Health Care Reform in Massachusetts: State Model for the Affordable Care Act Is Working And Broadly Popular
The Affordable Care Act was signed into law one year ago. It is modeled in large part on the landmark Massachusetts health reform law enacted four years earlier in 2006. Opponents of the Affordable Care Act often attack it by distorting the facts about the Massachusetts experience. They selectively alternate between snapshots of and trends in Massachusetts and comparisons between Massachusetts and the United States.
The most appropriate way to assess the impact of the Massachusetts law is to compare changes over time in things like health coverage and premium costs in Massachusetts to changes over time in the United States as a whole. We use that approach below to debunk many of the myths opponents propagate regarding Massachusetts’s experience with health care reform.
Massachusetts increased health coverage while coverage declined in the rest of the country.
Myth
The Massachusetts law failed to significantly reduce the ranks of the uninsured in the state.
Fact
The Massachusetts health reform law dramatically increased the insurance rate in the state over a period when the national health coverage rate declined. As of the end of 2010, 98.1 percent of the state’s residents were insured compared to 87.5 percent in 2006 when the law was enacted. Almost all children in the state were insured in 2010 (99.8 percent). In comparison, at the national level the health insurance rate dropped from 85.2 percent in 2006 to 84.6 percent in 2010.
Employers continued the same level of health coverage in Massachusetts while dropping people in the rest of the country.
Myth
The Massachusetts health reform law is eroding employer-sponsored health insurance.
Fact
The number of people in Massachusetts with employer-sponsored health insurance has not dipped below 2006 levels since passage of the health reform law. Approximately 4.3 million people in Massachusetts obtained health insurance through their employer in 2006. This figure increased to 4.5 million in 2008 before returning to 2006 levels in 2010. In comparison, the number of nonelderly people in the United States with employer-sponsored health coverage declined from 161.7 million in 2006 to 156.1 million in 2009.
Since passage of Massachusetts’s health reform law, a larger share of the state’s employers have offered health insurance to their workers when compared to the United States as a whole. At the national level only 60 percent of employers offered health coverage to their employees in 2005. This is significantly lower than Massachusetts’s rate of 70 percent at that time. The Massachusetts rate increased to 76 percent in 2009, which is 7 percentage points higher than the national figure for 2010.
People buying insurance on their own in Massachusetts are paying lower premiums. Premiums in the nongroup market have increased in the rest of the country.
Myth
Massachusetts residents are paying higher premiums in the nongroup market as a result of the health reform law.
Fact
Nongroup health insurance premiums in Massachusetts have fallen by as much as 40 percent since 2006 because health reform brought healthy people into the insurance market. In contrast, at the national level nongroup premiums have risen 14 percent over that period of time.
More than 98 percent of Bay Staters met the law’s individual insurance requirement.
Myth
A significant portion of Massachusetts residents are ignoring the mandate and only purchasing health insurance when they need care.
Fact
The size of Massachusetts’s individual market more than doubled after passage of the health reform law. This boost and the accompanying drop in the average cost of individual premiums were due in part to more healthy—and previously uninsured—individuals entering the market. Only 1.3 percent of the state’s 4 million tax filers who were required to and did report their coverage status were assessed a penalty for lacking coverage in 2008, the last year for which complete data are available. About 26,000 of these 56,000 people were actually in compliance for part of the year.
The cost of health care in Massachusetts is in line with expectations.
Myth
The Massachusetts law is bankrupting the state.
Fact
The fiscally conservative Massachusetts Taxpayers Foundation, or MTF, finds that under reform, “State spending is in line with what [the organization] expected.” An MTF report released in 2009 found that state spending on health reform increased from $1.041 billion in fiscal year 2006 to a projected $1.748 billion in fiscal year 2010—an increase of $707 million over the four-year period, half of which is covered by the federal government.
