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

As states implement the Affordable Care Act, there is mounting concern that the influx of large numbers of newly insured individuals into the health care system could have a negative effect on access to care for the already-insured. Recent studies have shown, for example, that Medicaid expansion is associated with higher rates of use of office and emergency department visits (Baicker et al. 2013; Taubman et al. 2014); in the setting of a fixed supply of providers and appointments, this could unduly strain the system and worsen access to care. Indeed, this was the concern that led Congress to provide funds for more primary care training slots as well as additional pay for primary care visits under the Medicaid program (Patient Protection and Affordable Care Act 2010). However, while these interventions may help improve primary care capacity in the long run, the impact of the ACA will be felt in the short run—before many of these fixes take effect. The potential impact of insurance expansion on access to care may be particularly important for patients with ongoing health care needs, including older Americans, and especially those with chronic illness. These patients, who rely on readily available access, could face longer wait times to see a physician, potentially worsening the management of chronic disease or impeding the delivery of high-quality preventive services. Reduced access to care, particularly in the urgent setting, could also lead to increased use of emergency department services or unplanned hospitalization, both of which could increase total costs; prior evidence suggests that crowding in emergency departments, for example, is associated with worse quality and clinical outcomes (Bernstein et al. 2009). Indeed, if the influx of newly insured patients decreases the ability of older, chronically ill Americans to access outpatient care as a result of crowding in already-busy clinics, the clinical and economic consequences could be substantial. While this concern has been widely discussed, the empirical evidence to assess whether it is likely to occur or not is weak. One place to begin to assess how insurance expansion affects access to care for previously insured, chronically ill, older Americans is to examine what happened in Massachusetts. The Commonwealth expanded to near-universal insurance coverage in 2006, yet its impact on access to timely visits for this vulnerable population has not been examined. Given the importance of understanding the impact of insurance expansion on the broader health care system, and given that Massachusetts was arguably the model of the ACA, it may serve as the best available laboratory to understand what happened to chronically ill older Americans as an influx of new patients came into the system. Therefore, in this study, we set out to answer three questions, using Massachusetts as a test case for the impact of health insurance expansion on the already-insured, and comparing its experience to that of nearby states without insurance expansion. First, what was the impact of Massachusetts health reform on access to outpatient care for the already-insured, as measured by number of annual visits for patients with chronic illnesses before versus after health reform was implemented? Second, what was the impact on the quality of outpatient care received? Third, what was the impact on total costs of care? As states consider options for Medicaid expansion and roll out health insurance exchanges, understanding the impact of these expansions on the broader health care system, and particularly on some of its most vulnerable patients, can provide important guidance for policy makers.