MASSACHUSETTS HEALTH REFORM: IMPACT ON WOMEN’S HEALTH

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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

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DATA SOURCES

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

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

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

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MASSACHUSETTSBEFORE HEALTH REFORM

• Prohibited Insurance Practices:– Gender and disease-based premium rating– Denial of coverage based on sex, age, occupation,

health status or actual or expected health condition– Designation of domestic violence or pregnancy as a pre-

existing condition

• Pre-existing Condition Limitations- technically allowed by law but no major insurer imposed

• Pro-choice legislature and government

• 26 Mandated Benefits including maternity, mammography and contraceptive services

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HOW DOES REFORM IN MA COMPARE TO NATIONAL

REFORM?Provision MA USIndividual mandate √ √Employer Mandate √ √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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IMPROVEMENT IN COVERAGE SINCE REFORM

• MA Health reform extended coverage to 364,000 residents, the majority (68%) of whom receive subsidized insurance

• The Massachusetts Health Reform Survey found that all populations of women experienced significant coverage gains since reform

• 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

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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%

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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

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Women’s Health Policy and Advocacy Program

Health Insurance Coverage of Men vs Women 18-64: Massachusetts 2008

9.1%1.4%

14.5%

4.3%

70.8%

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

Men Women

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IMMIGRANT WOMEN • Prior to June 2009, Massachusetts

insured Legal Permanent Residents (LPRs) under subsidized Commonwealth Care but cut coverage due to budget constraints

• The state created a separate insurance plan to cover the nearly 30,000 LPRs that lost coverage but the plan has capped enrolment

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WHO ARE THE UNINSURED? • Women that remain uninsured are

disproportionately young, single and Hispanic

• More than half of uninsured women are employed (often in smaller firms)

• More than 75% of the nearly 60,000 uninsured women in MA have incomes under 300% FPL, meaning they may qualify for subsidized coverage

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Access to Care

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THE NUMBERS • As of Fall 2009, 97.1% of Massachusetts

women were insured, up from 91.4% in 2006

• 92.8% of Massachusetts women had a usual source of health care in 2009

• 90% had a general doctor visit and 82% had a preventative care visit

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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

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• In general, health reform has expanded access to contraceptives

• Barriers to Accessing contraceptives - New ways of obtaining contraceptives- Some Young Adult Plans and Student Health Plans do not have prescription drug coverage- Difficulty understand what contraceptive services plans will cover- Frequent changes in insurance status impact cost and continuity of contraceptive use

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

• MA funds medically necessary abortions for Medicaid recipients

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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

Gynecology92% 81%

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Figure 4

Massachusetts Women 18-64 Without a Personal Doctor by Race and Ethnicity

2001-2008

8% 8%9%

11%13%

10%

22%

19%17%

0%

5%

10%

15%

20%

25%

2001-2006 2007 2008

White Black Hispanic*

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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 on low-premium, subsidized insurance plans•Young women enrolled in Young Adult Plans (YAPs)•Women transitioning from no cost-sharing 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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AGE RATING

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

woman in Boston, MAPlan 31 year-old 59 year-old

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

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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. The next slide shows lowest cost Bronze, Silver and Gold plans available to her by geographic breakdown: Boston and Springfield, MA.

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

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Coverage and Eligibility Transitions

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• Women are more likely to experience life changes like enrollment in college, pregnancy or marriage and variable income, which impact income eligibility

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

• In 2009, an average of 9,80 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 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 below 200% FPL. Christina must apply for Medicaid 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 [email protected]

www.brighamandwomens.org/womenspolicy

Women’s Health Policy and Advocacy Program