At the Intersection of Health, Health Care and Policy Cite this article as: James Maxwell, Dharma E.

Corts, Karen L. Schneider, Anna Graves and Brian Rosman Massachusetts' Health Care Reform Increased Access To Care For Hispanics, But Disparities Remain Health Affairs, 30, no.8 (2011):1451-1460 doi: 10.1377/hlthaff.2011.0347

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By James Maxwell, Dharma E. Corts, Karen L. Schneider, Anna Graves, and Brian Rosman

Massachusetts Health Care Reform Increased Access To Care For Hispanics, But Disparities Remain
Hispanics are more likely than any other racial or ethnic group in the United States to lack health insurance. This paper draws on quantitative and qualitative research to evaluate the extent to which health reforms in Massachusetts, a model for the Affordable Care Act of 2010, have reduced disparities in insurance coverage and access to health care. We found that rates of coverage and the likelihood of having a usual provider increased dramatically for Massachusetts Hispanics after the states reforms, but disparities remained. The increase in insurance coverage among Hispanics was more than double that experienced by non-Hispanic whites. Even so, in 2009, 78.9 percent of Hispanics had coverage, versus 96 percent of non-Hispanic whites. Language and other cultural factors remained significant barriers: Only 66.6 percent of Hispanics with limited proficiency in English were insured. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009, and 26.8 percent reported not seeing a doctor because of cost, up from 18.9 percent in 2005. We suggest ways to reduce such disparities through national health care reform, including simplified enrollment and reenrollment processes and assistance in finding a provider and navigating an unfamiliar care system.
ABSTRACT

doi:

10.1377/hlthaff.2011.0347 HEALTH AFFAIRS 30, NO. 8 (2011): 14511460 2011 Project HOPE The People-to-People Health Foundation, Inc.

James Maxwell (jmaxwell@ jsi.com) is the director of research at the JSI Research and Training Institute, in Boston, Massachusetts. Dharma E. Corts is a senior research associate at the Mauricio Gastn Institute for Latino Community Development and Public Policy of the University of Massachusetts, in Boston. Karen L. Schneider is a senior research scientist at the JSI Research and Training Institute. Anna Graves is a research associate at the JSI Research and Training Institute. Brian Rosman is research director of Health Care For All, in Boston.

n 2006 Massachusetts enacted comprehensive health reform legislation, known as Chapter 58, to provide all residents of the state with access to insurance coverage, regardless of their income, health, or previous insurance status. Chapter 58 was a model for the federal Affordable Care Act of 2010, in particular through its provisions designed to reduce racial and ethnic disparities. Several studies have tracked the implementation and outcomes of Chapter 58 during its first four years.1,2 The findings indicate that Massachusetts has achieved the highest rate of health insurance coverage in the nation; employer-based coverage has increased; and the states health reform law is supported by the public and a broad coalition of stakeholder

groups.3,4 Evidence of improvements in residents health and health caresuch as reduced hospitalization rates for preventable conditions, including diabetes, heart disease, and asthma is emerging.5 One of the secondary goals of health care reform in Massachusetts was to reduce racial and ethnic disparities in coverage. In Chapter 58, Massachusetts legislators explicitly recognized the importance of eliminating disparities by establishing it as a goal of the Health Care Quality and Cost Council.6 Chapter 58 also established the Health Disparities Council, which monitors and makes recommendations regarding racial and ethnic disparities in access to high-quality care and in health outcomes.7 To implement the new law, the state created August 2011 30:8 Health Affa irs 1451

