The Blue Cross Blue Shield Foundation of Massachusetts (BCBSF) put out an annual survey this week on the Massachusetts health reform law, along with a Health Affairs piece that has left me shaking my head. The presentation of the results seems to overstate the findings and draws unlikely conclusions about the federal law.
- In my humble opinion, Health Affairs has lost some credibility with the pieces they publish on Massachusetts. Editor-in-chief Susan Dentzer admitted the publication’s bias in a recent speech to the Massachusetts Association of Health Plans.
On the actual BCBSF report, just a couple of comments:
- The survey is a great way to capture a snapshot of what is taking place in Massachusetts, but the phone survey method should always be taken with a grain of salt.
- Self-reported ER visits are predictably unreliable. Individuals know they should not have gone to the ER for their care, so they are prone to underreport their true actions. One year of a slight decline in visits is not worth a major finding; only a multi-year downward trend in ER visits will be noteworthy. Most state data has shown the opposite for ER visits. So, survey results from one year and one state report using administrative data (cited in the Health Affairs article) should be cautiously interpreted. I hope the trend holds, but the survey data should not be used as a talking point in support of the Massachusetts law– yet.
- The study has a odd way to define affordability: “…there have been gains in the affordability of care for adults since 2006, as evident in a lower burden from out-of-pocket health care spending (excluding premiums)…” Why would you exclude premiums in your definition? This exclusion is like celebrating a decrease in the price of printer ink while ignoring the increase in the price of the actual printer.
- The discussion section of the Health Affairs article contains a heavy does of spin and takes every opportunity to highlight a positive slant on the data. There is only minor passing mention of possible differences in states, and no mention of differences between the Massachusetts and Federal laws.
Taken together, Massachusetts’s experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.
Just as Massachusetts’s 2006 health reform legislation provided the template for the Affordable Care Act, so the state’s experience under that legislation provides an example of the potential gains under federal health reform. Of course, the trajectory of policy and health reform will vary across the states, given the wide differences in their political, economic, and cultural environments and the wide range in the different states’ starting points
The comparison has become a messaging tactic by liberals and supporters of the federal law, most recently illustrated by John McDonough in his Families USA piece. These folks want the public to think Massachusetts is the same as the rest of the country, and the ACA will have the exact same impact nationally as it has locally.
I will offer just two examples why this is unlikely:
1) Do health policy officials really believe that the outcomes from a
high-income; geographically compact; historically heavily regulated insurance market; non-profit dominated insurer and provider market; medically and technologically advanced state, with a younger and more active demographic makeup; and a culture of health insurance
state, such as Massachusetts play out in the same manner in as a
low-income; geographically spread out; drastically different regulated insurance environment; mixed with both private and non-profit insurers; dealing with scarcity in medical infrastructure; heavily employed in service and tourism industries; ethnically diverse; and without a culture of insurance
state, such as New Mexico?
2) Differences between the two health care laws will lead to significantly different behavior and outcomes. One example: In Massachusetts, if employees are offered employer based insurance, they are not allowed into the exchange. (The only way into the exchange is if employees were to go uninsured for 6 months.)
In the ACA, entry into the exchange is based on an “affordability” threshold of 9.5% of your income or an actuarial value of your employer based insurance of less than 60. In other words, it is much easier to access the exchange and the economics are very good for employers to dump their employees into the exchange. This is a completely different world in public policy and a much more expensive one at that.