Romneycare’s inability to make inroads may not bode well for Obamacare

Program had trouble cutting some hospitalization rates: study

By Russ Britt
Marketwatch, April 1, 2015

In a finding that could strike at the heart of Obamacare, researchers at Harvard University have determined the Massachusetts health-reform effort did little to bring down the rate of preventable hospitalizations and couldn’t make much progress toward reducing racial disparities in the rate of those instances.

Authors of the study, published Wednesday in BMJ, formerly known as the British Medical Journal, say it suggests access to doctors on an outpatient basis may not have improved much as a result of the Massachusetts effort, also known as Romneycare.

Improving access to lower-income patients and cut back on ethnic disparities in medical treatment is considered one of the main tenets of the Affordable Care Act, which was implemented nearly eight years after Massachusetts put its own health reform into effect. The Massachusetts effort, however, is showing some signs that may not bode well for Obamacare, says Dr. Danny McCormick, associate professor at the Harvard Medical School and one of the authors of the study.

“I think it’s potentially troubling,” McCormick said.

The study shows that from late 2004—about 21 months before Romneycare was implemented—to late 2009, the rate of preventable hospital admissions came down 2.1% in Massachusetts. But in three nearby states that had no health reform—New York, New Jersey and Pennsylvania—that rate came down 3.5% during that time.

Further, the study shows that the rate of preventable admissions for white and Hispanics came down at a faster rate in those three nearby states than they did in Massachusetts. For blacks, preventable admissions went up at an unadjusted rate of 1.8% from 2004 to 2009 in Massachusetts, and slightly higher—2.1% -- in the other three states.

The Harvard study might be a bit more comprehensive than that of earlier studies, McCormick says. Roughly 900,000 patient records were examined as part of the effort. Since Obamacare was implemented last year, Massachusetts has altered its health plan to get in line with the federal tenets, including provisions for minimum coverage.

There are several key differences between the earlier Massachusetts experience and Obamacare, McCormick says, but it doesn’t erase all concerns.

“It’s hard to assign a weight to all of these factors,” he said.

First, Romneycare also only offered subsidies to households with income at 300% of the federal poverty level. Obamacare raised that threshold to 400% of the federal poverty level, he says.

Massachusetts also had a so-called “safety net” before 2006 in which hospitals that treated indigent patients were reimbursed by the state, a feature that doesn’t exist in many other states.

Finally, the uninsured rate in Massachusetts was much lower than the rest of the nation, sitting at roughly 12% before Romneycare, and brought down to about 6% afterward. In states such as Texas and California, the uninsured rate had exceeded 30%, McCormick says, but the average reduction in the number of uninsured will be roughly seven to eight points.

“That’s higher than [Massachusetts] but it’s not dramatically higher,” he said.

Henry Aaron, senior fellow at the Brookings Institution, says the stronger health-care system that existed in Massachusetts before Romneycare could prove to be a major difference between it and Obamacare.

“Massachusetts was already the best-insured state in the U.S. even before Romneycare went into effect,” Aaron said, pointing out it also offered cutting-edge care.

“Most of the rest of the U.S. can’t make that statement,” Aaron said.

Russ Britt is the Los Angeles bureau chief of Marketwatch.


Where Romneycare fell short — and what that could mean for Obamacare

By Jason Millman
The Washington Post, April 1, 2015

The landmark 2006 Massachusetts health-care law that inspired the federal overhaul didn't lead to a reduction in unnecessary and costly hospitalizations, and it didn't make the health-care system more fair for minority groups, according to a new study that may hold warnings for the Affordable Care Act.

Massachusetts’ uninsured rate was cut by half to 6 percent in the years immediately following the health-care law signed by then-Gov. Mitt Romney. Blacks and Hispanics, who have a harder time accessing necessary medical care, experienced the largest gains in insurance coverage under the Massachusetts law, though they still were more likely to be uninsured than whites.

The new study, published in the BMJ policy journal, examined the rates of hospitalizations for 12 medical conditions that health-care researchers say wouldn't normally require hospitalization if a patient has good access to primary care. These include hospitalizations for minor conditions like a urinary tract infection, or chronic conditions that would require repeat primary care visits over the course of a year.

"It's thought to be a good measure and one of the few objective ways of looking at access [to health-care provider] in the community," said Danny McCormick of Harvard Medical School, the study's lead author.

McCormick, along with Boston University School of Medicine researchers, looked at every single such hospital admission in Massachusetts in almost two years before and after the state's health-care law was enacted. They compared the results to three control states — New Jersey, New York and Pennsylvania — that didn't have a similar coverage scheme.

You would probably expect that more people having insurance means better access to primary care, meaning fewer people who would be hospitalized for avoidable conditions. However, the rates of preventable hospitalizations were practically the same in the first few years of the Massachusetts health reform, the researchers found. Further, blacks and Hispanics continued to have higher rates of hospitalization, and the disparity gap didn't narrow in a meaningful way.

"Because the national reform is really closely based on the Massachusetts reform, the results are concerning," said McCormick, also a primary care physician with the Cambridge Health Alliance system.

The study's authors offer a few explanation for the results, some that pertain to Massachusetts specifically. The state already had a relatively low rate of uninsured before the reform and a robust safety net serving the uninsured — so the reform may have had little affect on how the state's residents accessed care. The effects might have been greater in a state with a higher rate of uninsured individuals.

The findings, though, might emphasize deeper shortcomings in the health-care system that an insurance card alone won't fix. Out-of-pocket costs for doctor visits and drugs may be preventing many of the newly insured from affording necessary primary care that would have otherwise kept them out of the hospital. Patients may have a hard time finding a doctor. And there are socioeconomic factors at play, like fewer community resources and lower levels of literary and English proficiency among the uninsured.

But the country's health-care system is the midst of transforming from one that rewards doctors for treating people when they get sick to one that rewards doctors for keeping patients healthier in the first place. That's resulted in experiments that are better targeting patients in their communities and ensuring they receive care before their conditions worsen.

"Ten years ago, we wanted patients to show up — it was all upon the patient," McCormick said. "Now there's much more recognition of all the social factors that influence whether patients can get the care they need."

Jason Millman covers all things health policy, with a focus on Obamacare implementation. He previously covered health policy for Politico.