Effect of Massachusetts Health Reform on Chronic Disease Outcomes

In 2006, Massachusetts enacted landmark legislation that provided near universal health insurance coverage for residents. The Massachusetts Healthcare Reform (hereafter, “the 2006 reform”) law instituted individual and employer mandates to obtain health insurance, established a new purchasing pool, expanded Medicaid coverage, and created a subsidized insurance program called Commonwealth Care for households earning less than 300 percent of the Federal Poverty Level (Massachusetts 2006). Prior to the 2006 reform, health care institutions that provided care to uninsured persons were reimbursed through the state's Uncompensated Care Pool. In the year preceding the 2006 reform, Massachusetts hospitals provided nearly $663 million ($212 million inpatient and $451 million outpatient care) of allowable uncompensated care to the uninsured (Iseline 2007). Community health centers provided an additional $46 million of uncompensated care. Uncompensated care was classified as full uncompensated care, partial uncompensated care, medical hardship, or emergency bad debt. Eighty-eight percent of inpatient hospitalizations were for emergent or urgent care. Outpatient pharmacy services comprised the largest proportion of outpatient volume (19 percent) and generated 9 percent of the outpatient cost (Iseline 2007). Through these mechanisms, most uninsured adults (61.1 percent) in Massachusetts reported having a usual source of care, excluding emergency department visits, before the 2006 reform (Long and Stockley 2010). Similarly, the 2003 National Health Interview Survey revealed that 93 percent of uninsured persons with diabetes, 82 percent with hypertension, and 80 percent with hyperlipidemia self-reported visiting a health care professional within the prior year (Davidoff and Kenney 2005). The 2006 reform reduced the rate of uninsured Massachusetts residents from an average of 10.3 percent in 2004–2006 to 4.3 percent in 2010–2012 (DeNavas-Walt et al. 2007, 2013). Surveys have found that previously uninsured Massachusetts residents report improved subjective health status and better access to health care providers after the 2006 reform (Maxwell et al. 2011; Pande et al. 2011). Studies using administrative data found that the 2006 reform may have reduced emergency department utilization and increased inpatient surgical procedures among the poor, suggesting improved access patterns (Chen, Scheffler, and Chandra 2011; Smulowitz et al. 2011; Hanchate et al. 2012). However, other studies have questioned the effectiveness of the 2006 reform in improving health outcomes, noting that the 2006 reform has been associated with a low uptake of mammography and addiction treatment services (Capoccia et al. 2012; Keating et al. 2012). To our knowledge, no studies have examined the impact of the 2006 reform on disease control. Because the leading cost driver of the Massachusetts Uncompensated Care Pool in 2006 was circulatory disease (Iseline 2007), we analyzed whether the 2006 reform affected hyperlipidemia, diabetes, and hypertension disease control in uninsured adults who received care before and in the 5 years after the passage of the 2006 reform. We hypothesized that uninsured patients, especially those who received insurance in the follow-up period or those with poorly controlled disease at baseline, would experience favorable trends in disease control after the 2006 reform implementation.