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					The Impacts of Massachusetts Health
Reform on Coverage and Health Care
Access and Affordability for Women


                   Shanna Shulman, Ph.D.
     Blue Cross Blue Shield of Massachusetts Foundation


                     December 8, 2010
  Massachusetts Health Reform


    Enacted in 2006 with goal of near-universal coverage


    Like ACA, Massachusetts health reform included:
                 •       Expansion of existing public programs
                 •       Exchange to provide more affordable coverage options
                 •       Individual mandate, government subsidies, employer share


    Unlike ACA, Massachusetts health reform involved:
                 •       Conditions ripe for reform success
                 •       No cost containment provisions



Blue Cross Blue Shield of Massachusetts                                             22
  How we measure reform impact: Data


    Massachusetts Health Reform Survey
                 •       Pre-reform survey--fall 2006
                 •       Post-reform surveys--fall 2007, 2008, 2009
                 •       Telephone interviews with samples of adults 18 to 64
                              — Sample sizes 3000+ in each year
                 •       Questions on insurance coverage and on access, use, and affordability of care


    Project team: Sharon K. Long and Karen Stockley, Urban Institute




Blue Cross Blue Shield of Massachusetts                                                                  33
How we measure reform impact: Methods


    Estimate impact of reform as change over time from fall 2006
                 •       Estimates capture recession and health care cost trends


    Multivariate regression models that control for demographic characteristics, health
       and disability status, socioeconomic status, and region of state
                 •       Estimate linear probability models, controlling for complex survey design




Blue Cross Blue Shield of Massachusetts                                                              44
Health insurance coverage
 Women are more likely to have health insurance coverage under health reform

                                                 97% ***
           100%
                                          91%
                                                                                                                                                          Fall 2006

              80%                                                                                                                                         Fall 2009
                                                                                                 69%
                                                                                    67%


              60%




              40%
                                                                                                                                            28% **
                                                                                                                                  24%

              20%




                0%
                              Any insurance coverage                               ESI coverage                         Public or other coverage



                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                               55
Health care access and use
 Women are more likely to have a regular health care provider and to have health care
visits under health reform


           100%                            93% **
                                     90%                                     91% ***                                                                         Fall 2006
                                                                     85%
                                                                                                                 82% **
                                                                                                         77%                                       79% ***   Fall 2009
             80%
                                                                                                                                           73%



             60%




             40%



             20%



                0%
                          Usual source of care                   Any doctor visit               Preventive care visit                      Dental visit




                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                                  66
Unmet need for care for any reason
 Unmet need for health care was lower for women under health reform
                        100%

                                                                                                                                                                         Fall 2006
                          80%                                                                                                                                            Fall 2009


                          60%



                          40%
                                          27%
                                                 21% ***
                          20%                                                                                                                             13%
                                                                                                10%                          9%                                 10% **
                                                                     7%       6%                        7% **                         6% **


                            0%
                                      Any unmet need              Doctor care                Medical tests,               Prescription                Dental care
                                       for health care                                       treatment, or                   drugs
                                                                                            follow-up care



                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                                              77
Problems with affordability of health care
 There were some gains in affordability of care for women under health reform in fall
2009, despite the recession and increasing health care costs

                 100%                                                                                                                                               Fall 2006
                                                                                                                                                                    Fall 2009
                   80%



                   60%



                   40%
                                                                                                                                                          29% **
                                                                                                                                                    25%
                                                                21%      22%                 21% 23%
                                                                                                                        17%
                   20%                                                                                                          14%**
                                          9%
                                               7%

                      0%
                                  OOP spending =>           Problems paying                Medical debt               Unmet need              Problems with other
                                   10% of family              medical bills                                          because of cost                 bills
                                      income


                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                                         88
Health insurance coverage
for subgroups of women
 Gains in coverage under health reform were particularly strong for women who
started out with lower levels of coverage prior to reform
                                                                            97% ***                           96% ***                         96% ***
                100%                        95% ***
                                                                     90%                              90%                             89%
                                          85%                                                                                                             Fall 2006
                                                                                                                                                          Fall 2009
                  80%



