Mass. reform increases access to hospital care in vulnerable groups

Healthcare reform providing near-universal insurance coverage in Massachusetts led to increased access to hospital care among vulnerable groups—especially Hispanic and low-income populations, suggests a paper in Medical Care. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

"Our findings are among the first to show that expanded insurance coverage on a population is associated with increase in use by such vulnerable populations," write Amresh D. Hanchate, PhD, of VA Boston Healthcare System and coauthors. The study provides evidence on the possible effects after implementation of national health care reform.

Reform Increases Access to Care in Vulnerable Groups
The researchers analyzed information on hospitalizations for 21 months before and after the implementation of Massachusetts health care reform in 2006. They focused on 17 common surgical procedures usually initiated by outpatient physician referral. For example, heart valve surgery was one of the 17 procedures, while coronary artery bypass surgery—often initiated after an emergency department visit—was not.

Changes in procedure rates were assessed in vulnerable population subgroups: particularly racial/ethnic minorities and people living in low-income areas. These groups are historically more likely to be uninsured thus limiting their access to health care (or delaying care until an urgent or emergency situation develops). The study excluded elderly patients, who are typically covered by Medicare.

Overall rates of the 17 procedures increased by eight percent among Massachusetts residents in low-income and medium-income areas, compared to a four percent increase for those living in high-income areas. Racial/ethnic minority groups also had greater increases in procedure rates: 23 percent for Hispanics and 21 percent for blacks, compared to seven percent for whites.

After adjustment for underlying trends unrelated to health care reform, procedure rates increased by 13 percent in low-income areas and 15 percent in medium-income areas, compared to two percent in high-income areas. The procedure rate increased by 22 percent for Hispanic patients, compared to seven percent for whites.

In contrast, the changes among blacks were no longer significant in the adjusted analysis. This seemed to reflect an accompanying, unexplained trend toward increased procedure rates among elderly blacks who qualified for Medicare.

Trends Reflect 'Pent-Up Demand' for Health Services
The 2006 Massachusetts health care reform package—including an "individual mandate," among other provisions—led to nearly 96.5 percent of residents obtaining health insurance. Uninsured rates decreased more sharply among lower-income groups and racial/ethnic minorities, which was one of the key goals of the legislation.

By looking at trends in surgical procedures typically initiated by outpatient referral, the new study suggests "potential improvements in access to outpatient care for these vulnerable groups." The researchers write, "Our finding of increased procedure use may reflect a combination of pent-up unmet need and need arising from new diagnoses following increased access to outpatient care."

Dr Hanchate and coauthors discuss the implications for predicting the likely impact of national health care reform, which shares "many key elements" with the Massachusetts legislation. "These findings suggest potentially improved access to outpatient care and may reflect demand built up prior to reform when individuals were uninsured," they conclude.

It remains to be seen whether increases in procedure rates among previously uninsured patients will taper off over time. Studies will also be needed to whether determine whether steps to improve access to health care will achieve their ultimate goal: improving health outcomes across the population at a "reasonable cost."