Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Saturday, December 8, 2007

The Massachusetts Health Reform: Does It Really Reform? – Jenny Shin Ahn

In an effort to produce reform, the Massachusetts executive and legislative branches passed the Health Care Reform Act in April 2006. This reform largely addresses the issue of health care by the power-coercive approach. In doing so, the act places an “individual mandate” on those without health insurance. As of July 1, 2007, individuals who lack health insurance will now fa­ce a financial penalty when filing taxes. By assigning this personal responsibility, the Health Care Reform Act fundamentally fails in its approach; it does not take into account factors that affect a patient’s medical outcome and quality of life.

The reform aims to have everyone covered under a health insurance program, but it incorrectly assumes that health insurance translates into access to care. Access to care is not a simple personal issue, but a problem deeply convoluted by cultural, gender and racial factors. Furthermore, the reform fails, because it contends that removing financial barriers will essentially make health care more affordable. It, however, does not tackle the fundamental issue of rising health care cost. Lastly, the Massachusetts Health Reform does not take into account the quality of care that patients receive. At its core, the Massachusetts Health Reform encourages the health coverage of individuals but does not guarantee an improved patient outcome.

Health Care Coverage ≠ Access to Care

Massachusetts will not succeed in creating true reform, until it addresses the non-financial barriers to health care access. Important factors such as location, race, gender and cultural competence, influence an individual’s access to care. In certain cases, having certain insurance plans may determine access. Focusing on universal coverage alone will not assure that everyone will receive the necessary treatments.

A few years ago, the New England Journal of Medicine published a controversial study on how race and sex affected physicians’ recommendations. The investigators asked 720 physicians to watch recorded interviews of black and white actors/actresses, who presented chest pain and other symptoms. The physicians then made recommendations accordingly. Black women only received cardiac testing referrals 79% of the time, while all other patients were referred 91% of the time. The findings suggest the direct influence of both gender and race on an individual’s access to care (1).

Closely linked to racism, cultural incompetence of health care professionals is another factor that deters health care access. In a study done on racial barriers for diagnosing Alzheimer disease, black family members of patients noted that cultural insensitivity prevented them from readily seeking out help. These black family members further commented how caring for loved ones was a private matter that involved extended family members. Without recognizing culture influences, black caregivers will not receive the support they need to care for loved ones with Alzheimer disease (2).

Geography also plays an important role in accessibility. There is a current primary care physician shortage in Boston’s teaching hospitals. Last year, Massachusetts General Hospital’s physician referral line told all callers that none of their 178 primary care physicians were accepting new patients. Boston Medical Center and Brigham and Women’s Hospital also face similar limited resource problems. Many of the uninsured, who obtained coverage through the Massachusetts reform, live in the city and now struggle to find a doctor in their geographic proximity (3).

Lastly, being enrolled in an insurance plan does not guarantee that health care providers will accept that particular plan. For many years, people on Medicaid and/or Medicare have struggled to find doctors that will accept them as patients because of the low reimbursement rates. One study on oral health services found that patients did not utilize their plans, because they could not find dentists who were willing to treat them. Again, simply ensuring health care coverage is a moot effort unless the fundamental issue of access to care is addressed (4).

Subsidized and Free Health Care Coverage ≠ Affordable Health Care

Although the Massachusetts Health Reform mandates individuals to purchase health insurance, it does acknowledge that everyone cannot afford the private health care plans. The state provides qualified individuals with a subsidized health plan or free coverage. The reform, however, has unrealistic affordability standards and avoids addressing other financial issues.

To receive subsidized care, an individual must have an income equal to 300 percent above the federal poverty level ($30,630). For free coverage, the income level must be 150 percent above the federal poverty level ($15, 315) (5). Subsidized care is still a financial problem for low-income families because of premiums and co-payments (6). Health care costs are especially burdensome for those living in the urban areas due to the associated higher costs of living. A recent Kaiser Family Foundation report compared the purchasing power of a family of four among the fifty states. While the average U.S. family needs $61, 950 to have the purchasing power equal to 300% of the federal poverty level, a Massachusetts family has to earn 32% more at $81,578 to have the same purchasing power (7).

Under the current standards, only 28% and 34% qualify for free coverage and subsidized plans, respectively. This means that 244,000 uninsured individuals receive no assistance from the state. In fact, they can look forward to being penalized with a fine when they file taxes next year. The middle class also takes a hit as more companies drop their job-based plans. Some companies have opted to pay a penalty than to provide care. Without assistance from the state or a job, the middle class faces high premiums and out-of-pocket expenses. The Boston Globe recently reported how one couple contemplated a plan that had an annual premium of $8638 with no drug coverage and a $2000 deductible per person. This couple will have to spend over $12,000 before the plan covers anything (6).

Most notably, the reform does not tackle the issue of rising health care costs. Massachusetts ranks first among the states in health care expenditures per capita at $6683. It seems impractical to make individual health insurance affordable to some while ignoring the matter of rising health care costs, which affects everyone (8). There are now concerns that the state’s insurer plans will rise by 10% to 12% next year (9).

