Is the MA Health Care Reform Law built on shaky assumptions?
Along with notification of an 11%+ increase in my firm’s health insurance premium, Blue Cross Blue Shield of MA sent along a handy explanation of the Massachusetts Health Care Reform Law. Point #5, “Funding,” says in part:
Since Massachusetts already pays at least $1.1 billion to provide health care for the uninsured, the additional funding requirements are expected to be modest. The bill will redirect the existing funds that currently pay for the cost of care, which is often accessed in the emergency room by people who lack insurance [emphasis mine.] In the future these funds will subsidize the cost of insurance, which will enable people to access care in more appropriate settings and establish relationships with PCPs.
Sounds good, but then along comes a new Health Affairs article (What Accounts For Differences In The Use Of Hospital Emergency Departments Across U.S. Communities?), which challenges the conventional wisdom. The abstract confirms that the point above is a common one:
Increases in the number of uninsured people, who lack access to other types of outpatient care, are often cited [as drivers of increased ER use]
But in a comparison of ER use in different cities in the article, we find that uninsured people don’t necessarily cause ERs to be crowded:
Despite popular perceptions, communities with the highest levels of ED use did not necessarily have the highest numbers of uninsured, low-income, racial/ethnic minority, or immigrant residents. For example, Cleveland and Boston had the highest ED use levels among the… sites [studied] and some of the lowest uninsurance rates.
The uninsured may seek a greater proportion of their care in the ER (or maybe not) but they tend to avoid the medical system in general. Meanwhile, insured people are at least as likely as the uninsured to use the ER in a given year.
According to the article, a significant driver of ER use is the difficulty in getting an appointment with a physician. Massachusetts (especially Boston) has some of the longest waiting lists to see physicians. Reducing the number of uninsured is likely to make waiting lists longer, as people who previously avoided the medical system now seek the chance to try out their new health insurance. As waiting lists get longer it may push more people into the ER.
That doesn’t mean the health care reform bill is a bad idea. It just means that absent other reforms –namely increasing throughput in physicians’ offices through the use of smarter scheduling and webVisits– it will lead to higher costs and lower service levels.
One caveat: The study analyzes the extent to which different factors are correlated with variations across communities, but doesn’t focus on what happens when changes –such as the MA reform bill– are implemented within a community.July 20, 2006