Early Results of Massachusetts Healthcare Reform on Racial, Ethnic, and Socioeconomic Disparities in Cardiovascular Care

Study Questions:

Do disparities in utilization and outcomes of cardiovascular care change after reducing insurance barriers?

Methods:

Expanded access to health insurance for millions of Americans could impact on disparities in the utilization and outcomes of cardiovascular care, but remains uncertain. Examining such effects in Massachusetts—a state which implemented a strategy similar to the Affordable Care Act (ACA)—may provide insights. The investigators used hospital claims data from Massachusetts to describe disparities in the utilization of invasive cardiac procedures (coronary artery bypass grafting, percutaneous coronary intervention) and outcomes associated with ischemic heart disease during hospitalizations, before and after health care reform in Massachusetts was implemented in April 2006. The groups examined included racial/ethnic groups, women, and lower socioeconomic groups (based on neighborhood-level estimates from zip code data).

Results:

The results largely suggest that disparities continued to exist and were largely consistent for the utilization of invasive cardiac procedures, with no evidence of diminishing effects over time as access to insurance expanded. This occurred despite evidence of declining use of invasive cardiac procedures over time. Differences in outcomes were less pronounced overall, but showed a similar pattern before and after access to insurance expanded.

Conclusions:

Increasing access to insurance by itself does not reduce disparities in the utilization of invasive cardiac procedures, and overall had a modest impact on the utilization and outcomes of cardiovascular care.

Perspective:

This is an important study that attempts to address a great unknown: What will the impact of the national ACA have on health care disparities in vulnerable populations? Overall, I interpret this study as pointing out the complexities around understanding and addressing health care disparities. The authors point out several reasons for their null findings, including the role of other social determinants of health care (beyond insurance), the potential for underinsurance, and the lack of change in referral patterns for these patients who continue to be cared for by organizations with fewer resources. There are important limitations to consider such as data from a single state with a unique health care environment (e.g., ‘free care pool’ in Massachusetts prior to reform) and a lack of clinically granular data (i.e., ensuring that disparities reflected underuse in vulnerable populations rather than overuse in others). Despite these limitations, this paper reminds us that to truly tackle disparities will require a more comprehensive effort, and that expanded access to insurance is only a piece of the puzzle.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Ethnic Groups, Myocardial Ischemia, Health Care Reform, Referral and Consultation, Social Determinants of Health, Healthcare Disparities, Patient Protection and Affordable Care Act, Massachusetts, Percutaneous Coronary Intervention, Vulnerable Populations, Research Personnel, Coronary Artery Bypass, Insurance, Health


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