For decades, many in the United States have been uninsured. For decades, many socioeconomically disadvantaged and racial and ethnic minorities have suffered worse health outcomes because of disparities in US health care. Often, these two groups have significant overlap.

It's been thought, therefore, that health care reform might improve both of these issues simultaneously. But it's not been known. A recent study published in the BMJ attempted to use reform in Massachusetts to see if this might be true. "Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics":

Objectives To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states.

Design Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform.

Setting Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States.

Participants Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007).

Main outcome measures Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs.

The main outcome of interest in this study was the admission rates for a number of ambulatory care sensitive conditions. The hypothesis was that improved health care coverage would improve primary care access, and lead to reductions in admissions for issues that are less likely to result in admission with proper ambulatory care. The authors looked at data from October of 2004 through June of 2006 (before Massachusetts reform) and January 2008 through September of 2009 (after reform). They compared data from Massachusetts, where reform occurred, to Pennsylvania, New York, and New Jersey, where reform did not.

Adults age 18-64 were studied, as children had better coverage through Medicaid and CHIP, and those 65 and over have pretty much universal coverage through Medicare. Analyses adjusted for confounders like race and ethnicity, age, sex, income, unemployment rate, and physician supply.

And after controlling for these factors, the researchers found that there was no significant difference between the rates of admission for chronic ACSCs before or after reform. There were also no improvements in the rate of admissions for any racial or ethnic group versus Whites.

Even when a subanalysis was performed that looked specifically at Massachusetts, to see if differences could be found between counties with low and high levels of uninsurance at baseline - none could be found.

The simple conclusion is this: Massachusetts health care reform did not result in significant improvements to racial and ethnic disparities in admissions for ambulatory care sensitive conditions, or the rates of these admissions overall. Some might assert that this means health care reform will fail.

But that is a very simplistic view. The much more likely truth is that insurance coverage is just the first step to improving care, and disparities. Many other factors are likely contributing, including physician supply, physician willingness to accept coverage, and disparities in ways people are treated even when they have coverage. It's also possible that increased coverage could lead to increased, not decreased, admissions, because now people can more easily get inpatient care. Finally, Massachusetts is sometimes not very generalizable, as its levels of insurance coverage were among the best in the US, even before reform.

The bottom line is that disparities are real, and they are not easily fixed. No one should assume that the ACA will do so. What evidence we have shows that they are remarkably complicated, and not easily remedied.


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