Study Finds State Gains in Insurance

By KEVIN SACK - The New York Times - June 3, 2008
Massachusetts reduced its proportion of uninsured adults by nearly half in the first year of mandatory health coverage and made gains in the share of people receiving routine preventive care, according to the first major study of the 2006 law.

The decline in the share of residents without insurance was nearly equivalent for those with low or moderate incomes and those with higher incomes.

The study, conducted by the Urban Institute and scheduled for online publication Tuesday by the journal Health Affairs, found no evidence that residents were dropping private health coverage to take advantage of state-subsidized policies, or that employers viewed the availability of new public programs as a reason to eliminate health benefits.

“The entire increase in coverage appears to have been drawn from the ranks of the uninsured, because there is no evidence that publicly funded programs are crowding out employer coverage,” wrote the study’s author, Sharon K. Long, a principal research associate with the Urban Institute, a nonpartisan research group in Washington.

Indeed, contrary to national trends, the share of residents receiving insurance through their employers increased in Massachusetts by nearly three percentage points from fall 2006 to fall 2007. Nationally, the percentages of employers that offer benefits and of workers who receive them have been sliding steadily throughout the decade.

Undercutting the positive trends for Massachusetts are signs that the state’s supply of primary care physicians is not sufficient to handle the increased demand created by newly insured residents. Though there were overall declines in the percentage of residents who said they were not receiving needed care, the study showed increases in the share who said they did not get care because they could not find a doctor.

That finding may support anecdotal reports from internists and family practitioners that they have been stretched by an influx of newly insured patients, causing long delays for some appointments. The study actually found a slight increase in the share of low-income residents who sought treatment in hospital emergency rooms for conditions that were not urgent.

“It would appear that there are opportunities to improve access to community-based care,” Ms. Long wrote.

Jon M. Kingsdale, director of the state authority that oversees the health plan, questioned whether the unmet demand for primary care was more severe in Massachusetts than elsewhere. Regarding emergency room use, he said the state was sometimes finding it easier to enroll the uninsured than to break their longstanding links to local hospitals.

“We’ve clearly identified that as behavior that has to be changed,” Mr. Kingsdale said.

The Massachusetts law, which took effect last year, made the state the largest to strive for universal coverage and a laboratory for federal policies proposed by Democratic presidential candidates. Senator Hillary Rodham Clinton has proposed mandatory coverage for all Americans, similar to the Massachusetts plan, while Senator Barack Obama would require coverage only for children, promising to make premiums affordable enough for adults that no mandate would be necessary.

Massachusetts residents were required to obtain insurance beginning in 2007, and state subsidies were provided on a sliding scale to make policies affordable for low-income residents. The 86,000 residents who did not comply faced modest first-year tax penalties of $219. The penalties will stiffen this year.

Mr. Kingsdale said that more than 350,000 of the estimated 600,000 residents who were uninsured before the program began had since gained coverage. Exemptions were granted to about 60,000 people who demonstrated that they could not afford even subsidized insurance. Enrollment in the subsidized plans has exceeded projections, and lawmakers and Gov. Deval Patrick, a Democrat, are negotiating a tobacco-tax increase to help sustain the program.

The Urban Institute survey found that 7 percent of Massachusetts adults ages 18 to 64 remained uninsured in the fall of 2007, compared with 13 percent in 2006. Those still uninsured are largely male, low-income and healthy, and a third of them said they did not know health insurance was now mandatory.

For adults with family incomes of less than three times the federal poverty level, or $66,600 for a family of four, the uninsured dropped to 13 percent from 24 percent. For those earning more, the rate dropped to 3 percent from 5 percent.

Among the lower-income group, 70 percent said they had received preventive care in the previous year, compared with 65 percent who said they had in 2006. Fifty-nine percent said they had visited a dentist in the past year, compared with 49 percent in 2006. There was a drop of 10 percentage points in the share who said they had deferred needed care in the past year because of cost, to 17 percent from 27 percent.