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the Health Care Reform Outreach Grant Program, which represented a revival of the Direct Service Outreach Grants Program that Massachusetts had used in the late 1990s to fund local nonprofit groups that helped people enroll in Medicaid programs created at that time.8 Several of the community groups that received grants in the 1990s have pioneered innovative enrollment assistance programs aimed at Hispanics and other disadvantaged populations.9 In addition, Chapter 58 gives community health centers and public hospitals financial incentives to enroll uninsured Hispanics in the states new insurance program and to provide care for them. Hispanics are the largest and fastest-growing ethnic minority group in Massachusetts. In 2010 the state had 6,547,629 residents, of whom 9.6 percent (627,654 people) identified themselves as Hispanica 46.4 percent increase from 2000.10 Policy makers and researchers have long recognized the barriers that Hispanics face in terms of access to health care and insurance coverageobstacles that have serious implications for their health.11,12 This paper evaluates the extent to which Chapter 58s comprehensive health reforms improved access to coverage and care for Hispanics in Massachusetts, compared to the states nonHispanic white population, and whether disparities between the groups have been reduced. We used quantitative data to compare rates of coverage and access to care before and after the enactment of Chapter 58 for Hispanic adults and non-Hispanic white adults. We also examined qualitative data, to provide a context in which to interpret the quantitative data and identify persistent barriers to coverage and care. The paper ends with a discussion of the implications of the Massachusetts experience for the implementation of national health care reform and strategies that might reduce disparities nationally. To measure health coverage and access to care, we used the following three questions in the survey: (1) Do you have any health coverage, including health insurance prepaid plans such as HMOs [health maintenance organizations], or government plans such as Medicare? (2) Do you have one person you think of as your personal doctor or health care provider? (3) Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? We coded race or ethnicity as nonHispanic white or Hispanic, excluding other racial or ethnic groups from the analyses. We further categorized Hispanic adults according to whether they completed the survey in English or Spanishinformation we used as a proxy for English proficiency. Citizenship and legal status were not a part of the survey questionnaire. We present unadjusted and adjusted rates because both provide important information. Unadjusted rates represent the real world experience, in which not all racial and ethnic groups are equal with respect to income, health status, education, and so forth. Adjusted rates show where racial and ethnic disparities exist even when there are no differences in those characteristics between groups. To adjust for the confounding effects of social status and demographic differences between groups, we constructed a multivariate logistic regression model that controlled for household income, employment status, age, health status, sex, disability status, education, marital status, smoking status, hypertension diagnosis, and diabetes diagnosis. This model included main effectsrace or ethnicity, year of survey, and a cross-classification of these two variablesand made population-based estimates of access to care and coverage for each combination of year and racial or ethnic group, while adjusting for all other variables.We tested differences by year and race or ethnicity using Wald chi-square tests (significant if p < 0:05). Focus Groups And Interviews Our qualitative data focused on compliance with the new state mandate for health insurance coverage, the process of obtaining coverage, perceptions of health insurance affordability, the meaning of insurance coverage, the difficulties in maintaining coverage, and the use of insurance once enrolled. Little research has been done on these topics for the newly insured, especially for members of minority populations. We conducted three focus groups with newly insured individuals in Englishone each in Boston, Cape Cod, and Worcesterand one group in Spanish, in Lowell. The groups ranged in size from seven to fourteen participants.We also conducted a focus group in Boston with enrollment specialists from commu-

Study Data And Methods

State-Based Telephone Survey Our study relied on analysis of 2005 and 2009 data from the Massachusetts Behavioral Risk Factor Surveillance System survey. This state-based telephone survey on health-related topics was conducted among people age eighteen or older by the Massachusetts Department of Public Health in collaboration with the Centers for Disease Control and Prevention.13 The Massachusetts survey was administered in English and Spanish, and cities with a high proportion of minority populations, especially Hispanic communities, were oversampled. We limited our analysis to respondents ages 1864 because health reform was specifically targeted at this age group. 1452 H e a lt h A f fai r s A u g u s t 201 1 30:8

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nity health centers. A standardized interview guide was used with each of the groups, and each session was transcribed. We also conducted twenty in-depth interviews with newly insured Hispanics age eighteen or older, who spoke English or Spanish and whose income was 150300 percent of the federal poverty level.14 All of the participants were legal residents of the United States. They had been born in Colombia, the Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Puerto Rico, the mainland United States, or Venezuela. Limitations There are several limitations to this study. First, the Behavioral Risk Factor Surveillance System survey relies on contact by landline telephone and thus does not capture information from people who use only mobile phonesa growing segment of the population. This can lead to the underrepresentation of younger and low-income groups. Second, the data are self-reported. However, the question used in the survey to determine current insurance status has been validated in other studies.15 Third, the questionnaire did not include questions on country of origin, citizenship, or legal status. Thus, we were unable to estimate the proportion of noncitizensboth legal and undocumentedwho responded to the survey. These are important topics that we sought to address in our qualitative research. Finally, the focus-group respondents and the participants in the in-depth interviews were not based on representative samples, and their responses might not be generalizable to the entire Hispanic population or to specific groups within it.

Study Results
Population Characteristics Exhibit 1 provides a summary of the Massachusetts survey sample characteristics in 2005 and 2009. Compared to non-Hispanic whites in 2005, Hispanics were generally younger (58.3 percent were under age thirty-five, compared to 32.0 percent), had less education (39.3 percent had not graduated from high school, compared to 3.5 percent), and had lower incomes (51.4 percent had annual household incomes of less than $25,000, compared to 12.2 percent). In comparison to Hispanics who completed the survey in English, those who used Spanish instead had lower incomes (67.3 percent reported annual household incomes of less than $25,000, compared to 42.7 percent) and less education (58.1 percent had not graduated from high school, compared to 28.1 percent). The demographic characteristics of the 2009 His-

