The Massachusetts Health Care Experiment
The changes in Massachusetts health care fascinate me. A program that Gov. Mitt Romney created in an effort to help his state morphed into something else. From the middle of America, it looks like that state is performing a scientific economic experiment, and the “lab rats” are the people of Massachusetts. The independence of each state is a longstanding American ideal, and the modicum of autonomy that each state has from the federal government allows Massachusetts to experiment with a plan that we may not want to do elsewhere. By reading their lab notes, however, we may learn something that can help Missourians.
Since Romney initiated “An Act Promoting Access to Health Care” in 2006, there has been an expansion of health coverage in that state. Currently, Massachusetts has nearly universal health care (approaching 97 percent), most of it supplied by private health insurance and paid for by a combination of employees and employers.
As many expected, despite the best efforts of the brightest people, costs continue to grow. The report from the Massachusetts Commission on the Health Care Payment System indicates that, “While the U.S. has the highest health care expenditures per capita among other industrialized countries, Massachusetts has among the highest health care costs in the U.S. In 2004, health care costs per capita in Massachusetts reached $6,683, and based on recent history, are projected to grow faster than for the U.S. as a whole.”
Although the cost issues have become a part of the national debate about health care, what seems overlooked is whether these changes will improve health. People can argue about how to pay the bill, but what if the result is no better than what we have now? Recent studies found that throughout the nation, adults receive just 55 percent of recommended care. If that is so, it may not matter who wins the health care debate; the result will still be less than desired.
Some years ago, a RAND experiment found that, in the short run, there were no clinically significant differences between the outcomes of people given free health care insurance and the outcomes of people who paid for health care insurance. Although that study was undertaken with relatively few patients, researchers hoped to find how patient copayments influenced the use of services. Its results, however, included information about whether people did any better with different insurance formats. During the study’s three years, one could “rule out clinically significant benefits from the additional services in the fee-for-service free plan relative to” the other groups. That is, although use of health care systems was related to out-of-pocket costs, during the study’s brief interval the clinical results showed that each group had similar outcomes.
Since completion of the RAND study, numerous investigations have shown economic and biologic long-term benefits to both individuals and society when people have regular access to health care. As stated by the Institute of Medicine, “A robust body of well-designed, high-quality research provides compelling findings about the harms of being uninsured and the benefits of gaining health insurance for both children and adults. Despite the availability of some safety net services, there is a chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death.”
If the data about increasing costs, limited short run benefits, and long term societal values are combined, it seems that current health care reform arguments are aimed wrong. In fact, the Special Commission examining the Massachusetts Health Care Payment System may have just stumbled upon this problem. Their analysis found that fee-for-service health care is a primary cause of increased health care costs. That is because the fee-for-service system rewards service volume rather than outcomes. In the current system physicians are rewarded for doing things to patients, and whether any one gets better has become a secondary goal. That emphasis is wrong.
Now the Massachusetts Commission is proposing further changes. They want to develop another way to pay physicians for the work that doctors do. The new goal is to reward physicians if the patient gets better, and not to pay just for doing tests and procedures. How they are going to do that still remains a mystery. But isn’t it nice that this experiment is being conducted a half continent away, so we can observe it from a safe distance. Maybe we can learn something from them?