Massachusetts Health Reform Research Articles

Does Health Reform Lead to an Increase in Early Retirement? Evidence from Massachusetts

This article estimates the impact of the 2006 Massachusetts health reform on the decision of individuals to retire early. Using data from the American Community Survey that spans 2004 through 2012, the authors estimate difference-in-differences models for retirement using individuals from other northeastern states as the control group. The estimates suggest that the reform led women to increase early retirement from full-time work by 1.1 percentage points (from a base of 4.8%) and to increase part-time work by 1.1 percentage points (from a base of 30%). Though no significant effects were found for men overall, the estimates imply that the reform led to an increase in retirement and part-time work among lower-income men.

The ACA: Impacts on Health, Access, and Employment.

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. This comprehensive health care reform legislation sought to expand health care coverage to millions of Americans, control health care costs, and improve the overall quality of the health care system. The ACA required that all US citizens and legal residents have qualifying health insurance by 2014. In this paper we give readers a brief overview of the effects of the ACA based on recent research. We then turn our attention to the possibility of using the ACA expansion to answer important underlying questions, such as: To what extent does the holding of insurance lead to improvements in access to care? To what extent does the holding of coverage lead to improvements in health? In mental health? Are there likely general equilibrium effects on labor force participation, hours worked, employment setting, and indeed even the probability of marrying? By necessity, researchers' ability to answer these questions depends on the availability of data, so we discuss current and potential data sources relevant for answering these questions. We also look to what has been studied about the health reform in Massachusetts and early Medicaid expansions to speculate what we can expect to learn about the effects of the ACA on these outcomes in the future.

Massachusetts Health Reform Cost Less and Was More Effective for Uninsured Individuals With Venous Thromboembolism: A Cost-Effectiveness Analysis.

Patients with venous thromboembolism (VTE) require access to comprehensive physician and pharmacy benefits to prevent recurrence and hemorrhage. Before 2006, Massachusetts provided these benefits through a program restricted to safety net hospitals called Free Care. Providing portable health insurance through Massachusetts health reform could improve outcomes for uninsured with VTE but its cost-effectiveness is unknown. We constructed a Markov decision analysis model comparing our conceptualization of the Massachusetts health reform (health reform strategy) to no health reform strategy for a patient beginning warfarin for new episode of VTE. In the model, a patient may develop recurrent VTE or develop hemorrhage or stop warfarin after 6 months if no event occurs. To measure effectiveness, we analyzed laboratory data from Boston Medical Center, the largest safety net hospital in Massachusetts. Specifically, we measured the probability of having a subtherapeutic warfarin level for patients newly insured compared with those on Free Care prereform adjusting for secular trends. To calculate inpatient costs, we used the Health Care Utilization Project. We then calculated the incremental cost-effectiveness ratio for the health reform strategy adjusted to 2014 USD per quality-adjusted life-year (QALY) and performed sensitivity analyses. The health reform strategy cost less and gained more QALYs than the no health reform strategy. Our result was most sensitive to the odds that Health Reform protected against a subtherapeutic warfarin level, the cost of Health Reform, and the percentage of total health care costs attributable to VTE in Massachusetts. The health reform strategy cost less and was more effective than the no health reform strategy for patients with VTE.

Do premium tax credits increase private health insurance coverage? Evidence from the 2006 Massachusetts health care reform

I use the Current Population Survey March Supplement and a regression discontinuity design to demonstrate a positive impact of premium tax credits, implemented as a part of the 2006 health reform in Massachusetts, on non-group private health insurance coverage.

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights From Massachusetts.

To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease. Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act. We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion. Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states. The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.

What Health Care Reform Means for Immigrants: Comparing the Affordable Care Act and Massachusetts Health Reforms.

