Two New Studies: MA Health Reform Continues to Exceed Expectations

Two new studies have some remarkably positive findings about Massachusetts health reform.

Insurance Coverage For Population Subgroups 2006 to 2009
Percent reporting coverage at time of survey

The first, the latest Massachusetts Health Reform Survey from the Urban Institute and the Blue Cross of Massachusetts Foundation, is based on a large random survey of Bay State adults (click for detailed findings, and chartbook, pdfs). Lead researcher Sharon Long has been conducting these surveys each year since 2006, so they provide a rich source of analysis of trends in coverage and access to health care.

Highlights from the report include:

  • The percentage of nonelderly adults who are uninsured fell from 12.5% in 2006 to 4.2% in the fall of 2009.
  • In fall 2009, 98% of nonelderly adults reported having health insurance at some point in the previous year, compared to 90% in fall 2006.
  • Significant gains were made in insurance coverage rates among low and middle-income adults, adults without dependent children, and adults with a chronic health condition (see chart above).

In addition to the coverage gains, indicators demonstrate that health care access has improved significantly since 2006 as well:

  • The number of people reporting that they had a usual source of care increased, as did the proportion of the population that had had a general doctor, preventive care, or dental visit in the previous year.
  • The overall percentage of those reporting that they had any unmet need for care dropped from 25% to 20%.
  • The percentage of adults who reported unmet need in every specific type of care mentioned decreased as well. This includes doctor care; specialist care; medical tests, treatment, and follow-up care; preventive care screenings; prescription drugs; and dental care.

Racial/Ethnic Disparities Under Health Reform 2009
Percent Reporting Outcome

The most eye-popping finding was very positive trends among vulnerable population subgroups. Prior to health care reform, ethnic and racial minority populations reported having lower levels of insurance coverage, poorer access to care, less use of care, and more problems with care affordability than white, non-Hispanic populations. Lower-income adults and those with chronic conditions also struggled to attain health insurance and to pay for their needed medical care. As of fall, 2009, however:

  • Ethnic disparities in these categories have been nearly eliminated, with minority and white, non-Hispanic populations reporting nearly identical levels of health care coverage and access (see chart above).
  • Adults with lower income levels or a chronic condition reported increased rates of health coverage, as well as decreased financial strain as a result of medical costs and a sharp decline in unmet care due to costs.

The second study is much more complex, but just as interesting. In their May 2010 paper, “The Impact of an Individual Health Insurance Mandate on Hospital and Preventive Care: Evidence from Massachusetts,” economists Jonathan T. Kolstad and Amanda E. Kowalski use hospital discharge data to look at the impact of health care reform in Massachusetts on health insurance coverage, utilization, and patient outcomes. (UPDATE: an updated version was published in 2012)

Kolstad and Kowalski compare outcomes in Massachusetts after reform to outcomes in Massachusetts before reform and outcomes in other states. Using rigorously adjusted hospital data, they find that health care reform in Massachusetts

  • decreased length of hospital stays,
  • decreased the number of inpatient admissions from the emergency room, and
  • reduced hospitalizations for preventable conditions, suggesting that preventive care increased outside of hospitals.

While all of these positive changes were taking place, Kolstad and Kowalski find no evidence that the cost of hospital care increased.

The study finds that health care reform in Massachusetts resulted in a 3.2% reduction in hospital admissions from the emergency room, which suggests that more people were seeking outpatient preventative care instead of using the emergency room. This finding was especially true for people from zip codes with the lowest average incomes.

Kolstad and Kowalski also look at the impact of reform on prevention by looking at measures developed by the Agency for Healthcare Research and Quality (AHRQ), specifically the Prevention Quality Indicators (PQIs). They explain that the appearance of particular preventable conditions in hospitalized individuals (for example, complications from diabetes) shows that these individuals were not getting adequate outpatient preventive care. The results from Kolstad and Kowalski’s analysis show that the overall PQI decreased by approximately 1.7%, which suggests that health care reform in Massachusetts decreased inpatient admissions for preventable conditions.

Here’s their eye-popping result: Statistically significant improvements due to health reform in prevention-related quality indicators were noted in lower hospital admission rates, including decreased admissions for diabetes complications, heart disease, hypertension, infections, and asthma.

As the national debate over health reform ebbs and flows, the ongoing Massachusetts laboratory continues to provide real data.
-Oliver McClellan and Emma Smizik

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5 Responses to Two New Studies: MA Health Reform Continues to Exceed Expectations

  1. Pingback: Happy 7th (and last) Birthday, Massachusetts Health Reform |

  2. dennis byron says:

    Dear anonymous

    Actually no, I was referring to the likely inaccuracy of the difference-in-difference strategy the authors embeded in an instramental variable framework and the resulting conclusions drawn by commenting on results “Among the population discharged from the hospital in Massachusetts…” Like a lot of the academic research, it surveys the wrong people: the few uninsured rather than the six million (94% before Romneycare) that have always been insured. It was a very complicated yet potentially flawed way — vs straight review of the statistics with or without some regression analysis — to say what very straightforward analysis of all the absolute numbers already showed us here in Massachusetts: Romneycare moved the needle very little in terms of increasing the uninsured.

    When the authors say “the reform decreased uninsurance by 28% relative to its initial level” what they are not telling you is that over 94% of us already had insurance here in Massachusetts. The 28% refers to the small group that did not and most of them have still chose not to be insured despite the mandate.

    And those making that choice appears to be growing but we can’t be sure because the Deval Patrick-controlled state agency responsbile for putting out the straight statistics from the insurers — without all the academic goobledygook — is three months late releasing the latest quarterly report.

    My guess is that the most recent statistics further illustrate the “train wreck” in progress here (in the words of the Deputy Insurance Commissioner, a civil servant and not beholden to the Patrick machine) in Massachusetts.

    But that all begs the bigger question I asked in my original comment: If it is working, why isn’t Romneycare reducing ER visits not increasing them as the academics say they have proved. That is the promise (among many not being kept) of Obmacare.

    Anyone that does not want to hide behind anonmymity, send me an email at and I’ll send you the most recent — albeit now dated — state statistics.


  3. zosima says:

    Hey Dennis,
    Maybe you’re just claiming there are methodological problems without naming them because you’d like to discredit the study without having to defend your amateur opinion.

  4. ? says:


    The study most likely has methodological problems too numerous to mention. I couldn’t make it past the incompetent title. Did Kolstad and Kowalski ever bother to read Ch. 58, where the “mandate” is a penalty for not having health insurance (not a mandate to have insurance), and that it is not applicable to everyone?

  5. Dennis Byron says:

    “The study finds that health care reform in Massachusetts resulted in a 3.2% reduction in hospital admissions from the emergency room…”

    The Kowalski study has methodological problems too numerous to mention but does the conclusion quoted above even make sense? If many people were using the emergency room as their primary care physician before Romneycare because they didn’t have healthcare insurance, you would think that hospital admissions from the emergency room would increase not decrease once the uninsured had insurance. In other words, there would be more true health emergencies and therefore more subsequent admissions.

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