panic sample were similar to those of the sample from 2005, although the 2009 group was slightly older and had had more education. Insurance Coverage As documented in previous studies of Massachusetts health care reform, coverage increased significantly among state residents, from 88.3 percent in 2005 to 93.9 percent in 2009 (Exhibit 2). Note that these data are for the total state population, of all races and ethnicities. Both the non-Hispanic whites and the Hispanics in our sample experienced increases in coverage. The increase among Hispanics was more than double that experienced by non-Hispanic whites, but a 17.1-percentagepoint difference remained in 2009 between the non-Hispanic white and Hispanic populations. Hispanics who completed the survey in Spanish were more likely to remain uninsured than those who completed it in English. Exhibit 3 shows the results of multivariate regression analyses. The adjusted rates of coverage for the non-Hispanic whites (95.4 percent) and the Hispanics who completed the survey in English (95.0 percent) were nearly identical in 2009. In comparison, the adjusted rate of coverage for Spanish-speaking Hispanics was 84.0 percent. The bivariate and multivariate results of the quantitative data analysis do not offer a full explanation of why the disparities in coverage persist, nor do they identify the remaining barriers to coverage for Hispanics. However, our qualitative analyses indicate that coverage disparities are related to peoples status as undocumented immigrants, their familiarity with the insurance mandate, the affordability of coverage, and the complexity of the enrollment and reenrollment processes. Cultural attitudes, language differences, and degree of acculturation all influence decisions to purchase and use health insurance. One of the reasons for the increase in coverage is a broad awareness among Hispanics of the individual mandate to obtain health insurance coverage and of the tax penalties for not enrolling. Hispanics who knew about the mandate sought out coverage, many reporting a strong desire to obey the laws of the state.Whether they are legal residents or undocumented immigrants, Hispanics are often concerned about the effect of their actions on their immigration status. Understanding How To Enroll Communitybased organizations that provided enrollment counseling services were crucial in helping bridge the disparity in insurance coverage. Focus-group participants expressed their gratitude to these organizations, and one Spanishspeaking woman indicated that without help from a community-based organization, it would August 2011 30:8 Health Affa irs 1453

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Exhibit 1
Characteristics Of Adult Hispanic And Non-Hispanic White Massachusetts Respondents To Telephone Survey, 2005 And 2009 Hispanic (%) Total (%) 2005 (n = 6,103) 51.0 74.3 15.8 19.1 36.3 28.8 6.5 9.7 9.5 13.5 60.9 2009 (n = 10,314) 51.6 74.2 17.0 17.5 34.2 31.3 6.1 9.2 7.5 11.4 65.8 Non-Hispanic white (%) 2005 (n = 5,371) 50.9 75.7 14.2 17.8 37.3 30.7 4.8 7.4 8.1 13.6 66.2 2009 (n = 9,106) 51.9 75.8 15.6 16.9 34.4 33.2 4.3 6.7 7.1 11.1 70.9 Total 2005 (n = 732) 51.9 63.2 28.7 29.6 28.0 13.6 22.3 29.1 21.9 12.3 14.4 2009 (n = 1,208) 49.2 61.3 28.7 22.1 32.7 16.6 21.3 31.4 11.4 14.8 21.1 English-speaking 2005 (n = 428) 56.4 61.2 35.1 23.4 25.3 16.2 17.7 25.0 20.9 15.1 21.3 2009 (n = 607) 50.8 65.4 27.8 24.1 33.5 14.7 13.6 26.2 12.1 14.7 33.4 Spanish-speaking 2005 (n = 304) 43.9 66.3 18.0 40.0 32.6 9.4 30.6 36.7 23.4 7.3 2.0 2009 (n = 601) 46.8 55.8 29.7 19.6 31.6 19.1 32.6 39.0 10.4 14.7 3.3

Characteristic Female Employed Age (years) 1825 2634 3549 50 or more Household income Less than $15,000 $15,000$24,999 $25,000$34,999 $35,000$49,999 $50,000 or more Education status Less than high school diploma High school diploma only Some college/technical school Bachelors degree or more Marital status Married/partnered Divorced/separated Widowed Never married Health status Fair/poor overall health status Disabled Currently smokes High blood pressurea Diabetesa