Health Care Coverage ≠ Quality of Care

Finally, the health reform neglects to look at the issue of quality of care. Similar to access to care, factors involving race, gender, language and socioeconomic status can affect quality of care. The likelihood of medical negligence is three times greater in hospitals that mainly care for low-income families. Simply put: better care translates to better outcomes. Forcing an individual to get coverage is worthless if the quality of care that an individual receives is poor.

Women are 50% more likely to report dissatisfaction with their care. They are also more likely to say that their physician did not believe their problems were real. The Institute of Medicine also notes that there is a great disparity in the quality of care between white patients and racial and ethnic minority patients (10).

Language barriers can also affect the outcome of patients. One study indicated that 46% of emergency department cases involving limited English language proficiency did not use an interpreter. Patients with language barriers have increased risk of non-adherence to medication and higher rates of hospitalization and drug complications (11).


The Massachusetts Health Reform does have a respectable goal of statewide health coverage for everyone. Unfortunately, the reform’s cursory goals convolute the more fundamental issues. An individual mandate deflects attention from the larger issue of access to care. Possessing coverage does not ensure everyone will have access to the appropriate care because of racial, gender and other barriers. While the individual mandate offers assistance and free coverage to some, the reform does not address the high costs of care. Health care is not only expensive for low-income families, but it is also unaffordable for many middle class families. The reform also fails to acknowledge the problem of quality of care. Again, coverage alone does not determine the quality of care given to patients. Without looking at language, gender and racial disparities, quality and outcome will continue to suffer.

Issues regarding access to care, affordability, and quality of care are immense and systematic. Placing attention on individual behavior through a mandate is not going to solve these problems. Massachusetts, instead, needs to look at regulating hospitals and the insurance industry. These organizations and companies look to profit from this reform by gaining new customers and patients. Massachusetts should closely examine funding more community health centers to serve minorities and low-income families. Such endeavors would more directly provide the access to care for those who need it. Improving the quality of care requires investing in translators and recognizing groups that are vulnerable to inferior care. Whatever Massachusetts decides to do, its sole objective cannot be universal coverage through an individual mandate.


  1. Schwartz, Lisa M., Steven Woloshin and H. Gilbert Welch. “Misunderstandings about the Effects of Race and Sex on Physicians’ Referrals for Cardiac Catheterization.” The New England Journal of Medicine 341.4 (1999): 279-83.
  2. Stephenson, Joan. “Racial Barriers May Hamper Diagnosis, Care of Patients With Alzheimer Disease.” Journal of the American Medical Association 286.7 (2001): 779-80.
  3. Kowalczyk, Liz. “Hospital Doctors Shut Doors to New Patients.” The Boston Globe 12 November 2006.
  4. Health Coverage for Low-Income Americans: An Evidence-Based Approach to Public Policy. The Kaiser Commission on Medicaid and the Uninsured. January 2007 .
  5. The Henry Kaiser Family Foundation. “Massachusetts Health Care Reform Plan: An Update.” Kaiser Commission on Key Facts June 2007.
  6. Woolhandler, Steffie and David Himmelstein. “Health Reform Failure.” The Boston Globe 17 September 2007 .
  7. .
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  9. Sack, Kevin. “Massachusetts Faces a Test on Individual Health Insurance Mandate.” New York Times 25 November 2007 .
  10. Bodenheimer, Thomas S. and Kevin Grumbach. Understanding Health Policy: A Clinical Approach. New York: Lange Medical, 2002.
  11. Flores, Glenn. “Language Barriers to Health Care in the United States.” New England Journal of Medicine 355.3 (2006): 229-31.

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  • At December 13, 2007 at 4:12 PM , Blogger Victoria said...

    I like the information you included about the Alzheimer's patients. It is true that there are people who don't have health care and don't want it, either. What do you think MA could do to encourage more people to access healthcare instead of mandating insurance (which, as you point out, is not the only reason people don't get the care they need)?

  • At December 14, 2007 at 9:10 AM , Anonymous Judy said...

    You did a good job pointing out that access to care is not the same thing as health insurance. A lot of those who are now insured had better access before reform, through the Uncompensated Care Pool.

  • At December 14, 2007 at 11:08 AM , Anonymous Deinera said...

    Really great points. I think your paper covers a lot of the primary problems with this law, including that making health insurance mandatory does not make it affordable. By allowing people to opt-out if they are not eligible for subsidized care but cannot afford individual insurance premiums, the program does not really make receiving insurance any more attainable for those who need it. I think the argument regarding affordability also extends to coverage, since many of the plans are "bare bones" plans with high out of pocket payments (as you discussed in your second argument). Great paper!

  • At December 16, 2007 at 8:47 AM , Blogger ER said...

    This was a great paper. Made me think about the policy in a different way. Great points and very informative.


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