative services

Changes to the Determination of Need

process - broadening its scope to include

ambulatory surgery, large outpatient

capital projects and beds added to

hospital satellites

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We need to be a part of payment reform

• Learning more about the process and

the opportunities

• Learning the language (ACOs, medical

loss ratio, global payments, ROI)

• Making the case

• Clarifying our priorities and specifying

our requests

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Payment Reform: conceptualizing 3

areas where prevention occurs

1. Clinical preventive measures

2. Community health

The grey zone (sometimes ties

to clinical and sometimes

ties to community via a non

clinical CHW, patient

navigator, pt. trainings and

education

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So…What can we expect?

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Conclusions

• Health care reform will benefit from a close

partnership with public health

• But there is no substitute for a healthy and

robust public health system - Caution

should be taken in assuming that reform

has taken over public health functions

• Public health needs to adapt and grow to

ensure the success of health care reform

& address the new conditions