Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees. Only primary care fees grew at the rate of inflation-20 percent between 2003 and 2008. However, because of slow growth in Medicare fees, Medicaid fees closed a small portion of their ongoing gap relative to Medicare-growing from 69 percent to 72 percent of Medicare. The increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.

The Massachusetts health reform initiative enacted into law in 2006 continued to fare well in 2010, with uninsurance rates remaining quite low and employer-sponsored insurance still strong. Access to health care also remained strong, and first-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery in the state. There were also improvements in self-reported health status. The affordability of health care, however, remains an issue for many people, as the state, like the nation, continues to struggle with the problem of rising health care costs. And although nearly two-thirds of adults continue to support reform, among nonsupporters there has been a marked shift from a neutral position toward opposition (17.0 percent opposed to reform in 2006 compared with 26.9 percent in 2010). Taken together, Massachusetts's experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.

No abstract

With the passage of national health reform legislation modeled on Massachusetts' 2006 reform initiative, the Bay State continues to provide important lessons for the nation. Most recently, Massachusetts has shown that although it is difficult, sustaining the gains of health reform in a severe recession is possible. The state's uninsurance rate, 4.8 percent for nonelderly adults, remained at a record low in fall 2009. Access to health care improved, and the burden of high health care costs on individuals was reduced. However, challenges remain, as some barriers to care persist and escalating health care costs continue to be an issue.

Objective. To analyze the effects of health reform efforts in two large states--New York and Massachusetts. Data Sources/Study Setting. National Health Interview Survey (NHIS) data from 1999 to 2008. Study Design. We take advantage of the ''natural experiments'' that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings. Data Collection/Extraction Methods. Nonelderly adults ages 19-64 in the NHIS. Principal Findings. We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope--the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state's reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state's reform initiative was fully implemented. Conclusions. Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.