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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
Impact of Hypertension on Healthcare Costs Among Children
Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model
Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson, MA; Rohan Parikh, MS; Rebecca Symes, BS; and Elliott S. Fisher, MD
Potential Role of Network Meta-Analysis in Value-Based Insurance Design
James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
Currently Reading
Massachusetts Health Reform and Veterans Affairs Health System Enrollment
Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Potential Benefits of Increased Access to Doula Support During Childbirth
Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
Synchronization of Coverage, Benefits, and Payment to Drive Innovation
Annemarie V. Wouters, PhD; and Nancy McGee, JD, DrPH
The Effect of Depression Treatment on Work Productivity
Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
Economic Implications of Weight Change in Patients With Type 2 Diabetes Mellitus
Kelly Bell, MSPhr; Shreekant Parasuraman, PhD; Manan Shah, PhD; Aditya Raju, MS; John Graham, PharmD; Lois Lamerato, PhD; and Anna D'Souza, PhD
Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan
Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
Does CAC Testing Alter Downstream Treatment Patterns for Cardiovascular Disease?
Winnie Chia-hsuan Chi, MS; Gosia Sylwestrzak, MA; John Barron, PharmD; Barsam Kasravi, MD, MPH; Thomas Power, MD; and Rita Redberg MD, MSc
Effects of Multidisciplinary Team Care on Utilization of Emergency Care for Patients With Lung Cancer
Shun-Mu Wang, MHA; Pei-Tseng Kung, ScD; Yueh-Hsin Wang, MHA; Kuang-Hua Huang, PhD; and Wen-Chen Tsai, DrPH
Health Economic Analysis of Breast Cancer Index in Patients With ER+, LN- Breast Cancer
Gary Gustavsen, MS; Brock Schroeder, PhD; Patrick Kennedy, BE; Kristin Ciriello Pothier, MS; Mark G. Erlander, PhD; Catherine A. Schnabel, PhD; and Haythem Ali, MD

Massachusetts Health Reform and Veterans Affairs Health System Enrollment

Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Health reform increased Medicaid enrollment, but was not associated with Veterans Health Administration and private insurance enrollment among Massachusetts veterans.
Veterans Health Administration (VA) operates the largest integrated health system in the nation. The Affordable Care Act (ACA) does not require any changes to VA, but the individual mandate and expanded health insurance options may change veterans’ preferences for coverage. We examined the impact of healthcare reform in Massachusetts, which also included these policy changes, on veterans’ enrollment in VA, private insurance, and Medicaid.
Study Design
Massachusetts’ healthcare reform in June 2006 served as a natural experiment. Using data from the 2004-2013 Current Population Surveys, we examined enrollment in VA, private insurance, and Medicaid, comparing veterans residing in Massachusetts with veterans residing in neighboring New England states that did not undergo health reform.

We estimated the probability of being enrolled in VA, private insurance, and Medicaid before and after healthcare reform, using multivariate probit models while adjusting for individual characteristics. Using a difference-in-difference approach, we compared pre-post changes in enrollment probability among Massachusetts and non-Massachusetts veterans, respectively.

Compared with other New England veterans, Massachusetts veterans decreased their enrollment in VA and private insurance by 0.2 (P = .857) and 0.9 (P = .666) percentage points, respectively, following health reform. In contrast, Medicaid enrollment increased by 2.5 percentage points (P = .038).

Healthcare reform in Massachusetts was associated with greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Our results are significant for informing VA fiscal planning in the post ACA era.

Am J Manag Care. 2014;20(8):629-636
Prior studies examining healthcare reform in Massachusetts have not measured the impact on enrollment in the Veterans Health Administration (VA), the largest integrated health system in the United States.
  • Overall, healthcare reform was not significantly associated with VA enrollment; this relationship, however, was contingent on the state of the economy.
  • Veterans who might otherwise have enrolled in VA or private insurance opted for Medicaid instead.
  • Understanding the impact of healthcare reform in Massachusetts is important to inform policy makers about veterans’ likely VA enrollment in the post Affordable Care Act era.
The Veterans Health Administration (VA) is the largest integrated health system in the United States. In fiscal year 2012, 8.8 million of the nation’s 21.2 million veterans were enrolled in VA.1 The minimum requirement for VA enrollment is veteran status, defined as discharge from active military, naval, or air service for any reason other than dishonorable. Veterans must actively apply for VA health benefits and are enrolled based on service-related disability, financial means, or special circumstances, such as prisoner of war status.2 Once enrolled, veterans have full access to all VA health services. Veterans who are sufficiently disabled due to their military service or have income below a means-tested threshold may qualify for VA care exempt from co-payments. All other veterans are required to make co-payments when obtaining VA services, including $15 and $50 co-payments for primary and specialty care visits, respectively.

