The Secret of our Success -- Revealed!
Why has Massachusetts been so successful in increasing heath care coverage to uninsured residents? A new study provides the answer! The study, by Urban Institute researched Stan Dorn and colleagues, was funded by The Robert Wood Johnson Foundation.
As the report notes, by the summer of 2008—less than two years after Massachusetts’ health care reform law became effective— only 2.6 percent of Massachusetts’s residents were uninsured. This was the lowest proportion ever recorded in an American state. The state’s gains in coverage were particularly large for adults with incomes low enough to qualify for subsidies - that is, at or below 300 percent of the federal poverty level (FPL). For them, the percentage without coverage dropped from 23.8 percent in 2006 to just 7.6 percent in 2008.
While Massachusetts mandates insurance coverage for adults, the mandate does not apply to children and is not enforced against adults with incomes below 150 percent FPL. Yet, these two groups represent nearly half of the increase in coverage since 2006.
The study finds that the individual mandate was not the key factor in the state’s extraordinary results placing the low-income uninsured into subsidized health coverage. Rather, innovative outreach and enrollment strategies played a central role. This study concludes that four outreach and enrollment strategies have played a central role in helping Massachusetts enroll so many eligible, low-income uninsured individuals:
As officials planned the implementation of Massachusetts’s reforms, the state’s Medicaid agency already had eligibility records for people who received care through the Uncompensated Care Pool (UCP). Using these data, the Medicaid agency identified UCP beneficiaries who appeared eligible for the new program created with health reform, Commonwealth Care. These individuals were automatically “converted” to Commonwealth Care coverage, without any need to submit a new application.
By June 2007 (eight months into the new program), “auto-converted” members represented more than 80 percent of CommCare participants. A second round of auto-conversion took place from January through March 2007, for approximately 62,000 people who qualified for CommCare based on UCP data showing income between 100 and 300 percent FPL. By December 2007, nearly 100,000 out of 158,000 total CommonCare enrollees were former UCP patients.
An integrated eligibility system that serves multiple programs
A single application called Medical Benefit Request (MBR) is used for Medicaid, CommCare, the UCP/Health Safety Net, and other subsidy programs. The MBR form is processed by a single statewide unit, within the Medicaid agency, that uses automated procedures to determine eligibility. As a result, consumers submit just one application to learn the program for which they qualify; they are not required to go from agency to agency, submitting multiple applications until they find the right program.
From the beneficiary’s perspective, such an integrated eligibility system greatly simplifies the enrollment process. Only one form must be completed, after which the consumer learns which program (if any) will provide coverage. By contrast, in many other states that operate multiple health coverage programs, consumers may need to file applications with one agency after another before they finally qualify for the right program.
The Massachusetts system is further streamlined through the state’s “Virtual Gateway.” Since 2004 this system allows deputized, state-trained staff of safety net providers and Community-Based organizations to fill out and file applications for consumers over a secure, internet portal.
Health care providers and community-based organizations completing application forms
Through the state’s “Virtual Gateway,” trained and deputized staff from different agencies complete application forms on-line. As consumers’ authorized representatives, the agencies receive copies of state requests for additional documentation needed to establish eligibility. This lets them educate consumers about applicable procedural requirements and ensure necessary follow-through.
Furthermore, the state denies providers full reimbursement when a patient does not fully complete the application for health coverage. As a result, safety-net hospitals and community health centers devote significant staff resources to completing applications for patients through the Gateway and ensuring that patients follow-up as needed.
Also, community-based organizations have received “mini-grants,” from the state, enabling these organizations to educate consumers and enroll them into coverage. The amount of the mini-grants was between $2.5 and $3.5 million annually. Also these amounts were supplemented by the Blue Cross and Blue Shield of Massachusetts Foundation grants ranging from $5,000 to $20,000 per organization.
An intensive public education campaign
State residents were informed about both new assistance and the individual mandate through a multi-faceted public education campaign. Low-income households, whose members may not have understood that they were effectively exempt, worried about possible sanctions and therefore paid great attention to health coverage, which helped increase enrollment into Medicaid and CommCare. One of the state’s strategies was to partner with the Red Sox on television, radio, and game time advertisements. In addition, advertisements on buses and subway trains were part of the educational campaign along with targeted outreach media outreach in ethnic communities. Major companies such as CVS and Bank of America partnered with the State in educating the public. Furthermore, the Connector, which is the agency administering the Commonwealth Care program, purchased mass media advertisements and sent millions of postcards to taxpayers and hundred of thousands of mailings to employers explaining the new law.
The authors suggest that for future reforms at either the national or state level to accomplish the basic objective of enrolling the low-income uninsured into health insurance, it will be important to incorporate lessons from Massachusetts into the design of coverage expansion.