Sharon K. Long

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study

Context After passage of a 2006 law that expanded health insurance coverage, studies have found many changes in health and health care, but none has reported changes in mortality. Contribution This study found that when Massachusetts counties were compared with similar counties in other states, all-cause and health careamenable mortality decreased after Massachusetts passed the law. Caution The study design cannot rule out the effects of unidentified confounders and thus cannot establish cause and effect. Implication The association between more insurance coverage and fewer deaths reported here is consistent with other evidence that expanding insurance coverage can improve health. The Editors Massachusetts passed comprehensive health care reform in 2006 with the goal of near-universal coverage. The lawwhich expanded Medicaid, offered subsidized private insurance, and created an individual mandatewas a model for the Affordable Care Act (1). Thus, understanding the effects of the Massachusetts law has important policy implications. Previous research documents that the Massachusetts reform succeeded in expanding health insurance among adults aged 19 to 64 years by 3 to 8 percentage points (15). Studies also indicate improvements in access to care (68), self-reported physical and mental health (9), use of preventive services (2, 10), and functional status (1, 11). However, there has been no evidence on the laws effect on mortality. Previous research on the effect of health insurance on mortality is mixed. Some observational studies suggest as much as a 40% increased risk for death for uninsured versus insured adults (12, 13), and an analysis of Medicaid expansion to low-income adults detected a 6% decrease in statewide mortality (14). Other studies, including 2 randomized trials of insurance expansion, found little or no effect on mortality (1517). Our studys objective was to examine the changes in mortality associated with the Massachusetts reform. We hypothesized that the reform reduced mortality, particularly from causes potentially treatable with timely care (such as cardiovascular disease, infections, and cancer), and that larger changes occurred among groups likely to benefit from the lawpreviously uninsured adults and those with higher prereform mortality rates. Methods Study Design Our study used a quasi-experimental prepost design with a control group and compared average mortality in Massachusetts before and after reform to mortality changes over the same period for similar populations in states without reforms (also known as a differences-in-differences analysis [18]). Our preferred specification used propensity score methods to create a control group of counties in nonreform states that best matched the distribution of prereform characteristics in Massachusetts counties (19, 20). The Massachusetts law had several components: Medicaid expansion starting in July 2006, subsidized private plans for adults with incomes less than 100% of the federal poverty level in October 2006, and expanded coverage subsidies for adults with incomes up to 300% of the federal poverty level in January 2007. It included an individual mandate effective for the 2007 tax year and minimum creditable coverage insurance standards (21). We defined the postreform period as 2007 to 2010, with 2006 omitted as a transitional year (although we included 2006 in sensitivity analyses). The prereform period was 2001 to 2005. Data Our data came primarily from the Centers for Disease Control and Preventions Compressed Mortality File, which provides county-specific annual mortality rates stratified by age, sex, and race (22). For confidentiality, the publicly available data set suppresses death counts for cells with fewer than 10 deaths. We obtained access to the nonsuppressed data set under agreement with the Centers for Disease Control and Prevention. Our sample was adults aged 20 to 64 years, the reforms primary target group (with 19-year-olds excluded because persons aged 15 to 19 years are grouped together in the data set). In addition to age, sex, and race, our estimates were adjusted for year-specific county-level poverty rates, median income, unemployment, and the percentage of Latino persons in the population (all from the Area Resource File [ARF] [23]). Subgroup analyses used prereform county-level uninsured rates from the U.S. Census Bureaus 2005 Small Area Health Insurance Estimates (24). We also analyzed measures of coverage, health care access, and self-reported health status from 2 nationally representative household surveys: the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System (BRFSS) and the Census Bureaus Current Population Survey (CPS). These data sets have been used previously to examine the effect of the Massachusetts reform on coverage and access (24, 8, 9, 25). We present independent estimates using methods analogous to our mortality analysis to provide additional context for our results. For these data sources, we were able to include 19-year-olds, so the sample contains all adults aged 19 to 64 years. This project used preexisting deidentified data and was deemed exempt from review by the Harvard Institutional Review Board. The project received no external funding. Outcome Measures Our primary outcome was all-cause mortality. Our secondary outcome was mortality amenable to health care, adapted from previous research (2629), to focus on deaths related to conditions that are more likely to be preventable or treatable with timely care, including heart disease, stroke, cancer, infections, and other conditions (30). Table 1 of the Supplement lists the diagnosis codes from the International Classification of Diseases, 10th Revision, used in this definition and a more restrictive alternate definition tested in a sensitivity analysis. Supplement. Supplementary Material Additional outcomes were health insurance from the CPS and self-reported health (excellent or very good vs. good, fair, or poor) and access-to-care measures (cost-related delays in care, lack of a usual source of care, and absence of a preventive visit in the past year) from the BRFSS. Statistical Analysis Annual county-level death counts based on age, sex, and race were the unit of observation for the mortality analysis. Table 1 describes the analytic sample, which contains information on the number of counties; states; age-, sex-, and race-specific county-level cells; and population per year. Table 1. Analytic Sample Our regression models estimated the average annual prepost change in mortality for age-, sex-, and race-specific cells in Massachusetts counties relative to comparison counties in nonreform states (31). The study contained 5 years of prereform data (2001 to 2005) and 4 years of postreform data (2007 to 2010). Given that our outcome variable is number of deaths in each cell, our multivariate regression analyses fitted a generalized linear model using a negative binomial distribution and log link, with cell population as the exposure variable. We adjusted our analyses for race, sex, age, state, year, and economic factors (unemployment rate, poverty rate, and median income) specific to the county year (Supplement). Robust SEs were clustered at the state level to account for serial autocorrelation and for the state-level nature of the policy intervention (18), which is standard in population-based policy analyses (14, 3237). Sensitivity analyses included the pooling of annual data into prereform and postreform periods to remove potential autocorrelation, an interrupted time series model, adding 2006 (the implementation year) to our postreform data, and county-level clustering of SEs. We also tested a linear model using death rate per 100000 adults as the outcome to provide simple estimates of absolute change and results similar to prior research (14). Cells were weighted by population size to yield representative estimates. Secondary analyses used individual-level information from the BRFSS and CPS on coverage, access, and health status and were adjusted for age, sex, race/ethnicity, employment, household income, year, and state. For these binary outcomes, we used a generalized linear model with a logit link and predicted probabilities to describe the magnitude of absolute changes (38). Selection of Control Group For the mortality analysis, we used propensity scores to define a control group of counties in nonreform states that were most similar to prereform Massachusetts counties. We estimated propensity scores with a population-weighted logistic regression model using age distribution, sex, race/ethnicity, poverty rate, median income, unemployment, uninsured rate, and baseline annual mortality as predictors (Table 2 of the Supplement). The quartile of counties with the highest propensity scores, indicating the closest match to the overall population of Massachusetts 14 counties, was used as the control group in the mortality analysis. This approach yielded excellent balance on key features between Massachusetts and our control group (Table 2) and provided adequate sample sizes for subgroup analyses. We also tested a more traditional propensity scoreregression adjustment method and a 2:1 nearest-neighbor propensity scorematching approach, which yielded similar overall results (Supplement). Table 2. Summary Statistics for Study Sample Before Reform Identifying a control group with similar mortality trends in counties not in Massachusetts is the key to our approach (20). We tested for differences in the prereform mortality trends for 2001 to 2006 between Massachusetts and the control group using linear and quadratic time trends interacted with an indicator variable for Massachusetts. We repeated this test for the entire U.S. population. For the analysis of coverage, access, and self-reported health in the CPS and BRFSS, we compared Massachusetts with the other New England states (Maine, Vermont, New Hampshir

