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The Effect of Massachusetts Health Reform on Access to Care for Medicaid Beneficiaries
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The Effect of Massachusetts Health Reform on Access to Care for Medicaid Beneficiaries

Laura G. Burke, MD, MPH; Thomas C. Tsai, MD, MPH; Jie Zheng, PhD; E. John Orav, PhD; and Ashish K. Jha, MD, MPH
Although concerns remain that expanding insurance coverage may have a “crowding-out” effect, we saw no evidence of this for Medicaid beneficiaries in Massachusetts following statewide health reform.
There are several possible explanations for our findings, which suggest that Massachusetts health reform did not impair access to care for already-insured Medicaid beneficiaries. First, Massachusetts was unique relative to other states in that it already had a relatively low number of uninsured, compared with the national average. Despite reports of physician shortages in Massachusetts, the per capita supply of physicians was higher in Massachusetts compared with control states, as well. These factors may have made the state optimally suited to implement near-universal coverage without significantly overburdening the existing system. Although there were anecdotal reports of increased wait times to see a physician,4,5 there have been no peer-reviewed studies, to our knowledge, investigating wait times directly. It is also conceivable that healthcare providers and practices were able to appropriately triage the needs of new and existing patients so that any delays in care did not have any observable adverse outcomes.


Our study has a number of limitations. It did not include claims for enrollees in Medicaid Managed Care, as their claims were not available in the MAX database for Massachusetts nor for 2 out of 3 control states during our study period. Our study sample was limited to fee-for-service beneficiaries and those in PCCM plans; in Massachusetts, managed care plans tend to reimburse at higher rates than fee-for-service plans.23 Also, Medicaid managed care beneficiaries tend to have lower medical complexity than those enrolled in PCCM plans.24 Given that higher reimbursement rates for Medicaid are associated with improved care access,25 the de facto exclusion of this group from our study leaves us with an even more vulnerable population for which a negative spillover effect would be even more likely. Yet, despite studying the most vulnerable and medically complex Medicaid beneficiaries, we saw no negative spillover effect in access to outpatient care in Massachusetts, and we actually saw improvement in several of these measures.

Second, after applying our exclusion criteria, our sample consisted of less than 10% of the total beneficiaries in a given year. Given that Medicaid beneficiaries are a heterogeneous group with significant turnover,26 we felt that these exclusion criteria were necessary to have complete claims for nonelderly, nonpregnant adults. Medicaid programs also vary substantially across states in terms of eligibility criteria. For example, New Hampshire had significantly less generous income eligibility criteria for parents of dependent children (51%-56% of the federal poverty level) relative to the remaining 4 states (133%-191% of the federal poverty level) in both study years.27 Our finding that New Hampshire Medicaid beneficiaries had more than double the rate of inpatient hospitalizations relative to other New England states likely reflects a more impoverished beneficiary pool with greater medical and social needs.

Additionally, although PQIs are a well-validated set of metrics used as indicators of adequate primary care access, they are still an indirect measure of access to outpatient care. We did not look specifically at changes in outpatient utilization or wait times to see a physician that would mediate any observed increases in preventable admissions. Finally, another limitation noted by previous investigators is that Massachusetts had a high baseline rate of insurance relative to many other states even before insurance expansion. Thus, the experience in Massachusetts may not be generalizable to other states with lower rates of health insurance and/or physician supply. Yet, the consistent lack of negative spillover effects in several studies should be reassuring to policy makers implementing health reform in their jurisdictions.


We examined the effect of the first statewide health insurance expansion on access to care for Medicaid beneficiaries. Despite fears that an increase in the number of insured could lead to delays in primary care access, we found no evidence of a negative spillover effect in this particularly vulnerable population.

Author Affiliations: Department of Emergency Medicine, Beth Israel Deaconess Medical Center (LGB), Boston, MA; Department of Health Policy and Management (LGB, TCT, JZ, AKJ) and Department of Biostatistics (EJO), Harvard T.H. Chan School of Public Health, Boston, MA; Department of Surgery (TCT) and Department of Medicine (AKJ), Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA.

Source of Funding: Rx Foundation grant: “The Impact of Insurance Expansion on Medicaid Patients.”

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LB, AKJ, EJO, TCT, JZ); acquisition of data (AKJ, TCT, JZ); analysis and interpretation of data (LB, AKJ, EJO, TCT, JZ); drafting of the manuscript (LB, AKJ, TCT); critical revision of the manuscript for important intellectual content (LB, AKJ, EJO, TCT); statistical analysis (LB, EJO, JZ); obtaining funding (AKJ); administrative, technical, or logistic support (LB, JZ); and supervision (AKJ, EJO).

Address Correspondence to: Laura G. Burke, MD, MPH, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA 02215. E-mail

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