7.5 23.5 23.4 45.7 63.4 10.9 1.6 24.1

6.3 22.3 24.6 46.8 66.7 8.8 1.3 23.2

3.5 23.0 24.1 49.5 65.3 10.4 1.7 22.6

3.6 21.4 24.6 50.4 68.6 8.4 1.2 21.9

39.3 27.6 17.9 15.2 47.7 15.0 1.1 36.3

27.7 29.4 24.6 18.3 52.2 12.0 1.6 34.3

28.1 29.7 21.7 20.5 42.5 14.8 1.1 41.6

13.0 27.4 33.3 26.3 52.2 10.9 1.8 35.0

58.1 24.1 11.5 6.3 56.3 15.2 1.0 27.5

46.9 32.2 13.1 7.8 52.1 13.3 1.4 33.2

10.9 15.0 20.4 18.1 4.6

9.5 15.6 16.4 18.8 5.3

9.7 15.2 20.6 18.3 4.4

7.8 15.3 16.5 18.7 5.1

20.7 13.2 18.9 16.4 6.4

23.2 19.7 15.3 19.6 6.8

15.6 12.6 16.4 16.4 7.0

13.7 15.1 18.8 19.2 5.6

29.0 14.0 23.0 16.5 5.2

35.7 26.3 10.8 20.0 8.4

SOURCE Note 13 in text. NOTES Sample sizes are unweighted. Percentages are weighted, and not all percentages sum to 100 because of rounding. English-speaking and Spanish-speaking refer to the language the person used to take the Behavioral Risk Factor Surveillance System telephone survey. Disabled means that a persons activities are limited by a health condition. aHave you ever been told by a health provider that you have this condition?

have been impossible for her to obtain health insurance: I would not have been able to do it on my own. Spanish speakers and individuals with low literacy levels in our focus groups more often reported needing help with enrollment than did those who spoke English, but they were less likely to receive such assistance. This problem was reported in the initial enrollment phase and in the yearly reenrollments for coverage. Some of the programs aimed at Hispanics in Massachusetts are effective, but their capacity is quite limited.16 Both our qualitative and quantitative data 1454 H ea lt h A f fai r s Augus t 201 1 30: 8

underscore the point that Spanish-speaking Hispanics continue to face barriers in acquiring coverage. Finding The Money For Coverage Another reason for continuing disparities is the fact that insurance premiums put a strain on low-income Hispanic households. Even after signing up for insurance plans, our focus-group participants reported reconsidering their commitment because they felt they would not be able to afford the copayments and monthly premiums. One Spanish-speaking person commented, We were in a double bind: we wanted to pay for [insur-

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ance], but we did not have enough money, and we did not even know how we were going to be able to pay the [state tax] penalty for non compliance with the mandate. Access To Care Access to care, as measured in terms of having a personal provider, has increased across Massachusetts (Exhibit 3). Using unadjusted rates, we found that Hispanics had a higher percentage increase between 2005 and 2009 (15.2 percentage points) than nonHispanic whites (1.8 percentage points), but significant differences remained in 2009 between non-Hispanic whites and Hispanics. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009. Cost remained a key barrier to care. Although this problem decreased somewhat between 2005 and 2009 for most groups in the study, using both adjusted and unadjusted rates, it increased significantly for Spanish-speaking Hispanics (Exhibit 3). The unadjusted rates for 2005 show that 18.9 percent of that group reported not seeing a doctor because of cost, but the number was 26.8 percent in 2009. Our multivariate regression analyses show that non-Hispanic whites and English-speaking Hispanics had similar rates of having a personal provider in 2009, while Spanish-speaking Hispanics had a significantly lower rate (Exhibit 3). Even after the variables listed in the notes to Exhibit 3 were adjusted for, the difference between Spanish-speaking and English-speaking

Exhibit 2
Rates Of Health Insurance Coverage For Adult Hispanic And Non-Hispanic White Massachusetts Respondents To Telephone Survey, 2005 And 2009

Percent Insured

Total

Non-Hispanic white

Total Hispanic

Hispanic Hispanic English-speaking Spanish-speaking

SOURCE Note 13 in text. NOTE The rates are unadjusted (see the explanation in the text).

Hispanics was 10 percentage points, while the difference between Spanish speakers and nonHispanic whites was 10.7 percentage points. Similarly, the adjusted 2009 rates for not seeing a doctor in the past year because of cost were nearly identical for non-Hispanic whites (7.1 percent) and English-speaking Hispanics (6.8 percent), while the rate for Spanish-speaking His-

Exhibit 3
Rates Of Insurance Coverage And Access To Care For Adult Hispanic And Non-Hispanic White Massachusetts Respondents To Telephone Survey, 2005 And 2009 Non-Hispanic white (%) 2009 (n = 10,314 94.1 89.1 2005 (n = 5,371) 91.2 89.0 2009 (n = 9,106) 96.0a 90.8a Hispanic (%) Total 2005 (n = 732) 67.9b 60.6b 2009 (n = 1,208) 78.9a,b 75.8a,b English-speaking 2005 (n = 428) 78.1b 72.8b 2009 (n = 607) 88.3a,b 83.4a,b Spanish-speaking 2005 (n = 304) 50.8b 40.2b,c 2009 (n = 601) 66.6a,b 66a,b,c

Total (%) Responses to survey questions Unadjusted rates Has health coverage Has a personal provider Didnt see a doctor in the past year because of cost Adjusted rates Has health coverage Has a personal provider Didnt see a doctor in the past year because of cost 2005 (n = 6,103) 88.6 85.8

