Michael Doonan

Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate

CONTEXT Much can be learned from Massachusettss experience implementing health insurance coverage expansions and an individual health insurance mandate. While achieving political consensus on reform is difficult, implementation can be equally or even more challenging. METHODS The data in this article are based on a case study of Massachusetts, including interviews with key stakeholders, state government, and Commonwealth Health Insurance Connector Authority officials during the first three years of the program and a detailed analysis of primary and secondary documents. FINDINGS Coverage expansion and an individual mandate led Massachusetts to define affordability standards, establish a minimum level of insurance coverage, adopt insurance market reforms, and institute incentives and penalties to encourage coverage. Implementation entailed trade-offs between the comprehensiveness of benefits and premium costs, the subsidy levels and affordability, and among the level of mandate penalties, public support, and coverage gains. CONCLUSIONS National lessons from the Massachusetts experience come not only from the specific decisions made but also from the process of decision making, the need to keep stakeholders engaged, the relationship of decisions to existing programs and regulations, and the interactions among program components.

Choice in the American healthcare system: Changing dynamics under the Affordable Care Act

Implementation of the Affordable Care Act (ACA) in the United States changed the available options of healthcare coverage and providers. Through a comparative case study methodology, this article analyzes variations and trends in choice of provider and/or health plan and implications for consumers. Choice is explored at the national and state level for public and private health insurance options. This includes employer-based insurance, marketplace options, and the public Medicare and Medicaid programs. Findings indicate that too much choice can create confusion and lead to economically inefficient plan selection. Employer structuring of choice retains a wide choice of providers, but passes more cost on to employees. ACA marketplaces come short of structuring managed competition where choice drives efficiency. While the previously uninsured have far better options under reform, the system-wide range, degree, and complexity of choice tend to favor insurers over consumers.