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Massachusetts holds health reform lessons
By Adam Sonfield
Senior Public Policy Associate
With Congress edging closer to enacting broad health care reform legislation, questions abound about its potential impact on patients and providers.
Family planning centers can look for at least some guidance to the experience in Massachusetts, according to Rachel Benson Gold, Guttmacher Institute's director of policy analysis. Gold, who has looked into this matter extensively, observes that Massachusetts enacted its own reform legislation in 2006 that has served in part as a model for the federal effort.1 As would the bills under consideration in Congress, the Massachusetts law imposed mandates on individuals and businesses, established a new marketplace for insurance, and provided subsidies for low-income residents, all in an effort to make coverage more affordable and prevalent.
By 2008, only 2.6% of Massachusetts residents were uninsured, compared with 6.4% in 2006, and more residents reported having a usual source of medical care and making use of care in the last year.2,3 Yet, several problematic signs have emerged, including still-escalating costs; disproportionate levels of uninsurance among groups such as immigrants, young adults, and the poor; and — notably for safety-net providers — difficulties accessing care. Large numbers of low- and middle-income residents reported that they did not get care they thought they needed in 2008 and that physicians were either not accepting any new patients or not accepting patients with their type of insurance.3
For the most part, the federal health care reform legislation looks to community health centers (CHCs) as the solution to ensuring that millions of newly insured low-income Americans will have a place to go to make use of that insurance. Between the economic stimulus law passed early in 2009 and the health reform bills themselves, CHCs are being showered with billions of dollars in new funds each year to expand their reach and capacity.
Yet, although federal law requires CHCs to provide family planning (and nearly all report doing so), they serve relatively few family planning clients per center than do specialized family planning centers.4 Anecdotal evidence from Massachusetts indicates that women themselves still see a need for specialized centers, with several major family planning providers reporting that they are serving large numbers of clients covered by the state's new, subsidized plans.1 Furthermore, at least some CHCs appear reluctant to promote themselves specifically as a family planning provider, lest they taint their broad political appeal, or to invest in advanced training and expertise in reproductive health issues.
Role of the provider?
Health care reform appears likely to drive in new clients for CHCs and specialized family planning centers and should also offer centers an opportunity to formalize and be reimbursed for their role as a primary entry point to further health care, particularly for young women. Part of this role, as always, will be evaluating their clients' needs and referring them to other community providers when necessary. However, now they will refer them with more assurances that their clients will have insurance to pay for this care.
Family planning centers, moreover, might be able to help their clients enroll in an insurance plan that best fits their needs and navigate insurers' bureaucracy. Many already do so in several states that have expanded Medicaid eligibility specifically for family planning services.5 Tapestry Health in western Massachusetts is being funded to serve that role for the state's new private insurance marketplace. Tapestry Health is helping clients with a range of key tasks such as comparing and choosing from among competing plans, completing an online application, locating in-network providers and labs, and understanding insurers' jargon.1
A prerequisite for family planning centers to adequately serve and be compensated as an entry point to insurance and to broader care is for them to be part of plans' provider networks. Only 28% of family planning agencies nationwide in 2003 had even a single contract with a private insurance plan.6 To address this problem, the federal health reform proposals include provisions requiring plans in the new marketplaces to contract with "essential community providers," a group of safety-net providers that includes family planning centers.
Just as much a prerequisite is for policy-makers, insurers, and providers to address the shortcomings currently built into the private insurance system. These barriers include accessing specialists, inadequate information to enrollees on their benefits and rights, and insurance procedures that inadvertently violate a clients' confidentiality. These procedures include explanation of benefits forms routinely sent to the primary policyholder, who might not be the client herself.7
If all parties can find ways to adapt to a changing world, health reform can provide real opportunities for family planning centers to serve their clients better and improve their access to the full range of services they need.