Massachusetts leads the nation in health insurance coverage following implementation of the landmark 2006 legislation An Act Providing Access to Affordable, Quality, Accountable Health Care, and continues to make progress on expanding universal health insurance and closing disparities in coverage. According figures from theUS Census Bureau Current Population Survey, over the years 2007 and 2008 Massachusetts had the highest rate of people with health insurance among all 50 states and DC (94% compared to 85% nationwide) and the greatest increase in the percent of the population with insurance (up nearly 5 percentage points over 2005-2006 compared to less than one percentage point nationwide). (see Indicator 7.2.1)
Massachusetts and Boston residents have high rates of access to Primary Care physicians and regular well-visit; however, both the public health and health care delivery systems are experiencing shortages of qualified workers, particularly in primary care, and many Massachusetts residents are waiting longer to receive primary care or forego treatment altogether because of lack of doctors and appointment. While over 2008 and 2009, more than 90% of Massachusetts residents had a regular place that they went to for health care and in both years 78% of residents had at least one doctor visit for preventative care. (see indicator 7.2), theMassachusetts Medical Society's 2008 Physician Workforce Survey found a “severe” or “critical” shortage of doctors in 12 of 18 specialties studied and noted that implementation of the state’s health care reform law establishing mandatory health insurance enrollment for all Massachusetts residents would create further stress on physician labor markets. (see Indicator 7.2.4).
Despite high rates of coverage and access to care, the cost of health care continues to rise at rates well above inflation for Massachusetts’ municipalities, families and businesses.
- A recent report byFamilies USAon personal health care costs projects that in 2009, nearly 300,000 Massachusetts residents will pay more than 25 of their gross income for health insurance—a 47% increase since 2000. This increased cost can inhibit access to care, according to the Massachusetts 2009 Health Insurance Survey, which found that 21% of residents did not get necessary care due to cost, 15% did not go to the dentist due to cost and 8% did not fill a prescription.
- Rising health insurance premiums for employers increased by 77% between 2000 and 2008, and as of 2008, Greater Boston’s per employee premiums were the 2nd highest of all US metros. This may impede the ability of some employers to offer health insurance to workers.
- Government health care costs and spending are rising so rapidly that they are crowding out investment in other priorities, public health spending to curtail high-cost chronic disease. In 2007, health care expenditures accounted for 15.2% of Massachusetts GDP and between 2000 and 2007 per capita spending increased by 65% to more than $8,000 per person—by 2018 per cap spending is expected to reach $16,000 in MA if nothing changes. Likewise, in Boston, the increase in Health Insurance Premiums has outpaced all other human resources costs—including salaries, and non-personnel spending (see Indicator 7.8.1)
Consistent with national trends, the rate of preventable chronic, preventable disease in Boston continues to rise particularly among youth and people of color, increasing both life burdens and health care costs. According to the Massachusetts Health Council, obesity-related illnesses—including diabetes and hypertension—cost Massachusetts more than $1.82 billion annually, and the rate of overweight and obese adults has risen 25% statewide and 52% respectively among Boston’s adults since 2000, with higher rates among African Americans and Latinos (see Indicators 7.3.1). Along with obesity, rates of diabetes, hypertension, asthma and other chronic diseases have skyrocketed among teens and adults in Boston and Massachusetts. (see Indicator 7.4.2).
The City of Boston’s exemplary Public Health Commission, along with a comprehensive network of community health centers and focused multi-partner great initiatives are achieving great progress in reducing some major health risks and risky behaviors:
- Boston has high rates of quality pre-natal care along with declining risky behaviors such as smoking in pregnancy (see Indicator 7.5.1).
- The City of Boston has made significant progress on environmental health risks such as child lead poisoning, which declined by 91% between 1995 and 2008 among Boston’s children (See Indicator 7.7.1).
- Boston’s youth report a decline in risky behaviors such as smoking, drug use, unprotected sex, teen pregnancy rates and suicide attempts (See Indicator 7.5.3).
- Boston has seen a drop-off in the number of new HIV/AIDS cases reported annually, down 58% from 1999 (See Indicator 7.3.3).