9.4 89.4 86.8

7.4 94.4 89.3

8.3 90.5 88.6

6.3a 95.4a 90.1

19.2b 85.8b 76.9b

18.7b 90.7b 86a

19.3b 90.5 82.6b

12.4b 95.0 89.4

18.9b 75.5b,c 63.2b,c

26.8b,c 84.0b,c 79.4a,b,c

8.6

7.5

8.2

7.1

10.4

9.3

11.7

6.8

8.6

12.4b,c

SOURCE Note 13 in text. NOTES The three survey questions are listed in the text. Adjusted rates are adjusted for household income, employment, age, health status, disability, sex, education, marital status, smoking status, hypertension diagnosis, and diabetes diagnosis. For all significant differences, p < 0:05. aSignificant compared to 2005. bSignificant compared to non-Hispanic whites. cSignificant compared to English-speaking Hispanics.

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panics was significantly higher (12.4 percent). Our qualitative interviews helped explain why Hispanics continued to be less likely to have a regular source of care and why cost remained a significant barrier to care for Hispanics. Providers Language Skills And Cultural Competence Hispanics were less likely to have a primary care provider to begin with, and they may have had extra difficulty finding a provider with the appropriate language skills and cultural competence. Some Hispanic interviewees and focus-group participants said that finding a provider was just as challenging as finding a health insurance plan. One Spanish-speaking participant reported obtaining health insurance coverage but not using it because she could not find a provider: I got one [a health insurance plan]. I pay for it. I have not used it yet because of the inconvenience of finding a doctor. She said that the hospital she usually visited did not accept her new insurance, so she had to change providers. Then she had to wait for an appointment with her new primary care physician. Another Spanish-speaking woman complained that she had to wait four months to see her new physician, even though she had been suffering from a painful and swollen leg for months. Another challenge for Hispanics was finding a provider with whom they felt comfortable discussing sensitive health issues. Our focus-group participants reported that they would have preferred to see Spanish-speaking providers instead of relying on interpreters, but such providers were difficult to find and had long waiting lists. Common reasons for feeling less comfortable with interpreters included concern over confidentiality, unease about having a third party between them and their provider, and both miscommunication and uncertainty over whether the interpreter was accurately translating their words. One participant commented, How do you know if the interpreter said what I said exactly? A few participants reported saying yes to providers questions despite being unsure that they had understood what the provider was asking. Some insurance plans guaranteed that they would provide interpreters. Although at least one focus-group participant had had a good experience with this approach, others reported bringing their own paid interpreter or an English-speaking acquaintance whom they trusted. Financial Barriers Low-income groups, including Hispanics with public coverage, may be at a particular disadvantage in finding a provider because many providers accept only patients with private insurance. One Hispanic focusgroup participant said, You need to do your research. Call doctors first and see if they accept MassHealth [the state Medicaid program]. Many do not. Among Spanish-speaking Hispanics, the proportion of individuals not seeing a doctor in the past year because of cost increased although not significantlybetween 2005 and 2009 (Exhibit 3). Even when they have a regular source of care, some Hispanics reported reluctance to see their providers because of copayment fees for office visits and medication. Participants who ended up with high copayments reported forgoing medications and routine preventive care. Some were surprised when they had to pay for medication in addition to making copayments for visits to a provider. This confusion about what costs are covered may influence whether or not people decide to keep paying their insurance premiums.

Discussion
Massachusetts comprehensive health care reform has greatly expanded the portion of the states population with health insurance. Like other national and state studies, ours found that Hispanics were much less likely to have insurance than other residents prior to the passage of reform legislation.17,18 Since the enactment of Chapter 58, the rate of coverage increased more rapidly among Hispanics than among nonHispanic whites, but important disparities remained. Although only 4 percent of the nonHispanic white population was uninsured in 2009, 21 percent of Hispanics still lacked coverage at that time (Exhibit 2), which translates to approximately 82,752 Hispanic adults. The disparities were most pronounced among Hispanics with limited English proficiency. Also like national studies, our research found that much of the disparity in coverage between non-Hispanic whites and Hispanics in Massachusetts could be explained by differences in demographic factors, social status, language, and health status.19 After confounding factors were adjusted for, the rates of coverage for non-Hispanic whites and English-speaking Hispanics were similar in 2009. This result implies that if policies could address the social determinants of health, disparities in coverage could be greatly decreased. However, the differences in coverage between non-Hispanic whites and Spanish-speaking Hispanics persisted even after these observable demographic characteristics were controlled for. This finding is consistent with our qualitative research, which suggests that language, acculturation, and other cultural factors remain

