Short-Term Effects of Health-Care Coverage Legislation --- Massachusetts, 2008

Morbidity and Mortality Weekly Report (MMWR)MMWR
Care Coverage Legislation --- Massachusetts, 2008
Weekly
March 12, 2010 / 59(09);262-267


On April 12, 2006, Massachusetts enacted legislation to provide nearly universal health-care coverage to state residents (1). Beginning in mid-2006, various components of the law were launched in approximate 6-month intervals. One key component required all Massachusetts residents to purchase health insurance by July 1, 2007, either through private insurers or Commonwealth Care, a new state-subsidized health insurance program. To analyze the short-term effects of this legislation on health insurance coverage, the Massachusetts Department of Public Health (MDPH) reviewed data from the state's Behavioral Risk Factor Surveillance System (BRFSS) survey. An 18-month pre-law period and an 18-month post-law period were identified for comparison; the 12-month transition period from July 1, 2006, to June 30, 2007, during which the law took effect, was not included in the analysis. BRFSS data from the pre-law and post-law periods were compared to evaluate effects on the overall adult population aged 18--64 years and on various subpopulations. This report summarizes the results of those comparisons, which determined that health insurance coverage statewide increased by 5.5%, from 91.3% in the pre-law period to 96.3% in the post-law period, and that coverage increased 14.2% among Hispanics, from 77.9% to 89.0%. Despite the limitations inherent in this analysis, the increases in coverage likely are attributable to the new law. MDPH is using these results to target outreach more precisely to increase health insurance enrollment and health-care access among state residents.

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years and is conducted by state health departments in collaboration with CDC (2).* The overall sample size for the Massachusetts BRFSS increased from 8,906 respondents in 2005 to 20,559 respondents in 2008 because of increased participation by state public health programs. The response rate† for the Massachusetts BRFSS ranged from 38% in 2005 to 48% in 2008, based on Council of American Survey and Research Organizations (CASRO) guidelines. The cooperation rate was 81% in 2008.

To gather information on health insurance, beginning in 1998 MDPH added three supplementary questions to the Massachusetts BRFSS survey. One new question asked all respondents who had health insurance to identify the type of coverage they used to pay for most of their medical care. Response options included various private, public, and other insurance plans;§ Commonwealth Care¶ was added as a public plan response option in 2008. Beginning in September 2007 and continuing through 2008, the survey also included a set of questions tracking awareness of health-care reform and asking whether the respondent obtained health-care coverage because of the recent changes in Massachusetts law (3).

To analyze the effect of the law, two 18-month periods were chosen: January 1, 2005--June 30, 2006 (the pre-law period) and July 1, 2007--December 31, 2008 (the post-law period). The 12-month transition period from July 1, 2006, to June 30, 2007, during which the law took effect, was not included in the analysis. Health indicators for various population subgroups were analyzed, comparing the pre-law and post-law periods. Since 1994, the Massachusetts BRFSS has oversampled cities with highly diversified populations, including large Hispanic communities. Data for adults aged 18--64 years were analyzed; data for adults aged 18--34 years also were analyzed separately to more closely examine this traditionally underinsured age group. The statistical significance (p<0.05) of differences between health indicators in the pre-law and post- law periods was estimated using the Wald chi-square test. Variability of point estimates of weighted** proportions was indicated by 95% confidence intervals.

The percentage of respondents who reported having health insurance rose 5.5%, from 91.3% in the pre-law period to 96.3% in the post-law period (Table 1). Among major subpopulations, the largest increases were observed among Hispanics (14.2%), persons with less than a high school diploma (12.0%), and persons with annual household incomes <$25,000 (11.9%). Nonetheless, in the post-law period, these same three subpopulations continued to have the lowest percentages of health insurance coverage: 89.0% for Hispanics, 88.6% for persons with less than a high school diploma, and 89.0% for persons with annual household incomes <$25,000.

By 2008, approximately 8% of publicly insured Massachusetts residents were obtaining their health insurance through the new public Commonwealth Care program. The percentage of insured residents with public health insurance (including those aged 18--64 years who were eligible for Medicare) increased 29.7%, from 14.8% in the pre-law period to 19.2% in the post-law period (Table 1). The percentage of insured residents with private insurance decreased 3.2%, from 80.8% to 78.2%, and the percentage of insured residents with other types of insurance (e.g., a self-directed plan or student health insurance) decreased 40.9%, from 4.4% to 2.6% (Table 1).