Higher-than-expected enrollment in Commonwealth Care, the state-subsidized health insurance program, initially raised fears that policymakers had dramatically underestimated the number of low-income uninsured in Massachusetts. These concerns, however, were unfounded. Commonwealth Care enrollment peaked in mid-2008 with 176,000 members. The MTF attributes the initial rapid growth in Commonwealth Care enrollment to the state’s early success in getting residents signed up for the program.
The majority of people in Massachusetts like the health reform law, and it has gotten more popular over time.
Myth
The Massachusetts health reform law is highly unpopular among members of the public, the business community, and policymakers.
Fact
Support for the law is strong among members of the public. Sixty-one percent of the Massachusetts nonelderly population approved of the law when it passed in 2006. Two years later, 69 percent of nonelderly adults viewed the law favorably. In a survey of employers conducted in 2007—shortly after passage of the health reform law—a majority of Massachusetts firms surveyed agreed that “all employers bear some responsibility for providing health benefits to their workers.”20 A survey of employers conducted a year later—after the individual and employer mandates were implemented— found that a majority of firms believed the law was “good for Massachusetts.”
The Massachusetts health reform law was also a bipartisan achievement, drawing support from both sides of the aisle throughout the process. The law was passed by a Democratic legislature with support from its Republican members and then signed by GOP Gov. Mitt Romney.
Massachusetts is building on its 2006 reforms to promote better quality care at lower costs.
Myth
Current Gov. Deval Patrick is proposing to ration health care in Massachusetts.
Fact
Gov. Patrick’s proposal would make Massachusetts a leader in nationwide efforts to reform health care delivery and bring down costs. The governor has proposed new tools for achieving integrated care—by holding providers accountable for working with each other and their patients to coordinate and delivery higher-quality care at a lower cost.
These innovative tools encourage providers to deliver better care—replacing the current payment system’s set of incentives that provide more care regardless of value. Indeed, more care can sometimes be harmful to patients. Hospital-acquired infections and medical errors are among the most common causes of preventable deaths and injuries in U.S. hospitals. Medical errors accounted for 238,000 preventable deaths in Medicare and cost the program $8.8 billion from 2004 to 2006. A recent study found that sepsis and pneumonia caused by hospital-acquired infections resulted in 48,000 deaths in 2006 and cost the program $8.1 billion.
Conclusion
The Massachusetts health reform law is a success story from every perspective. The state has expanded health coverage to almost all of its residents, maintained a strong market for employer-sponsored health insurance, gained the support of the business community and the public, and is moving forward in containing costs. We can look forward to a similar positive experience across the nation as we implement the Affordable Care Act modeled in large part on the Massachusetts law.
By: Nichole Cafarella and Tony Clark, Center for American Progress, April 13, 2011
What Paul Ryan’s Constituents Think And Why It Matters
Rep. Paul Ryan’s (R) Wisconsin district isn’t competitive. Over the last decade, his most competitive race was the one he won by “only” 26 points. Last year, the margin was 38 points.
But when the Associated Press checked in with some of the far-right congressman’s constituents, they were aware of their representative’s plan to eliminate Medicare, and they weren’t exactly on board with the plan.
Brian Krutsch has been long one of many automatic votes here for Rep. Paul Ryan…. But this week, admiration has been tinged with apprehension as one of Ryan’s signature ideas — ending Medicare’s status as a full, guaranteed benefit for senior citizens — suddenly took a step toward reality.
“I think that’s one of the things they should probably leave alone — you know — unless it’s absolutely necessary,” Krutsch said as he took a break from reviewing job openings at the Rock County Job Center. “Old people need help with medical bills. There’s too many people under-insured right now — especially people like myself right now who don’t have insurance.”
Howard Gage, a 74-year-old Medicare recipient who owns a three-person video-production company, said he has voted for Ryan in all seven races, still supports the congressman and likes him as a person. But, he added, it’s hard to accept that fixing the budget should mean that his family wouldn’t receive the same Medicare benefits that he relies on.