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significant barriers to coverage for Hispanics.We expected that some of this disparity would persist, given that Chapter 58 excludes undocumented immigrants from coverage. However, our data do not provide a precise estimate of the percentage of Hispanics who lack coverage because of their immigration status. Our qualitative research shed additional light on the coverage issues and barriers that may be unique to Hispanics. Regardless of their ethnicity, many of the newly insured did not fully grasp the meaning of health insurance and the purpose of their premium payments. Many of them also found the enrollment and reenrollment processes confusing. Our findings suggest that these problems were magnified for Hispanics, especially non-English speakers, who were more likely than English-speaking Hispanics to be recent immigrants. Limited English proficiency made it difficult for them to navigate the states complex enrollment and reenrollment processes. Because Massachusetts did not establish special enrollment programs for these Hispanics, they had to seek out enrollment counseling on their own. Given the limited capacity and geographic scope of enrollment programs conducted in Spanish, many Hispanics did not receive assistance and remained uninsured. People who have insurance are also more likely to have a personal provider and less difficulty paying for care compared to people without insurance.20 The percent of Hispanics with a personal provider increased from 60.6 percent in 2005 to 75.8 percent in 2009 (unadjusted rates; see Exhibit 3), but that left 94,310 people without a provider. Cost also remained a barrier to receiving care. Our multivariate analyses showed that having a low income and not being proficient in English helped explain why a lower percentage of Hispanics than non-Hispanic whites had a personal provider and why a higher percentage reported not seeing a doctor because of cost. However, these factors did not fully explain the disparities between Spanish-speaking Hispanics and nonHispanic whites. Key features of the health delivery system continued to be barriers to access for Hispanics. Many newly insured Hispanics did not have a primary care provider before they had coverage and did not know how to find one, unless their insurer automatically assigned one to them. Many Hispanics indicated their preference for seeing Spanish-speaking primary care providers, but because such providers are relatively rare, a new patient may have to wait for weeks or even months to get an appointment. In addition, affordability of care remained a problem for Hispanics, even those with insurance.

Lessons For National Reform

Similarities The Affordable Care Act is similar to the Massachusetts health reform law both in general and in the way in which it deals with health disparities. The federal law makes it easier to qualify for subsidized coverage, on the assumption that the change will give ethnic minority groups better access to coverage and care. It addresses racial and ethnic disparities by taking steps similar to those in the Massachusetts law. Specifically, the federal law expands the monitoring of health disparities, establishes Offices of Minority Health in federal health agenciessuch as the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Servicesand provides funding to the states for independent consumer outreach and assistance programs.21 Differences The Affordable Care Act differs from the Massachusetts approach in that the federal government has provided funds for a huge expansion of community health centers that traditionally serve disadvantaged populations, including Hispanics. The Affordable Care Act also differs from Chapter 58 in that the former expands funding for the education and recruitment of more minority health professionals to work in medically underserved areas. Policy Implications Although deeply rooted social and environmental factors play a decisive role in health disparities, as our findings show, health policy makers can take certain actions to reduce racial and ethnic disparities in the context of health reform. As the numbers of Hispanics continue to increase and their rates of insurance coverage remain lower than those of other groups, it is imperative that we design and implement more-effective strategies for expanding Hispanics insurance coverage and access to care. Developing policies specifically for Hispanics is a national priority, but it is especially important in states with large Hispanic populations. Our research has three major implications for implementing a national strategy aimed at Hispanics. First, the Massachusetts experience demonstrates that existing outreach and enrollment programs for the uninsured may not be sufficient to meet the complex cultural, linguistic, and economic needs of Hispanics. Massachusetts was fortunate that the state had a successful grant program for outreach and enrollment and that community and provider groups took the initiative to develop programs for Hispanics by extending outreach to churches, community clinics, and other institutions that chiefly served Hispanics. However, many of these programs were underAugust 2011 30:8 Health A ffairs 1457

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funded, and collectively they reached only a small percentage of the Hispanic population. More state and national programs specifically for Hispanics are needed, and they must have stable funding sources. In addition, programs need to be targeted to those Hispanics who are most at risk of not having insurance or access to care. The Massachusetts experience suggests the need for both a top-down and a bottom-up approach to addressing disparities. In other words, federal and state governments need to explicitly adopt strategies for enrolling Hispanics especially Spanish-speaking Hispanicswhile at the same time encouraging local initiatives and innovations. Second, our study shows that programs serving Hispanics need to do more than simply provide outreach and assistance at the time of enrollment. Enrollment is not a single-step process for many Hispanics, who need to reenroll annually and find new coverage if their income or employment changes. Simplified enrollment and reenrollment processes, coupled with staff who have appropriate cultural and linguistic training, could make enrollment easier but still would
Some elements of this article were presented at the National Congress on Health Insurance Reform, Washington, D.C., January 17, 2011, and the Families USA Conference, Washington, D.C., January 28, 2011. The authors thank Pat Fairchild and Natalie Truesdell of John

not eliminate the need for ongoing assistance. Because many of the newly insured have never before had health insurance, they may also require help in finding a provider and navigating an unfamiliar care system. Ongoing training and technical assistance would be beneficial. Finally, it is important to maintain the health care safety net. Federal health reform is unlikely to secure health insurance for 100 percent of the Hispanic or other historically disadvantaged populations, and the safety net is critical for those who remain outside the system. The Affordable Care Act greatly expands funding for the federal health center program, but it is too soon to know whether this funding will be directed to Hispanics. The safety net in other states that are implementing health reform should include tools for outreach to Hispanic communities and other disadvantaged populations, and funding to pay for their care. Without specialized tools and adequate funding, the widespread disparities in coverage and access to care in the current system may be reduced, but they are not likely to be eliminated.

