Mass Appeal?

Three years after enacting its controversial plan to cover every state resident, results in the Bay State are mixed. The good news is that the percentage of Massachusetts residents who are uninsured has declined to the low single-digits. About 440,000 previously uninsured residents now have coverage, leaving perhaps fewer than 170,000 - less than 3 percent of the population - uninsured.

That kind of decline is hardly surprising when the law mandates coverage and punishes holdouts with tax penalties. Still, compared with America’s uninsured rate of about 16 percent - and rising, surely, as the economy sours - Massachusetts’ achievement can’t be dismissed. The principal goal of the reform was to get everyone covered. And looked at in that context, it’s working.

Yet Massachusetts is also learning that simply fixing the uninsured problem is not the same thing as fixing healthcare. Even as it has widened insurance coverage, it has done little or nothing to solve other fundamental problems with the state’s healthcare system - and may have exacerbated still others.

It is often said that the states are test laboratories for reform. If so, then Congress, as it moves forward this summer on a national healthcare reform strategy, would do well to put the Bay State’s Petri dish under a powerful microscope.

The state in 2006 began requiring people to get insurance coverage or face tax penalties. It offered subsidies for low-income residents, taxed businesses, and set up a new state agency, called the Connector, to help link citizens who need coverage to companies that provide it.

Today, Massachusetts is discovering the limits of this strategy. For starters, a greater number of the formerly uninsured have told surveyors with Harvard’s School of Public Health that they’ve been more harmed by the law’s mandates and expenses than helped by its subsidies and coverage. They’re poorer, they say, thanks to the premiums they’re now required to pay, but they’re not necessarily getting better access to physicians than they were before, when many had free access to a robust system of safety-net care through community clinics and public hospitals. That system is being defunded to pay for the new universal-coverage plan, whose costs, expected to hit $1.3 billion this year, are growing beyond initial estimates.

“We’re seeing patients who now can’t afford vital medications and treatments that they’ve been on for years because of the new copayments and deductibles imposed by the law,” Steffie Woolhandler, an associate professor of medicine at Harvard, says.

Woolhandler is a cofounder of Physicians for National Healthcare Reform, a group that advocates for a single-payer system. It is this and other liberal organizations - more so than conservative or business groups angered by Massachusetts’ tax increases, government mandates, and do-gooder intentions - that have been the loudest opponents of the state’s strategy.

Aside from the cost of care, many of Massachusetts’ newly insured are having a hard time finding a primary-care doctor with open appointment slots. The state had a primary-care physician shortage before its reform, even though it has more doctors per-capita than most states. After the reform, the problem is growing into a crisis: The Massachusetts Medical Society’s annual work force study, released in October, found the average wait time for a new-patient appointment with an internal medicine physician is 50 days; almost half of internists in the state have closed their practices to new patients altogether - up from 31 percent in 2006.

Bruce Auerbach, an emergency physician and president of the society, said the plan has “put enormous pressure on primary care, and we now know that … universal coverage does not equal universal access.”

Here’s hoping our national leaders are paying attention.

Bob Keaveney is the executive editor of Physicians Practice. Join the conversation he’s started on this topic at http://forum.physicianspractice.com, or e-mail him directly at bob.keaveney@cmpmedica.com.

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This article originally appeared in the April 2009 issue of Physicians Practice.