Access to Care After Massachusetts' Health Care Reform: A Safety Net Hospital Patient Survey

Department of Medicine, Cambridge Health Alliance, 1493 Cambridge St
Journal of General Internal Medicine (Impact Factor: 3.42). 07/2012; 27(11):1548-54. DOI: 10.1007/s11606-012-2173-7
Source: PubMed

ABSTRACT Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.
To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.
We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.
Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.
Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.
Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid. OBJECTIVE To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid. MAIN OUTCOMES AND MEASURES Self-reported access to care and annualized emergency department use. RESULTS Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance. CONCLUSIONS AND RELEVANCE We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.
    JAMA Internal Medicine 04/2014; 174(6). DOI:10.1001/jamainternmed.2014.588 · 13.25 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose Health care reform was introduced in Massachusetts in 2006 and serves as a model for what was subsequently introduced nationally as the Patient Protection and Affordable Care Act (ACA) (1). The Boston Area Community Health (BACH) survey collected data before (2002-2005) and after (2006-2010) introduction of the Massachusetts health insurance mandate, providing a unique opportunity to assess its effects in a large, epidemiological cohort. Methods We report on the apparent effects of the mandate on the same participants over time, focusing specifically on the vulnerable working poor. We evaluated differences in subpopulations of interest at pre- and post-reform periods in order to explore whether Massachusetts health care reform resulted in an overall gain in insurance coverage. Results Massachusetts health care reform was associated with net gains in health insurance coverage overall and among the subgroups studied. Our findings suggest that despite being targeted by health care reform legislation, the working poor in Massachusetts continue to report lower rates of insurance coverage compared to both the non-working poor and the not poor. Conclusions Massachusetts health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage. Disparities in insurance coverage persist among some subgroups following health care reform implementation in Massachusetts. These results have important implications for health services researchers and policy makers, particularly in light of the ongoing implementation of the ACA.
    Annals of epidemiology 04/2014; 24(4). DOI:10.1016/j.annepidem.2014.01.003 · 2.15 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey). Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform. US hospitals in Massachusetts, New York, and New Jersey. Adults aged 18-64 admitted for any cause, excluding obstetrical. Readmissions at 30 days after an index admission. After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates. In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome.
    BMJ (online) 03/2014; 348:g2329. DOI:10.1136/bmj.g2329 · 16.38 Impact Factor