Snow Inc. (JSI) for their contributions to the Care beyond Coverage Project sponsored by the Blue Cross Blue Shield of Massachusetts Foundationon which this article was based. Dharma Cortes appreciates the contributions of Rodolfo Vega to the qualitative research

reported here. This research was supported by a contract with the Blue Cross Blue Shield of Massachusetts Foundation to JSI and by grant funding to Cortes from the Robert Wood Johnson Foundations New Connections program.

NOTES
1 Massachusetts Division of Health Care Finance and Policy. Health insurance coverage in Massachusetts: results from the 20082010 Health Insurance Surveys [Internet]. Boston (MA): The Division; 2010 Dec [cited 2011 Jun 3]. Available from: http://www.mass.gov/ Eeohhs2/docs/dhcfp/r/pubs/10/ mhis_report_12-2010.pdf 2 Long SK, Masi PB. Access and affordability: an update on health reform in Massachusetts, fall 2008. Health Aff (Millwood). 2009;28(4): w57887. DOI: 10.1377/hlthaff .28.4.w578. 3 Long SK, Stockley K. Sustaining health reform in a recession: an update on Massachusetts as of fall 2009. Health Aff (Millwood). 2010; 29(6):123441. 4 Gabel JR, Whitmore H, Pickreign J, Sellheim W, Shova KC, Bassett V. After the mandates: Massachusetts employers continue to support health reform. Health Aff (Millwood). 2008;27(6):w56675. DOI: 10.1377/hlthaff.27.6.w566. 5 Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts [Internet]. Cambridge (MA): National Bureau of Economic Research; 2010 May [last revised 2010 Oct 13; cited 2011 Jun 28]. (NBER Working Paper No. 16012). Abstract available from: http://www.nber.org/papers/ w16012 6 187th General Court of the Commonwealth of Massachusetts. Massachusetts General Laws, chap. 6A, sec. 16K, Health Care Quality and Cost Council [Internet]. Boston (MA): The Court; 2010 Oct 1 [cited 2011 Jun 28]. Available from: http:// www.malegislature.gov/Laws/ GeneralLaws/PartI/TitleII/ Chapter6A/Section16K 7 187th General Court of the Commonwealth of Massachusetts. Massachusetts General Laws, chap. 6A, sec. 160, Health Disparities Council; duties; composition; meetings; annual reports [Internet]. Boston (MA): The Court; 2010 Oct 1 [cited 2011 Aug 1]. Available from: http://www.malegislature.gov/ Laws/GeneralLaws/PartI/TitleII/ Chapter6A/Section16O MassHealth. MassHealth fact sheet: Health Care Reform Outreach Grant Program [Internet]. Boston (MA): MassHealth; 2010 Feb [cited 2011 Jun 28]. Available from: http:// outreachgrants.ehs.state.ma.us/ uploadedFiles/Outreach_Grants/ Outreach%20Grants%20Fact% 20Sheet%20cy2009.pdf Abreu M, Hynes HP. The Latino Health Insurance Program: a pilot intervention for enrolling Latino families in health insurance programs, East Boston, Massachusetts, 20062007. Prev Chronic Dis. 2009;6(4):A129. Ennis SR, Ros-Vargas M, Albert NG. The Hispanic population: 2010 [Internet]. Washington (DC): Census Bureau; 2011 May [cited 2011 Jun 28]. (2010 Census Brief). Available for download from: http:// 2010.census.gov/2010census/data/ Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE 3rd. Race and insurance status as risk factors for trauma mortality.

