Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

Will the Commonwealth Truly Connect its Citizens to High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care?

A Critique of the Massachusetts Health Care Reform Legislation - Jahera Otieno

Health Care coverage continues to become an issue of growing importance in the US. As people begin to lose essential health insurance coverage or start having to pay for portions of their health care due of rising costs, health care coverage, or lack thereof, is becoming a topic of increasing significance. As the 2008 presidential race picks up, republican and democratic candidates alike, are sharing their attempts on how they plan address the concerns related to paying for our nation’s health. We are spending more on doctors, prescription drugs and procedures than we ever have before but there are still over 40 million uninsured persons coming from every race, culture, ethnicity and income (3). With health care costs rising to over $2 trillion in 2007, will health care really be a “good” that is accessible to all peoples? This question is one that the state of Massachusetts hopes to answer.

In 2006, Health Care Reform became law in Massachusetts, initiating a national conversation about healthcare. The legislation plans to bring about a healthier Massachusetts with everyone - individuals, government and employers - doing their part and sharing the responsibility to provide all citizens with access to quality health care. While this legislation allegedly makes health care more accessible (mainly by eliminating cost), it also requires, or mandates, that all people have coverage and no longer making it an individual choice. This reform makes Massachusetts the first state in the nation to provide all citizens, if successful, with health care, and in turn, creating a model of universal health care for our country (2,3). Massachusetts becomes the first state in the Nation providing all of it citizens, if successful, High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1), creating a model of Universal Health Care for our country (2,3).

As this legislation is working to provide access to hundreds of thousands of people in the state with health care, it is also setting the stage for similar legislation to happen all around the country and in our nation as a whole. In moving forward, it is important that many questions and concerns that key stakeholders have are addressed. Is this legislation truly providing an easier way for all Massachusetts’s residents to access health care? Will there be enough money to support the program while not taking away from current services? Will “affordable” health care really be affordable? With there being an increased demand those primary healthcare services being, will the quality of care that is received here remain cutting-edge or suffer? The Massachusetts Health Care Reform Legislation claims to be providing “affordable” care to Massachusetts’s residents, but its citizens still will not access to affordable health care services.

Argument I: Massachusetts Health Care Reform Legislation does not account for other barriers, outside of cost to health care.

The Massachusetts Health Care Reform Legislation claims that it will provide all it citizens with access to affordable high quality health care but there are some known implicit and explicit barriers to health care that prohibit many people from using health care services. The cost of care will always discourage people from getting regular health care, but there are also many non-financial barriers to health care like culture, race and ethnicity that may deter someone from accessing basic and preventative health care. While the legislation does address some of these issues, there are key elements that have not been addressed throughout the policy.

First and foremost, the cost of health care is the primary reason that health care is not accessed by many people. According to Bodenheimer and Grumbach, Understanding Health Policy, “Access to care has two major components. First and most frequently discussed is the ability to pay”(4). The cost of health care, and its persistent rise, is the primary reason that many do not access care and one of the primary issues addressed by the legislation. By potentially eliminating cost as the barrier to care, it is believed that people should have no major hindrance to accessing health care. Past attempts at controlling cost and political unwillingness to stop the rising cost of health care continue to promote the inaccessibility of health care for many people. For some, health care is still out of reach. The legislation included a caveat that exempts some from having to obtain health insurance coverage (5). Even with the reform aiming for universal coverage, it is still out of reach for some 60,000 people. With Massachusetts having approximately 500,000 uninsured, there is still a large portion of the population for which coverage remains out of reach (5). The cost of care needs to reach a place where care is within reach so that all can access it.

But there are a variety of other reasons, which inhibit people from accessing necessary healthcare services. First, there are major cultural and language barriers that may stop a person from accessing services. "The availability of culturally competent services can make a real difference in whether a patient comes in for care or returns for a second visit (6)." For example, if a woman can’t speak English and is being seen by a male physician, it may be an uncomfortable experience for her and stop her from seeing that doctor, or any doctor, in the future. A New England journal of medicine article states that language barriers can have deleterious effects. Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of non-adherence to medication (7).

Additionally, issues regarding race, may also stop a person from accessing health care. It has been shown that persons of color are less likely to receive primary health care services when compared to whites (8). According to the report from HRSA, racial and ethnic minorities face significant health disparities. Compared with white infants, infant mortality rates among blacks and Native Americans are 2.5 and 1.5 times higher, respectively. Black men less than 65 years of age have double the rate of prostate cancer compared with white men. The prevalence of diabetes is 70 percent higher among blacks and nearly 50 percent higher among Hispanics than among whites (7). On CommonHealth, WBUR’s blog, about health care in the commonwealth, Elmer Freeman talks about how it is not a matter of how you’re covered but it’s how you’re treated (9). Mr. Freeman states that while it may be unhealthy to be uninsured, health insurance is no assurance of better health, particularly for the diverse racial and ethnic minority groups across the Commonwealth (9). It is true that insurance doesn’t equal access because if a person is not comfortable accessing services, simply having insurance will not open that door.

While, the legislation has established a statewide Racial and Ethnic Health Disparities Council to track disparities data but it does not seem likely that this new legislation will achieve significant results in addresses issues that will persist in baring people for essential care. There are many issues that affect a person’s ability access to health care, regardless of having insurance. It is imperative that the commonwealth continues to watch these issues and others as they arise and work to address.

Argument II: By using the Power-Coercive Model, the MA Health Care Reform Legislation will not increase use of health care through its individual mandate.