The overall percentage of respondents who reported having a personal health-care provider increased significantly, from 86.1% in the pre-law period to 87.7% in the post-law period (Table 2). The largest reported increases occurred among Hispanic respondents who answered the survey in Spanish (30.3% increase) and among Hispanics overall (17.0% increase).

The percentage of respondents who reported having a routine checkup within the past year also increased significantly, from 71.9% in the pre-law period to 74.1% in the post-law period (Table 3). The largest reported increases occurred among Hispanic respondents who answered the survey in Spanish (19.9% increase) and among Hispanics overall (14.1% increase). The percentage of men reporting a routine checkup increased 5.1%, from 66.4% to 69.8%, but the percentage of women reporting a routine checkup did not change significantly. The percentage of respondents with chronic conditions who reported having a personal health-care provider or having had an annual checkup also did not change significantly after enactment of the health-care coverage law.

Reported by
L Tinsley, MPH, B Andrews, MPH, H Hawk, PhD, B Cohen, PhD, Bur of Health Information, Statistics, Research, and Evaluation, Massachusetts Dept of Public Health.

Editorial Note
The results of this analysis indicate that the estimated percentage of Massachusetts residents covered by health insurance increased significantly after passage of health-care coverage legislation. A wider comparison, between 2005 BRFSS state survey results and 2008 results, indicated that health insurance coverage increased from 89% to 97% among all state residents (including children and adults aged ≥65 years); the increase included an estimated 300,000 newly insured persons aged 18--64 years (3). After implementation of the health-care coverage law, the proportion of respondents who said they lacked health insurance was approximately cut in half, and 8% of publicly insured respondents were obtaining health insurance through the state's new Commonwealth Care program. The effects observed likely are attributable to the new law; although, because of limitations inherent in such studies, a causal link cannot be proven. Increases in health insurance coverage can result from multiple factors, such as a higher employment rate, reduction in health insurance premiums, or expansion of existing public health insurance programs. During 1996--1999, Massachusetts observed an increase in the percentage of persons with health insurance (3) after the state expanded Medicaid eligibility; as a result, an additional 124,000 Massachusetts residents obtained insurance coverage (4).

In this analysis, the observed increases in the percentage of insured among traditionally underserved subpopulations (e.g., Hispanics, persons with less than a high school diploma, and persons with annual household incomes <$25,000) serve to strengthen the hypothesis that the increases in insurance coverage are attributable to the health-care coverage law, because implementation of heavily subsidized health insurance programs likely would affect these subpopulations first. Data from similar surveys in Massachusetts support this same hypothesis (5--7). For example, reports from the Massachusetts Division of Health Care Finance and Policy, which were focused on insurance status specifically, found that from fall 2006 to fall 2008, the number of uninsured working-age adults was reduced by nearly 70%. Most of the gains in insurance coverage were concentrated among lower-income adults (7). In contrast, according to U.S. Census data, from 2007 to 2008, the overall proportion of U.S. adults with health insurance declined (8).

The largest increases in insurance coverage were among Hispanic respondents overall and Hispanic respondents who answered the survey in Spanish. Traditionally, a larger proportion of Hispanics in Massachusetts have lacked access to health care, compared with other racial/ethnic populations (9,10). The results showed an 18.4% increase for persons responding in Spanish and a 14.2% increase for Hispanics overall. However, despite these increases, Hispanics continued to have the lowest health insurance coverage and the lowest percentage of persons with a personal health-care provider than any other subpopulation. The percentage of younger adults, whites, blacks, and persons with chronic diseases who reported having a personal health-care provider did not change significantly. One reason might be that more time is needed for the effects of improved health-care access to be realized in these groups. Another reason might be that health-care providers are not equally accessible for certain groups or in certain areas of the state. Although the cost of a doctor visit might also be a factor, 2008 BRFSS data have shown that only 6% of all respondents reported that they were unable to visit a doctor during the past year because of cost, compared with 8% in 2006 (9).

In addition to an increase in the percentage of persons with health insurance, the findings in this analysis indicate changes in the proportion of plans that were private, public, or other (e.g., a self-directed plan or student health insurance) in Massachusetts. Those proportions changed from 80.8% private, 14.8% public, and 4.4% other before the law was enacted to 78.2%, 19.2%, and 2.6%, respectively. These changes were similar to U.S. Census data, which found that the proportion of adults with private health insurance declined from 2007 to 2008, while the proportion of publicly insured adults increased (8).

