Secrets of Massachusetts' success: Why 97 percent of state residents have health coverage

Less than two years after Massachusetts' 2006 health care reform law was implemented, 2.6% of residents were uninsured—the lowest proportion ever recorded in an American state. The state's individual mandate alone does not explain this result: it is not enforced against adults with incomes at or below 150% FPL or children. This study examines how Massachusetts implemented this reform and succeeded in enrolling a remarkably high percentage of low-income uninsured residents into subsidized coverage. Researchers conducted a site visit in July 2009 to Boston, MA and interviewed over 35 key informants, including Medicaid and Commonwealth Care (CommCare) officials, public/private providers, health plan administrators, advocates, policy researchers, and community-based outreach agencies. The research team also reviewed several published reports and state programs analyses. Researchers found that adoption of the following innovative administrative strategies was essential to successful enrollment and substantial reduction in the number of uninsured residents: (1) Data-Driven Eligibility. Roughly one in four newly-insured state residents qualified for assistance based on existing data collected for the state's Uncompensated Care Pool; these individuals were “auto-converted” into CommCare and never completed an application form; (2) Integrated Eligibility System. A single state agency determines eligibility for most programs, based on a common application form, resulting in lowered administrative costs, while preventing erroneous eligibility determinations and increasing enrollment; (3) Community-Based Application Assistance. Over half of all successful enrollments were accomplished by trained safety-net provider or community-based organization staff using the state's online enrollment system; (4) Intensive Public Education Campaign: A public health education campaign gained consumers' attention by describing subsidies, the individual mandate, and penalties for not enrolling in state reform. For future national- and/or state-level reforms to accomplish the objective of enrolling low-income uninsured into health insurance, it will be important to incorporate these lessons from Massachusetts into coverage expansion design.