“It bothers me that my kids or grandchildren might be affected by whatever has to be done” to curb spending, he said.
At face value, it’s interesting that those who elected Ryan aren’t at all sold on Ryan’s vision. If they’re not on board, it stands to reason more vulnerable Republican lawmakers from more competitive districts have reason to be concerned, and may very well balk at embracing such a radical move that won’t pass anyway.
But there’s more to it than that. As Greg Sargent explained, “These folks are worried about doing away with Medicare as we know it, but they are grappling with whether or not this will be necessary to put the nation on firmer fiscal footing.”
Right. Reading the piece, it seems these folks want to do the right thing. They’re uncomfortable with an extreme overhaul of Medicare, but they’re willing to listen to what’s “absolutely necessary.”
But the point is, the privatization of Medicare isn’t “necessary” at all. It won’t even lower health care costs. Paul Ryan’s plan is ostensibly about debt reduction, but even that’s a charade — he’s going after entitlements and other domestic priorities while slashing tax rates for the rich.
Or as Greg added, these voters “are proceeding from the premise that Ryan’s Medicare proposal is about fixing our fiscal situation in a way that would spread the pain around evenly — and not aware that it would shift the burden for fixing our fiscal situation downward, in keeping with conservative tax-cutting ideology.”
Guess what message Democrats should be pushing right now? Or put another way, what do you suppose those folks in Southeastern Wisconsin would say if they knew going after Medicare wouldn’t be at all necessary if Ryan weren’t so desperate to give millionaires another massive tax break?
By: Steve Benen, Washington Monthly-Political Animal, April 11, 2011
How The Media Promotes Ignorance And Stifles Debate
Friday night, my eyes were glued to to the news, as I awaited any and all emerging details about the possible government shutdown. As outlets began reporting that republicans and democrats had finally reached a deal, I immediately felt a sense of relief. Thank goodness, I thought, so much unnecessary suffering averted. But the relief didn’t last long, because in the pit of my stomach was fear for the many millions of people who will be affected by the $38 billion in budget cuts passed by congress. Unfortunately, the media feels differently, preferring to discuss ad-nausium the budget cut’s political ramifications for the two parties.
The same thing happened when the GOP was determined to shutdown the government if democrats did not sign on to defunding Planned Parenthood. Again, the media’s focus was not on the health of the 3 million people the organization treats every year, by providing cancer screenings, HIV and STI checks, and contraceptives. They focused on how this painted republicans as partisan ideologues, or the democrats as supporters for women’s rights, which party was to blame for the almost-shutdown, and most notably, the consequences this would have on their popularity.
Almost all of the reporting by the establishment media centers around how X will affect the democrats favorability numbers, or how Y will affect the republicans chances in 2012. Whether I was watching MSNBC or CNN, the sole concern was always on the political implications of the budget cuts, rather than the real life consequences for the many millions of Americans already suffering from unemployment, foreclosures, and sky-rocketing medical costs.
And therein lies the problem with our media establishment: Every major policy issue is strangled by the established “right vs left” consensus. Whether it’s civil liberties, our endless wars, healthcare reform, or the economy, all are presented through the prism of democrat and republican disagreement. Not only does this ignore the tribulation of people around the country, but most importantly the media omits discussion of issues that receive bipartisan support, which has increasingly become the case, issue after issue.
There is very little that republicans and democrats in office disagree on. They both support the wars, the private insurance industry, tax cuts for the wealthy, deregulation, budget cuts during an economic recession, and the list goes on. Perhaps this is because both parties are corporately owned by the same interests. The only real difference today remains their position on social issues. Republicans are still against women’s reproductive rights and marriage equality, while democrats remain pro-choice and advocates for ending institutionalized discrimination against homosexuals (although they don’t do a very good job at consistently standing up for these rights). While these issues are of great importance, they are not the only problems afflicting the nation.