There are a variety of strategies that Public Health professionals use when developing interventions to address health care issues. “When a person or group is entrenched in power in a social system, in command of political legitimacy and of political and economic sanctions, that a person or group can use power coercive strategies in effecting changes, which they consider desirable, with much awareness on the part of those out of power in the system” (10) and people are often aware when something is being pushed on them. The Power-Coercive Model can be effective when implementing system-wide change, but it can also make some feel powerless when an initiative, program or policy, be it beneficial or not, is being forced upon them to accept.

One particular troublesome element to the Massachusetts Health Care Reform are the individual and employer mandates. The mandate is being enforced through the use of a penalty system. By working to create change by using a mandate-penalty strategy, the state is use of a Power-Coercive technique will hopefully create state wide social change in regards to health. Unfortunately, by using the Power-Coercive technique to enact a policy that Massachusetts feels is most beneficial to all it citizens, the reform may not be as successful as hoped. The Power-coercive model places emphasis on political and economic sanctions in the exercise of power (10) and it can have a detrimental effect on the change desired. Some may fight back or simply “opt-out” of the requirement.

“A mandate is critical, however, to helping the state (MA) achieve near-universal coverage and it is hard to force people to buy coverage, especially when some people do not think they need it” (11,12). By enacting an individual mandate into the legislation, it shifts the responsibility to the person to find their own health care and “as most people in the United States rely on their employers or a government program for coverage, and individuals seeking insurance on their own are faced with a difficult, sometimes impossible, task” (11,12). Having that responsibility can be an overwhelming task, even for those who have an understanding of health care. And for some MA residents, it may just be easier and cheaper to pay the penalty than to get health insurance (14). Easier, because looking for and accessing care can be a daunting task, even for those who have their coverage paid for. And for a family that is not eligible for the free or less expensive health care coverage options, the cost to provide care simply may not be affordable and a penalty may be the only reasonably priced option.

Argument III: MA Health Care Reform Legislation will not decrease or contain the spiraling cost of healthcare in Massachusetts.

The cost of health care in America continues to rise. With the US forecasted to spend over two and a half trillion dollars on health care in 2007, the cost of basic and essential health services are slowly moving out of reach of individuals, government and employers. But there are a variety of ways to slow down these rising costs including increasing efficiency of health care delivery or limiting the resources available to the health care system (13). The health reform legislation created a Quality and Cost Council which is responsible for setting benchmarks for quality improvement and cost containment, but there was no central focus in the legislation on containing cost overall.

There is a major need for health care accountability for the rising cost of care, particularly on the part care providers. In article by Jon Hurst, he states that “we need answers and accountability from health care providers and that we need to put health care under the microscope to truly examine where the money is going for all this health care (17). As health insurance premiums could cost up to 20% of a total compensation (15), the commonwealth needs to examine where all this money is going to come from to pay for the coverage it has promised it citizens. “What we need is a revolution through which we can replace our resignation with hope -- and our disengagement with a new community-based activism driven not by partisan politics but by an unwillingness to accept a system that has become obsessed with the delivery of health care as an economic commodity at the expense of health for the American people (16). If the state is able to effectively control costs, consumers will get more value for their money while still providing exceptional care. In moving forward, ee as a commonwealth need to collaborate with all stakeholders to control these costs before they get out of hand.

Massachusetts claims that it will address concerns of all it citizens and provide High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1)? And while there have been many strides towards providing all citizens with health insurance, it is unlikely that it will provide the highest quality and affordable care possible. It is unlikely that all people will access health care with insurance now even if they have it or if they are being forced to use the services. According to the World Health Organization Constitution, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (18) but this is not a belief held by all. As the state moves into year two of this legislation, it will need to stay in control of the service they are providing. It will need to continue to provide affordable care to all those who need it. It will need to look closer at the beliefs, ideas and expectations of all it peoples that it had that may not have been examined closely before.


  1. The 185th General Court of The Commonwealth of Massachusetts Chapter 58 of the Acts of 2006. An Act Providing Access to Affordable, Quality, Accountable Health Care.
  2. “Health Care Reform: An Overview”. Massachusetts Commonwealth Connector
  3. Lee, C. Massachusetts Begins Universal Health Care. The Washington Post. 2007
  4. Bodenheimer, Thomas S. , Grumbach, Kevin. Understanding Health Policy. 2001.
  5. Families USA. Massachusetts Health Reform of 2006 PDF. August 2007
  6. Preboth, Monica. Breaking Cultural Barriers in Health Care. American Family Physician,
  7. Flores, G. Language Barriers to Health Care in the United States. New England Journal of Medicine. 2006;355;229-231.
  8. Altman, S., Doonan, M. Can Massachusetts Lead the Way in Health Care Reform? New England Journal of Medicine. 2006;354:2093-2095 M
  9. Freeman, E. It’s Not How You’re Covered…It’s How You’re Treated. CommonHealth, 2007.
  10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.
  11. McDonough, J. The Individual Mandate is about to get serious. CommonHealth, 2007.
  12. Abelson, R. Mandatory Coverage Is Easier Said Than Done. New York Times. 2007
  13. Controlling Health Care Cost. New England Journal of Medicine .Volume 351:1591-1593 October 14, 2004
  14. Lawmakers Say Employer Mandate Key To Massachusetts Health Reform Law

  1. A cure for spiraling healthcare costs .By Stuart H. Altman | January 2, 2007
  2. Kitzhaber, J Health care system lacks accountability. October 7, 2005. Seattle Post-Intelligencer
  3. Hurst, J. When will we just say no to big health care. Commonhealth. 2007
  4. Constitution of the World Health Organization.. Basic Documents, Forty-fifth edition, Supplement, October 2006

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