Expert Commentary

Massachusetts’ health care reform and emergency department utilization

2011 study in the New England Journal of Medicine on the impact of Massachusetts’ expanded health care reforms on emergency room usage.

How best to reduce the rate of emergency hospital visits, which significantly raise costs for the health system, remains a contentious point in the U.S. health care reform debate. Reform proponents argue that allowing a large uninsured population to persist results in overuse of emergency departments (ED), and that steering more of the population into a system of preventive care may diminish this. However, critics of government-sponsored expanded care reforms say that such policies will actually increase the rate of emergency visits.

A 2011 study by the Washington University School of Medicine, Yale Law School, and the Harvard Kennedy School published in the New England Journal of Medicine, “Massachusetts’ Health Care Reform and Emergency Department Utilization,” compared the rate of emergency department usage — both in-and out-patient services — over five years in Massachusetts, Vermont and New Hampshire. Massachusetts distinguished itself in 2006 by enacting a law requiring that nearly all citizens have health care; by 2009, this resulted in a 7.7% decrease in the rate of uninsured adults under the age of 65.

The study’s findings include:

  • “[Emergency department] use increased in Massachusetts after reform but also increased by similar amounts in New Hampshire and Vermont, states that did not implement insurance expansions.”
  • Comparing the overall data between the three states, the researchers found that the “continuous upward trend in ED utilization throughout … is remarkably consistent from state to state; if we didn’t know which state had implemented the reform law, we could not guess on the basis of these data.”
  • The researchers suggest that an explanation for the apparently neutral effect of expanded coverage on ED is that there are two contradictory influences at work: “that the Massachusetts insurance expansion increased prevention, thereby reducing ED use, but that this effect has been offset by the reduced out-of-pocket cost of using the ED or difficulties in finding primary care physicians.”

The researchers conclude that their findings “underscore the problem with evaluating policies by looking only at single trends and not examining simultaneous countervailing trends or comparable trends that cannot be attributed to the policies in question.”

A 2011 study in the Annals of Emergency Medicine, “Emergency Department Utilization After the Implementation of Massachusetts Health Reform,” draws the same conclusion about the overall trends, but also notes that the state’s reform was “associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform.”

Tags: medicine, Congress, campaign issue, health care reform