Look no further than the lack of coverage on economic suffering for proof. Republicans want to cut all social spending, while democrats prefer to cut a fraction of social services that benefit the public at large. So rather than discussing alternatives to austerity aimed at the working class and poor, the media solely focuses on how much austerity is enough. Poll after poll shows that Americans overwhelmingly support increasing taxes on the wealthy to reduce the deficit. In addition, major cuts to Medicaid, Medicare, or Social Security to balance the budget are wildly unpopular. But the mainstream narrative does not even challenge whether budget cuts are necessary, or if other alternatives for deficit reduction exist, let alone the public’s opinion.
The media also refuses to bring up defense spending, which costs upwards of $1 trillion annually. Probably because both parties agree that the national security and warfare state are untouchable. Which is interesting, given that the public prefers cutting defense spending rather than social spending to reduce the deficit. Then again public support for the Afghanistan war is at an all-time low, but the bipartisan Washington consensus in support of the war remains unmoved. The fact that war spending is draining our treasury should be a significant story for the media, particularly since the government just launched another war in Libya, while ironically calling for fiscal responsibility.
If they aren’t even capable of exposing the cost of war, it is no surprise that the casualties of war, both the injured and dead, soldiers and civilians, are completely omitted from discussion. Again, this makes sense, given the bipartisan support for war, with tactical nuances making up the few points of contention. This was most apparent in the lead up to the Iraq war, which enjoyed strong bipartisan support, with the media following suit by forcing a pro-war narrative and firing those who loudly dissented.
The same is true for healthcare reform. Americans overwhelmingly support a single payer, medicare-for-all system, but since democrats and republicans are both in the pockets of the private insurance industry, single-payer is not a viable topic for debate on the airwaves. Even climate change has become a forgotten issue. Now that President Obama and his fellow democrats have adopted the Bush approach — i.e. refusing to cut greenhouse gas emissions, regulate resource exploiting industries, or invest in alternative energy — climate change and it’s very real, disastrous effects, are almost never examined.
It is no wonder so many Americans are turned off by politics. Many don’t realize how political decisions effect their everyday lives, from the quality of the water and air that they breath, to the seat-belts they wear and sick days they receive. If not for independent media outlets like Democracy Now! and independent journalists like Glenn Greenwald, Jeremy Scahill, and Marcy Wheeler, to name a few, I would be an apathetic liberal uninterested in “silly political debate”.
If the goal of the establishment media class is to portray significant political decisions as boring ideological nonsense, then they have succeeded. One doesn’t need to attend journalism school to understand that the mainstream media has failed at its job of informing the public and holding those in power accountable. Instead they have successfully promoted ignorance and stifled debate, to the detriment of truth and social justice.
By: Rania Khalek, CommonDreams.org, April 10, 2011
Why Are People Acting Like Health Care Reform Never Happened?
Ezra Klein, responding to the widespread perception that Paul Ryan has a plan to tackle medical cost inflation and Democrats don’t, points out that this is the opposite of the truth:
The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.
If those initiatives work, they head over to the Independent Payment Advisory Board (IPAB), which can implement cost-controlling reforms across Medicare without congressional approval — an effort to make continuous reform the default for Medicare, even if Congress is gridlocked or focused on other matters. And if they don’t work, then it’s up to the Center for Medicare and Medicaid Innovation, a funded body that will be continually testing payment and practice reforms, to keep searching and experimenting, and when it hits on successful ideas, handing them to the IPAB to implement throughout the system.
The law also goes after bad and wasted care: It cuts payments to hospitals with high rates of re-admission, as that tends to signal care isn’t being delivered well, or isn’t being follow up on effectively. It cuts payments to hospitals for care related to infections caught in the hospitals. It develops new plans to help Medicare base its purchasing decisions on value, and new programs to help Medicaid move patients with chronic illnesses into systems that rely on the sort of maintenance-based care that’s been shown to successfully lower costs and improve outcomes.