Veterans who enroll in VA can concurrently enroll in and obtain care through other health insurance programs including Medicare, Medicaid, and private insurance. Survey data indicate that 77% of VA enrollees have at least 1 other source of health coverage.3 Dual enrollment is particularly common among VA enrollees who are eligible for Medicare.4,5 According to studies in Medicare-eligible veterans’ preference for care prior to Part D and the Affordable Care Act (ACA), veterans’ choice of VA care was driven, in part, by other available provider options.6

To date, no studies have examined the potential impact of the ACA on veterans’ enrollment in VA and use of VA health services. Veterans eligible for VA health benefits may continue to use VA as they did before ACA, but specific aspects of healthcare reform may change the way veterans interact with VA. Taken together, these elements of healthcare reform may cause total VA enrollment and enrollees’ use of VA services to increase or decrease markedly. VA enrollment may decrease for at least 2 reasons, since ACA increases the number of health plan options available through health in- surance exchanges and the expansion of Medicaid. First, uninsured veterans who might otherwise rely on VA may take advantage of these new options. Second, these new non-VA options may also be appealing to low-income veterans already enrolled in VA if they are eligible for health insurance subsidies or are able to take advantage of expanded Medicaid coverage.

At least 2 aspects of healthcare reform may result in greater VA enrollment. First, veterans with commercial insurance may seek VA care if small businesses decide to stop offering coverage as a result of the employer mandate. A prior study found employees of small firms faced higher insurance premiums and greater out-of-pocket costs after healthcare reform in Massachusetts.7 Second, if the options in health insurance exchanges or the Medicaid expansion are not appealing, uninsured veterans who did not previously use VA may seek health coverage through VA in order to satisfy the requirements of the individual mandate under ACA.

In this study, we sought to examine the potential impact of ACA on veterans’ enrollment in VA, private insurance, and Medicaid. We used the Massachusetts Health Care Reform Act (MHCRA), implemented in June 2006, as a proxy for ACA. MHCRA includes many of the components currently in ACA, so examining the impact of MHCRA on veterans’ enrollment in VA, private insurance, and Medicaid may inform policy makers about veterans’ likely VA enrollment from other status in the post ACA era.



Data for this study were drawn from the Current Population Survey (CPS) over the period 2004-2013.9 CPS is a publicly available database jointly sponsored by the US Census Bureau and the Bureau of Labor Statistics. CPS is traditionally known for labor market statistics; however, individual-level sociodemographic, behavioral, and health measures such as health insurance coverage are also included. Sample households in CPS responded to a core set of questions on a monthly basis for 4 months, then were not interviewed for 8 months, and finally were re-interviewed for 4 additional months. Supplemental questions, including those related to health plan coverage, were asked annually in the CPS March Supplement.

Study Sample

Implementation of the MHCRA began in June 2006, which served as a natural experiment because the MHCRA introduced an individual mandate as well as greater health insurance options and an expansion of Medicaid. Since MHCRA was a natural experiment, any enrollment changes among Massachusetts veterans after 2006 are likely to be attributable to MHCRA and not confounded by other factors. To consider the effect of healthcare reform in Massachusetts, we examined enrollment in VA, private insurance, and Medicaid, comparing veterans residing in Massachusetts with veterans residing in neighboring states in New England that did not undergo health reform. Using CPS data, we identified 131,330 individuals self-identified as veterans who completed the March Supplement during the period 2004-2013. We defined the treatment group as the set of veterans residing in Massachusetts. Correspondingly, the control group consisted of all other New England veterans residing in Connecticut, Maine, New Hampshire, Rhode Island, or Vermont. We defined the pre-MHCRA period as the interval from March 2004 to March 2006 and the post MHCRA period as March 2007 to March 2013. Of the sample of New England veterans, 4581 were from the pre-MHCRA period (630 Massachusetts and 3951 non-Massachusetts) and 9535 were from the post MHCRA period (1053 Massachusetts and 8482 non-Massachusetts). The unit of analysis was individual-level observations.

Enrollment in VA, Medicaid, and Private Health Insurance

The CPS March Supplement contains a series of yes/no questions to ascertain individuals’ sources of health coverage. Our primary outcome, VA enrollment, was a dichotomous variable equal to 1 if an individual reported being covered by VA at any time during the prior calendar year. We defined analogous measures for private insurance and Medicaid as secondary outcomes. We considered individuals to have private health insurance if coverage was obtained through an employer, purchased on the private market, or obtained through another individual’s plan. Enrollment outcomes (VA, private insurance, and Medicaid) are not mutually exclusive since veterans are able to concurrently enroll in VA and other health plans.