The 2010 Patient Protection and Affordable Care Act (ACA) was passed to provide more affordable health coverage to Americans beginning in 2014. Modeled after the 2006 Massachusetts health care reform, the ACA includes an individual mandate, Medicaid expansion, and health exchanges through which middle-income individuals can purchase coverage from private insurance companies. However, while the ACA provisions exclude all undocumented and some documented immigrants, Massachusetts uses state and hospital funds to extend coverage to these groups. This article examines the ACA reform using the Massachusetts reform as a comparative case study to outline how citizenship status influences individuals' coverage options under both policies. The article then briefly discusses other states that provide coverage to ACA-ineligible immigrants and the implications of uneven ACA implementation for immigrants and citizens nationwide.

Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients.

IntroductionThe Affordable Care Act (ACA) and the 2006 Massachusetts (MA) health reform law, on which the ACA was based, aimed to improve the affordability of care largely by expanding publicly sponsored insurances. Both laws also aimed to promote consumer understanding of how to acquire, maintain and use these public plans. A prior study found an association between the level of cost-sharing required in these plans and the affordability of care. Preparatory to a quantitative study we conducted this qualitative study that aimed to examine (1) whether cost sharing levels built into the public insurance types that formed the backbone of the MA health reform led to unaffordability of care and if so, (2) how insurances with higher cost sharing levels led to unaffordability of care in this context.MethodsWe interviewed 12 consumers obtaining the most commonly obtained insurances under MA health reform (Medicaid and Commonwealth Care) at a safety net hospital emergency department. We purposefully interviewed a stratified sample of higher and low cost sharing recipients. We used a combination of inductive and deductive codes to analyze the data according to degree of cost-sharing required by different insurance types.ResultsWe found that higher cost sharing plans led to unaffordability of care, as evidenced by unmet medical needs, difficulty affording basic non-medical needs due to expenditures on medical care, and reliance on non-insurance resources to pay for care. Participants described two principal mechanisms by which higher cost sharing led to unaffordability of care: (1) cost sharing above what their incomes allowed and (2) poor understanding of how to effectively acquire, maintain and utilize insurance new public plans.ConclusionsFurther efforts to investigate the relationship between perceived affordability of care and understanding of insurance for the insurance types obtained under MA health reform may be warranted. A potential focus for further work may be quantitative investigation of how the level of calibration of cost-sharing to income and understanding of insurances under the MA reform was associated with perceived affordability of care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-015-0240-5) contains supplementary material, which is available to authorized users.

Did Massachusetts Health Care Reform Lower Mortality? No According to Randomization Inference

ABSTRACTIn an earlier article, Sommers, Long, and Baicker concluded that health care reform in Massachusetts was associated with a significant decrease in mortality. I replicate the findings from this study and present p-values for the parameter estimates reported by Sommers, Long, and Baicker that are based on an alternative and valid approach to inference referred to as randomization inference. I find that estimates of the treatment effects produced by Sommers, Long, and Baicker are not statistically significant when p-values are based on randomization inference methods. Indeed, the p-values of the estimates reported in Sommers, Long, and Baicker derived by the randomization inference method range from 0.22 to 0.78. Therefore, the authors’ conclusion that health reform in Massachusetts was associated with a decline in mortality is not justified. The Sommers, Long, and Baicker analysis is largely uninformative with respect to the true effect of reform on mortality because it does not have adequate statistical power to detect plausible effect sizes.

Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform.

IntroductionUnder the Massachusetts health reform, low income residents (those with incomes below 150 % of the Federal Poverty Level [FPL]) were eligible for Medicaid and health insurance exchange-based plans with minimal cost-sharing and no premiums. Those with slightly higher incomes (150 %-300 % FPL) were eligible for exchange-based plans that required cost-sharing and premium payments.MethodsWe conducted face to face surveys in four languages with a convenience sample of 976 patients seeking care at three hospital emergency departments five years after Massachusetts reform. We compared perceived affordability of insurance, financial burden, and satisfaction among low cost sharing plan recipients (recipients of Medicaid and insurance exchange-based plans with minimal cost-sharing and no premiums), high cost sharing plan recipients (recipients of exchange-based plans that required cost-sharing and premium payments) and the commercially insured.ResultsWe found that despite having higher incomes, higher cost-sharing plan recipients were less satisfied with their insurance plans and perceived more difficulty affording their insurance than those with low cost-sharing plans. Higher cost-sharing plan recipients also reported more difficulty affording medical and non-medical health care as well as insurance premiums than those with commercial insurance. In contrast, patients with low cost-sharing public plans reported higher plan satisfaction and less financial concern than the commercially insured.ConclusionsPolicy makers with responsibility for the benefit design of public insurance available under health care reforms in the U.S. should calibrate cost-sharing to income level so as to minimize difficulty affording care and financial burdens.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-015-0235-2) contains supplementary material, which is available to authorized users.