Keep in mind that the Congressional Budget Office made the very conservative decision not to assign savings to these measures, on the assumption that since they had never been tried before, there was no way of measuring how well they would work, so it gave them no financial savings value. And the Affordable Care Act also included a limit on the tax deduction for expensive health insurance, a powerful cost-saving tool that the CBO did score.
But to zoom out for a second, what Klein’s identifying here is part of a larger phenomenon. It’s not just that the debate about health care costs seems to take place as if the ACA never happened. The entire political debate seems to take place as if the ACA never happened. Moderate liberal Jacob Weisberg lamented liberal opposition to Paul Ryan as advocating government health care for the old but nobody else — when of course we now have government-provided health insurance for everybody else (except illegal immigrants.)
The deficit hawks embrace Paul Ryan’s plan as a starting point of a debate about deficit. (David Brooks today: “Because he had the courage to take the initiative, Paul Ryan’s budget plan will be the starting point for future discussions.”) But of course the ACA was not just a starting point but an enormous stride forward. Ryan proposes to undo much of it. Yet he is the courageous leader, and his critics passive observers.
What happened? The details of the ACA’s cost-containment are wonky, and few people paid attention to them. Staunch liberals either didn’t care about cost containment, or devoted their energy to agitating for more sweeping alternatives. Moderate liberals supported the measure, but, taking their cue from policy wonks, took the very honest posture of conceding that some parts might not work as planned, and thus contributed to a massive asymmetry of passion. Centrists simply assumed that any deficit plan that wasn’t a grand bipartisan deal could not be a real deficit plan, since their fundamental premise is that a grand bipartisan deal is the only way to address the deficit. And the whole health care issue was sucked into the vortex of an unhinged debate, so that millions of conservatives understand the whole package as nothing more than an assault on freedom, with little or no grasp of the particulars.
The end result of all this is a debate around an issue with a peculiar backwards character.
By: Jonathan Chait, The New Republic, April 4, 2011
The Democrats Have A Plan For Controlling Health-Care Costs, Paul Ryan Doesn’t
There’s increasingly an understanding that the mixture of cuts and taxes in Paul Ryan’s budget aren’t quite fair, and the underlying assumptions it uses don’t quite work. But it’s left people hungry for a budget that does work, and annoyed that Democrats haven’t provided one. “If Democrats don’t like his budget ideas, they should propose their own,” writes Fareed Zakaria. “The Democrats and Obama now have to offer a response,” warned Andrew Sullivan. “As of this evening, the Democratic policy plan consists of yelling ‘You suck!’” complained Megan McArdle.
I’ve made similar comments. And I think those comments are mostly right. Democrats need to step up on taxes, on defense and non-defense discretionary, on Social Security, and on energy. But there’s one huge, glaring exception: controlling health-care costs. There, the reality is that Democrats have a plan and Ryan doesn’t. But the perception, at this point, is just the opposite.
At the heart of Ryan’s budget are policies tying the federal government’s contribution to Medicare and Medicaid to the rate of inflation — which is far, far slower than costs in the health-care sector typically grow. He achieves those caps through cost shifting. For Medicaid, the states have to figure out how to save the money, and for Medicare, seniors will now be purchasing their own insurance plans and, in their new role as consumers, have to figure out how to save the money. It won’t work, and because it won’t work, Ryan’s savings will not materialize.
Even Ryan’s fans agree you can’t hold health-care costs down to inflation. But even if you grant that Ryan’s target is too low, his vision for reforming Medicare would like miss a more reasonabke target, too. Consider the program Ryan names as a model. He said his budget converts Medicare into “the same kind of health-care program that members of Congress enjoy.” The system he’s referring to is the Federal Employee’s Health Benefits Program, and cost growth there has not only massively outpaced inflation in recent years, but actually outpaced Medicare, too. Ryan’s numbers are so fantastic that Alice Rivlin, who originally had her name on this proposal, now opposes it.
