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Health Care Reform: Massachusetts One Year Later. Sarah Iselin Massachusetts Division of Health Care Finance and Policy October 26, 2007. The Massachusetts Law: Why So Much Attention?. Ambitious goal: Near universal coverage Transcends ideology Bipartisan support

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health care reform massachusetts one year later

Health Care Reform:Massachusetts One Year Later

Sarah Iselin

Massachusetts Division of Health Care

Finance and Policy

October 26, 2007

the massachusetts law why so much attention
The Massachusetts Law:Why So Much Attention?
  • Ambitious goal: Near universal coverage
  • Transcends ideology
    • Bipartisan support
    • Combines policy solutions from the right and the left
    • Partnership between federal government and state
  • Novel approaches
    • Individual mandate, employer responsibility, insurance market changes
massachusetts the building blocks for reform
Massachusetts:The Building Blocks for Reform
  • Relatively low rate of uninsurance
  • History of health coverage expansions
  • Broad Medicaid program
    • 1115 Waiver
  • Uncompensated Care Pool
  • Highly regulated small group and individual health insurance markets
how will we get there
How Will We Get There?
  • Medicaid expansions and restorations
  • Subsidized coverage for low-income adults
  • Changes to the insurance market to help individuals and small businesses
  • Individual mandate
  • Employer responsibilities (for firms with > 11 employees)
massachusetts health reform how do the pieces fit together
Massachusetts Health Reform:How Do the Pieces Fit Together?

Percent of State’s Total Uninsured Targeted by Different Aspects of Law

medicaid 56 000 members

MassHealth Caseload

1,150,000

Commonwealth

Care

Health Care

• Discontinued

1,100,000

Reform

MassHealth Basic

• Premiums for some

Initial Gateway roll-

optional populations

out

1,050,000

1,000,000

950,000

900,000

MassHealth Essential

850,000

800,000

Jul-02

Jul-05

Jul-03

Jul-04

Jul-06

Jul-07

Jan-03

Oct-02

Oct-03

Oct-04

Jan-05

Oct-05

Jan-06

Oct-06

Jan-07

Apr-04

Jan-04

Apr-07

Apr-03

Apr-05

Apr-06

Medicaid: +56,000 Members

August 2007 1,090,000

1,034,000

meanwhile uncompensated care demand is falling
Meanwhile, Uncompensated Care Demand is Falling

* Growth rate reflects October-August data in both periods

individual mandate the benefits minimum creditable coverage
Individual Mandate: The Benefits (Minimum Creditable Coverage)

Benefits

  • Preventive and primary care (at least 3 visits prior to deductible)
  • Emergency services, hospitalization benefits, ambulatory patient services, mental health services and all state mandated benefits
  • Prescription drug coverage

Cost-sharing

  • Deductible capped at $2,000 for individual coverage and $4,000 for family coverage
  • Separate drug deductible may not exceed $250 for individual and $500 for family coverage
  • Maximum out-of-pocket spending for in-network services capped at $5,000/$10,000
    • Must include the upfront deductible, most co-insurance, and any services that require $100 or more in co-payments
employer responsibilities
Employer Responsibilities
  • Fair Share Contribution
    • Make “fair and reasonable” contribution to health insurance or pay assessment (no more than $295 per employee per year)
      • Employee take-up rate of 25% or more, or
      • Offer to pay 33% toward cost of coverage
  • Offer Section 125 Plans or could be subject to Free Rider Surcharge
    • Allow employees to make pre-tax contributions to health insurance or pay “fair share” charge
  • Applies only to employers with ≥ 11 full-time employees
challenges ahead
Challenges Ahead
  • Education, outreach and enrollment
  • Sustaining public support
  • Ensuring access for the newly insured
  • Financing – strong state economy
  • Continued federal support for waiver renewal
  • Maintaining strong safety net for those who will remain uninsured
  • Moderating health care cost trends
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