On The Road To Universal Coverage: Impacts Of Reform In Massachusetts At One Year

In April 2006, Massachusetts passed legislation intended to move the state to near-universal coverage within three years and, in conjunction with that expansion, to improve access to affordable, high-quality health care. In roughly the first year under reform, uninsurance among working-age adults was reduced by almost half among those surveyed, dropping from 13 percent in fall 2006 to 7 percent in fall 2007. At the same time, access to care improved, and the share of adults with high out-of-pocket costs and problems paying medical bills dropped. Despite higher-than-anticipated costs, most residents of the state continued to support reform.

Access And Affordability: An Update On Health Reform In Massachusetts, Fall 2008

Massachusetts continues to move forward on comprehensive health reform. Uninsurance is at historically low levels, despite the recent economic downturn. Building on that coverage expansion, access to and affordability of care in the commonwealth have improved. Notwithstanding these successes, some of the early gains in reducing barriers to care and improving the affordability of care had eroded by fall 2008, reflecting trends that predate health reform in Massachusetts: constraints on provider capacity and increasing health care costs. Because these are national concerns as well, Massachusetts continues to offer lessons for national reform efforts.

Safety-Net Providers After Health Care Reform: Lessons From Massachusetts

BACKGROUND National health reform is designed to reduce the number of uninsured adults. Currently, many uninsured individuals receive care at safety-net health care providers such as community health centers (CHCs) or safety-net hospitals. This project examined data from Massachusetts to assess how the demand for ambulatory and inpatient care and use changed for safety-net providers after the states health care reform law was enacted in 2006, which dramatically reduced the number of individuals without health insurance coverage. METHODS Multiple methods were used, including analyses of administrative data reported by CHCs and hospitals, case study interviews, and analyses of data from the 2009 Massachusetts Health Reform Survey, a state-representative telephone survey of adults. RESULTS Between calendar years 2005 and 2009, the number of patients receiving care at Massachusetts CHCs increased by 31.0%, and the share of CHC patients who were uninsured fell from 35.5% to 19.9%. Nonemergency ambulatory care visits to clinics of safety-net hospitals grew twice as fast as visits to non-safety-net hospitals from 2006 to 2009. The number of inpatient admissions was comparable for safety-net and non-safety-net hospitals. Most safety-net patients reported that they used these facilities because they were convenient (79.3%) and affordable (73.8%); only 25.2% reported having had problems getting appointments elsewhere. CONCLUSIONS Despite the significant reduction in uninsurance levels in Massachusetts that occurred with health care reform, the demand for care at safety-net facilities continues to rise. Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after health care reform programs are established.

