The Development and Initial Success of Health Care Reform in Massachusetts

Prior to health care reform in Massachusetts, there were several policies and programs in place designed to ensure that low-income women could access reproductive health care. First, a comprehensive Medicaid program (known in Massachusetts as MassHealth) has historically covered all contraception and abortion services at relatively low cost. Second, in 2003 Massachusetts enacted contraceptive equity regulations that required most health insurance plans that cover prescription medication to provide equitable coverage for all FDA-approved contraceptive methods (General Court of the Commonwealth of Massachusetts 2011). Massachusetts law also requires insurers that provide pregnancy-related benefits to also provide coverage for the diagnosis and treatment of infertility (Massachusetts General Law 2011a). Although these regulations apply to many public and private insurers in the Commonwealth, religious organizations and self-insured employers are exempt from the requirements (Massachusetts General Law 2011b). Low-income women without health insurance have had long-standing access to family planning and other reproductive health services on a sliding scale basis through freestanding family planning clinics and community health centers funded by the MDPH. Many of these MDPH-funded family planning clinics also receive significant funding from Title X, the federal family planning program, as well as reimbursement from MassHealth. (Data regarding funding sources of MDPH-funded family planning clinics were provided directly from the MDPH Family Planning Program and are not available in a published format.)

It is in this context that the Massachusetts legislature passed Chapter 58, an act aimed at improving access to comprehensive health care in the Commonwealth. Key elements of Massachusetts reform parallel national reform efforts. These include an individual mandate for coverage, expansions of MassHealth, the development of a health insurance exchange, and the creation of Commonwealth Care.

Commonwealth Care is a subsidized, low- or no-cost insurance program for low-income residents. To qualify for the program, an individual must be a Massachusetts resident with an income at or below 300 percent of the federal poverty level (FPL), with no access to employer-sponsored health insurance, and not eligible for other public insurance (such as MassHealth). The plans' benefits were modeled on MassHealth benefits and cover primary and preventive care, prescription medications, inpatient services, mental health treatment, substance abuse services, and family planning services, including prescription contraceptives and abortion care. Several insurance companies offer Commonwealth Care plans, and the costs of the available plans are similar. None of the plans have deductibles, and premiums and co-pays vary based on the individual's income (table 1).

Table 1 Commonwealth Care Summary of Costs by Plan Type (Omitted)

Between 2006 and 2010 the number of nonelderly adults with insurance rose from 86.6 percent to 94.2 percent (Long, Stockley, and Dahlen 2012). Most of the increased coverage since reform is the result of increased enrollment in public insurance programs, such as MassHealth and Commonwealth Care (Blue Cross Blue Shield of Massachusetts Foundation 2011). During this time, access to and use of health services also rose. These changes appear to have led to gains in health: four years after reform, the number of nonelderly adults reporting that their health status was very good or excellent rose to 53.2 percent from 46.7 percent before reform (Long, Stockley, and Dahlen 2012).

Though the above shows that there have been marked increases in insurance, access to health services, and residents' health status, little is known about how low-income Massachusetts women seeking contraceptive services have been affected by health care reform. Likewise, little is known about how family planning providers, who have traditionally been important safety net providers for low-income women in Massachusetts, have been affected by health care reform. This article seeks to fill this gap.

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Reports from study participants show that though health care reform has led to significant improvements in access to health insurance and health care for Massachusetts women, there are still challenges in accessing insurance and benefits. Access to health care has not improved or has gotten worse for some populations of women. The populations that women and providers identified as facing barriers to care under reform were remarkably similar: immigrants, young women and minors, those with erratic insurance coverage, and those not living in urban areas were reported to have been “left out” of health care reform. After discussing participants' overall assessments of how access to insurance and benefits has changed since health care reform, we focus on the specific challenges faced by populations that have fallen through the cracks of reform and remain in particular need of support to consistently access health care services. Table 5 shows a summary of the article's main findings and quotations illustrating those findings.

Table 5 Primary Study Findings and Illustrative Quotations (Omitted)