Massachusetts’ reform failed to reduce racial and ethnic disparities

The BMJ
April 1, 2015
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

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

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.



Note: One of the authors is a member of the Board of Directors of
Physicians for a National Health Program and an advocate of single payer
reform. Mention of the option of single payer was excluded from the
paper at the request of at least one of the other authors. They did
advocate for contemplation of "a mix of private and public funding and
individual mandates" - the ACA model, which their own study shows was
ineffective in reducing these disparities. If they really are interested
in correcting the deficiencies they list (financial barriers, provider
network inadequacy, and lack of universal coverage), they should have
included at least a mention of single payer.