Exploring Massachusetts Health Care Reform Impact on Fee-for-Service-Funded Substance Use Disorder Treatment Providers

The Affordable Care Act (ACA) is forecast to increase the demand for and utilization of substance use disorder (SUD) treatment. Massachusetts implemented health reforms similar to the ACA in 2006–2007 that included expanding coverage for SUD treatment. This study explored the impact of Massachusetts health reforms from 2007 to 2010 on SUD treatment providers in Massachusetts, who relied on fee-for-service billings for more than 50% of their revenue. The changes across treatment facilities located in Massachusetts were compared to changes in other similar fee-for-service-funded SUD treatment providers in Northeast states bordering Massachusetts and in all other states across the US. From 2007–2010, the percentage changes for Massachusetts based providers were significantly different from the changes among providers located in the rest of the US for admissions, outpatient census, average weeks of outpatient treatment, residential/in-patient census, detoxification census, length of average inpatient and outpatient stays, and provision of medication-assisted treatment. Contrary to previous studies of publicly funded treatment providers, the results of this exploratory study of providers dependent on fee-for-service revenues were consistent with some predictions for the overall effects of the ACA.

Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care?

Pancreatic cancer is increasingly common and poised to become the second leading cause of cancer deaths by the year 2020. Surgical resection is the only chance for cure, yet significant disparities in resection rates exist by insurance status. The 2006 Massachusetts health care reform serves as natural experiment to evaluate the unknown impact of health insurance expansion on treatment of pancreatic cancer. Using the Agency for Healthcare Research and Quality's State Inpatient Databases, this cohort study examines nonelderly, adult patients with no insurance, private coverage, or government-subsidized insurance plans, who were admitted with pancreatic cancer in Massachusetts and 3 control states. The primary end point was change in pancreatic resection rates. Difference-in-difference models were used to show the impact of Massachusetts health care reform on resection rates for pancreatic cancer, controlling for confounding factors and secular trends. Before the Massachusetts reform, government-subsidized and self-pay patients had significantly lower rates of resection than privately insured patients. The 2006 Massachusetts health reform was associated with a 15% increased rate of admission with pancreatic cancer (p = 0.043) and a 67% increased rate of surgical resection (p = 0.043) compared with control states. Measured disparities in likelihood of resection by insurance status decreased in Massachusetts and remained unchanged in control states. The 2006 Massachusetts health care reform was associated with increased resection rates for pancreatic cancer compared with control states. Our findings provide hopeful evidence that increased insurance coverage can help improve equity in pancreatic cancer treatment. Additional studies are needed to evaluate the longevity of these findings and generalizability in other states.

Changes in the Care of Patients with Cervical Spine Fractures following Health Reform in Massachusetts

There is a substantial concern among spine surgeons that health care reform efforts will alter the processes through which spine care is delivered and decrease overall quality.

