Effects of Healthcare Reforms on Coverage, Access, and Disparities

Quasi-Experimental Analysis of Evidence from Massachusetts


      The 2010 Patient Protection and Affordable Care Act (PPACA) has been controversial. The potential impact of national healthcare reform may be considered using a similar set of state-level reforms including exchanges and a mandate, enacted in 2006 in Massachusetts.


      To evaluate the effects of reforms on healthcare access, affordability, and disparities.


      Interrupted time series with comparison series.


      Longitudinal survey data from 2002 to 2009 from the Behavioral Risk Factor Surveillance System including 178,040 nonelderly adults residing in Massachusetts, Vermont, New Hampshire, Rhode Island, and Connecticut. Analysis was conducted from January to August 2010.


      Massachusetts 2006 healthcare reform, which included an individual health insurance mandate.

      Main outcome measures

      Being uninsured, having no personal doctor, and forgoing care because of cost, evaluated in Massachusetts and four comparison states before (2002–2005) and after (2007–2009) the healthcare reform. Effects on disparities defined by race, education, income, and employment also were assessed.


      Living in Massachusetts in 2009 was associated with a 7.6 percentage point (95% CI=3.9, 11.3) higher probability of being insured; 4.8 percentage point (–0.9, 10.6) lower probability of forgoing care because of cost; and a 6.6 percentage point (1.9, 11.3) higher probability of having a personal doctor, compared to expected levels in the absence of reform, defined by trends in control states and adjusting for socioeconomic factors. The effects of the reform on insurance coverage attenuated from 2008 to 2009. In a socioeconomically disadvantaged group, the reforms had a greater effect in improving outcomes on the absolute but not relative scale.


      Healthcare reforms in Massachusetts, which included a health insurance mandate, were associated with significant increases in insurance coverage and access. The absolute effects of the reform were greater for disadvantaged populations. This is important evidence to consider as debate over national healthcare reform continues.
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      1. Health Care and Education Affordability Reconciliation Act of 2010 (H.R. 4872).
        • Iglehart J.K.
        Historic passage—reform at last.
        N Engl J Med. 2010; 362: e48
        • Hall M.A.
        Health care reform—what went wrong on the way to the courthouse.
        N Engl J Med. 2011; 364: 295-297
      2. Massachusetts General Laws.
        • Steinbrook R.
        Health care reform in Massachusetts—expanding coverage, escalating costs.
        N Engl J Med. 2008; 358: 2757-2760
        • Burrows A.M.
        • Moser R.P.
        • Weaver J.P.
        • Litwin D.E.
        • Pilitsis J.G.
        Massachusetts health insurance mandate: effects on neurosurgical practice.
        J Neurosurg. 2010; 112: 202-207
        • Smulowitz P.
        • Landon B.E.
        • Burke L.
        • Baugh C.
        • Gunn H.
        • Lipton R.
        Emergency department use by the uninsured after health care reform in Massachusetts.
        Intern Emerg Med. 2009; 4: 501-506
        • Long S.
        What is the evidence on health reform in Massachusetts and how might the lessons from Massachusetts apply to national health reform?.
        Urban Institute, Washington DC2010
        • Long S.K.
        • Masi P.B.
        Access and affordability: an update on health reform in Massachusetts, fall 2008.
        Health Aff. 2009; 28: w578-w587
        • Long S.K.
        On the road to universal coverage: impacts of reform in Massachusetts at one year.
        Health Aff. 2008; 27: w270-w284
        • Long S.K.
        • Stockley K.
        Sustaining health reform in a recession: an update on Massachusetts as of fall 2009.
        Health Aff. 2010; 29: 1234-1241
        • Long S.K.
        • Stockley K.
        The impacts of state health reform initiatives on adults in New York and Massachusetts.
        Health Serv Res. 2011; 46: 365-387
        • Chandra A.
        • Gruber J.
        • McKnight R.
        The importance of the individual mandate—evidence from Massachusetts.
        N Engl J Med. 2011; 364: 293-295
        • Long S.K.
        • Stockley K.
        • Yemane A.
        Another look at the impacts of health reform in Massachusetts: evidence using new data and a stronger model.
        Am Econ Rev. 2009; 99: 508-511
        • Zhu J.
        • Brawarsky P.
        • Lipsitz S.
        • Huskamp H.
        • Haas J.S.
        Massachusetts health reform and disparities in coverage, access and health status.
        J Gen Intern Med. 2010;
        • Miller T.
        Massachusetts: more mirage than miracle.
        Health Aff. 2006; 25: w450-w452
        • Shadish W.R.
        • Cook T.D.
        • Campbell D.T.
        Experimental and quasi-experimental designs for generalized causal inference.
        Houghton Mifflin Company, Boston2002
        • CDC
        Behavioral Risk Factor Surveillance System: survey data and documentation.
        • Weissman J.S.
        • Zaslavsky A.M.
        • Wolf R.E.
        • Ayanian J.Z.
        State Medicaid coverage and access to care for low-income adults.
        J Health Care Poor Underserved. 2008; 19: 307-319
        • Clogg C.C.
        • Petkova E.
        • Haritou A.
        Statistical methods for comparing regression coefficients between models.
        Am J Sociol. 1995; 100: 1261-1293
        • Kowalczyk L.
        Across Mass., wait to see doctors grows.
        • Couch K.A.
        • Joyce T.J.
        What can Massachusetts teach us about national health insurance reform?.
        J Pol Anal Manage. 2011; 30: 177-178
      3. Health Care Reform Legislation. Vermont health care reform.

        • CDC
        BRFSS annual survey data: summary data quality reports.
        CDC, National Center for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor Surveillance System, Atlanta GA2010 (
        • Curtin R.
        • Presser S.
        • Singer E.
        The effects of response rate changes on the index of consumer sentiment.
        Public Opin Q. 2000; 64: 413-428
        • Keeter S.
        • Miller C.
        • Kohut A.
        • Groves R.M.
        • Presser S.
        Consequences of reducing nonresponse in a national telephone survey.
        Public Opin Q. 2000; 64: 125-148
        • Galesic M.
        • Tourangeau R.
        • Couper M.P.
        Complementing random-digit-dial telephone surveys with other approaches to collecting sensitive data.
        Am J Prev Med. 2006; 31: 437-443
        • Curtin R.
        • Presser S.
        • Singer E.
        Changes in telephone survey nonresponse over the past quarter century.
        Public Opin Q. 2005; 69: 87-98
        • Simon T.R.
        • Mercy J.A.
        • Barker L.
        Can we talk?.
        Am J Prev Med. 2006; 31: 406-410