Three years ago, the Commonwealth of Massachusetts enacted a far-reaching health reform law that politicians and the media hailed as a model for other states and the federal government. That law has become the major blueprint for health system change on a national scale, and its advocates, with Sen. Edward Kennedy at the top of the list, are aggressively marketing some variation of the Massachusetts plan as the reform of choice. Until recently, there has been little analysis of how the law has worked. This is the fifth in an occasional series of posts that will explore the Massachusetts law, with an eye toward helping the press and the public understand the flashpoints as legislation based on the Bay State’s experiment winds its way through Congress. The entire series is archived here.
Perhaps the most informative segment in last March’s otherwise off-the-mark Frontline documentary, Sick Around America, concerned Dale and Alison Abrams of Great Barrington, Mass. The Abrams’s story illustrates what many people in the state are beginning to realize—that affordable health insurance is beyond their reach even under the health reform law, and that the state’s much touted shopping/brokerage service, called the Connector, may not help much.
The Abrams’s income, about $63,000 per year, was a bit too high to qualify for subsidized coverage when the law took effect. (The cutoff for state help was just over $60,000.) The state’s affordability schedule indicated that families with annual incomes of $63,000 a year should have been able to spend up to $352 a month on premiums. But Frontline reported that when the Abrams’s searched the state web site, the cheapest monthly premium available for them through the Connector cost $800. They finally choose a policy costing around $1100, nearly twice the family’s mortgage and three times its food budget. Eventually Alison got a job with benefits.
The law established the Connector, the brainchild of the conservative Heritage Foundation, to make it easier for residents to shop for the insurance they are required by law to buy. All residents (with some exceptions) must carry insurance or pay a tax penalty, this year about $1000 per person. Those with incomes 300 percent above the federal poverty level, or $66,150 for a family and $32,496 for an individual, receive full or partial subsidies to help buy insurance. An independent, quasi-governmental agency with a budget this year of $33 million, the Connector contracts with managed care organizations that provide coverage for residents receiving subsidies. It also offers a kind of Good Housekeeping seal of approval for policies sold through its Web site, a program called Commonwealth Choice.
It was hoped that the state’s insurers would compete through the Connector for the new business generated by the mandate, and people like Dale and Alison Abrams would have their pick of lower-premium policies. But premiums for many are still sky high because medical costs are so high. “I don’t believe if you just give consumers an outpouring of information that it will be possible for them to be in the driver’s seat and make changes in the marketplace,” says Nancy Turnbull, an associate dean at the Harvard School of Public Health. “Consumer-driven health care is based on so much misconception, and yet that’s what many of the high deductible plans in the Connector are.”
Policies have to meet minimum standards and offer what the state calls creditable coverage, and most adults must have a policy with coverage for inpatient hospital care, physician services, diagnostic tests, outpatient care, and prescription drugs. Deductibles cannot exceed $2000 for individuals and $4000 for families. That still presents a huge out-of-pocket expense for middle-income wage earners, who have to pay those amounts for care before their Connector policies kick in. Preventive care is not subject to the deductible, and the most a family has to pay out-of pocket is $10,000 ($5000 for individuals). Those, too, are high, but still offer some protection against catastrophic expenses. Outside of those parameters, insurers are free to design the policies anyway they like—with copayments and coinsurance applied to different kinds of services such as mental health, drugs, or hospital inpatient stays.
Commonwealth Choice policies are expensive even with their high deductibles, and a few offer a limited choice of providers to keep the cost down. Shoppers can choose among Gold policies that cost more and offer more; Bronze policies that are cheapest and may not cover as much; or Silver policies that fall somewhere in between. There are also special policies for young adults, with somewhat smaller benefit packages.