Spillover Effects of Massachusetts Health Reform on Mental Health Use by VA and Medicare Dual Enrollees

  • Edwin S. WongEmail author
  • Matthew L. Maciejewski
  • Paul L. Hebert
  • John C. Fortney
  • Chuan-Fen Liu
Original Article


Older veterans can obtain care from the Veterans Affairs Health System (VA), Medicare or both. We examined whether their use of mental health care was impacted by capacity effects stemming from younger, uninsured veterans’ enrolling in VA to satisfy the individual mandate within Massachusetts Health Reform (MHR). Using administrative data, we applied a difference-in-difference approach to compare pre-post changes in mental health use following MHR implementation. Findings indicated MHR was associated with increases in use through Medicare and the probability of dual VA-Medicare use. These results provide support for the possibility that limited capacity led to care seeking outside VA.


Healthcare reform Mental health Utilization Access Veterans affairs 



Dr. Wong is supported by a VA Health Services Research and Development Career Development Award (CDA 13-024). Dr. Maciejewski (RCS 10-391) and Dr. Fortney (RCS 17-153) are VA Research Career Scientists.

Compliance with Ethical Standards

Conflict of interest

Dr. Wong reports ownership of common stock in UnitedHealth Group Inc. All other authors declare they have no potential conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. Angrist, J. D., & Pischke, J. S. (2008). Mostly harmless econometrics: An empiricist’s companion. Princeton: Princeton University Press.Google Scholar
  2. Bertrand, M., Duflo, E., & Mullainathan, S. (2004). How much should we trust differences-in-differences estimates? Quarterly Journal of Economics, 119(1), 249–275.CrossRefGoogle Scholar
  3. Bond, A. M., & White, C. (2013). Massachusetts coverage expansion associated with reduction in primary care utilization among Medicare beneficiaries. Health Services Research, 48(6 Pt 1), 1826–1839.CrossRefPubMedGoogle Scholar
  4. Buntin, M. B., & Zaslavsky, A. M. (2004). Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures. Journal of Health Economics, 23(3), 525–542.CrossRefPubMedGoogle Scholar
  5. Burgess, J. F. Jr., Maciejewski, M. L., Bryson, C. L., et al. (2011). Importance of health system context for evaluating utilization patterns across systems. Health Economics, 20(2), 239–251.CrossRefPubMedGoogle Scholar
  6. Centers for Medicare and Medicaid Services. (2018). Berenson-Eggers type of service (BETOS) codes. Accessed 1 October 2018.
  7. Department of Veterans Affairs. (2018). Veterans access, choice and accountability act of 2014 fact sheet. Accessed 1 October 2018.
  8. Department of Veterans Affairs. (2018). Department of Veterans Affairs FY 2018–2024 strategic plan. Accessed 1 October 2018.
  9. Department of Veterans Affairs. (2018). Corporate Data Warehouse (CDW). Accessed 1 October 2018.
  10. Department of Veterans Affairs. (2018). VA Mental Health Services—Public Report. Accessed 1 October 2018.
  11. Fortney, J. C., Burgess, J. F. Jr., Bosworth, H. B., Booth, B. M., & Kaboli, P. J. (2011). A re-conceptualization of access for 21st century healthcare. Journal of General Internal Medicine, 26(Suppl 2), 639–647.CrossRefPubMedGoogle Scholar
  12. Gagne, J. J., Glynn, R. J., Avorn, J., Levin, R., & Schneeweiss, S. (2011). A combined comorbidity score predicted mortality in elderly patients better than existing scores. Journal of Clinical Epidemiology, 64(7), 749–759.CrossRefPubMedGoogle Scholar
  13. Huang, G., Kim, S., Gasper, J., et al. (2016). Survey of veteran enrollees’ health and use of health care. Accessed 1 October 2018.
  14. Joynt, K. E., Chan, D. C., Zheng, J., Orav, E. J., & Jha, A. K. (2015). The impact of Massachusetts Health Care Reform on access, quality, and costs of care for the already-insured. Health Services Research, 50(2), 599–613.CrossRefPubMedGoogle Scholar
  15. Long, S. K., & Masi, P. B. (2009). Access and affordability: An update on health reform in Massachusetts, fall 2008. Health Affairs, 28(4), w578–587.CrossRefPubMedGoogle Scholar