Individuals or families seeking to healthier lifestyles often lack information and options for more physical activity and healthier food choices. Recent state budget cuts have reduced the capacity of Boston’s network of community health centers to offer critical preventive health promotion activities and safety net services. A recent series of investigative articles byThe Boston Globe found that 25% of Boston Public School Students in 15 schools had no access to physical education or in-school sports in school year 2007/08. These barriers are even more pronounced for Boston’s low-income communities, many of which have been found to be “food deserts” without ready access to nutritious foods at affordable prices (see Indicator 7.6.1).
Greater Boston’s health care and life sciences sectors continue to be source of economic expansion and innovation, even in a recession economy. Massachusetts has not had a net employment increase since the dot-com bubble burst of 2001/02 and since June 2008 has continued to see employment decline in every industry sector except for Education and Health Services. In fact, from October 2008 to October 2009, Massachusetts total employment declined by a net 3%--more than 100,000 jobs—however, jobs in Health Services increased by a net 2% or 8,900 jobs. This trend holds true for Greater Boston. (see Indicator 7.1.1)
Health expenditures tend to disproportionately focus on access to care and treatment at the expense of improving healthy behaviors and reducing adverse environmental exposures. Based on data indicating that one-third of American health care expenditures are unnecessary, it has been calculated that of the total $60 billion spent annually the Bay State on public and private health expenditures, about one-third or $17 billion is spent in the state on unnecessary or harmful care. Recouping even a fraction would free up resources for education, housing, recreation, nutrition, environmental health and other determinants of health that together make up more than 70% of health status yet now are competing unsuccessfully with health care for public and private resources. (For details, see theNew England Healthcare Institutestudy, The Boston Paradox: Lots of Health Care, Not Enough Health).
Despite progress on some maternal health and recent planned investment in such initiatives as the City of Boston’s 10-year road map to improve early childhood development outcomes,Thrive in 5, Boston has experienced an up-tick in natality and birth risk factors such as low birth weights, with more infants at risk for long-term developmental and cognitive delays. In 2007, 9.6% of babies born to Boston residents weighed less than 5.5 lbs at birth—up from 8.7% in 1995. Pre-term births to Boston mothers have also increased over the last decade along with infant mortality rates. African American infants, who account for about one-third of all babies born to Boston residents, show consistently higher rates of birth risk factors than all others, even in those born to African American women with a BA or higher. (see Indicator 7.4.1).
Hunger and homelessness are rising in Boston and Massachusetts, putting children in particular danger of developmental risks. Project Bread's 2008 Status Report on Hunger in Massachusetts found that 3% of Massachusetts households experienced hunger from 2004-2006 (up from 2.3% from 2001 to 2003) and 5.1% were at risk (up from 3.9% in 2001-2003), with nearly one-third of school-age children in Massachusetts living in food insecure households, and in Boston about 20%. TheCity of Boston’s annual count of homeless persons in 2008 found that the fastest-growing homeless population is families with children. (see Indicator 6.5.1).
Disparities in health outcomes persist across lines of race/ethnicity, income and educational attainment: According to a report by the Boston Public Health Commission, chronic diseases such as asthma, diabetes, high blood pressure and heart disease in Boston show stark racial/ethnic disparities. In 2006 (the most recent data available), rates of asthma and diabetes for African Americans were more than double that of whites and Asians. African Americans consistently have the highest rates of heart disease hospitalization (27 per 1,000) while rates among Latinos have increased the fastest. Heart disease is the leading cause of death for all Bostonians except Asians. In 2006, 17% of Latinos, 20% of whites and 27% of African Americans had high blood pressure, with Asians at 5% (see Indicator 7.4.3).
Boston’s public health infrastructure faces many challenges with respect to emergency preparedness. The Federal government is withdrawing funding and responsibility for disaster preparedness, leaving cities like Boston to address the issue with far fewer resources. With shrinking numbers of available hospital beds, public health officials and emergency department physicians have raised concerns about capacity in the event of a natural disaster or widespread epidemic of a contagious disease such as avian influenza. Concerns have been expressed that in Boston--as in New Orleans--the most vulnerable populations would be those most affected by a disaster.