The Impact of Health Reform on Job Mobility: Evidence from Massachusetts

This paper estimates the impact of the implementation of the 2006 Massachusetts health reform on job mobility. Theoretically, the effect is ambiguous, as the public health insurance expansion and low-income subsidies would be expected to increase mobility, but the employer mandate and price effects could either increase or decrease mobility depending on the relative impacts on an individual's current job and the attractiveness of other modes of employment or retirement. Utilizing data from tax returns that span 2002–10, in which job changes are identified using employer information reported on W-2 forms, we estimate the impact of the Massachusetts reform using a difference-in-differences approach, comparing the prevalence of job changes in Massachusetts to those of a comparison group, while controlling for individual fixed effects. The estimates suggest the Massachusetts reform generally did not have a significant impact on job separations overall, though it may have increased separations from primary jobs among married women. There is evidence, however, that mobility increased among low-income married couples, young married men, and older married women.

Influence of Health Insurance Expansion on Disparities in the Treatment of Acute Cholecystitis.

To evaluate the impact of the 2006 Massachusetts (MA) health reform on disparities in the management of acute cholecystitis (AC). Immediate cholecystectomy has been shown to be the optimal treatment for AC, yet variation in care persists depending upon insurance status and patient race. How increased insurance coverage impacts these disparities in surgical care is not known. A cohort study of patients admitted with AC in MA and 3 control states from 2001 through 2009 was performed using the Hospital Cost and Utilization Project State Inpatient Databases. We examined all nonelderly white, black, or Latino patients by insurance type and patient race, evaluating changes in the probability of undergoing immediate cholecystectomy and disparities in receiving immediate cholecystectomy before and after Massachusetts health reform. Data from 141,344 patients hospitalized for AC were analyzed. Before the 2006 reform, government-subsidized/self-pay (GS/SP) patients had a 6.6 to 9.9 percentage-point lower (P < 0.001) probability of immediate cholecystectomy in both MA control states. The MA insurance expansion was independently associated with a 2.5 percentage-point increased probability of immediate cholecystectomy for all GS/SP patients in MA (P = 0.049) and a 5.0 percentage-point increased probability (P = 0.011) for nonwhite, GS/SP patients compared to control states. Racial disparities in the probability of immediate cholecystectomy seen before health care reform were no longer statistically significant after reform in MA while persisting in control states. The MA health reform was associated with increased probability of undergoing immediate cholecystectomy for AC and reduced disparities in undergoing cholecystectomy by insurance status and patient race.

Changes in the care of patients with cervical spine fractures following health reform in Massachusetts

IntroductionThere is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality.We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform. MethodsThis was a pre–post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003–2006 and 2008–2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann–Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables. ResultsThe rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: −0.18, 95% CI: −0.22, −0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94). ConclusionsIn the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives.Level of Evidence III.

Abstract P1-17-01: Anticipating ACA's impact on breast cancer screening for medically underserved women reached through the Avon Breast Health Outreach Program: Understanding the Massachusetts experience