  16. Long, S. K., Stockley, K., & Dahlen, H. (2012). Massachusetts health reforms: Uninsurance remains low, self-reported health status improves as state prepares to tackle costs. Health Affairs, 31(2), 444–451.CrossRefPubMedGoogle Scholar
  17. McDonough, J. E., Rosman, B., Butt, M., Tucker, L., & Howe, L. K. (2008). Massachusetts health reform implementation: Major progress and future challenges. Health Affairs, 27(4), w285–297.CrossRefPubMedGoogle Scholar
  18. Miller, S. (2012). The effect of the Massachusetts reform on health care utilization. Inquiry, 49(4), 317–326.CrossRefPubMedGoogle Scholar
  19. Miller, S., & Wherry, L. R. (2017). Health and access to care during the first 2 years of the ACA medicaid expansions. The New England Journal of Medicine, 376(10), 947–956.CrossRefPubMedGoogle Scholar
  20. Olenick, M., Flowers, M., & Diaz, V. J. (2015). US veterans and their unique issues: Enhancing health care professional awareness. Advances in Medical Education and Practice, 6, 635–639.CrossRefPubMedGoogle Scholar
  21. Pande, A. H., Ross-Degnan, D., Zaslavsky, A. M., & Salomon, J. A. (2011). Effects of healthcare reforms on coverage, access, and disparities: Quasi-experimental analysis of evidence from Massachusetts. American Journal of Preventive Medicine, 41(1), 1–8.CrossRefPubMedGoogle Scholar
  22. Patel, K., & McDonough, J. (2010). From Massachusetts to 1600 Pennsylvania avenue: Aboard the health reform express. Health Affairs, 29(6), 1106–1111.CrossRefPubMedGoogle Scholar
  23. Pizer, S. D., & Prentice, J. C. (2011). Time is money: Outpatient waiting times and health insurance choices of elderly veterans in the United States. Journal of Health Economics, 30(4), 626–636.CrossRefPubMedGoogle Scholar
  24. Research Data Assistance Center. (2018). Outpatient RIF. Accessed 1 October 2018.
  25. Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167(5), 476–482.CrossRefPubMedGoogle Scholar
  26. Sommers, B. D., Baicker, K., & Epstein, A. M. (2012). Mortality and access to care among adults after state Medicaid expansions. The New England Journal of Medicine, 367(11), 1025–1034.CrossRefPubMedGoogle Scholar
  27. Sommers, B. D., Long, S. K., & Baicker, K. (2014). Changes in mortality after Massachusetts health care reform: A quasi-experimental study. Annals of Internal Medicine, 160(9), 585–593.CrossRefPubMedGoogle Scholar
  28. Sullivan, G., Arlinghaus, K., Edlund, C., Kauth, M., & Kemp, J. (2018). Guide to VA mental health services for veterans and families. Accessed 1 October 2018.
  29. Tanielian, T., Farris, C., Batka, C., et al. (2014). Ready to serve: Community-based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. Santa Monica: RAND Corporation.Google Scholar
  30. U.S. Department of Health and Human Services. (2018). Area health resource file. Accessed 1 October 2018.
  31. U.S. Government Accountability Office. (2018). Number of veterans receiving care, barriers faced, and efforts to increase access. Accessed 1 October 2018.
  32. Watkins, K. E., Smith, B., Akincigil, A., et al. (2016). The quality of medication treatment for mental disorders in the department of veterans affairs and in private-sector plans. Psychiatric Services, 67(4), 391–396.CrossRefPubMedGoogle Scholar
  33. Wong, E. S., Maciejewski, M. L., Hebert, P. L., et al. (2018). Did massachusetts health reform affect veterans affairs primary care use? Medical Care Research and Review, 75(1), 33–45.CrossRefPubMedGoogle Scholar
  34. Wong, E. S., Maciejewski, M. L., Hebert, P. L., Bryson, C. L., & Liu, C. F. (2014). Massachusetts health reform and Veterans Affairs health system enrollment. The American Journal of Managed Care, 20(8), 629–636.PubMedGoogle Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2018

Authors and Affiliations

  1. 1.Center for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattleUSA
  2. 2.Department of Health ServicesUniversity of WashingtonSeattleUSA
  3. 3.Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamUSA
  4. 4.Department of Population Health SciencesDuke UniversityDurhamUSA
  5. 5.Department of PsychiatryUniversity of WashingtonSeattleUSA

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