How’s that working?

In 2006, Massachusetts signed into law the nation’s first state universal health insurance program. It was to be the test ground to see how well universal health coverage would work here in the United States. So, why do we hear so little about how it’s going?

Background

As this third wealthiest state in the country focused its resources on ensuring all of its residents were insured, it quickly became apparent that the state’s estimates of what it would cost taxpayers had been underestimated by more than five-fold. The program also created an enormous set of new bureaucracies (no less than ten new agencies, six financial-management funds, and three new programs) to establish, oversee and enforce... and proved more expensive and less efficient.

Similarly, forced to purchase the managed care plans approved by the state (with coverage mandates they may not need or want) or have their tax returns docked, some families and employers found their healthcare costs and insurance premiums rising and their choices restricted. This past June, results of the first survey of the new law were released, finding that nearly 100,000 Massachusetts taxpayers had been fined for failing to purchase state mandated health insurance.

What care was available, how it was delivered, who gets it and when, fell under a state “Care Quality and Cost Control Council,” which was directed to lower or contain costs. Healthcare providers found their care graded on their compliance with state-insurer performance measures, rather than what might be best for individual patients or hold the greatest medical efficacy. This May, doctors with the Massachusetts Medical Society had taken legal action to protest the state insurance agency's ranking of doctors by cost-based performance measures.

Within weeks of the law's deadline for people to have purchased insurance, the state was scrambling, as it realized it not only hadn’t accurately budgeted for the program, but health insurance was not the same as access to care. Who would provide the care? With a shortage of primary-care providers [the gatekeepers in managed care plans], people found that 95% of these doctors weren’t accepting more patients, and rationing of services and growing waits for care began.

By February of this year, the state was asking the Federal government to bail it out and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.

Insurance companies, of course, support government mandates for residents to purchase their insurance, or states to subsidize it for low-income and illegal alien residents. The strongest lobby for universal health coverage since the 1990s has been, of course, Robert Wood Johnson Foundation. Their take on the Massachusetts plan is that it’s a success, most employers and residents support it, and that it could be a model for universal health coverage across the country. But surprisingly little information from consumers and healthcare professionals is reaching the rest of the country.

Latest news

Yesterday, the Boston Globe, reported on the latest progress of the country’s first state universal health coverage. As governors across the country are proposing their own universal health coverage programs patterned after Massachusetts, you’d think this information would be front page news in every local newspaper. But the media silence is, as they say, deafening. Reporter Liz Kowalczyk reports:

Across Mass., wait to see doctors grows

Access to care, insurance law cited for delays

The wait to see primary care doctors in Massachusetts has grown to as long as 100 days, while the number of practices accepting new patients has dipped in the past four years, with care the scarcest in some rural areas. Now, as the state's health insurance mandate threatens to make a chronic doctor shortage worse, the Legislature has approved an unprecedented set of financial incentives for young physicians, and other programs to attract primary care doctors. But healthcare leaders fear the new measures will take several years to ease the shortage.

Senate President Therese Murray, who championed the legislation, said that many of the roughly 439,000 people who obtained health coverage under the 2006 insurance law are struggling to find a doctor. "You can take a look at the whole state and you are not going to find a primary care physician anytime soon." ...

Doctors and patient advocates report growing stress for patients trying to get care, and for physicians trying to squeeze them in: In Williamstown... In Amherst...And in Great Barrington, Volunteers in Medicine, a clinic for the uninsured, is for the first time treating insured patients....

Access to care is not just a problem for the newly insured. Herman Berkman of Adams fell down some stairs a couple of months ago. But his primary care doctor, Robert Jandl, and an orthopedist's office were busy, Berkman said, so the 85-year-old went to the emergency room... Jandl has watched his colleagues in the Berkshires retire, move away, and quit high-stress practices to work predictable shifts in a hospital. With few new physicians replacing them, he had taken on so many patients that earlier this year, he closed his practice to new patients...

The Globe went on to report on the annual physician survey conducted by the Massachusetts Medical Society, the state's largest physician organization. It found that among 100 internists, the average wait time for an appointment for a new patient was 50 days, with some reporting waits of up to 100 days. This compares to average wait times in 2004, prior to the universal healthcare coverage laws, of 47 days, with the longest recorded wait of 87 days. The MMS survey found waits for appointments with obstetrician/gynecologists and family practitioners had also increased. The Medical Society also reported fewer primary care doctors are accepting new patients, with nearly half (42%) having closed their practices entirely to new patients, a one-third increase since 2004.

Reporter Kowalczyk wrote:

Amherst family physician Kate Atkinson decided to open her practice to new patients in January partly so she could take on the newly insured, especially since, by her count, 18 doctors in the area had closed their practices over the last two years. Most of those physicians have become hospitalists, caring for patients in the hospital, she said. "There were so many people waiting to get in, it was like opening the floodgates," Atkinson said. "Most of these patients hadn't seen the doctor in a long time so they had a lot of complicated problems." She closed her practice to new patients again six weeks later. "We literally have 10 calls a day from patients crying and begging," she said.

The Massachusetts legislature has passed more health regulation legislation in a single year than any other state, trying to control costs and solve the problem of access to primary care providers, said Richard Cauchi of the National Conference of State Legislatures. These additional costs to taxpayers include $1.5 million to subsidize medical students who agree to work as primary care doctors for four years; $1.7 million to subsidize medical school loans for doctors who agree to work in community health centers and $500,000 to pay off debts of doctors who agree to work in primary care for at least two years. The law also allotted $1.7 million, along with a $5 million grant from Bank of America, to help doctors buy houses, hoping to attract primary doctors to the state. But, as the president of the Massachusetts Medical Society noted, all of these legislative programs have a long lag time before effects are seen.

The rate of uninsured people in Massachusetts has gone from 10.3% in 2004-5 to 7.9% in 2006-7, according to the just-released Income, Poverty and Health Insurance Coverage in the United States report from the U.S. Department of Commerce, U.S. Census Bureau. It would appear, however, that there are significant challenges that this national pilot test program has yet to resolve before success in financial viability and improving health care is demonstrated.