                  60%



                  40%



                  20%



                     0%
                                    Lower-income                  Racial/ethnic                  Women 50 to 64                  Women without
                                       women                     minority women                                                dependent children



                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                               99
Health care use for subgroups women:
Doctor visits

 Strong gains in health care use for subgroups of women under health reform

                100%
                                                90% ***                                               90%        91%                          91% **
                                                                             86% ***                                                  85%
                                                                                                                                                          Fall 2006
                                          81%
                                                                                                                                                          Fall 2009
                  80%                                                75%




                  60%



                  40%



                  20%



                     0%
                                    Lower-income                  Racial/ethnic                  Women 50 to 64                  Women without
                                       women                     minority women                                                dependent children



                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                               1010
Health care use for subgroups of women:
Unmet need for care for any reason
 Strong reductions in unmet need for health care under health reform for subgroups of
women
                100%
                                                                                                                                                           Fall 2006
                                                                                                                                                           Fall 2009
                  80%



                  60%



                                          36%
                  40%
                                                                     32%
                                                26% ***                                                                               28%
                                                                                23% **                23%
                                                                                                                                                 20% ***
                                                                                                                17% **
                  20%



                     0%
                                    Lower-income                  Racial/ethnic                  Women 50 to 64                  Women without
                                       women                     minority women                                                dependent children



                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                                1111
Health care use for subgroups of women:
Unmet need for care because of cost

 Strong reductions in unmet need for health care because of costs under health reform for
subgroups of women, despite the recession and increasing health care costs

                100%
                                                                                                                                                          Fall 2006
                                                                                                                                                          Fall 2009
                  80%



                  60%



                  40%
                                          27%

                                                                     21%                                                              19%
                                                16% ***
                  20%                                                                                 13%                                       13% ***
                                                                               12% ***
                                                                                                                10% *


                     0%
                                    Lower-income                  Racial/ethnic                  Women 50 to 64                  Women without
                                       women                     minority women                                                dependent children




                          * (**) (***) Regression-adjusted estimate of difference from Fall 2006 significant at .10 (.05) (.01) level, two-tailed test.




Blue Cross Blue Shield of Massachusetts                                                                                                                               1212
Despite gains under reform, challenges remain


      Estimate ~60,000 women uninsured in fall 2009


      Roughly 1 in 5 women reported:
                   • Difficulties finding a provider who would see them
                   • Going without needed health care
                   • Problems paying medical bills
                   • Medical debt




Blue Cross Blue Shield of Massachusetts                                   1313
Who are the remaining uninsured women?

      Disproportionately young, Hispanic, and single


      More than 25% in fair or poor health


      More than 75% with family income <300% of the federal poverty level


      From American Community Survey:
                   • More than 25% not a US citizen
                   • Nearly 20% do not speak English well




Blue Cross Blue Shield of Massachusetts                                     1414
  Early evidence: Affordability gaps increased
  between women and men

      Pre-reform, women more likely to have coverage, access compared to men
                   • Affordability about equal for men and women



      Post-reform, coverage and access gaps narrowed
                   • Women face more affordability problems, despite higher levels of coverage
                            compared to men
                                 —Increasingly more likely to report problems paying medical bills, unmet need
                                  due to cost
                                 —Particularly among young women (age 18-45)




Blue Cross Blue Shield of Massachusetts                                                                      1515
Summary of Impacts of Health Reform on Women
      Strong gains in insurance coverage
                   • No evidence of ESI crowd-out
                   • Strongest gains among vulnerable women


      Strong gains in access to and use of health care

      Some challenges remain
                   • Affordability: Recession and continuing increase in health care costs leading to increasing
                     financial problems for women
                   • Barriers to care persist for some women




Blue Cross Blue Shield of Massachusetts                                                                       1616

				
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