Access to Care After Massachusetts' Health Care Reform: A Safety Net Hospital Patient Survey
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.
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ABSTRACT: To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%). Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions. © McCormick et al 2015.BMJ (online) 04/2015; 350(mar30 9):h1480. DOI:10.1136/bmj.h1480 · 16.38 Impact Factor
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ABSTRACT: To determine rates of maternal postpartum hepatitis B virus (HBV) follow-up with a HBV specialist and identify factors associated with poor follow-up, as prior research has focused on infant outcomes and not maternal care.American Journal of Obstetrics and Gynecology 09/2014; 212(3). DOI:10.1016/j.ajog.2014.09.032 · 3.97 Impact Factor
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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