After accounting for temporal trends in New England, we found that Massachusetts health reform was associated with expanded insurance coverage and reduced financial barriers in obtaining health care for working-age adults. These early successes were not accompanied by overall improvements in access to a regular physician or in self-reported health. Although there were improvements in coverage and cost barriers for some disadvantaged groups relative to trends in New England, there were no improvements in racial/ethnic or socioeconomic disparities in these outcomes, in large part because of comparable or larger improvements among whites and those earning ≥300% FPL. Further, the 3% decline in uninsurance observed during the study period needs to be placed within the context of substantial declines in the rate of uninsurance in Massachusetts prior to the enactment of this reform.18,19
Because minorities and low-income adults are overrepresented among the uninsured,16
health insurance expansion may be particularly beneficial for these groups.9
Enrollment following health reform was largest in the subsidized plans. Nearly 90% of the uninsured below 100% FPL have enrolled, yet only 29% of the uninsured between 200%–300% FPL.24
We found, however, that under health reform disparities in access persisted. Lasting disparities in care and health status despite health coverage have been demonstrated in other settings for both private and public health plans.10–15
This observation is also consistent with the persistence of disparities in countries with universal health coverage, like Canada and the UK.25,26
Taken together these findings suggest that health reform policies should address social determinants of health more broadly if a goal is to advance health equity.27
The observation that access to a personal physician did not improve with health reform suggests the importance of additional barriers beyond coverage. These results are consistent with reports that between 2006 and 2008, substantially more primary care providers in Massachusetts reported closed patient panels with substantial wait times for a new patient to providers with an open practice.28
An influx of newly insured adults may have exacerbated existing strains on the health care delivery system, such as a critical shortage of primary care physicians.7
Although health insurance coverage generally improves health status,29
this effect largely occurs because of increased access to care and utilization of services. Moreover, it may still be too early post-reform to detect impacts on health outcomes.
These findings build upon previous studies that assess the impact of health insurance coverage on racial/ethnic and socioeconomic disparities. Several studies have found that health insurance explains a portion of racial/ethnic disparities in health care.9,30–34
Remaining gaps may be due to various factors including cultural or linguistic barriers, or lack of infrastructure within underserved communities to promote outreach and enrollment in health plans or facilitate the establishment of a relationship with a primary care provider.16,27,33,35,36
Finally, some individuals may still feel that insurance is unaffordable, as the majority of new enrollees since reform have been covered under fully subsidized plans.7
In addition, health reform is not likely to eliminate the need for a safety net.37
Because health reform in Massachusetts may have left fewer resources for safety net providers, individuals who remained uninsured after health reform may have had fewer options for care, and others with new coverage may have been displaced from existing relationships.37,38
Thus, health reform may be more effective at promoting health care equity when implemented alongside complementary strategies such as minority health report cards that specifically track outcomes for underrepresented groups,39
language resources and cultural competency training,40
diversification of the health care workforce, and systemic changes in the quality, delivery, and management of care.27,39
Massachusetts health reform did include initiatives to reduce racial/ethnic disparities using pay-for-performance goals for MassHealth and a Health Disparities Council.2
Pay-for-performance goals have included reducing disparities in readmission rates, avoidable hospitalizations, and the screening and management of chronic illnesses, outcomes not assessed by this study. The Disparities Council is charged with making recommendations to reduce and eliminate disparities in health care and health outcomes in Massachusetts; because the Council had met only once as of March 2008,2
its influence may not yet be apparent in these data.
As in Massachusetts, national health reform strives to reduce disparities in access to and quality of care, the PPACA includes provisions such as enhanced collection of data on race/ethnicity and improved monitoring of trends in disparities.17
Despite some similar features between the two plans, including insurance exchanges, individual and employer mandates, and expanded Medicaid coverage, it is unlikely that the Massachusetts experience will predict that of the US. Various factors that have played into the initial expansion of health insurance in Massachusetts are not applicable on the national scale, including a low baseline rate of uninsurnace; a lower undocumented immigrant population than other states; and an established health care infrastructure including an extensive community health network.
Several limitations of this work should be noted. First, because of sociodemographic differences and policy changes in other states, there is no ideal control group. During the study period, two other New England states began health reform, though not as comprehensive.22,41,42
Sensitivity analyses found that the exclusion of these states from the control group or use of the continental US as an alternative does not influence our conclusions. Second, although the BRFSS sample is large, our power was limited to detect small changes over time. In general, we had 80% power to detect a difference-in-difference of approximately 5% over 3 years for disparities in Massachusetts compared to New England. Smaller reductions in disparities may be too small to be considered meaningful. Third, our analyses used self-reported data from the BRFSS, and patterns of self reporting may vary by race/ethnicity.43
Any self-reporting biases are likely to be consistent over time. Fourth, since implementation of reform measures were staggered, some effects of the legislation may not yet be apparent.
In conclusion, this work confirms that Massachusetts health reform was associated with improvements in coverage and a decline in financial barriers to care. We extend what is known about this health reform by demonstrating that the expansions were not associated with increased access to a personal physician or improvements in self-rated health. This work suggests that health reform is necessary but not sufficient to achieve equity in health care. These results are particularly salient with the passage of the PPACA. The Massachusetts experience suggests the need to prioritize strategies to specifically address health care disparities such as incorporating disparities reduction goals into health plan provider contracts; linking monetary incentives to reducing disparities in health care; analyzing utilization and performance data by race/ethnicity and socioeconomic status of enrollees; and increasing culturally and linguistically appropriate care. Ongoing monitoring of access and affordability will be important to ensure that health reform improves equity.