Statistical Analysis

  The impact of MHCRA on veterans’ enrollment in VA, private insurance, and Medicaid was examined using a difference-in-difference approach (DID).10 Specifically, we calculated the change in the adjusted probability of being enrolled in VA from the pre-period prior to MHCRA to the postperiod after MHCRA for veterans in Massachusetts and outside of Massachusetts, respectively. We then subtracted the pre-post change among Massachusetts veterans by the pre-post change among the non-Massachusetts veterans to produce the change in VA enrollment probability attributable to MHCRA. This DID estimate accounts for trends in VA enrollment that were common to all veterans and would otherwise confound estimated treatment effects. Analogous DID estimates were calculated for private insurance and Medicaid enrollment. Because outcome variables measure enrollment over a calendar year, DID estimates reflect the change in average annual enrollment.

We calculated the adjusted probability of being enrolled in VA, private insurance, and Medicaid jointly using multivariate probit models. We estimated a 3-equation model allowing for correlation in the error terms across equations. The multivariate probit model allows for veterans to be enrolled in 1 or more sources. All models include 3 explanatory variables to generate probabilities for the DID approach: indicator for Massachusetts veteran, indicator for post MHCRA observation, and the interaction between these 2 variables. Regression models also adjusted for demographics (age, gender, marital status, race, education, income, residence in urban area, household size), employment status, self-reported health, and disability.

All analyses were weighted to the average annual veteran population in New England over the 10-year sample period. Standard errors for regression coefficients were calculated using a bootstrap procedure.11 The delta method was then used to estimate DID standard errors. A nominal P value of .10 was used to test statistical significance. Statistical models were fit using the STATA Software (Version 12.0, College Station, Texas).


  Veterans Before and After Healthcare Reform

Table 1 presents descriptive statistics for veterans in the pre- and post MHCRA periods, stratified by state of residence (Massachusetts or non-Massachusetts) and weighted to the average annual population of New England veterans. Prior to MHCRA, veterans in Massachusetts were older (P = .009), less likely to be married (P =.001), and more likely to have postbaccalaureate education (P <.001), have a disability preventing work (P =.032), and reside in an urban area (P <.001), compared with non-Massachusetts veterans. After implementation of MHCRA, veterans in Massachusetts remained older (P <.001), more likely to have postbaccalaureate education (P <.001), and more likely to reside in urban areas (P <.001) compared with non-Massachusetts veterans. Massachusetts veterans were also less likely to be employed full-time (P = .005) or part-time (P = .007) following MHCRA.

Unadjusted Enrollment in VA, Private Insurance, and Medicaid

Table 2 presents unadjusted rates of enrollment in VA, private insurance, and Medicaid in Massachusetts and other neighboring New England states before and after MHCRA. VA enrollment increased 2.1 percentage points from the pre-MHCRA period to the post MHCRA period for Massachusetts veterans (pre-MHCRA = 5.3%, post MHCRA = 7.4%) and 3.2 percentage points for non- Massachusetts veterans (pre-MHCRA = 6.2%, post MHCRA = 9.4%). Private insurance enrollment decreased 0.5 percentage points for Massachusetts veterans, from 72.2% pre-MHCRA to 71.7% post MHCRA, but decreased 2.3 percentage points from pre-MHCRA to post MHCRA (72.9% to 70.6%) for non-Massachusetts veterans. Medicaid enrollment increased 2.2 percentage points from the pre-MHCRA period to the post MHCRA period for Massachusetts veterans (pre-MHCRA = 5.9%, post MHCRA = 8.1%) and 1.0 percentage point for non-Massachusetts veterans (pre-MHCRA = 5.8%, post MHCRA = 6.8%). 

The Figure presents unadjusted trends in VA enrollment for Massachusetts and non-Massachusetts veterans, respectively. Trends in VA enrollment were similar across groups in the pre-MHCRA (2004-2006) period. In the 2 years following MHCRA (2007-2008), VA enrollment decreased for both groups; however, the decline was more substantial among Massachusetts veterans. In 2009, VA enrollment increased sharply in the Massachusetts group compared with a more modest increase in the non-Massachusetts group. Between 2011 and 2013, VA enrollment decreased modestly among Massachusetts veterans, but increased among non-Massachusetts veterans. 

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