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Arch Surg. 2008;143(10):9459. 12 Insaf TZ, Jurkowski JM, Alomar L. Sociocultural factors influencing delay in seeking routine health care among Latinas: a community-based participatory research program. Ethn Dis. 2010;20(2):14854. 13 Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: 2005 and 2009 survey data. Atlanta (GA): CDC; [last updated 2010 Oct 28; cited 2011 Jun 28]. Available from: http:// www.cdc.gov/brfss/technical_ infodata/surveydata.htm 14 Cortez DE. No one asked me: Latinos experiences with Massachusetts health care reform [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2010 Feb [cited 2011 Jun 28]. (Lessons Learned). Available from: http:// www.rwjf.org/files/research/ 4268.52233.pdf 15 Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability

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and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soz Praventivmed. 2001;46(Suppl 1):S342. Fairchild P, Maxwell J, Schneider K, Truesdell N, Mathur J. Access to health care in Massachusetts: the landscape in 2009. Boston (MA): John Snow Inc.; 2009 Nov. (Unpublished report). Massachusetts Division of Health Care Finance and Policy. Health care in Massachusetts: key indicators [Internet]. Boston (MA): The Division; 2009 Feb [cited 2011 Jun 28]. Available from: http://www.mass .gov/Eeohhs2/docs/dhcfp/r/pubs/ 09/key_indicators_02-09.pdf Patel N, Bae S, Singh KP. Association between utilization of preventive services and health insurance status: findings from the 2008 Behavioral Risk Factor Surveillance System. Ethn Dis. 2010;20(2):1427. Crow SE, Harrington ME, McLaughlin CG. Sources of vulner-

ability: a critical review of the literature on racial/ethnic minorities, immigrants, and persons with chronic mental illness [Internet]. Ann Arbor (MI): University of Michigan Economic Research Initiative on the Uninsured; 2002 Oct [cited 2011 Jun 28]. (ERIU Working Paper No. 14). Available from: http://www.rwjf-eriu.org/pdf/ wp14.pdf 20 Cerise FP, Chokshi DA. Orienting health care reform around universal access. Arch Intern Med. 2009; 169(20):18302. 21 Foster J. Moving toward health equity: health reform creates a foundation for eliminating disparities [Internet]. Washington (DC): Families USA; 2010 May [cited 2011 Jun 29]. (Issue Brief). Available for download from: http://www .familiesusa.org/issues/healthequity/resource-center/otherhealth-equity-topics.html

ABOUT THE AUTHORS: JAMES MAXWELL, DHARMA E. CORTES, KAREN L. SCHNEIDER, ANNA GRAVES & BRIAN ROSMAN
consultants in Boston, and is nationally recognized for his expertise on health insurance and financing issues. He was the lead consultant to the Douglas administration in the development of Vermonts 2006 comprehensive health care reform plan, and he helped establish that states Governors Commission on Healthy Aging. Maxwell also recently has reviewed payment reform methodologies used by public and private payers, including pay-forperformance, rate setting, and accountable care organizations. He previously was a consultant for Colorados health care quality council. He received a doctorate in public policy from the Massachusetts Institute of Technology.

James Maxwell is the director of research at the JSI Research and Training Institute.

Dharma E. Corts is a senior research associate at the Mauricio Gastn Institute for Latino Community Development and Public Policy.

In their paper in Health Affairs this month, James Maxwell and coauthors present Massachusetts as a model for reducing disparities in coverage and access as other states implement national health reform. The paper builds on an earlier study on health care access sponsored by the Blue Cross Blue Shield of Massachusetts Foundation. That study surveyed 100 newly insured peoplemostly Hispanic and Spanish- or Portuguese-speakingand held focus groups with Hispanics and non-Hispanics who were newly insured. Maxwell is the director of research at the JSI Research and Training Institute, health care

Dharma Corts is an instructor at Cambridge Health Alliance and Harvard Medical School, a senior research associate at the Mauricio Gastn Institute for Latino Community Development and Public Policy of the University of Massachusetts, and an adjunct associate professor at Northeastern Universitys Institute on Urban Health Research. She has been conducting community-based research with Latinos in the United States for fifteen years. Her work focuses on culture, mental and physical health, health literacy, and the use of health and mental health services. She has a doctorate in sociology from Fordham University.

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Karen L. Schneider is a senior research scientist at the JSI Research and Training Institute.

Anna Graves is a research associate at the JSI Research and Training Institute.

Brian Rosman is research director of Health Care For All.

Karen Schneider, a senior research scientist at the JSI Research and Training Institute, has extensive experience analyzing large secondary data sets to explore disparities in health and access to care. At JSI, Schneider has been the data and statistical consultant on evaluation projects, designing studies, creating surveys, and writing reports. She has a doctorate in epidemiology from Brown University.

Anna Graves is a research associate at the JSI Research and Training Institute. She has been accepted into the Medical Scientist Training Program at the University of Alabama at Birmingham. Her research interests include perinatal epidemiology and maternal and child health policy issues among minority populations. She recently received a masters degree in epidemiology and medical anthropology from Boston University.

Rosman is research director of Health Care For All, a Boston-based health advocacy organization. His work focuses on policy research and analysis related to Massachusetts and national health reform, health payment methods, and other policy issues. He was research director and general counsel for the House staff of the Joint Committee on Health Care of the Massachusetts legislature and was counsel to the Massachusetts Senate Committee on Ways and Means. He has a law degree from the University of Pennsylvania.

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