Mass. healthcare reform offers mixed results, but are they relevant to rest of U.S.?
With the general election less than one month away and healthcare policy remaining a prominent point of discussion among the candidates, an article in the October issue of the Journal of the American College of Radiology examined the results of the Massachusetts healthcare reform law that served as the model for the Patient Protection and Affordable Care Act.

The bottom line: while the reforms in Massachusetts brought mixed results for both patients and physicians, it’s unclear how successful such reforms would be outside of the unique circumstances of that state, according to Alexander Norbash, MD, of Boston University School of Medicine, and colleagues.

House Bill 4479, also known as the Affordable Healthcare Act, was signed into law in Massachusetts by then Gov. Mitt Romney on April 12, 2006, in response to spiraling healthcare costs. Insurance premiums in Massachusetts were the highest of any state, and the law sought to reduce costs, while also expanding coverage, using a combination of mandates and creative vehicles for supplying coverage to residents, explained the authors.

Mandates were directed at both consumers and employers. Residents were required to have insurance or they risked losing personal state tax exemptions, and businesses with 10 or more employees were mandated to offer health insurance or face financial penalties of their own.

To help supply affordable coverage, a public authority known as the Massachusetts Connector was created with two broad purposes: create subsidized insurance products for those earning less than 300 percent of the federal poverty level, and help higher earning individuals and families purchase unsubsidized, but affordable, plans from a group of private insurers.

Benefits and shortfalls

“The implementation of the affordable health care act had the beneficial effects of increasing affordable resident coverage for all different demographic groups and increasing employer-based coverage from 70 percent in 2005 to 77 percent in 2010,” wrote the authors. “The affordable health care act has also created the highest insurance coverage rate for state residents within the United States.”

In addition, Massachusetts no longer bears the distinction of having the highest healthcare costs, falling to ninth place and ceding the top spot to Delaware.

But Massachusetts’ new ranking doesn’t mean costs in the state fell. On the contrary, annual healthcare costs in the state continued to increase, with a rate of growth that reached as high as 10.3 percent in 2009.

Norbash and colleagues also pointed out that the law’s implementation added to the workload of an already overburdened primary care system, increasing wait times to more than one month to see family practitioners and 48 days for internal medicine practitioners. Ironically, though the law was expected to reduce unnecessary emergency department (ED) visits by decreasing the number of uninsured who didn’t have access to primary care, the number of ED visits rose 4 percent from 2006 to 2008.

Surveys shed some light on the opinions of Massachusetts physicians in the wake of reform, and here, too, a mixed picture emerged. The authors noted that the percentage of physicians reporting satisfaction with the practice environment has steadily increased since 2002, though the greatest increases came before both the reform law and the recession. Radiologists demonstrated average dissatisfaction rates compared with other specialties, though they held the most pessimistic outlook on future income prospects. Average recruitment time for all physicians dropped from 12.8 months in 2006 to 12.2 months in 2011, but the change was much more severe for radiology—recruitment time for radiologists over the same period dropped from 13.8 months to 6.2 months, shortest of any specialty.

“This suggests that in radiology, we have the highest ratio of job seekers to open positions, compared with all other specialties. This may also reflect our perception of either an overabundance of radiologists or concerns regarding selective radiologist targeting as overpaid,” wrote the authors.

What about my state?

While the effects of healthcare reform in Massachusetts are becoming clearer by the year, what is less certain is how much other states or the nation as a whole can learn from this episode. Norbash and colleagues explained that the success of the Massachusetts reform could be attributable to the fact that the state has a relatively small and stable population, low numbers of undocumented immigrants, a relatively large healthcare delivery system and a more robust economy than many other states. It also had a low uninsured rate prior to reform.

“It is possible that this environment may have been relatively unique to Massachusetts and perhaps to only a handful of other states, calling into question the ease of implementing similar legislation in a more widespread manner, particularly in states lacking these conditions.”