In addition to the limitations on establishing causality, the findings in this report are subject to at least three other limitations. First, BRFSS only samples households with landline telephones. Minorities, persons with lower socioeconomic status, and younger adults typically have lower landline telephone coverage and might be underrepresented in this report. However, poststratification weighting might correct some bias resulting from lack of landline telephones. Second, depending on when the survey was administered, some responses might pertain to health-care activities (e.g., having a personal-care provider in the past year) that actually occurred during the 12-month transition period. Finally, BRFSS data are based on self-report and might be subject to error (e.g., underreporting of chronic conditions).

The findings in this report and others (10) can help local health departments in areas with large underserved populations assess local public health needs, enhance cultural competency, engage hospitals in community primary-care efforts, and address the availability of health-care providers. MDPH is targeting outreach more precisely to increase health insurance enrollment and health-care access among state residents.

References
1.Massachusetts General Laws. Chapter 58 of the acts of 2006. An act providing access to affordable, quality, accountable health care. April 12, 2006. Available at http://www.mass.gov/legis/laws/seslaw06/sl060058.htm. Accessed March 5, 2010.
2.CDC. Public health surveillance for behavioral risk factors in a changing environment: recommendations from the Behavioral Risk Factor surveillance team. MMWR 2003;52(No. RR-9).
3.Massachusetts Department of Public Health. Massachusetts Behavioral Risk Factor Surveillance System surveys and reports, 1996--2008. Available at
http://www.mass.gov/?pageID=eohhs2homepage&L=1&L0=Home&sid=Eeohhs2. Accessed March 5, 2010.
4.McDonough J, Hager C, Rosman B. Health care reform stages a comeback in Massachusetts. N Engl J Med 1997;336:148--51.
5.Long SK, Masi PB. Access and affordability: an update on health reform in Massachusetts, fall 2008. Health Aff (Millwood) 2009;28:w578--87.
6.Kaiser Commission on Medicaid and the Uninsured. Massachusetts health care reform: three years later. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2009. Available at http://www.kff.org/uninsured/upload/7777-02.pdf . Accessed March 5, 2010.
7.Massachusetts Division of Health Care Finance and Policy; Key indicators, November 2009. Boston, MA; 2009. Available at http://www.mass.gov/Eeohhs2/docs/dhcfp/r/pubs/09/key_indicators_nov_09.pdf . Accessed March 5, 2010.
8.US Census Bureau. Current population reports: income, poverty, and health insurance coverage in the United States: 2008. Washington, DC: US Census Bureau; 2009. Available at http://www.census.gov/prod/2009pubs/p60-236.pdf . Accessed March 8, 2010.
9.Massachusetts Department of Public Health. A profile of health among Massachusetts adults, 2008: results from the Behavioral Risk Factor Surveillance System. Boston, MA: Health Survey Program; 2008. Available at
http://www.mass.gov/Eeohhs2/docs/dph/behavioral_risk/report_2008.pdf . Accessed March 5, 2010.
10.Massachusetts Department of Public Health. A profile of health among Massachusetts adults in selected cities, 2008: results from the Behavioral Risk Factor Surveillance System. Boston, MA: Health Survey Program; 2008. Available at
http://www.mass.gov/Eeohhs2/docs/dph/behavioral_risk/cities_08.pdf . Accessed March 5, 2010.
* BRFSS survey information is available at http://www.cdc.gov/BRFSS/technical_infodata/surveydata/2008.htm.

† The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.

§ Type of insurance was classified as 1) private insurance: coverage through an employer, someone else's employer, or a plan purchased by the person covered; 2) public insurance: Medicare, Medicaid, MassHealth, CommonHealth MassHealth, health maintenance organizations offered through Neighborhood Health Plan, Fallon Community Health Plan, BMC HealthNet or Network Health, Commonwealth Care, the military, CHAMPUS, TriCare, Veterans Administration (VA), CHAMP-VA, Indian Health Service, or the Alaska Native Health Service; or 3) other insurance: some other source of health insurance, such as a self-directed plan or student health insurance.

¶ A key element of the health-care legislation in Massachusetts was creation of the Commonwealth Health Insurance Connector, the agency responsible for connecting residents to either Commonwealth Care, a subsidized program for certain adults who have not been offered employer-sponsored insurance, or Commonwealth Choice, an unsubsidized offering of six private health plans available through the Health Connector to individuals, families, and certain employers.

** Data were weighted to the total Massachusetts population. The BRFSS weighting methodology is available at http://www.cdc.gov/brfss/technical_infodata/surveydata/2008/overview_08.rtf .