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MASSACHUSETTS HEALTH REFORM: IMPACT ON WOMEN’S

HEALTH

Tracey Hyams, JD, MPH, DirectorLaura Cohen, Policy Analyst

Women’s Health Policy and Advocacy ProgramConnors Center for Women’s Health and Gender

BiologyBrigham and Women’s Hospital

Women’s Health Policy and Advocacy Program

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DATA SOURCES

Women’s Health Policy and Advocacy Program

• The Blue Cross Blue Shield of Massachusetts Foundation: http://bluecrossfoundation.org/

•Ibis Reproductive Health: http://www.ibisreproductivehealth.org/

•Suffolk University Center for Women’s Health and Human Rights:http://www.suffolk.edu/college/10649.html

•Brigham and Women’s Center for Community Health and Health Equity:www.brighamandwomens.org/communityprograms/

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MASSACHUSETTSBEFORE HEALTH REFORM

• Strong consumer protections• No pre-existing condition limitations• Pro-choice legislature and

government• 26 mandated benefits including: maternity, mammography, contraceptive

services, HRT,pap smears, infertility treatment, mental health

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HOW DOES REFORM IN MA COMPARE TO NATIONAL

REFORM?Provision MA USIndividual mandate √ √Employer penalty √ √Medicaid expansion √ √Insurance exchanges √ √Sliding scale subsidies for certain individuals and families

√ √

A required set of health benefits for all private plans

√ √

No gender or health-status premium rating allowed

√ √

Caps on out-of-pocket spending √ √Direct access to an OB/GYN without referral √ √

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LANGUAGE OF MASSACHUSETTS HEALTH REFORM

• Health Insurance Connector

• Minimum Creditable Coverage (MCC)

• Commonwealth Care (subsidized)

• Commonwealth Choice (unsubsidized)

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EVALUATING MASSACHUSETTS HEALTH REFORM

• Coverage• Access• Affordability • Transitions• Remaining Opportunities

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Coverage

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IMPROVEMENTS IN COVERAGE SINCE REFORM

• Most newly-insured have subsidized coverage– 68 percent covered through MassHealth or CommCare– 12 percent non-group individual, 20 percent ESI

• All populations of women experienced significant coverage gains since reform– Lower income– Racial and ethnic minorities– Women 50 – 64– Women without dependent children

• Total enrollment in subsidized coverage remains higher among women than men

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Figure 2

Uninsurance Trends Women 18-64 United States vs. Massachusetts

2003-2009

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2003 2005 2007 2009

United States Massachusetts

Women’s Health Policy and Advocacy Program

Source: Current Population Survey 2003 - 2009

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Figure 1

Distribution of the Newly Insured June 2006-June 2009

CommCare (Premium-

Paying), 54,000, 13%

Non-Group (Individual), 49,000, 12%

CommCare(No Premium),

123,000, 31%

MassHealth, 99,000, 24%

Private Group (ESI), 83,000,

20%

Women’s Health Policy and Advocacy Program

Source: Massachusetts Division of Health Care Finance and Policy

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Women’s Health Policy and Advocacy Program

Insurance Coverage of Women 18-64: United States and Massachusetts, 2008

18.1%

3.2%10.2%5.9%

62.6%

5.6%1.8%

16.9%4.8%

70.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Employer Individual Medicaid Other Public Uninsured

United States Massachusetts

Source: Current Population Survey 2008

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Women’s Health Policy and Advocacy Program

Source of Coverage Fall 2006

Fall 2009

Difference

Any insurance coverage

91.4 97.1 + 5.7

ESI coverage 67.1 68.7 + 1.6 Public or other coverage

24.3 28.4 + 4.1 Source: Sharon Long. The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use, and Affordability

for Women in Massachusetts. The BCBS of MA Foundation.

HEALTH COVERAGE OF WOMEN IN MASSACHUSETTS

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IMMIGRANT WOMEN • Until June 2009, legal permanent

residents eligible for subsidized coverage through CommCare. – Cut due to budget constraints

• “CommBridge” created to cover nearly 30,000 LPRs who lost coverage– Capped enrolment– Limited benefits

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WHO ARE THE UNINSURED WOMEN IN MA?

• Nearly 60,000 women remain uninsured• Uninsured women are disproportionately

– Young– Single – Hispanic

• Over half are employed (often in smaller firms) • Over 75 percent of have incomes under 300

percent FPL and may qualify for subsidized coverage

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Access to Care

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IMPROVEMENTS IN ACCESS AMONG WOMEN IN MA

Women’s Health Policy and Advocacy Program

Fall 2006

Fall 2009

Difference

Had usual source of care 90.3 92.8 + 2.5Any doctor visit past 12 months 84.8 90.7 + 5.8

Visit for preventive care 77.4 82.0 + 4.6 Any dental visit past 12 months 72.7 79.1 + 6.4

Did not get needed care for any reason in past 12 months

26.9 21.2 - 5.7

Source: Sharon Long. The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use, and Affordability for Women in Massachusetts. The BCBS of MA Foundation.

