1. Tracking the Impacts of Health Reform: Lessons from Massachusetts Sharon K. Long University of Minnesota Measuring the State-Level Impact of Health Reform 2011 Minnesota Health Services Research Conference March 1, 2011

2. 2 Health reform in Massachusetts Legislation passed in April 2006, with implementation beginning in July 2006 Major goals: Extend comprehensive insurance coverage to all Massachusetts residents Improve access, affordability, and quality of health care Became the foundation for the 2010 national health reform legislation

3. 3 Elements of Massachusetts health reform Expanded eligibility for public programs Created health insurance exchanges Provided subsidies for low- and moderate- income individuals Expanded dependent coverage Individual mandate Requirements for employers Standards for covered benefits

4. Key changes in coverage options under health reform in Massachusetts 4 Note: FPL is federal poverty level

5. 5 Stakeholders began planning for an impact evaluation in May 2006 Reviewed available data sources National surveys MA sample size too small Survey content too narrow Data available too late for policy/program purposes Existing state data (survey and administrative data) Available outcomes relatively narrow Stakeholder concerns about access to state data Decided to invest in a new state survey Funded by BCBSMA Foundation, with support from Commonwealth Fund and RWJF

6. 6 Data Massachusetts Health Reform Survey Sample of non-elderly adults 18-64 years old Baseline survey in 2006, follow-ups 2007 to 2010 (underway) Oversamples of the lower-income and uninsured adults who were targeted by reform Telephone interviews, with cell-phones added in 2010 Sample size ~3000 each year

7. 7 Outcome measures Health insurance status—current, prior year Availability of/adequacy of employer sponsored insurance Access to care/barriers to obtaining care Use of health care services Affordability of health care services and medical debt Attitudes toward health reform and, particularly, the individual mandate

8. 8 Methods Estimate impact of health reform as change over time from fall 2006 Pre-post estimates will also capture recession & health care cost trends Consistent findings from studies using national data to estimate difference-in-differences models that compare changes in MA to other states Multivariate regression models control for demographic characteristics, health and disability status, socioeconomic status and region of state

9. 9 Health insurance coverage, 2006-2009 Adults more likely to have health insurance under health reform. Source: 2006-2009 Massachusetts Health Reform Survey Note: Regression-adjusted estimates * (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.

10. 10 Type of health insurance coverage, 2006-2009 Employer-sponsored insurance coverage increased under health reform. Source: 2006-2009 Massachusetts Health Reform Survey Note: Regression-adjusted estimates * (**) (***) Significantly different from fall 2006 at the .10 (.05) (.01) level, two-tailed test.

11. 11 Employers’ insurance offer and employees’ take-up, 2005-2009 Employers more likely to offer health insurance coverage to workers and workers more likely to take-up coverage under health reform. Source: 2006-2009 Massachusetts Division of Health Care Finance and Policy Employer Survey

12. 12 Health care access and use, 2006-2009 Adults more likely to have a regular health care provider and to have had health care visits over the prior year under health reform Source: 2006-2009 Massachusetts Health Reform Survey Note: Regression-adjusted estimates *(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two tailed test

13. 13 Unmet need for care, 2006-2009 Adults less likely to have unmet need for any reason under health reform Source: 2006-2009 Massachusetts Health Reform Survey Note: Regression-adjusted estimates *(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test

14. 14 Health care costs and affordability for individuals, 2006-2009 Improvements in affordability of care under health reform despite increasing health care costs and economic recession Source: 2006-2009 Massachusetts Health Reform Survey Note: Regression-adjusted estimates *(**) (***) Significantly different from fall 2006 at .10, (.05) (.01) level, two-tailed test

15. Additions to the state survey in anticipation of national health reform Provider capacity/barriers to care After hours care/emergency care use Health care costs/medical debt Medical home/care coordination Experiences navigating health programs and the health care system Employers’ response to reform/quality of employer-sponsored insurance coverage 15