Health Reform Lessons from Massachusetts, Part VIII

Unintended consequences for patients

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 blueprint for health system change on a national scale, and its advocates have aggressively marketed some variation of the Massachusetts plan as the reform of choice. Until recently, there has been remarkably little analysis of how the law has worked. This is the eighth 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.

Earlier this year, Atul Gawande, The New Yorker’s star medial journalist and endocrine cancer surgeon at Brigham and Women’s Hospital in Boston, wrote an investigative piece in which he discussed how other Western countries’ health care systems came to be. He talked of the Medicare prescription drug program in the U.S.—a privatized approach—and how it got off to a rocky start. Gawande used that as a parable to debunk what he called “the lure of the ideal,” a siren song sung by single-payer advocates and free-market enthusiasts.

Toward the end of the piece, Gawande delivered his punch line: “We can build a new system on the old one.” The new system, Gawande suggested, could be patterned on reform in Massachusetts, which didn’t “organize a government takeover of the state’s hospitals or insurance companies, or force people into a new system of state-run clinics. It built on what existed.”

Gawande reported that the “results have been remarkable” and recited the oft-quoted statistic about some 97 percent of the state’s residents having insurance coverage. (It’s less now.) He noted that surveys have found at least two-thirds of the state’s residents support reform, but didn’t mention that among those who had to buy insurance as a result of the law, support for reform was considerably less.

Gawande implied that reform had been good for medical specialists like himself and for his hospital, a member of the vast Partners HealthCare System, which wields tons of power in the state. Gawande said he no longer had patients who delayed surgery or asked about the costs of necessary tests. But he didn’t mention a significant problem for thousands of residents who now have insurance—the lack of primary care doctors to treat everyday illness and prevent more serious disease. When nearly 500,000 residents suddenly got the ticket to buy care, the state found that there weren’t enough sellers.

Massachusetts has more doctors per capita than any other state, but garden variety primary care docs are in short supply, as they are in other parts of the country. In the U.S., only about one-third of all physicians are primary care docs; about half the physician force in other developed countries consists of primary care docs. The shortage of primary care doctors means that it’s hard to get in the door when you’re sick, which means that waiting lists and long lines develop—rationing care, so to speak. That’s what’s happening in the Bay State, a point the media should remember next time they’re tempted to report that long lines exist only in countries with national health insurance.

Very few news outlets have taken a critical look at the waits developing as a result of bringing newly insured people into a system that didn’t have enough doctors to begin with. In the last few weeks, The New York Times and Kaiser News Service explored the Massachusetts doctor mess. The Times reported that the Massachusetts Medical Society released its 2008 doctor survey, which showed that about one-quarter of all the state’s residents—up from 16 percent in 2007—had trouble getting the care they needed.

The study also found that only 60 percent of family doctors accept new patients—down from 65 percent in 2008 and 70 percent in 2007. For those able to get through the door, the Society reported that the waiting period to get an appointment with a family doc increased from thirty-six days in 2008 to forty-four now. The wait to see internal medicine specialists shortened a bit, but for the first time Massachusetts reported shortages of OB/GYNs, who many women use as their primary care providers. The Society also reported that nearly seventy percent of physicians said they had trouble referring patients to specialists. “With our state health reform initiative, we quickly learned that universal coverage doesn’t equate to universal access,” Dr. Mario Motto, the Society’s president, told the Times.

All this, of course, is not news to people in Massachusetts who must wait or go without care, or to outreach workers who deal with those frustrations. Last fall, Community Partners surveyed its Health Access Network of 1,200 workers who help state residents find coverage. They, too, reported that people were not able to see doctors and that there was really little choice of providers, showing that in the Bay State (and elsewhere) the mantra of choice is more useful as political slogan than an as an actuality. One worker said that finding a doctor who takes the cheapest plan subsidized through the Connector, the state’s brokerage service, is not always easy. Nor is it easy for people now eligible for the state’s expanded Medicaid coverage to find a physician who will accept the insurance they have.

Last winter on The Daily Nightly, an MSNBC blog, one comment caught my eye. Dr. Alice D. Barton of North Chatham on Cape Cod explained the doctor problem this way:

The truth of “universal” health care in Massachusetts is that it is not true. I am one of the only physicians in my area who accepts the state health insurance. I actually pay to provide health care for these individuals. If no doctors accept this insurance, how does it provide health care to anyone? Please tell the truth about this.

Hey, the media need to help out with this one. An informative piece by Phil Galewitz for Kaiser News Service examined the chances that the primary care shortage problem would be solved soon. The article didn’t end on a hopeful note, suggesting, as Massachusetts shows, that for too many the promise of health insurance may be little more than a cruel joke. The public needs to know that simply changing insurance company practices—the current goal of health reform—will not bring medical Nirvana. If the media don’t tell them that, who will?

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.