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ACCESS AMONG WOMEN IN MA• Essential Women’s Health Benefits

– Reproductive Health– Primary Care (Ob/Gyn)– Mental Health, Dental Care, Preventive Screenings

• Vulnerable Populations– Younger Women– Racial and Ethnic Minorities– Immigrants

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REPRODUCTIVE HEALTH

Women’s Health Policy and Advocacy Program

• Generally, health reform expanded access to contraceptives

• Cost does not appear to be a barrier to contraceptive use after health reform

• Remaining barriers- Women receive Rx instead of contraceptives - No Rx coverage in some young adult-target plans- Difficulty understand what plans cover- Frequent changes in insurance status impact cost and continuity of contraceptive use

• Insurers continue to cover abortions

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ACCESS TO PRIMARY CARE

Women’s Health Policy and Advocacy Program

• In 2009, one in five women reported difficult finding a provider • “Several labor market conditions”- internal medicine, family medicine and Ob/Gyn • Wait times for internal medicine, family medicine and Ob/Gyn unacceptably long

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ACCESS TO PRIMARY CARE PROVIDERS

Percent of Massachusetts Primary Care Providers Accepting New Patients

Service 2008 2009Family Medicine 65% 60%Internal Medicine 52% 44%Obstetrics and Gynecology 92% 81%

Women’s Health Policy and Advocacy Program

Source: Massachusetts Physician Workforce Study. 2009. Massachusetts Medical Society.

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Affordability

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Women’s Health Policy and Advocacy Program

WHO IS MOST AT RISK?•Moderate-income women•Women choosing low-premium, high deductible health plans•Women enrolled in young adult-target plans•Women transitioning from the safety net to cost-sharing plans

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Malika is a student who became pregnant while covered through her college’s student health plan (SHP). Although her SHP covers pregnancy, coverage is capped at $25,000 per injury or illness. Malika had a complicated delivery, which required ambulance transportation to a hospital better able to handle her high-risk care. Unfortunately, her plan has an individual service cap on ambulance transportation, leaving her responsible for $1,500 in out-of-pocket costs. The hospital charged $24,000 for Malika’s care and $32,000 for her baby’s care. Her health plan decided to count Malika and her baby’s care as a single episode of illness, leaving her with $31,000 in additional out-of-pock costs. Her massive medical bills qualify her for the Health Safety Net; however, she is still responsible for paying a significant portion of the costs herself - $16,000.

MEET MALIKA

“If the insurance barely helped me then what am I paying them for?”

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MEET ANNAnn is 56 years old, divorced with two adult children. She makes $62,000 a year and a realtor for a small firm not required to offer health insurance. This year, Ann had an annual mammogram which detected an abnormal mass in her right breast. She was diagnosed with breast cancer and had a mastectomy. Ann’s income qualifies her for a Commonwealth Choice plan. This chart highlights her out-of-pocket costs (premiums, deductibles and co pays) for one year under different Commonwealth Choice Plans. Plan (with Rx) Total Annual

CostBronze $7,128Silver $4,004Gold $5,234

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MEET JENNIFER Jennifer is 31 years-old and self-employed. She makes $32,600 a year and does not qualify for subsidized Commonwealth Care. It is important to note that Jennifer make $100 dollars more than the income cut off for Commonwealth Care program ($32,500) yet she pays between $83 and $108 more per month on premiums.

Jennifer will pay between $996-$1,296 more per-year just on premiums because she makes $100 dollars more than the income cap for Commonwealth Care.

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MEET DIANADiana is a 28-year old single adult working at a small firm that does not provide health insurance. She makes 32,400 dollars a year, making her eligible for Commonwealth Care.

Diana pays $116 a month on premiums, far less than her sister Jennifer, despite the fact that Diana only makes $200 dollars more than Jennifer.

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AGE RATING

Lowest-cost Commonwealth Choice Plans for a 31 year-old vs. 59-year old

woman in BostonPlan 31 year-old

Jennifer59 year-old

LilyBronze $224 $444Silver $272 $544Gold $392 $799

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Transitions in Eligibility and

Coverage

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• Women are more likely to experience life changes and variable income, which impact eligibility

• Income eligibility for Medicaid and subsidized coverage are only dollars apart

• In 2009, an average of 9,800 people transitioned into MassHealth from Commonwealth Care and the Health Safety Net (HSN)

• 9,400 transitioned from MassHealth and HSN to Commonwealth Care

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MEET CHRISTINA below 200% FPL. Christina must apply for Medicaid Christina is a 27 year old single woman earning 150% of the Federal Poverty Level ($16,245 a year) working as a waitress and is eligible for Commonwealth Care. Christina become pregnant and is now categorically eligible for Medicaid because her income is because eligibility for public insurance negates Commonwealth Care eligibility. While she waits for MassHealth eligibility, she in insured by MassHealth Prenatal, a short-term program designed to cover pregnant women while they wait for MassHealth approval. After birth, she must re-apply to Commonwealth Care because her income makes her MassHealth ineligible (mothers with Medicaid eligible children can remain beneficiaries if they make 133% or less of the FPL). In one year, Christina has applied to three

insurance plans and transitioned between plans four times.

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OPPORTUNITIES FOR MA AND NATIONAL HEALTH REFORM • Collect and Stratify Data by Sex• Reduce Costs / Monitor Affordability • Administrative Simplicity / Patient Navigation • Primary Care Shortage• Vulnerable Populations

- Young Women- Immigrant Women- Racial and Ethnic Minorities - Caregivers

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To read the Women’s Health Policy and Advocacy Program’s Issue Brief, please click this link: http://www.brighamandwomens.org/ConnorsCenter/images/ConnorsCenter.pdf Contact Information Tracey Hyams, JD, MPHDirector, Women’s Health Policy and Advocacy ProgramConnors Center for Women’s Health and Gender BiologyBrigham and Women’s HospitalBoston, MA thyams@partners.org

www.brighamandwomens.org/womenspolicy

Women’s Health Policy and Advocacy Program