Study: Mass Health Reform Did Not Reduce Preventable Hospitalizations

In the first three years after Massachusetts implemented its 2006 health care reform law, which reduced the number of uninsured people in the state by roughly half, the rate of preventable hospitalizations did not decline compared with the rate in states with similar populations that had not not expanded health insurance coverage.

Nor did the reform reduce racial and ethnic disparities in the rate of such hospitalizations.

Those are some of the chief findings of a new study by researchers at Harvard Medical School and the Boston University School of Medicine, published today in The BMJ. The study is based on data gathered from nearly 900,000 patient hospitalization records in Massachusetts, New York, New Jersey and Pennsylvania.

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Hospitalization rates for a dozen “ambulatory care sensitive conditions”—conditions such as a urinary tract infection, diabetes or high blood pressure, which are treatable if an individual has good access to a primary care physician—would have been expected to decline in Massachusetts if access to outpatient care had increased significantly after the reform was implemented, the study authors said.

“Our findings suggest that despite the insurance expansion under the Massachusetts reform, access to timely outpatient visits to a doctor may not have improved much,” said lead author Danny McCormick, HMS associate professor of medicine and primary care physician at Cambridge Health Alliance.

“While prior research has demonstrated the critical role health insurance plays in obtaining access to care, other factors are also important, such as the availability of physicians willing to accept your insurance and financial barriers to care such as copays and deductibles,” McCormick said. “Less than half of outpatient physicians accept the public forms of insurance most people received under the reform, and some of these insurance types required copays of up to $12.50 per medication per month.”

Prior to the Massachusetts reform, black and Hispanic residents had significantly higher rates of preventable hospitalizations than white residents. The new study found no evidence that this gap in rates decreased post-reform.

“This continuing gap is disappointing because improving racial and ethnic disparities in access was a key objective of the reform,” said Amresh Hanchate of the section of general internal medicine at Boston Medical Center, an assistant professor at the Boston University School of Medicine and a study co-author.

“Although a higher percentage of black and Latino residents than white residents gained insurance under the reform, a higher percentage remains currently uninsured than white residents,” said Hanchate.

In contrast to previous studies of access to care in Massachusetts that have relied on patient surveys, which the authors say may be subject to potential biases due to patient recall or other factors, the new study is one of the few to rely on objectively measured outcomes and was based on nearly every hospital admission occurring in Massachusetts and the comparison states for nearly two years before and two years after the reform was implemented.

The researchers noted that their study does not invalidate the well-documented benefits of expanding health insurance coverage.

“Our findings may tempt some to call for a rollback of Massachusetts’ or even national health reform,” said Nancy Kressin, head of the Health/care Disparities Research Program in the Department of Medicine at the Boston University School of Medicine, member of the section of general internal medicine at Boston Medical Center and senior author of the study.

“But we are more likely to improve access to care and reduce preventable hospitalization rates if we focus on offering residents insurance plans that minimize cost barriers and are widely accepted by doctors,” said Kressin.

This research was funded by grants from the National Institutes of Health (1U01HL105342–01) and the Rx Foundation. Kressin is also supported in part by a senior research career scientist award from the Department of Veterans Affairs, Health Services Research and Development Service (RCS 02-066-1).

Adapted from a Cambridge Health Alliance news release.