State’s health care plan assessed

An architect of Massachusetts’ year-old experiment with universal health coverage said Monday (Sept. 17) that because of the experiment 170,000 people have insurance today who otherwise would not, but that the problem may be bigger than initially thought.

Nancy Turnbull, associate dean for educational programs and senior lecturer on health policy at the Harvard School of Public Health, said that the enrollment increases were the result of three programs set up or modified in the new state health insurance law, passed in April 2006. The law’s passage put Massachusetts among a small handful of states with laws requiring that health coverage be extended to as many residents as possible.

Changes to Medicaid, the government-funded program for the poor, sparked an increase of 48,000 people to the rolls, while enrollment in a state-subsidized health insurance plan created under the law, Commonwealth Care, reached 115,000. The remaining 7,000 enrolled in a suite of health plans — called Commonwealth Choice — created for working people who don’t qualify for free or subsidized insurance.

Turnbull said the 48,000 new Medicaid enrollees falls short of state estimates of 89,000 eligible, while the Commonwealth Care enrollment exceeded expectations, particularly for those who qualify for free insurance. The low rate of enrollment in Commonwealth Choice is troubling, she said, as those plans are targeted at the group that will be hit hardest when the individual mandate to acquire health insurance becomes fully effective.

The main difficulty ahead, however, may be that the original estimates of the number of uninsured were too low, Turnbull said. The state originally estimated that 395,000 Massachusetts residents didn’t have health insurance. A recent estimate by the economic and social policy research organization Urban Institute, Turnbull said, is probably more accurate and indicates that 571,000 Massachusetts residents are uninsured.

Those extra bodies represent not only a greater outreach challenge, Turnbull said, but also a potentially dramatic increase in the program’s cost.

Turnbull spent nine years in the Massachusetts Division of Insurance as first deputy commissioner and deputy commissioner for health policy, and also served as president of the Blue Cross Blue Shield of Massachusetts Foundation before coming to the Harvard School of Public Health. She spoke at the Harvard School of Public Health’s Snyder Auditorium as a keynote speaker for the School’s annual Community Partnership Day.

The event, “Health Care Reform and Health Equity: The Promise in Massachusetts and the U.S. — One Year Later,” featured Turnbull and John E. McDonough, executive director of Health Care for All and an adjunct lecturer in health policy and management at the Harvard School of Public Health. In addition, a panel discussion was held with Barbara Keller of Lawrence General Hospital, Clara Savage of Common Pathways of Worcester, and Gadyflor St. Clair of the Mayor’s Health Line in Boston.

McDonough said universal health coverage is an important first step — but just a first step — in addressing health care inequities affecting minorities. Recent federal statistics indicate the problem is getting worse. In 2005, 44.8 million people were thought to be without health insurance. In 2006, that number rose to 47 million, with almost the entire increase among the black and Hispanic communities.

“Universal coverage won’t solve the problem, but until we get universal coverage, we have no prayer of addressing [the problem],” McDonough said. “The goal is not universal coverage. The goal is the best possible health care and the best possible health for every American.”

McDonough said that closing the health equity gap has taken longer than expected. A decade ago, the U.S. Surgeon General set a goal that would eliminate health disparities in six disease categories by 2010. Though those goals were thought to be achievable at the time, McDonough said it appears none will be reached.

McDonough said the knowledge base about health disparities has been well established. What’s needed now is to develop a social strategy and the political will for reform.

One hurdle in addressing disparities may come from the minority communities themselves. Both Savage and Keller said that the timing of national immigration reform is interfering with health care reform by fostering fear and distrust in minority communities.

Several expressed concern that the state’s uncompensated care pool, out of which hospitals are paid to care for uninsured patients, will see funding reductions as the insurance reform continues, leaving it short of funds.

Keller said hospitals are expecting to take a financial hit from the reforms. Lawrence Hospital alone expects a one-year hit of $2.7 million and annual costs of $950,000.

With more uninsured in Massachusetts than expected, Turnbull said, the program will doubtless cost more than original estimates. If that’s the case, the health of the economy as the reforms are implemented may be an important factor in how it fares.

“We’re off to a good start, but there’re lots and lots of challenges ahead,” she said. “Pray for a strong economy. It may be more important than any other factor in our ability to continue to have change.”