Health Status, Risk Factors, and Medical Conditions Among Persons Enrolled in Medicaid vs Uninsured Low-Income Adults Potentially Eligible for Medicaid Under the Affordable Care Act

IMPORTANCE Under the Affordable Care Act (ACA), states can extend Medicaid eligibility to nearly all adults with income no more than 138% of the federal poverty level. Uncertainty exists regarding the scope of medical services required for new enrollees. OBJECTIVE To document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. These data will help physicians, other clinicians, and state Medicaid programs prepare for the possible expansions. DESIGN, SETTING, AND PATIENTS Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1042 uninsured adults aged 19 through 64 years with income no more than 138% of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid. MAIN OUTCOMES AND MEASURES Prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including medical conditions, and risk factors such as measured obesity status. RESULTS Compared with those already enrolled in Medicaid, uninsured adults were less likely to be obese and sedentary and less likely to report a physical, mental, or emotional limitation. They also were less likely to have several chronic conditions. For example, 30.1% (95% CI, 26.8%-33.4%) of uninsured adults had hypertension, hypercholesterolemia, or diabetes compared with 38.6% (95% CI, 32.0%-45.3%) of those enrolled in Medicaid (P = .02). However, if they had these conditions, uninsured adults were less likely to be aware of them and less likely to have them controlled. For example, 80.1% (95% CI, 75.2%-85.1%) of the uninsured adults with at least 1 of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4% (95% CI, 53.7%-73.1%) of adults enrolled in Medicaid. CONCLUSION AND RELEVANCE Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.

Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs

The Massachusetts health reform initiative enacted into law in 2006 continued to fare well in 2010, with uninsurance rates remaining quite low and employer-sponsored insurance still strong. Access to health care also remained strong, and first-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery in the state. There were also improvements in self-reported health status. The affordability of health care, however, remains an issue for many people, as the state, like the nation, continues to struggle with the problem of rising health care costs. And although nearly two-thirds of adults continue to support reform, among nonsupporters there has been a marked shift from a neutral position toward opposition (17.0 percent opposed to reform in 2006 compared with 26.9 percent in 2010). Taken together, Massachusettss experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.

Does high caregiver stress predict nursing home entry

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.

What is driving the black–white difference in low birthweight in the US?

This is a first effort to quantify the contribution of different factors in explaining racial difference in low birthweight rate (LBW). Mothers health, child characteristics, prenatal care, socioeconomic status (SES), and the socioeconomic and healthcare environment of mothers community are important inputs into the birthweight production function, and a vast literature has delved into obtaining causal estimates of their effect on infant health. What is unknown is how much of the racial gap in LBW is explained by all these inputs together. We apply a nonlinear extension of the Oaxaca-Blinder method proposed by Fairlie to decompose this gap into the portion explained by differences in observed characteristics and the portion that remains unexplained. Data are obtained from several sources in order to capture as many observables as possible, although the primary data source is the Natality Detail Files. Results show that of the 6.8 percentage point racial gap in LBW, only 0.9-1.9 points are explained by white-black differences in endowments across those measures, and of those endowments, most of the gap in LBW is explained by the differences in SES. The unexplained difference is attributed to racial differences in the returns to or the marginal product of investments in infant health.

Uninsurance Disparities Have Narrowed For Black And Hispanic Adults Under The Affordable Care Act

Black and Hispanic adults have long experienced higher uninsurance rates than white adults. Under the Affordable Care Act, differences in uninsurance rates have narrowed for both black and Hispanic adults compared to their white counterparts, but Hispanics continue to face large gaps in coverage.

Florida’s Medicaid Reform: Informed Consumer Choice?

Florida is among the first states to implement Medicaid reform using a competitive consumer choice model. Using data from a 2006-07 Kaiser Family Foundation survey of Medicaid recipients newly enrolled in Floridas reform program, we examine how well they understood the changes taking place and their experiences in selecting a health plan. We find important gaps in peoples understanding of major components of the reform: About 30 percent were not aware that they were enrolled in reform, and more than half had trouble understanding plan information. These problems were not particular to any group but instead were experienced broadly across the full Medicaid population.