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Perspective: Massachusetts provides lessons on healthcare access


John A. Graves, PhD, discusses the lessons about healthcare reform that Massachusetts can share as the Affordable Care Act is implemented across the United States.

John A. Graves, PhD, helped provide the White House Office of Health Reform with budgetary estimates that informed the development of the Affordable Care Act (ACA). He previously had done similar work for Massachusetts policymakers working on then-Gov. Mitt Romney's healthcare reforms. The assistant professor at the Vanderbilt School of Medicine in Nashville, Tennessee, recently spoke with Medical Economics Editor-in-Chief Lois A. Bowers, MA, about his research, which spans the intersection of health policy, health economics, statistics, and health services research.

Q: What lessons can the country learn from Massachusetts as ACA implementation proceeds?

A: One study I worked on with Jonathan Gruber, PhD, of the Massachusetts Institute of Technology, showed that those who obtained coverage through the individual market-not through Medicaid, not through their employers-saw dramatic reductions in their premiums, largely because premiums were subsidized for those with incomes up to three times the poverty level.

Other research, done with Katherine Swartz, PhD, of the Harvard School of Public Health, found that Massachusetts saw the greatest declines in its uninsured, almost 20%, in people who otherwise would’ve been uninsured for 4 to 24 months. But after 24 months, Massachusetts looked like the rest of the country. There’s still a small but significant group of long-term uninsured in Massachusetts, and it’s something that we have to think about as we implement the ACA.

Q: Tell me about your latest work.

A: In research funded by the Robert Wood Johnson Foundation, we’re looking at coverage expansions under the ACA and how they are going to impact access to primary care once they are implemented.

For cities with mainly “short-spell” uninsured, the utilization of primary care might just shift around in time. The new demand for care in such places is probably going to be much less than in “long-spell” places, where people are really having trouble accessing care despite the fact that they have subsidies and, potentially, Medicaid available to them.

This project is trying to drill down into a very local area to highlight areas where a lot of uninsured may be coming into the insured population with huge demands on primary care. We are relating these expansion populations to local healthcare workforces.

Q: Other research you conducted has indicated the need for improved income assessment tools to reduce errors as the government tries to determine eligibility for subsidized health insurance. What did you find?

A: In Massachusetts, premiums are based on current income. The ACA calculates premiums based on a person’s most recent federal tax return, and then any over- or undersubsidization is reconciled in the future via tax return. There are implications on both sides of this for how many people actually end up getting covered, because maybe they’re worried about this reconciliation process. We recommended that Congress measure income the same way for Medicaid and subsidized exchanges and that states try to provide quickly a 6-month record of wages.

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