Democrats don’t just have a proposal that offers a more plausible vision of cost control than Ryan does. They have an honest-to-goodness law. The Affordable Care Act sets more achievable targets, and offers a host of more plausible ways to reach them, than anything in Ryan’s budget. “If this is a competition betweenRyan and the Affordable Care Act on realistic approaches to curbing the growth of spending,” says Robert Reischauer, who ran the Congressional Budget Office from 1989 to 1995 and now directs the Urban Institute, “the Affordable Care Act gets five points and Ryan gets zero.”
The Affordable Care Act holds Medicare’s cost growth to GDP plus one percentage point, which makes a lot more sense. It’s the target Ryan’s Medicare plan originally used, back when it was called Ryan-Rivlin. But the target is not really the important part. The important part is how you achieve the target. And the Affordable Care Act actually includes reforms and new processes for future reforms that would help Medicare — and the rest of the medical system — get to where the costs can be saved, rather than just shifted.
The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.
If those initiatives work, they head over to the Independent Payment Advisory Board (IPAB), which can implement cost-controlling reforms across Medicare without congressional approval — an effort to make continuous reform the default for Medicare, even if Congress is gridlocked or focused on other matters. And if they don’t work, then it’s up to the Center for Medicare and Medicaid Innovation, a funded body that will be continually testing payment and practice reforms, to keep searching and experimenting, and when it hits on successful ideas, handing them to the IPAB to implement throughout the system.
The law also goes after bad and wasted care: It cuts payments to hospitals with high rates of re-admission, as that tends to signal care isn’t being delivered well, or isn’t being follow up on effectively. It cuts payments to hospitals for care related to infections caught in the hospitals. It develops new plans to help Medicare base its purchasing decisions on value, and new programs to help Medicaid move patients with chronic illnesses into systems that rely on the sort of maintenance-based care that’s been shown to successfully lower costs and improve outcomes.
I could go on, but instead, I’ll just link to the Kaiser Family Foundation’s excellent primer (pdf) on everything the law does. The bottom line is this: The Affordable Care Act is actually doing the hard work of reforming the health-care system that’s needed to make cost control possible. Ryan’s budget just makes seniors pay more for their Medicare and choose their own plans — worthy ideas, you can argue, but ideas that have been tried many times before, and that have never cut costs in the way Ryan’s budget suggests they will.
That’s why, when the Congressional Budget Office looked at Ryan’s plan, they said it would make Medicare more expensive for seniors, not less. The reason the deficit goes down is because seniors are paying 70 percent of the cost of their insurance out-of-pocket rather than 30 percent. But that’s not sustainable: We’ve just taken the government’s medical-costs problem and pushed it onto families.
No one who knows health-care policy will tell you that the Affordable Care Act does everything we need to do in exactly the way we need it done. That’s why Resichauer gave it a five, not a 10. But it does a lot of what we need to do and it sets up systems to help us continue doing what’s needed in the future.
Ryan’s proposal, by contrast, does almost none of what we need to do. It appeals to people who have an ideological take on health-care reform and believe we can make Medicare cheaper by handing it over to private insurers and telling seniors to act like consumers. It’s a plan that suggests health-care costs are about insurance, as opposed to about health care. There’s precious little evidence of that, and when added to the fact that Ryan’s targets are so low that even his allies can’t defend them, the reality is that his savings are largely an illusion.
The Affordable Care Act has taken a lot of hits. It’s not popular, and though very few of the political actors confidently attacking or advocating it can explain the many things it’s doing to try and control costs, people have very strong opinions on whether it will succeed at controlling costs. But the irony of everyone demanding Democrats come up with a vision for addressing the drivers of our deficit in the years to come is that, on the central driver of costs and the central element of Ryan’s budget, Democrats actually have something better than a vision. They have a law, and for all its flaws, their law actually makes some sense. Republicans don’t have a law, and their vision, at this point, doesn’t make any sense at all.
By: Ezra Klein, The Washington Post, April 8, 2011
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