Plans are chosen through the health insurance exchange, called the Commonwealth Health Insurance Connector. Those plans include the following:
• Commonwealth Care. Open to anyone with an income of up to 300% of the federal poverty line. The state subsidizes their coverage and pays for coverage for those with incomes up to 150% of the poverty line.
• Commonwealth Choice. Plans – rated bronze, silver, or gold – must meet certain coverage and cost standards.
• Mass Health. This is the state Medicaid plan, which covers children in families up to 300% of the poverty level.
As is the case in the U.S. Affordable Care Act, there are disincentives for residents and employers to go without health coverage. Employers with 11 or more workers must either cover their workers or pay the state a contribution of up to $295 per year per worker.
Adults with incomes greater than 150% of the poverty level must either buy insurance or pay a penalty. In 2011, penalties ranged from $19 to $101 a month.
As more residents gain coverage, the number paying the penalty has decreased: In 2008, 45,000 paid; in 2010, 44,000 were assessed a penalty.
Can the Workforce Keep Up?
Many private practice physicians – especially those in primary care – are also struggling to meet demand.
Dr. Bigby, the state HHS secretary, said that fears about a primary care shortage had not been realized. Within a year of the reform’s being enacted, the state’s community health system had increased physician and nurse practitioner appointments by 50,000 visits, she said. But Dr. Gravel and Dr. Dupee said there was a continued shortage of primary care doctors, and that there were gaps in access. Hospitals have not increased the number of training slots over the last 6 years, they said.
"The hospitals have been slow to transform their training to primary care because the basic incentives have been to produce specialists," said Dr. Gravel, director for the Lawrence (Mass.) Family Medicine Residency program.
Primary care residents generate less clinical revenue, and cost more to train, said Dr. Gravel. The Affordable Care Act made it possible for his program to expand from 8 residents to 10. But state funds for family medicine training were reduced 3 years ago.
When residents finish training, they are not as interested in private practice, said Dr. Dupee. Instead, they go to work for hospitals or community clinics, where they have a guaranteed salary and less administrative hassle.
There are no clinics in many areas of the state, such as between Boston and Worcester, or between Worcester and Springfield, said Dr. Dupee. "Rural areas are underserved and will continue to be until something is done about it," he said.
Both he and Dr. Gravel also said that they believe many primary care physicians in their 50s will be retiring sooner rather than later, driven out by the shift out of fee for service.
Dr. Kuchnir agreed that private practices were threatened, mostly by the lower reimbursement offered by state plans. It’s not a question of having enough physicians to meet the demand for care, but whether the compensation is enough for practices to survive, he said.
He and the other physicians agreed, however, that it was a good thing that most state residents could now get insurance, because they can now also get needed care.
And unlike other states, the doctor is not "left holding the bag when patients can’t get what they need," said Dr. Gravel.