Abstract Background The Avon Breast Health Outreach Program (BHOP) supports community-based organizations to conduct education and outreach to link low-income and uninsured women to routine breast cancer screening and care. Through the Affordable Care Act (ACA), the number of uninsured individuals is expected to decrease as of 2014. While ACA implementation varies by state, BHOP grantees may benefit from understanding the health reform experience in Massachusetts (MA) in 2006 and its impact on the number and proportion of uninsured clients served over time. Objective Describe changes in client volume, health insurance status, and demographics following implementation of health reform in MA to anticipate upcoming impact of ACA on BHOP grantees. Methods Confidential client intake records of continuously funded BHOP grantees from 2004-2012 were analyzed; dataset included females aged 40-64, recruited for breast cancer screening. We compared records for 11,199 clients served by 4 ‘MA’ BHOP programs with 283,720 clients served by 52 ‘control’ agencies funded in the US during the same time period. We examined trends across years in agency-specific rates of health insurance coverage, and client volume adjusting for annual funding. Changes in key demographic characteristics over time were also analyzed. Results The proportion of uninsured MA clients decreased dramatically from 46.6% to 6.2% from 2004-2012, with the biggest decrease occurring in the 3 years following health reform (42.1% to 13.0% from 2006-2009); as compared to only a slight drop among controls from 2004-2012 (69.3% to 67.4%). After adjusting for changes in annual BHOP funding, MA experienced a 74% increase in client volume from 2006-2009, compared with a 15% increase among controls. From 2004-2012, the mean age of clients (53 years) remained stable and similar for MA and controls. The proportion of racial/ethnic minorities served increased considerably in MA, from 62.0% to 77.7%, versus a smaller increase of 60.1% to 63.0% in controls. Likewise, the proportion of clients born outside the US rose from 37.2% to 50.7% in MA, compared with 33.7% to 36.6% among controls. However, the proportion of low-income clients (annual household income &amp;lt;$25,000) decreased overall from 90.4% to 83.1% in MA, and from 83.1% to 79.1% for controls. Conclusion In BHOP, Massachusetts observed a marked decrease (most noticeably in the 3 years following health reform) in the proportion of uninsured clients served, while overall client volume and the proportion of racial/ethnic minorities and foreign-born women increased. Discussion Historically, many BHOP grantees have relied on funding from the CDC’s National Breast and Cervical Cancer Early Detection Program or charity funds to pay for screening services for uninsured clients. As more clients nationally gain access to health insurance, BHOP grantees need to be prepared for the changing landscape and potential increase in client volume, as experienced by MA. Additionally, grantees should plan to update systems that aid in health insurance eligibility determination, assist with enrollment, and strengthen provider partnerships and referral systems that accept multiple types of insurance. Citation Format: Lindsay Senter, Marvin R Aliaga, Yixin Hu, Kelly Morrison Opdyke, Kathryn Gates-Ferris, Marc Hurlbert. Anticipating ACA's impact on breast cancer screening for medically underserved women reached through the Avon Breast Health Outreach Program: Understanding the Massachusetts experience [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-17-01.

Massachusetts health reform and disparities in joint replacement use: difference in differences study

Objective To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly...

The Impact of Near-Universal Insurance Coverage on Breast and Cervical Cancer Screening: Evidence from Massachusetts.

This paper investigates the effect of expansion to near-universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low-income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low-income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low-income women. Our results suggest that reform was successful in promoting preventive care among targeted populations.

Does Health Reform Lead to an Increase in Early Retirement? Evidence from Massachusetts

This paper estimates whether the implementation of the 2006 Massachusetts health reform law affected the decision of individuals to retire early. Using data from the American Community Survey that spans 2002-2012, we estimate difference-in-differences models for retirement, in which individuals from Massachusetts form our treatment group and individuals from other Northeastern states form our treatment group. The estimates suggest that, in the full sample, the reform led to an approximately 0.6 percentage point increase in retirement from full-time work (from a base of 2.6%) though not from part-time work. However, the reform may have led to an increase in retirement from any job (part- or full-time) among lower income individuals.

The impact of Massachusetts health care reform on access, quality, and costs of care for the already-insured.

To assess the impact of Massachusetts Health Reform (MHR) on access, quality, and costs of outpatient care for the already-insured. Medicare data from before (2006) and after (2009) MHR implementation. We performed a retrospective difference-in-differences analysis of quantity of outpatient visits, proportion of outpatient quality metrics met, and costs of care for Medicare patients with ≥ 1 chronic disease in 2006 versus 2009. We used the remaining states in New England as controls. We used existing Medicare claims data provided by the Centers for Medicare and Medicaid Services. MHR was not associated with a decrease in outpatient visits per year compared to controls (9.4 prereform to 9.6 postreform in MA vs. 9.4-9.5 in controls, p = .32). Quality of care in MA improved more than controls for hemoglobin A1c monitoring, mammography, and influenza vaccination, and similarly to controls for diabetic eye examination, colon cancer screening, and pneumococcal vaccination. Average costs for patients in Massachusetts increased from $9,389 to $10,668, versus $8,375 to $9,114 in control states (p < .001). MHR was not associated with worsening in access or quality of outpatient care for the already-insured, and it had modest effects on costs. This has implications for other states expanding insurance coverage under the Affordable Care Act.