PHILADELPHIA -- One of the major lessons from Massachusetts for the rest of the country: The more you communicate, the more you educate your state about health care reform, the higher the participation and the greater the approval.
That goes for state regulators and government staffers in counties and cities as well as the public at large, according to panelists at the annual Association of Health Care Journalists conference last week.
"Insurance regulations are extremely complex -- that's true for regulators as well as for the rest of us," said Robert Field, professor of law and health management and policy at Drexel University in Philadelphia.
"We found in Massachusetts a steady rise in the number of people who approved of the changes as they came to understand them. The state made a big effort to communicate what was going on and it paid off," Field said.
"It's one of the messages the feds don't seem to be learning," added Field, author of the 2007 book "Health Care Regulation in America: Complexity, Confrontation and Compromise."
Engagement, Approval Are Better Than Expected
With a two-year head start on many of the provisions of the Affordable Care Act, Massachusetts is seen as a potential classroom for other states embarking on health care reforms. In one of dozens of panels, workshops and speeches over three days designed to help journalists cover health care, Massachusetts experts shared what they've learned.
Rob Restuccia -- executive director of Community Catalyst, a national consortium of health consumer advocacy organizations, and professor at Boston University School of Public Health -- said he is pleasantly surprised at how well the Massachusetts law is working and how widely the changes are being accepted.
"I was incredibly skeptical from the start. I'm a full-time single-payer advocate and I was particularly concerned about the insurance mandate. I would have never predicted it was going to work as well as it has," Restuccia said.
More than 98% of the state's residents have health insurance two years after the full-coverage law was passed.
"There's little evidence that employers have dropped coverage or that public plans are crowding out private ones," Restuccia said. "I wouldn't have predicted that."
Cost Increases, Lack of Providers
Panelists said other states should be prepared for cost increases, shortages of primary care providers and turbulence surrounding the thorny issue of how to care for undocumented residents.
"Costs, realistically, are going to increase on the short term," Field said. "I don't think there can be any dispute about that. But in the long term? We'll see."
Massachusetts, where the health care industry is by far the largest private employer in the state, is suffering a bit from a shortage of health care providers. Experts predict more severe problems in other parts of the country where primary care physicians are scarce.
"In other states -- especially western states -- you're going to see this play out differently with much more reliance on nurse practitioners and physician assistants in primary care provider roles," said Irene Wielawski, independent journalist who served as moderator of the Massachusetts panel.
In response to a question about how undocumented immigrants are treated under the Massachusetts law and how they may fare elsewhere under the ACA, Restuccia said there is reason for worry.
"Massachusetts has adopted a kinder, gentler approach to undocumented immigrants. There are subsidies for kids and pregnant women and there is a pre-care pool for them," Restuccia said. "That's a dramatic difference from the ACA. We're a state that doesn't have the same anti-immigrant sentiment as much of the rest of the country. I'm very worried about that.
"There is a community benefit provision in ACA that could be used for this if states choose to. Depending on how states deal with this, that population could become much more vulnerable," Restuccia said.
New, Expanded Role for State Insurance Commissioners
Historically, insurance in America has been regulated at the state level. The ACA doesn't change that but it does focus attention and give some new clout to state insurance departments in the health arena. In many states (including California), other kinds of insurance -- life, fire, auto and homeowners -- are subject to a higher level of regulation than health insurance.
"The National Association of Insurance Commissioners will be key in all this. They don't have any power, but they have influence and they have data and research capabilities. Their voice will be heard," Field said.
NAIC is specifically empowered in the ACA to develop concepts and to consult with HHS as well as state insurance agencies.
"There will have to be some sort of uniformity across the country, and this organization is going to be key," Field predicted.
In California, the issue of overseeing health insurers is complicated because an additional state agency -- the state Department of Managed Health Care -- regulates part of the health care insurance spectrum. A campaign is building to bring the two agencies and the work they do under one regulatory roof.
Staff size and regulatory clout will be increasingly important for state insurance commissioners as more ACA provisions come into play, according to Field.
California Insurance Commissioner Dave Jones (D), who is in the process of staffing his office, could get more clout if AB 52 by Assembly members Mike Feuer (D-Los Angeles) and Jared Huffman (D-San Rafael) passes. The bill would give the state Department of Insurance regulatory authority over insurance premium increases.
Coming Down in Price, Up in Quality -- Like Computers
CMS Administrator Donald Berwick, in his keynote address to journalists, boiled the federal government's health care goals down to three major phases -- insurance coverage for all, prevention (he calls it "not getting sick in the first place"), and lowering costs.
Although the three steps are seen as a progression, efforts in each of the three phases are under way simultaneously.
"I see two ways to save money in our health care system," Berwick said. "One is to cut and the other is to improve. You're hearing a lot of talk about cutting right now. I don't like that approach. The best way to make costs go down is to make health care better.
"I have enormous confidence in the possibility of improving quality and lowering costs without cutting back on the amount of health care options we have available to us," Berwick said.
Calling chronic illness "a big part of our high costs," Berwick said formation of accountable care organizations will help improve continuity and coordination of care, which in turn will reduce costs.
Berwick said pilot projects in 15 states -- including California -- to develop strategies to improve care for individuals who qualify for both Medicare and Medicaid are aimed at reducing costs by improving the quality of care.
"It's health care's secret weapon," Berwick said. "Just like we've all seen costs go down and quality go up in computers over the past decade or so, we know it can work. It can work in health care as well."