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Massachusetts’ reform failed to reduce racial and ethnic disparities

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics

By Danny McCormick, Amresh D Hanchate, Karen E Lasser, Meredith G Manze, Mengyun Lin, Chieh Chu, Nancy R Kressin
The BMJ, April 1, 2015

Objectives

To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states.

Results

After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval −1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (−1.9%, −8.5% to 5.1%) or white and Hispanic people (2.0%, −7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, −2.3% to 5.3%).

Conclusions

Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.

From the Introduction

The Massachusetts reform was designed to achieve “near universal” coverage, to improve access to care, and to decrease racial and ethnic disparities in both coverage and access that are well documented within the US healthcare system. In addition to extending coverage to the lowest income individuals — disproportionately comprising racial and ethnic minorities — the Massachusetts reform made reducing disparities an explicit goal.

From the Conclusion and policy implications

Why might Massachusetts health reform have failed to affect preventable admissions or narrow pre-existing racial and ethnic disparities in this outcome? First, although estimates vary somewhat, the absolute decline in the number of uninsured residents was about 6% of the non-elderly population; this still left 6% of the non-elderly population uninsured after full implementation of the reform. While gains were larger for racial and ethnic minorities, so too was the proportion of uninsured after reform. Second, before reform, Massachusetts had a robust healthcare safety net system that provided free care to many of the uninsured, who were disproportionately from minority backgrounds, through the state’s Uncompensated Care Pool program. Third, the public insurance (Medicaid) and publicly subsidized (Commonwealth Care) and unsubsidized (Commonwealth Choice) exchange based private insurance that residents received under the reform might not have provided optimal access to outpatient care because patients had to share costs or of because of low provider reimbursement. In 2009 the Massachusetts Medical Society found that only 60% of internist physicians in Massachusetts accepted Medicaid and 40% accepted Commonwealth Care, and anecdotal evidence suggests that finding a physician after reform became more difficult. Lastly, there could have been insufficient capacity of outpatient primary care providers to fully accommodate the influx of newly insured residents, irrespective of insurance type.

In addition to being a key measure of access, preventable admissions represent a clinical failure for patients and a needless expenditure of scarce healthcare resources. Our findings therefore have important policy implications. A large body of evidence suggests that insurance substantially improves access to care across many settings, medical conditions, and populations. In fact, recent US longitudinal studies provide strong evidence that acquiring public forms of insurance such as Medicaid and Medicare improves a broad array of health outcomes including mortality. The fact that we found no evidence that the Massachusetts reform diminished either preventable admissions or disparities in such admissions, suggests that particular features of the Massachusetts reform might need to be optimized to realize improvements in access to outpatient care that can prevent admissions. Although our results do not point to specific modifications, they might include continued expansion of insurance to the remaining uninsured, reduction in cost related barriers to outpatient care among those with insurance, and more comprehensive outreach efforts to the insured and uninsured to ensure adequate knowledge of the processes for applying for and effectively utilizing insurance, particularly among residents with limited proficiency in English language and low health literacy. Future studies will need to define which of these or other improvements will maximize outpatient access to care. While healthcare delivery systems vary substantially internationally, our results could provide insight into reforms of healthcare financing built on a mix of private and public funding and individual mandates that both wealthy and less wealthy countries could contemplate.

http://www.bmj.com/content/350/bmj.h1480

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Comment:

By Don McCanne, MD

Goals of Massachusetts health care reform included extending coverage to low-income individuals (disproportionately comprising racial and ethnic minorities) and to reduce disparities in care. How well these goals have been achieved is particularly important since it can predict how effective the Affordable Care Act (ACA) - the same model as the Massachusetts plan - will be in achieving these goals.

So how has Massachusetts done? This study looked specifically at the rates of admission to hospitals for conditions that are sensitive to ambulatory care. With better access to outpatient care hospitalization rates should be lower, with racial and ethnic disparities diminishing. These did not happen. The admission rates did not decrease and the disparities for both blacks and Hispanics were unimproved.

Although many factors contribute to the disparities, insurance should reduce financial barriers and thus improve access. Why didn’t that happen here? Some blame should lie with the model of reform selected. In spite of mandates for coverage, many people still remain uninsured. Also the cost sharing associated with health plans erect financial barriers to care. Further, both narrow networks of the plans and the lack of willing providers reduce access. These factors can be enough to explain why there was no improvement in spite of the full implementation of the Massachusetts reform. We can anticipate the same disappointing results nationally in the years following full implementation of ACA since it incorporates the same policy deficiencies.

As a remedy, the authors suggest more of the same. They would try to expand coverage to the remaining uninsured - a very difficult feat in a multi-payer system with varying qualifications for public assistance in financing the care. They would reduce cost related barriers for those with insurance, but not eliminate them. They would increase outreach efforts to assist patients in negotiating the administrative quagmire of the various insurance plans. They provide no suggestion for expanding the networks of eligible providers. In their call for “reforms of healthcare financing built on a mix of private and public funding and individual mandates,” they are explicitly endorsing the same model that has already failed to reduce these disparities.

In a press release, one of the coauthors stated, “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.” The problem is that the ACA model of reform is driving the shift to ever greater cost barriers and much narrower networks of physicians.

Instead of an individual mandate, everyone should be covered automatically. Instead of erecting financial barriers to care, the health care system should be fully prepaid with first dollar coverage. Instead of perpetuating the administrative complexity of a multi-payer system of public and private insurers, one single simplified system should be put in place. Instead of separate restricted networks of providers, all professionals and institutions should be covered by one single program. Yes, the important model that they failed to mention is a single payer national health program such as an improved Medicare that covers everyone. That’s what we need.

Addendum (4/2/15): My comment that the “authors suggest more of the same” is not correct since they do recommend policies that would improve functioning of the financing system. My negative tone rests on the fact that when policy studies demonstrate the clear need for single payer reform, the current political environment within the academic policy and publishing communities results in the suppression of discussions of the single payer concept. That is a shame, especially when the need is so great.