0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental StudyChanges in Mortality After Massachusetts Health Care Reform

Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
[+] Article and Author Information

From the Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts, and The Urban Institute, Washington, DC.

Presented in part at the 36th Annual Meeting of the Society of General Internal Medicine in Denver, Colorado, on 26 April 2013 and the Annual Research Meeting of AcademyHealth in Baltimore, Maryland, on 24 June 2013.

Disclaimer: Dr. Sommers is an advisor in the Office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services. However, this paper was written in Dr. Sommers’ capacity as a Harvard employee and does not represent the views of the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank James Ware at the Harvard School of Public Health for thoughtful advice on our statistical analysis; Jacob Robbins and Sarah Gordon, Research Assistants at the Harvard School of Public Health, for their work on this project; and Katherine Hempstead at the Robert Wood Johnson Foundation for helpful suggestions related to health care–amenable mortality.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2275.

Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Dr. Sommers (e-mail, bsommers@hsph.harvard.edu).

Requests for Single Reprints: Benjamin D. Sommers, MD, PhD, Department of Health Policy and Management, Harvard School of Public Health, Kresge Building, Room 406, 677 Huntington Avenue, Boston, MA 02115; e-mail, bsommers@hsph.harvard.edu.

Current Author Addresses: Drs. Sommers and Baicker: Department of Health Policy and Management, Harvard School of Public Health, Kresge Building, Room 406, 677 Huntington Avenue, Boston, MA 02115.

Dr. Long: Health Policy Center, Urban Institute, 2100 M Street NW, Washington, DC 20037.

Author Contributions: Conception and design: B.D. Sommers, S.K. Long, K. Baicker.

Analysis and interpretation of the data: B.D. Sommers, S.K. Long, K. Baicker.

Drafting of the article: B.D. Sommers, S.K. Long, K. Baicker.

Critical revision of the article for important intellectual content: B.D. Sommers, S.K. Long, K. Baicker.

Final approval of the article: B.D. Sommers, S.K. Long, K. Baicker.

Statistical expertise: B.D. Sommers, S.K. Long, K. Baicker.

Collection and assembly of data: B.D. Sommers.


Ann Intern Med. 2014;160(9):585-593. doi:10.7326/M13-2275
Text Size: A A A

Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.

Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.

Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.

Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.

Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.

Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention's Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.

Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.

Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.

Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.

Primary Funding Source: None.

Figures

Grahic Jump Location
Figure.

Unadjusted mortality rates for adults aged 20 to 64 years in Massachusetts versus control group (2001–2010).

The shaded band designates the beginning of the Massachusetts state health care reform that was implemented starting in July 2006. “Health care–amenable mortality” is as defined in Table 1 of the Supplement. “Other-cause mortality” contains all other causes of death not included in that definition.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Comment
Posted on June 24, 2014
John Tayu Lee, Christopher Millett
Imperial College London
Conflict of Interest: None Declared
Sommers et al (2014)1 examined the impact of Massachusetts 2006 health care reform on socioeconomic disparities in mortality. Using sophisticated methods, their results suggested this policy has protective effect on all-cause mortality as well as mortality for conditions that are most susceptible to health care utilisation. Perhaps most importantly, they found the effects were larger for those from lower incomes and uninsured by conducting subgroup analyses. An alternative approach to model the differential impact of the policy is to use interrupted times series with interaction terms between socioeconomic groups and three main variables in ITS model: time trend, dummy variable for policy, and continuous variable for duration of exposure. This model specification would allow patients in different income groups to have different baseline time trend, level change, and slope change from the reference group. This study design will model on the whole sample which means it reduces the risk of inefficient sample size when conducting subgroup analysis. The use of interrupted times series is becoming common in the evaluation of health interventions, but as far as we know, very few studies that use this method to examine policy effect on health inequalities by including interaction terms.

REFERENCE
1. Sommers BD, Long SK, Baicker K. Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study. Annals of Internal Medicine 2014; 160(9): 585-93.

Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)