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Effects of Healthcare Reforms on Coverage, Access, and Disparities

Quasi-Experimental Analysis of Evidence from Massachusetts

      Background

      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.

      Purpose

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

      Design

      Interrupted time series with comparison series.

      Setting/participants

      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.

      Intervention

      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.

      Results

      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.

      Conclusions

      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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